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Adolescent Mild Traumatic Brain Injury in Primary Care
Adolescent Mild Traumatic Brain Injury in Primary Care Tracy E. Smith, MSN, FNP ABSTRACT
The issue of mild traumatic brain injury has been an underdiagnosed problem for many years. This was frequently due to a lack of insight that, although there was no evidence of injury on computed tomography scan, the impact/injury had created functional changes within the brain that could cause long-term complications. Over the past 10 years, health care providers and the public have become more aware of the true impact of this form of injury on adolescents (13-19) in sports and other trauma-related injuries. This is not an injury to ignore; the consequences can be life-threatening. Keywords: adolescents, mild traumatic brain injury, ongoing care, primary care assessment Ó 2015 Elsevier, Inc. All rights reserved.
INTRODUCTION
T
here are 1.6-3.8 million sports- and recreation-related traumatic brain injuries (TBIs) each year in the United States.1 Most of these are mild TBIs and do not receive medical attention. Of the 1.4 million TBI-related deaths, hospitalizations, and emergency department visits, 75%-90% are some form of mild TBI.1 In the adolescent population, mild TBIs account for 8.9% of all high school sports‒related injuries.2 Studies have indicated that adolescents and children may require a longer recovery time related to the continued growth process and more fragile state of the brain.2 In addition, researchers have determined that multiple concussions can increase symptoms and worsen long-term prognosis.3 Examining the recovery process of adolescents who have had a mild TBI will help guide understanding and future treatment approaches. Although the recovery period varies after a mild TBI, the majority of those affected often recover in a 7- to 10-day period.4 Unfortunately, as many as 15% of adolescents with concussion have a postconcussive syndrome that usually takes 3-6 months to resolve.5 Coping with this process of recovery, especially as an adolescent, can require significant adjustment. It may require backing off on important college prerequisites, no longer playing a sport or participating in a hobby www.npjournal.org
that they love, losing important friendships, and not being able to drive and be independent at a time in their lives when this is extremely important. They also may require increased support from family and friends for headaches, memory lapses, cognitive slowness, and emotional fluctuation. This article includes a review of the literature relevant to adolescent mild TBI and coping through the postinjury process as well as information on how to diagnose, treat, and manage mild TBI in primary care. To begin, I will examine the research relevant to how adolescent mild TBI can affect the child postinjury physically, cognitively, psychologically, and socially. I then review the literature concerning non‒injury-related life factors affecting coping. This will include pre- and postinjury factors. I then review how to diagnose concussion, the treatment process, and management for best long-term outcomes. COPING WITH ADOLESCENT MILD TBI Physical Coping
The adolescent brain has several key physical differences in composition when compared with the adult brain. Because the body and brain are still in the midst of maturing, both body and brain structures are more vulnerable from mild TBI. Physical symptoms often encountered are headaches, fatigue and decreased The Journal for Nurse Practitioners - JNP
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energy, sleep changes, nausea, problems with vision, ringing in the ears, dizziness and other balance issues, and an increased sensitivity to light and noise.6 When compared with adults, the bone and muscle structure is not as equipped to support the weight of the head.7 Also, the central and peripheral nervous system and myelin sheath are still in phases of development.7 In addition, the brain’s protection is limited because cranial bones are thinner and not fully developed.7 Cognitive Coping
Cognitive symptomatology and coping with related effects are a major part of the recovery process postinjury. Cognitive issues often seen postconcussion are delayed or slow thinking, lack of mental clarity, difficulty concentrating, increased distractibility, problems with learning and remembering, and difficulty with problem-solving.6 These symptoms can trouble adolescents as they attempt to focus on increasingly complex schoolwork and it may limit their learning at a crucial time in their academic lives. Although these cognitive symptoms usually dissipate within several months of injury, they can have a lasting impact on learning. Eisenburg and associates illustrated this in their study of the time resolution of postconcussive symptoms.3 They determined that cognitive symptoms were often present initially but could also develop during the course of recovery and tended to last longer than other types of symptoms.3 The researchers found that forgetfulness was the only symptom that usually resolved within a 2-week period after trauma.3 All other cognitive symptoms had a much slower progression toward recovery.3 Cognitive issues can be particularly difficult to deal with when faced with meeting important academic milestones and deadlines to prevent losing important scholastic ground. Brown and associates studied the effect of cognitive activity level on duration of postconcussion symptoms.8 Their study showed that reducing some cognitive activity level was beneficial and resulted in shorter symptom duration.8 The researchers also determined that complete withdrawal from cognitive activity was probably not necessary.8 In fact, they found that only the group engaged in the highest level of cognitive activity postinjury had any lengthening of cognitive symptomatology. All other groups with reduced 2
The Journal for Nurse Practitioners - JNP
cognitive activity had better results and improved symptom resolution.8 To decrease unnecessary cognitive stress and expectations, special guidelines should be encouraged to allow appropriate levels of cognitive rest, such as shortened school days and extended deadlines for completion of schoolwork.3 Each child must be evaluated individually because symptoms are so varied. They then should be closely watched by health care providers, school officials, and family to ensure they are coping adequately.3 Any new issues that develop must be addressed and the education plan revised accordingly. Psychological Coping
The effects of mild TBI on the adolescent age group psychologically is eye-opening. In a Canadian study, Ilie and associates found that, after surveying 4,685 students, 19.5% had suffered some form of TBI in their young lives.9 Of these adolescents, a significantly greater number identified having elevated levels of psychological distress, suicide attempts, counseling on a crisis hotline, and prescribed medication for depression, anxiety, or both. They also reported being bullied or cyberbullied, threatened with a weapon, bullying others, and displaying violent and nonviolent conduct problems.9 Although it is impossible to determine the exact etiology and whether their behaviors came first or after, it is important to note that this at-risk group should be closely monitored and early interventions established and provided to reduce long-term and possibly lifelong effects. Chrisman and Richardson presented another poignant statistic.10 They found a connection that links a history of concussion with a 3-fold increased risk for depression.10 Due to the potentially dangerous outcomes of depression, adolescents having experienced a mild TBI should be watched closely so that early intervention can take place and, hopefully, prevention or moderation of severe depression issues. Unfortunately, with increased depression, suicide risk also increases. Mackelprang and associates studied suicidal ideation risk in the first year after TBI.11 They found that an alarming 25% of study participants identified some form of suicidal ideation in the first year after their injury. This number is 7-fold greater than that of the general population.11 Sadly, this high Volume
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percentage likely does not decrease over time after injury.11 Awareness of potential psychological distress and suicidal ideation must be assessed during followup visits.
