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Diagnosing and managing mild TBI in rural kids

A family hike takes a scary turn when a two-year-old trips and strikes his head on a rock. When he arrives at the closest medical clinic, he is acting disoriented and lethargic. Neuroimaging services are an hour drive away. His parents are pushing for a head CT. Should the attending health care provider conduct in-office observation and see if his symptoms improve or call for emergency transport? Decisions like these are all too common for rural providers caring for a patient with a traumatic brain injury. A recent study published in NRHA’s Journal of Rural Health1 provides an overview of the challenges rural primary care providers face when diagnosing and managing pediatric TBI.

Every nine seconds there is a TBI-related emergency department visit, hospitalization, or death in the United States.2 A disproportionate number of these injuries occur in rural areas and among children.3-7 Pediatric patients in rural areas are more likely to die from TBI or experience worse health outcomes than children living in urban areas, affecting their physical and emotional well-being.8 While most TBIs are considered mild, symptoms may affect a child’s ability to go to school or participate in other daily activities during recovery.9 Whether the injury resulted from a fall, a cheerleading stunt, a slip while rock climbing, or a bicycle or ATV crash,10 there are tools to help rural health care providers diagnose and manage these injuries among children.11
Diagnosing mTBI
Diagnosing a mild TBI (mTBI) may be challenging as symptoms can worsen quickly, changing what at first appears to be a routine assessment to an emergency situation.12,13 Following a diagnostic checklist that takes into account circumstances of the injury and risk factors for prolonged recovery may help determine when to observe a patient and when emergency transport is needed.14 This may be particularly helpful in rural communities when it is often primary care providers performing the initial evaluation of a suspected pediatric mTBI. There are also several validated symptom scales that may be used to assess mTBI symptom type and severity. Examples include the Acute Concussion Evaluation form,15 Health and Behavior Inventory,16 and Post-Concussion Symptom Scale.16
Diagnosis of mTBI is not dependent on neuroimaging, and recent clinical guidelines recommend CT scans not be routinely conducted on pediatric patients with mTBI.17 Still, as noted in NRHA’s journal,1 health care providers may face pressure from parents yet not have access to CT equipment in their community. The Pediatric Emergency Care Applied Research Network rules17 were designed to help health care providers determine when a pediatric patient with mTBI should undergo a head CT. The rules help health care providers evaluate a variety of factors that, when assessed together, indicate when a patient is at increased risk for intracranial injury.17 The Choose Wisely campaign is another resource that provides guidance to help health care providers talk with patients and their parents about CT scans, the risks, and when they are needed to help manage parents’ expectations.
Managing return to activity
The speed and success of a child’s recovery from mTBI is likely to depend on appropriate management of their injury. Fortunately, providing discharge instructions and education to the patient and family about mTBI symptoms are simple steps health care providers can take to improve outcomes for their patients.9,11,18,19 There is some evidence,1 that rural health care providers in particular are not aware of available resources. It is important to ensure that these resources are disseminated more widely.  
Within a few days, a child who sustained an mTBI can begin cognitive and non-strenuous physical activities that do not substantially make their symptoms worse.19 This may include brisk walking for 15 to 20 minutes each day. Parents should closely monitor their child’s symptoms, noting any changes in severity and reporting any concerns to their health care provider. Children should be encouraged to return to school after a brief period of initial rest.20 Communication with the school regarding the types and severity of symptoms, as well as recommendations for student support, is often indicated and can be facilitated via a return-to-school letter.18,21 Examples of such support include breaks and adjustments to the classroom workload to minimize worsening of symptoms. Good communication with the school is essential to help make the transition easier for the child.20 Most students will recover within a few days of their injury and will not need any school adjustments, although increased monitoring of these students remains important.
