Mild Traumatic Brain Injury (TBI) and the Post-concussive Syndrome

The terms mild traumatic brain injury (TBI) and post-concussive syndrome are confusing, and may be used differently by different sources. Acutely, mild TBI, which is synonymous with concussion, describes a spectrum of brain injury that may include the following symptoms:

• confusion
• amnesia around the time of injury
• loss of consciousness for up to 30 minutes following the injury
• neurological or neuropsychological problems including problems with attention, concentration, memory, fatigue, dizziness, and others
• with a Glasgow Coma Scale of 13 or higher

For children with concussion or mild TBI in the emergency room, the primary focus is ruling out more serious injuries (e.g. subarachnoid hemorrhage).
Although the majority of children with mild TBI recover quickly, some go on to have problems for weeks or months. The constellation of chronic symptoms is often referred to as post-concussive syndrome, and also as part of the spectrum of mild TBI. There are no controlled studies detailing how often children who have sustained a concussion have these problems, but estimates in adults after concussions range from 40 to 80%. [Mittenberg: 2001] The symptoms of mild TBI vary from child to child, and symptoms may be mild or severe enough to interfere with daily living and quality of life. Children with mild TBI may experience:

• chronic headaches
• sleep problems
• problems with attention and concentration
• memory problems
• behavior problems, including anger, immature behavior, acting out
• moodiness, anxiety, and symptoms of depression
• fatigue and dizziness

It is difficult to predict which children will go on to have post-concussive syndrome. Generally, symptoms will appear in the first few days after the injury, but in rare cases may not show up for weeks or months afterwards. See Mild TBI (UpToDate), CDC Pediatric mTBI Guideline. Family and personal prior medical history and behavior/functioning of the child before the mild TBI may influence outcome. For instance, a child with attention problems before the injury may have an increase in those problems. A child with a family history of migraine may be more prone to getting headaches after the accident. [Yeates: 2009] [Anderson: 2011] Sleep problems, if present, should be treated early and aggressively, as they may contribute to other symptoms associated with post-concussive syndrome.

Families should be given anticipatory guidance regarding symptoms that might develop and referred for follow-up with a physiatrist or neurologist if those symptoms are noted, depending on local expertise, if these symptoms occur. See [Kamerling: 2003] [Lovell: 2008] [Kirkwood: 2006] [Lee: 2007] for more information.

Most children will recover fully within weeks to months after mild TBI/post-concussive syndrome. Mild TBI (UpToDate)

The management of mild TBI is very individual, depending on the child's functioning, [Anderson: 2011] [Yeates: 2009] extent of injury, and symptoms of mild TBI. A multi-disciplinary approach is often necessary to address problems with physical, emotional and behavioral functioning of the child. Management approaches may include medications, physical therapy, biofeedback, school interventions, and counseling. Referral to an experienced pediatric physiatrist or neurologist is recommended unless the Medical Home has sufficient expertise/experience with children with mild TBI.