life at 3 months postinjury.14 These findings suggest the importance of being aware of a person’s preinjury factors and including attention to these issues in postinjury care and response.
Social Coping
Postinjury Factors
Adolescents are at a crucial point in their lives where their social circle and friends are the primary focus. It is important to try to maintain this contact during the mild TBI recovery process. Heverly-Fitt and colleagues completed a study on friendship quality and psychosocial outcomes after mild TBI in children.12 They determined that friendship benefits these youth and actually protects them against adverse psychological outcomes. On the contrary, those children who did not have supportive friendship and were not accepted by their peer group were at greater risk for maladjustment and poorer outcomes.12
During my review of research, I found several studies illustrating how postinjury factors could significantly impact recovery from a mild TBI. One such study, by Grubenhoff and colleagues, addressed acute concussion symptom severity and delayed symptom resolution.15 They determined that delayed symptom resolution was not a result of acute symptom severity but most likely psychological postinjury factors.15 They suggested that acute injury factors were more valid in determining issues early in the recovery phase, whereas postinjury factors usually took on a more significant role several months after the injury. One major postinjury factor affecting recovery is pain related to other bodily injuries received at time of injury. Pain alone can have a major physical, cognitive, and psychological impact on behavior and one’s ability to cope. Another important consideration related to injury is the mechanism of injury and the potential presence of posttraumatic stress disorder. For instance, motor vehicle collisions tend to have a higher rate of posttraumatic stress disorder associated with them than some other mechanisms of injury.13 In addition, posttraumatic stress disorder has been tied to higher levels of postconcussive symptoms in the adult population.13 Hall and associates determined that there was no difference in postconcussion symptoms between trauma patients who had no head injury and TBI patients.16 This may indicate that postconcussion symptoms are often related to posttraumatic stress instead of the head injury alone. Therefore, inquiring about how the injury occurred may assist in monitoring for this issue in adolescents and promote earlier interventions and better outcomes. Potential family issues related to the injury may also affect coping postinjury. For instance, parental anxiety can cause increased tension and heightened concern that can lead to poor adaption and coping for the family. Taking time to assess and understand the coping ability of the parent as well as the support system available is essential to promote optimal
EXTERNAL FACTORS AFFECTING COPING WITH ADOLESCENT MILD TBI Preinjury Factors
A primary component of the adolescent’s ability to cope with the mild TBI is the preinjury functioning that exists. Any preinjury physical, learning, psychological, cognitive, family, and personal coping issues will potentially influence the postinjury recovery phase. In fact, McNally and colleagues determined that these preinjury factors had a significant effect on postconcussion symptoms.13 They discovered that preinjury factors had a greater impact on healthrelated quality of life than either the mild TBI or postconcussive symptoms at 3 months postinjury and beyond.13 Similarly, Maestas and associates performed a study of preinjury factors using a cluster analysis of individuals after TBI.14 They found 3 distinct groupings in relation to coping: high problemfocused/high avoidant; high problem-focused/low avoidant; and low problem-focused/low avoidant.14 They determined that those participants who had a high level of preinjury problem-focused and avoidant coping strategies had the lowest level of emotional functioning and quality of life at 3 months after TBI.14 They also discovered that a person’s preinjury coping could predict their level of anxiety, depression, and mental health quality of www.npjournal.org
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outcomes for the child. Although Yeates and associates used a much younger age bracket, they determined that better family functioning predicted better behavioral adjustment 18 months after injury in children 3-6 years old.17 It is not difficult to see how this may also carry over to the later years of childhood and adolescence. SELF-REPORT ATTITUDES
Another noninjury factor that can potentially alter outcome is the adolescent’s willingness to seek treatment and report head injury. Kurowski and colleagues studied high school athletes’ self-reports and determined that knowledge concerning mild TBI did not correlate positively with willingness to report.18 In fact, younger age, female, and soccer athletes were found to be more willing to report injury than older age, male, and football athletes.18 This suggests that the group potentially at risk for greatest impact does not tend to be willing to give up participation and admit injury. These athletes must be watched closely and standardized concussion testing needs to be completed after a strong impact to the head and body. REPETITIVE CONCUSSION INJURY