Most children no longer experience symptoms within three months of their injury, but some will require specialized follow-up care. In rural areas, these specialists can be hard to come by. In the Journal of Rural Health study, some providers noted that certain specialists are hundreds of miles away, meaning follow-up care must be provided in-house.1 Telemedicine22 can help reduce geographic disparities and improve access to specialists and interdisciplinary care for patients with TBI and other neurological conditions, including concussion.23-25 Telemedicine has the potential to remove transportation barriers, limit the need for interhospital transfers of patients, reduce costs for care, and improve access for rural residents to health care providers trained to treat complex conditions.22,26,27 However, telemedicine does have limitations, and uptake is still not widespread in rural areas.27 To promote the use of telemedicine and similar services in rural areas, telehealth initiatives such as the Project ECHO methodology28 have shown early success for other health conditions .29-31
Getting the latest clinical information
The Centers for Disease Control and Prevention’s Pediatric Mild Traumatic Brain Injury Guideline consists of 19 sets of clinical recommendations that cover diagnosis, prognosis, management, and treatment. Online training with free continuing education credits and tools to help with diagnosis and management of pediatric patients with mTBI are available on the CDC website.
The findings and conclusions in this post are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
1.           Daugherty J, Waltzman D, Popat S, Groenendaal AH, Cherney M, Knudson A. Rural Primary Care Providers’ Experience and Usage of Clinical Recommendations in the CDC Pediatric Mild Traumatic Brain Injury Guideline: A Qualitative Study. Journal of Rural Health. 2020. https://doi.org/10.1111/jrh.12530
2.           Centers for Disease Control and Prevention. Surveillance Report of Traumatic Brain Injury-related Emergency Department Visits, Hospitalizations, and Deaths—United States, 2014. U.S. Department of Health and Human Services. Atlanta, GA: 2019.
3.           Bazarian JJ, McClung J, Shah MN, Ting Cheng Y, Flesher W, Kraus J. Mild Traumatic Brain Injury in the United States, 1998–2000. Brain Injury. 2005;19(2):85-91.
4.           Yue JK, Upadhyayula PS, Avalos LN, Cage TA. Pediatric Traumatic Brain Injury in the United States: Rural-Urban Disparities and Considerations. Brain Sciences. 2020;10(3):135.
5.           Chapital AD, Harrigan RC, Davis J, Easa D, Withy K, Yu M, Takanishi DM Jr. Traumatic Brain Injury:
Outcomes from Rural and Urban Locations Over a 5-Year Period (Part 1). Hawaii Med J. 2007
6.           Johnstone B, Nossaman LD, Schopp LH, Holmquist L, Rupright SJ. Distribution of Services and Supports for People with Traumatic Brain Injury in Rural and Urban Missouri. Journal of Rural Health. 2002;18(1):109-117.
7.           Leonhard MJ, Wright DA, Fu R, Lehrfeld DP, Carlson KF. Urban/Rural Disparities in Oregon Pediatric Traumatic Brain Injury. Injury Epidemiology. 2015;2(1):32.
8.           Brown JB, Kheng M, Carney NA, Rubiano AM, Puyana JC. Geographical Disparity and Traumatic Brain Injury in America: Rural Areas Suffer Poorer Outcomes. Journal fo Neurosciences in Rural Practice. 2019;10(1):10-15.
9.           Arbogast KB, Curry AE, Metzger KB, et al. Improving Primary Care Provider Practices in Youth Concussion Management. Clinical Pediatrics. 2017;56(9):854-865.
10.         Stewart TC, Gilliland J, Fraser DD. An Epidemiologic Profile of Pediatric Concussions: Identifying Urban and Rural Differences. Journal of Trauma and Acute Care Surgery. 2014;76(3):736-742.
11.         Lumba-Brown A, Yeates KO, Sarmiento K, et al. Centers for Disease Control and Prevention guideline on the diagnosis and management of mild traumatic brain injury among children. JAMA Pediatrics. 2018;172(11):e182853-e182853.
12.         Iverson GL, Silverberg ND, Mannix R, et al. Factors Associated With Concussion-like Symptom Reporting in High School Athletes. JAMA Pediatrics. 2015;169(12):1132-1140.
13.         Asken BM, Snyder AR, Smith MS, Zaremski JL, Bauer RM. Concussion-like Symptom Reporting in Non-concussed Adolescent Athletes. The Clinical Neuropsychologist. 2017;31(1):138-153.