Another factor that affects recovery and coping is repetitive injury and the biochemical changes that occur within the brain after recurrent head injury. Eisenburg et al. studied the time interval between concussions and symptom duration.3 Their study findings suggest that those subjects who had a concussion in the past year had recovery times that were almost 3-fold longer than average.3 The closer the time between concussions the longer the time need for symptom resolution.3 However, those with concussion 1 year after their previous injury did not have the compounded effects. This is an increasingly highlighted area of research and some researchers have shown that repetitive injury puts adolescents at risk for developing chronic traumatic encephalopathy if guidelines for brain protection and return to play are not followed.7 To protect our youth we need to prevent repetitive injury and limit participation in contact sports after their concussion to promote best possible longterm outcome. 4
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PREVENTION
First, the best treatment for any adolescent injury is prevention, namely using safety measures and equipment to prevent head injury in contact sports. Every contact sports physical should include a detailed neurologic, balance, and vision/hearing assessment. Using the Sports Concussion Assessment Tool 3 for baseline evaluation as a part of the sports physical would be particularly helpful for comparison after a blow to the head when these same assessments can be replicated. Making sure that adolescent community sports programs are equipped to deal with concussion in an organized way is essential for safe play in contact sports.1 Second, promoting safe driving practices will go a long way in reducing concussion. School/community awareness programs must continue to increase awareness about the dangers of reckless, distracted driving. DIAGNOSIS/EVALUATION
To assist with diagnosis of concussion, the US Centers for Disease Control and Prevention has developed a variety of training tools to assist health care providers, teachers, and coaches in properly identifying and managing the condition. For providers, “Heads up: Brain Injury in Your Practice” is very useful.1 One form included in this packet that is especially helpful in information gathering for the nurse practitioner is the Acute Concussion Evaluation (ACE). It is helpful in organizing history, the event, signs/symptoms, red flags, referral needs, and care plan. A careful history-taking of the injury characteristics and condition after impact must be examined from the injured party and bystander statements/ report. A detailed accounting of signs and symptoms in all areas, including physical, cognitive, emotional, and sleep, must be identified. Those with preinjury factors, such as prior concussion, headaches, and developmental and psychiatric issues, are at risk for longer recovery intervals. Using reliable/valid screening tools for mental health issues may be helpful. There are valuable screening tools for adolescent depression, anxiety, posttraumatic stress disorder, and suicide risk on the Substance Abuse and Mental Health Services Administration website Volume
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(http://SAMHSA.gov/) that help identify and understand the type and depth of problems that may occur during the recovery process. Some red flags that must be further evaluated are worsening headaches, seizures, focal neurologic signs (ie, pupillary changes), difficulty in arousal/sleepiness, repeated vomiting, slurred speech, inability to recognize familiar faces/locations, increased agitation or confusion, weakness/paresthesia in arms/legs, neck pain, strange behavior, and alteration in level of consciousness.1 Monitoring immediately after the event is important, but frequently concussion symptoms develop within the next minutes, hours, and days after trauma. This makes it important to watch concussion sufferers for worsening status. If these symptoms exist/worsen, the client should receive emergency care/evaluation and be considered for neuroimaging. Often, concussion can be managed in the office without further referral if symptoms dissipate within the first 10-14 days.1 Using the Sports Concussion Assessment Tool 3 to assess symptoms and capacity to return to school/play can be quite helpful.1 No return to play should occur until symptoms are gone. Treatment plans and monitoring need to be individualized based on each adolescent’s injury response. TREATMENT
Rest, both cognitive and physical, is the best form of treatment. The quantity recommended varies based on expert, but it is essential in this age group to balance rest with reduced activity/social interaction. A stepwise approach that gradually increases cognitive work and environmental stimulation on an individualized basis will improve success and compliance with the treatment plan. Sleep issues need to be addressed. Sometimes the injury can cause fatigue and increased needs for sleep, whereas others may experience a decreased ability to sleep. If fatigue is an issue, quiet rest times should be provided. If insomnia is the issue, providing information on good sleep hygiene such as stopping television and electronics 1 hour before bed, sleeping in a dark quiet environment, avoiding caffeine, and going to bed at the same time every night may be helpful (Ontario Neurotrauma www.npjournal.org
Foundation Pediatric Concussion Guidelines, see http://onf.org/). Use of computers, gaming devices, and phones for texting will frequently cause symptoms to worsen. Limiting these activities and encouraging activities such as talking on the phone instead of texting, and low-key visits with 1 friend at a time may provide some relief from social isolation without causing symptoms to flare up (http://onf.org/). Use of acetaminophen to manage headache pain may be helpful for mild analgesia. However, there is no statistical evidence that acetaminophen is of benefit postconcussion. Nonsteroidal anti-inflammatory drugs and aspirin should be avoided immediately postinjury until intracranial bleeding can be ruled out. Being medication-free will help identify changes in symptom intensity when increasing physical activity.2 Return to play should be done in a stepwise fashion and the adolescent should be symptom-free 24 hours at 1 level before advancing to the next step.1 If symptoms return, the adolescent is be moved back a step until they are once again symptom-free for 24 hours.1 Careful monitoring and gradual activity increase is best for the recovery process. REFERRAL
If preinjury factors indicate the adolescent already has issues with behavior and development, further neuropsychological testing should be initiated. Referral to a neuropsychologist would be helpful for further monitoring and screening for exacerbated issues. In addition, if symptoms of mental illness are suspected, referral to neuropsychology or psychiatry is required.2 For more comprehensive return-to-play management, or if symptoms intensify/worsen at any point in the recovery process, referral to a concussion/sports medicine specialist may be beneficial for closer monitoring and treatment.2 In conclusion, there are many concerns that affect the health of adolescents with mild TBI. The physical, cognitive, psychological, and social impact at a very vulnerable life stage must be watched very closely. As health care providers, we must be aware of the issues that can develop in these areas as well as noninjury factors, self-report attitudes, and risk of The Journal for Nurse Practitioners - JNP
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recurrent injury. If we screen, diagnose, and manage effectively, we can decrease the likelihood of poor outcomes and improve the recovery process. References 1. US Centers for Disease Control and Prevention. Heads up: Facts for physicians about mild traumatic brain injury. 2014. http://cdc.gov. Accessed April 1, 2015. 2. Halstead ME, Walter KD. The Council of Sports Medicine and Fitness. Sport-related concussion in children and adolescents. Pediatrics. 2010;126(3):597-615. 3. Eisenburg MA, Andrea J, Meehan W, Mannix R. Time interval between concussions and symptom duration. Pediatrics. 2013;132(8):8-17. 4. Bass PF 3rd. Managing a patient after concussion. Contemp Pediatr. 2014:32-34. 5. Sroufe N, Fuller D, West B, Singal B, Warschausky S, Maio R. Postconcussive symptoms and neurocognitive function after mild traumatic brain injury in children. Pediatrics. 2010;125(6):e1331-e1339. 6. Kirkwood MW, Yeates KO, Wilson PE. Pediatric sport-related concussion: a review of the clinical management of an oft-neglected population. Pediatrics. 2006;117(4):1359-1371. 7. Norton C, Feltz SJ, Angela B, Granitto M. Tackling long-term consequences. Nursing. 2013:50-55. 8. Brown NJ, Mannix RC, O’Brien MJ, Gostine D, Collins MW, Meehan WP 3rd. Effect of cognitive activity level on duration of post-concussion symptoms. Pediatrics. 2014;133:e299-e304. 9. Ilie G, Mann RE, Boak A, et al. Suicidality, bullying and other conduct and mental health correlates of traumatic brain injury in adolescents. PLoS One. 2014;9(4):1-6. 10. Chrisman SP, Richardson LP. Prevalence of diagnosed depression in adolescents with history of concussion. J Adolesc Health. 2014;54: 582-586. 11. Mackelprang JL, Bombardier CH, Fann JR, Temkin NR, Barber JK, Dikmen SS. Rates and predictors of suicidal ideation during the first year after traumatic brain injury. Am J Publ Health. 2014;104(7): e100-e107.
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12. Heverly-Fitt S, Wimsatt MA, Menzer MM, et al. Friendship quality and psychosocial outcomes among children with traumatic brain injury. J Int Neuropsychol Soc. 2014;20(7):684-693. 13. McNally KA, Bangert B, Dietrich A, et al. Injury versus non-injury factors as predictors of post-concussive symptoms following mild traumatic brain injury in children. Neuropsychology. 2013;27(1):1-12. 14. Maestas KL, Sander AM, Clark AN, et al. Preinjury coping, emotional functioning, and quality of life following uncomplicated mild traumatic brain injury. J Head Trauma Rehabil. 2014;29(5):407-417. 15. Grubenhoff JA, Deakyne SJ, Brou L, Bajaj L, Comstock RD, Kirkwood MW. Acute concussion symptom severity and delayed symptom resolution. Pediatrics. 2014;134(1):54-62. 16. Hall EC, Lund E, Brown D, et al. How are you really feeling? A prospective evaluation of cognitive function following trauma. J Trauma Acute Care Surg. 2014;76(3):859-865. 17. Yeates KO, Taylor HG, Walz NC, Stancin T, Wade SL. The family environment as a moderator of psychosocial outcomes following traumatic brain injury in young children. Neuropsychology. 2010;24(3):345-356. 18. Kurowski B, Pomerantz WJ, Schaiper C, Gittelman MA. Factors that influence concussion knowledge and self-reported attitudes in high school athletes. J Trauma Acute Care Surg. 2014;77(301, Suppl):s12-s17.