14.         Bazarian JJ, Raukar N, Devera G, et al. Recommendations for the Emergency Department Prevention of Sport-Related Concussion. 2020;75(4):471-482.
15.         Schatz P, Pardini JE, Lovell MR, Collins MW, Podell K. Sensitivity and Specificity of the ImPACT Test Battery for Concussion in Athletes. Archives of Clinical Neuropsychology. 2006;21(1):91-99.
16.         Gioia GA, Schneider JC, Vaughan CG, Isquith PK. Which Symptom Assessments and Approaches are Uniquely Appropriate for Paediatric Concussion? British Journal of Sports Medicine. 2009;43 Suppl 1:i13-22.
17.         Kuppermann N, Holmes JF, Dayan PS, et al. Identification of Children at Very Low Risk of Clinically-Important Brain Injuries After Head Trauma: A Prospective Cohort Study. Lancet. 2009;374(9696):1160-1170.
18.         Zuckerbraun NS, Atabaki S, Collins MW, Thomas D, Gioia GA. Use of Modified Acute Concussion Evaluation Tools in the Emergency Department. Pediatrics. 2014;133(4):635-642.
19.         Zemek R, Barrowman N, Freedman SB, et al. Clinical Risk Score for Persistent Postconcussion Symptoms Among Children with Acute Concussion in the ED. JAMA. 2016;315(10):1014-1025.
20.         Halstead ME, McAvoy K, Devore CD, Carl R, Lee M, Logan K. Returning to Learning Following a Concussion. Pediatrics. 2013;132(5):948-957.
21.         Centers for Disease Control and Prevention. School Letter: Returning to School After a Concussion. 2018; https://www.cdc.gov/traumaticbraininjury/pdf/pediatricmtbiguidelineeducationaltools/mTBI_ReturntoSchool_FactSheet-Pin.pdf. Accessed June 12, 2019.
22.         Nelson R. Telemedicine and Telehealth: The Potential to Improve Rural Access to Care. The American Journal of Nursing. 2017;117(6):17-18.
23.         Ellis MJ, Russell K. The Potential of Telemedicine to Improve Pediatric Concussion Care in Rural and Remote Communities in Canada. Frontiers in Neurology. 2019;10:840.
24.         Ellis MJ, Boles S, Derksen V, et al. Evaluation of a Pilot Paediatric Concussion Telemedicine Programme for Northern Communities in Manitoba. International Journal of Circumpolar Health. 2019;78(1):1573163.
25.         Vargas BB, Channer DD, Dodick DW, Demaerschalk BM. Teleconcussion: An Innovative Approach to Screening, Diagnosis, and Management of Mild Traumatic Brain Injury. Telemedicine and e-Health. 2012;18(10):803-806.
26.         Tran V, Lam MK, Amon KL, et al. Interdisciplinary eHealth for the Care of People Living with Traumatic Brain Injury: A Systematic Review. Brain Injury. 2017;31(13-14):1701-1710.
27.         Wechsler LR, Tsao JW, Levine SR, et al. Teleneurology Applications: Report of the Telemedicine Work Group of the American Academy of Neurology. Neurology. 2013;80(7):670-676.
28.         University of New Mexico School of Medicine. Project ECHO. 2020; https://echo.unm.edu/. Accessed June 30, 2020.
29.         Lewiecki EM, Rochelle R, Bouchonville MF, II, Chafey DH, Olenginski TP, Arora S. Leveraging Scarce Resources With Bone Health TeleECHO to Improve the Care of Osteoporosis. Journal of the Endocrine Society. 2017;1(12):1428-1434.
30.         Arora S, Thornton K, Murata G, et al. Outcomes of Treatment for Hepatitis C Virus Infection by Primary Care Providers. New England Journal of Medicine. 2011;364(23):2199-2207.
31.         Komaromy M, Duhigg D, Metcalf A, et al. Project ECHO (Extension for Community Healthcare Outcomes): A New Model for Educating Primary Care Providers about Treatment of Substance Use Disorders. Substance Abuse. 2016;37(1):20-24.

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