Tracy E. Smith, MSN, FNP, CNE, is a registered nurse in the Trauma Surgery/Neuro Critical Care at the University of Tennessee Medical Cente, Knoxville, TN. She can be reached at [email protected]. In compliance with national ethical guidelines, the author reports no relationships with business or industry that would pose a conflict of interest. 1555-4155/15/$ see front matter © 2015 Elsevier, Inc. All rights reserved. http://dx.doi.org/10.1016/j.nurpra.2015.08.011
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The issue of mild traumatic brain injury has been an underdiagnosed problem for many years. This was frequently due to a lack of insight that, although there was no evidence of injury on computed tomography scan, the impact/injury had created functional changes within the brain that could cause long-term complications. Over the past 10 years, health care providers and the public have become more aware of the true impact of this form of injury on adolescents (13-19) in sports and other trauma-related injuries. This is not an injury to ignore; the consequences can be life-threatening. Keywords: adolescents, mild traumatic brain injury, ongoing care, primary care assessment Ó 2015 Elsevier, Inc. All rights reserved.
INTRODUCTION
T
here are 1.6-3.8 million sports- and recreation-related traumatic brain injuries (TBIs) each year in the United States.1 Most of these are mild TBIs and do not receive medical attention. Of the 1.4 million TBI-related deaths, hospitalizations, and emergency department visits, 75%-90% are some form of mild TBI.1 In the adolescent population, mild TBIs account for 8.9% of all high school sports‒related injuries.2 Studies have indicated that adolescents and children may require a longer recovery time related to the continued growth process and more fragile state of the brain.2 In addition, researchers have determined that multiple concussions can increase symptoms and worsen long-term prognosis.3 Examining the recovery process of adolescents who have had a mild TBI will help guide understanding and future treatment approaches. Although the recovery period varies after a mild TBI, the majority of those affected often recover in a 7- to 10-day period.4 Unfortunately, as many as 15% of adolescents with concussion have a postconcussive syndrome that usually takes 3-6 months to resolve.5 Coping with this process of recovery, especially as an adolescent, can require significant adjustment. It may require backing off on important college prerequisites, no longer playing a sport or participating in a hobby www.npjournal.org
that they love, losing important friendships, and not being able to drive and be independent at a time in their lives when this is extremely important. They also may require increased support from family and friends for headaches, memory lapses, cognitive slowness, and emotional fluctuation. This article includes a review of the literature relevant to adolescent mild TBI and coping through the postinjury process as well as information on how to diagnose, treat, and manage mild TBI in primary care. To begin, I will examine the research relevant to how adolescent mild TBI can affect the child postinjury physically, cognitively, psychologically, and socially. I then review the literature concerning non‒injury-related life factors affecting coping. This will include pre- and postinjury factors. I then review how to diagnose concussion, the treatment process, and management for best long-term outcomes. COPING WITH ADOLESCENT MILD TBI Physical Coping
The adolescent brain has several key physical differences in composition when compared with the adult brain. Because the body and brain are still in the midst of maturing, both body and brain structures are more vulnerable from mild TBI. Physical symptoms often encountered are headaches, fatigue and decreased The Journal for Nurse Practitioners - JNP
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energy, sleep changes, nausea, problems with vision, ringing in the ears, dizziness and other balance issues, and an increased sensitivity to light and noise.6 When compared with adults, the bone and muscle structure is not as equipped to support the weight of the head.7 Also, the central and peripheral nervous system and myelin sheath are still in phases of development.7 In addition, the brain’s protection is limited because cranial bones are thinner and not fully developed.7 Cognitive Coping
Cognitive symptomatology and coping with related effects are a major part of the recovery process postinjury. Cognitive issues often seen postconcussion are delayed or slow thinking, lack of mental clarity, difficulty concentrating, increased distractibility, problems with learning and remembering, and difficulty with problem-solving.6 These symptoms can trouble adolescents as they attempt to focus on increasingly complex schoolwork and it may limit their learning at a crucial time in their academic lives. Although these cognitive symptoms usually dissipate within several months of injury, they can have a lasting impact on learning. Eisenburg and associates illustrated this in their study of the time resolution of postconcussive symptoms.3 They determined that cognitive symptoms were often present initially but could also develop during the course of recovery and tended to last longer than other types of symptoms.3 The researchers found that forgetfulness was the only symptom that usually resolved within a 2-week period after trauma.3 All other cognitive symptoms had a much slower progression toward recovery.3 Cognitive issues can be particularly difficult to deal with when faced with meeting important academic milestones and deadlines to prevent losing important scholastic ground. Brown and associates studied the effect of cognitive activity level on duration of postconcussion symptoms.8 Their study showed that reducing some cognitive activity level was beneficial and resulted in shorter symptom duration.8 The researchers also determined that complete withdrawal from cognitive activity was probably not necessary.8 In fact, they found that only the group engaged in the highest level of cognitive activity postinjury had any lengthening of cognitive symptomatology. All other groups with reduced 2
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cognitive activity had better results and improved symptom resolution.8 To decrease unnecessary cognitive stress and expectations, special guidelines should be encouraged to allow appropriate levels of cognitive rest, such as shortened school days and extended deadlines for completion of schoolwork.3 Each child must be evaluated individually because symptoms are so varied. They then should be closely watched by health care providers, school officials, and family to ensure they are coping adequately.3 Any new issues that develop must be addressed and the education plan revised accordingly. Psychological Coping
The effects of mild TBI on the adolescent age group psychologically is eye-opening. In a Canadian study, Ilie and associates found that, after surveying 4,685 students, 19.5% had suffered some form of TBI in their young lives.9 Of these adolescents, a significantly greater number identified having elevated levels of psychological distress, suicide attempts, counseling on a crisis hotline, and prescribed medication for depression, anxiety, or both. They also reported being bullied or cyberbullied, threatened with a weapon, bullying others, and displaying violent and nonviolent conduct problems.9 Although it is impossible to determine the exact etiology and whether their behaviors came first or after, it is important to note that this at-risk group should be closely monitored and early interventions established and provided to reduce long-term and possibly lifelong effects. Chrisman and Richardson presented another poignant statistic.10 They found a connection that links a history of concussion with a 3-fold increased risk for depression.10 Due to the potentially dangerous outcomes of depression, adolescents having experienced a mild TBI should be watched closely so that early intervention can take place and, hopefully, prevention or moderation of severe depression issues. Unfortunately, with increased depression, suicide risk also increases. Mackelprang and associates studied suicidal ideation risk in the first year after TBI.11 They found that an alarming 25% of study participants identified some form of suicidal ideation in the first year after their injury. This number is 7-fold greater than that of the general population.11 Sadly, this high Volume
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percentage likely does not decrease over time after injury.11 Awareness of potential psychological distress and suicidal ideation must be assessed during followup visits.
life at 3 months postinjury.14 These findings suggest the importance of being aware of a person’s preinjury factors and including attention to these issues in postinjury care and response.
Social Coping
Postinjury Factors
Adolescents are at a crucial point in their lives where their social circle and friends are the primary focus. It is important to try to maintain this contact during the mild TBI recovery process. Heverly-Fitt and colleagues completed a study on friendship quality and psychosocial outcomes after mild TBI in children.12 They determined that friendship benefits these youth and actually protects them against adverse psychological outcomes. On the contrary, those children who did not have supportive friendship and were not accepted by their peer group were at greater risk for maladjustment and poorer outcomes.12
During my review of research, I found several studies illustrating how postinjury factors could significantly impact recovery from a mild TBI. One such study, by Grubenhoff and colleagues, addressed acute concussion symptom severity and delayed symptom resolution.15 They determined that delayed symptom resolution was not a result of acute symptom severity but most likely psychological postinjury factors.15 They suggested that acute injury factors were more valid in determining issues early in the recovery phase, whereas postinjury factors usually took on a more significant role several months after the injury. One major postinjury factor affecting recovery is pain related to other bodily injuries received at time of injury. Pain alone can have a major physical, cognitive, and psychological impact on behavior and one’s ability to cope. Another important consideration related to injury is the mechanism of injury and the potential presence of posttraumatic stress disorder. For instance, motor vehicle collisions tend to have a higher rate of posttraumatic stress disorder associated with them than some other mechanisms of injury.13 In addition, posttraumatic stress disorder has been tied to higher levels of postconcussive symptoms in the adult population.13 Hall and associates determined that there was no difference in postconcussion symptoms between trauma patients who had no head injury and TBI patients.16 This may indicate that postconcussion symptoms are often related to posttraumatic stress instead of the head injury alone. Therefore, inquiring about how the injury occurred may assist in monitoring for this issue in adolescents and promote earlier interventions and better outcomes. Potential family issues related to the injury may also affect coping postinjury. For instance, parental anxiety can cause increased tension and heightened concern that can lead to poor adaption and coping for the family. Taking time to assess and understand the coping ability of the parent as well as the support system available is essential to promote optimal
EXTERNAL FACTORS AFFECTING COPING WITH ADOLESCENT MILD TBI Preinjury Factors
A primary component of the adolescent’s ability to cope with the mild TBI is the preinjury functioning that exists. Any preinjury physical, learning, psychological, cognitive, family, and personal coping issues will potentially influence the postinjury recovery phase. In fact, McNally and colleagues determined that these preinjury factors had a significant effect on postconcussion symptoms.13 They discovered that preinjury factors had a greater impact on healthrelated quality of life than either the mild TBI or postconcussive symptoms at 3 months postinjury and beyond.13 Similarly, Maestas and associates performed a study of preinjury factors using a cluster analysis of individuals after TBI.14 They found 3 distinct groupings in relation to coping: high problemfocused/high avoidant; high problem-focused/low avoidant; and low problem-focused/low avoidant.14 They determined that those participants who had a high level of preinjury problem-focused and avoidant coping strategies had the lowest level of emotional functioning and quality of life at 3 months after TBI.14 They also discovered that a person’s preinjury coping could predict their level of anxiety, depression, and mental health quality of www.npjournal.org
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outcomes for the child. Although Yeates and associates used a much younger age bracket, they determined that better family functioning predicted better behavioral adjustment 18 months after injury in children 3-6 years old.17 It is not difficult to see how this may also carry over to the later years of childhood and adolescence. SELF-REPORT ATTITUDES
Another noninjury factor that can potentially alter outcome is the adolescent’s willingness to seek treatment and report head injury. Kurowski and colleagues studied high school athletes’ self-reports and determined that knowledge concerning mild TBI did not correlate positively with willingness to report.18 In fact, younger age, female, and soccer athletes were found to be more willing to report injury than older age, male, and football athletes.18 This suggests that the group potentially at risk for greatest impact does not tend to be willing to give up participation and admit injury. These athletes must be watched closely and standardized concussion testing needs to be completed after a strong impact to the head and body. REPETITIVE CONCUSSION INJURY
Another factor that affects recovery and coping is repetitive injury and the biochemical changes that occur within the brain after recurrent head injury. Eisenburg et al. studied the time interval between concussions and symptom duration.3 Their study findings suggest that those subjects who had a concussion in the past year had recovery times that were almost 3-fold longer than average.3 The closer the time between concussions the longer the time need for symptom resolution.3 However, those with concussion 1 year after their previous injury did not have the compounded effects. This is an increasingly highlighted area of research and some researchers have shown that repetitive injury puts adolescents at risk for developing chronic traumatic encephalopathy if guidelines for brain protection and return to play are not followed.7 To protect our youth we need to prevent repetitive injury and limit participation in contact sports after their concussion to promote best possible longterm outcome. 4
The Journal for Nurse Practitioners - JNP
PREVENTION
First, the best treatment for any adolescent injury is prevention, namely using safety measures and equipment to prevent head injury in contact sports. Every contact sports physical should include a detailed neurologic, balance, and vision/hearing assessment. Using the Sports Concussion Assessment Tool 3 for baseline evaluation as a part of the sports physical would be particularly helpful for comparison after a blow to the head when these same assessments can be replicated. Making sure that adolescent community sports programs are equipped to deal with concussion in an organized way is essential for safe play in contact sports.1 Second, promoting safe driving practices will go a long way in reducing concussion. School/community awareness programs must continue to increase awareness about the dangers of reckless, distracted driving. DIAGNOSIS/EVALUATION
To assist with diagnosis of concussion, the US Centers for Disease Control and Prevention has developed a variety of training tools to assist health care providers, teachers, and coaches in properly identifying and managing the condition. For providers, “Heads up: Brain Injury in Your Practice” is very useful.1 One form included in this packet that is especially helpful in information gathering for the nurse practitioner is the Acute Concussion Evaluation (ACE). It is helpful in organizing history, the event, signs/symptoms, red flags, referral needs, and care plan. A careful history-taking of the injury characteristics and condition after impact must be examined from the injured party and bystander statements/ report. A detailed accounting of signs and symptoms in all areas, including physical, cognitive, emotional, and sleep, must be identified. Those with preinjury factors, such as prior concussion, headaches, and developmental and psychiatric issues, are at risk for longer recovery intervals. Using reliable/valid screening tools for mental health issues may be helpful. There are valuable screening tools for adolescent depression, anxiety, posttraumatic stress disorder, and suicide risk on the Substance Abuse and Mental Health Services Administration website Volume
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(http://SAMHSA.gov/) that help identify and understand the type and depth of problems that may occur during the recovery process. Some red flags that must be further evaluated are worsening headaches, seizures, focal neurologic signs (ie, pupillary changes), difficulty in arousal/sleepiness, repeated vomiting, slurred speech, inability to recognize familiar faces/locations, increased agitation or confusion, weakness/paresthesia in arms/legs, neck pain, strange behavior, and alteration in level of consciousness.1 Monitoring immediately after the event is important, but frequently concussion symptoms develop within the next minutes, hours, and days after trauma. This makes it important to watch concussion sufferers for worsening status. If these symptoms exist/worsen, the client should receive emergency care/evaluation and be considered for neuroimaging. Often, concussion can be managed in the office without further referral if symptoms dissipate within the first 10-14 days.1 Using the Sports Concussion Assessment Tool 3 to assess symptoms and capacity to return to school/play can be quite helpful.1 No return to play should occur until symptoms are gone. Treatment plans and monitoring need to be individualized based on each adolescent’s injury response. TREATMENT
Rest, both cognitive and physical, is the best form of treatment. The quantity recommended varies based on expert, but it is essential in this age group to balance rest with reduced activity/social interaction. A stepwise approach that gradually increases cognitive work and environmental stimulation on an individualized basis will improve success and compliance with the treatment plan. Sleep issues need to be addressed. Sometimes the injury can cause fatigue and increased needs for sleep, whereas others may experience a decreased ability to sleep. If fatigue is an issue, quiet rest times should be provided. If insomnia is the issue, providing information on good sleep hygiene such as stopping television and electronics 1 hour before bed, sleeping in a dark quiet environment, avoiding caffeine, and going to bed at the same time every night may be helpful (Ontario Neurotrauma www.npjournal.org
Foundation Pediatric Concussion Guidelines, see http://onf.org/). Use of computers, gaming devices, and phones for texting will frequently cause symptoms to worsen. Limiting these activities and encouraging activities such as talking on the phone instead of texting, and low-key visits with 1 friend at a time may provide some relief from social isolation without causing symptoms to flare up (http://onf.org/). Use of acetaminophen to manage headache pain may be helpful for mild analgesia. However, there is no statistical evidence that acetaminophen is of benefit postconcussion. Nonsteroidal anti-inflammatory drugs and aspirin should be avoided immediately postinjury until intracranial bleeding can be ruled out. Being medication-free will help identify changes in symptom intensity when increasing physical activity.2 Return to play should be done in a stepwise fashion and the adolescent should be symptom-free 24 hours at 1 level before advancing to the next step.1 If symptoms return, the adolescent is be moved back a step until they are once again symptom-free for 24 hours.1 Careful monitoring and gradual activity increase is best for the recovery process. REFERRAL
If preinjury factors indicate the adolescent already has issues with behavior and development, further neuropsychological testing should be initiated. Referral to a neuropsychologist would be helpful for further monitoring and screening for exacerbated issues. In addition, if symptoms of mental illness are suspected, referral to neuropsychology or psychiatry is required.2 For more comprehensive return-to-play management, or if symptoms intensify/worsen at any point in the recovery process, referral to a concussion/sports medicine specialist may be beneficial for closer monitoring and treatment.2 In conclusion, there are many concerns that affect the health of adolescents with mild TBI. The physical, cognitive, psychological, and social impact at a very vulnerable life stage must be watched very closely. As health care providers, we must be aware of the issues that can develop in these areas as well as noninjury factors, self-report attitudes, and risk of The Journal for Nurse Practitioners - JNP
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recurrent injury. If we screen, diagnose, and manage effectively, we can decrease the likelihood of poor outcomes and improve the recovery process. References 1. US Centers for Disease Control and Prevention. Heads up: Facts for physicians about mild traumatic brain injury. 2014. http://cdc.gov. Accessed April 1, 2015. 2. Halstead ME, Walter KD. The Council of Sports Medicine and Fitness. Sport-related concussion in children and adolescents. Pediatrics. 2010;126(3):597-615. 3. Eisenburg MA, Andrea J, Meehan W, Mannix R. Time interval between concussions and symptom duration. Pediatrics. 2013;132(8):8-17. 4. Bass PF 3rd. Managing a patient after concussion. Contemp Pediatr. 2014:32-34. 5. Sroufe N, Fuller D, West B, Singal B, Warschausky S, Maio R. Postconcussive symptoms and neurocognitive function after mild traumatic brain injury in children. Pediatrics. 2010;125(6):e1331-e1339. 6. Kirkwood MW, Yeates KO, Wilson PE. Pediatric sport-related concussion: a review of the clinical management of an oft-neglected population. Pediatrics. 2006;117(4):1359-1371. 7. Norton C, Feltz SJ, Angela B, Granitto M. Tackling long-term consequences. Nursing. 2013:50-55. 8. Brown NJ, Mannix RC, O’Brien MJ, Gostine D, Collins MW, Meehan WP 3rd. Effect of cognitive activity level on duration of post-concussion symptoms. Pediatrics. 2014;133:e299-e304. 9. Ilie G, Mann RE, Boak A, et al. Suicidality, bullying and other conduct and mental health correlates of traumatic brain injury in adolescents. PLoS One. 2014;9(4):1-6. 10. Chrisman SP, Richardson LP. Prevalence of diagnosed depression in adolescents with history of concussion. J Adolesc Health. 2014;54: 582-586. 11. Mackelprang JL, Bombardier CH, Fann JR, Temkin NR, Barber JK, Dikmen SS. Rates and predictors of suicidal ideation during the first year after traumatic brain injury. Am J Publ Health. 2014;104(7): e100-e107.
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12. Heverly-Fitt S, Wimsatt MA, Menzer MM, et al. Friendship quality and psychosocial outcomes among children with traumatic brain injury. J Int Neuropsychol Soc. 2014;20(7):684-693. 13. McNally KA, Bangert B, Dietrich A, et al. Injury versus non-injury factors as predictors of post-concussive symptoms following mild traumatic brain injury in children. Neuropsychology. 2013;27(1):1-12. 14. Maestas KL, Sander AM, Clark AN, et al. Preinjury coping, emotional functioning, and quality of life following uncomplicated mild traumatic brain injury. J Head Trauma Rehabil. 2014;29(5):407-417. 15. Grubenhoff JA, Deakyne SJ, Brou L, Bajaj L, Comstock RD, Kirkwood MW. Acute concussion symptom severity and delayed symptom resolution. Pediatrics. 2014;134(1):54-62. 16. Hall EC, Lund E, Brown D, et al. How are you really feeling? A prospective evaluation of cognitive function following trauma. J Trauma Acute Care Surg. 2014;76(3):859-865. 17. Yeates KO, Taylor HG, Walz NC, Stancin T, Wade SL. The family environment as a moderator of psychosocial outcomes following traumatic brain injury in young children. Neuropsychology. 2010;24(3):345-356. 18. Kurowski B, Pomerantz WJ, Schaiper C, Gittelman MA. Factors that influence concussion knowledge and self-reported attitudes in high school athletes. J Trauma Acute Care Surg. 2014;77(301, Suppl):s12-s17.
Tracy E. Smith, MSN, FNP, CNE, is a registered nurse in the Trauma Surgery/Neuro Critical Care at the University of Tennessee Medical Cente, Knoxville, TN. She can be reached at [email protected]. In compliance with national ethical guidelines, the author reports no relationships with business or industry that would pose a conflict of interest. 1555-4155/15/$ see front matter © 2015 Elsevier, Inc. All rights reserved. http://dx.doi.org/10.1016/j.nurpra.2015.08.011
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