According to the most recent Consensus Statement of the International Conference on Concussion in Sport, held in 2016, a sport-related concussion is a traumatic brain injury (TBI) induced by biomechanical forces. A concussion may be caused by a direct or indirect force transmitted to the brain resulting in rapid yet short-lived neurological impairments. Loss of consciousness (LOC) does not need to occur to diagnose a concussion, because it does not occur the majority of the time. LOC occurs in less than 10% of concussions, whereas confusion and amnesia (retrograde and/or anterograde) are more common.
Symptoms of a concussion may develop over hours, and resolution typically follows a sequential course. In some instances, the symptoms may be prolonged, lasting days to sometimes weeks. The brain-related pathological changes are mostly caused by a functional rather than a structural injury, which is why imaging via computed tomography (CT) or magnetic resonance imaging (MRI) is often negative. The Fifth International Conference on Concussion in Sport also specified that concussion symptoms cannot be explained by illicit drugs, including alcohol or medications; psychosocial impairments; coexisting medical conditions; injuries to the cervical area; or peripheral vestibular system impairments.
Pathophysiology
A concussion is the result of a complex cellular dysfunction predominantly caused by neurotransmitters that are released after an injury. The consequential response is a cascade of events that ultimately leads to cellular death.
The cascade of damage is thought to begin with the release of glutamate :
Glutamate → efflux of K + → stabilized by influx of Ca 2+ → hyperglycolysis of cell → release of free radicals and enzymes (proteases, lipases, nitrogen oxide) → cytoskeleton damage → glucose overutilization or adenosine triphosphate (ATP) to repair → energy crisis → mitochondrial failure → lactate production → increased membrane permeability → apoptosis or necrosis
During this energy crisis, symptoms may develop and even worsen when physical or cognitive activities are performed.
On-field assessment
On-field assessment of a sport-related concussion requires the recognition of the signs and symptoms of a concussion. It is imperative that coaches, athletic trainers, parents, and athletes themselves be educated on the signs and symptoms of a concussion.
If there is any suspicion of a concussion, an athlete should be:
- •
Immediately removed from the game
- •
Medically evaluated onsite by a healthcare provider (to rule out more serious injury)
- •
Administered a sideline evaluation with the Sport Concussion Assessment Tool 5th Edition (SCAT5) assessment tool
- •
Routinely monitored for deterioration over the initial few hours
- •
Not allowed to return to play the same day
Concussion grading scales should never be used to determine the severity of a concussion.
Physician evaluation
After an athlete has been removed from play, they should seek a medical evaluation by a physician expert who is knowledgeable in the management and treatment of concussion.
Assessment of a concussion requires a thorough history and physical examination that includes:
- •
Injury details (how it occurred, immediate symptoms and evolution, presence of LOC or amnesia)
- •
Current symptom description, guided by the 22-item Post-Concussion Symptom Scale (PCSS) ( Table 50.1 )
TABLE 50.1
Post-Concussion Symptom Scale
None
Mild
Moderate
Severe
Headache
0
1
2
3
4
5
6
Nausea
0
1
2
3
4
5
6
Vomiting
0
1
2
3
4
5
6
Dizziness
0
1
2
3
4
5
6
Balance problems
0
1
2
3
4
5
6
Trouble falling asleep
0
1
2
3
4
5
6
Sleeping more than usual
0
1
2
3
4
5
6
Drowsiness
0
1
2
3
4
5
6
Sensitivity to light
0
1
2
3
4
5
6
Sensitivity to noise
0
1
2
3
4
5
6
More emotional than usual
0
1
2
3
4
5
6
Irritability
0
1
2
3
4
5
6
Sadness
0
1
2
3
4
5
6
Nervousness
0
1
2
3
4
5
6
Numbness or tingling
0
1
2
3
4
5
6
Feeling slowed down
0
1
2
3
4
5
6
Feeling like in a fog
0
1
2
3
4
5
6
Difficulty with concentrating
0
1
2
3
4
5
6
Difficulty with remembering
0
1
2
3
4
5
6
- •
Determine how the symptoms are affected, such as what makes them better or worse
- •
Discuss how symptoms may interfere with physical activities, work, school, computer/phone use, etc.
- •
Identify management received thus far such as being left out of school, testing received, or if medication has been taken to assist with the symptoms
When assessing concussion symptoms, it is relevant to group them into four symptom domains:
- 1.
Somatic: headache, nausea, vomiting, light and noise sensitivity, dizziness, poor balance, tinnitus, blurry vision, numbness, or tingling
- 2.
Cognitive: fogginess, difficulty concentrating or remembering, feeling slowed down
- 3.
Sleep: difficulty falling asleep, staying asleep, sleeping more than usual, fatigue, drowsiness
- 4.
Emotional: sadness, irritability, anxiety
Viewing concussion symptoms as domains can assist in understanding how symptoms interrelate with other symptoms; for example, insomnia may lead to daytime fatigue, headaches, and/or irritability. It is important to note that symptoms can be interpreted differently based on the athlete’s age or gender. Understanding the athlete’s motivations and goals can further assist in the assessment and overall management. Some athletes may confound their symptoms for earlier return to play, whereas others may not understand that the symptoms experienced are related to a concussion nor the importance of immediate treatment.
Prior comorbid history may guide the management of the current concussion. Other relevant medical history to obtain includes a history of:
- •
Headaches or migraines in self or family members
- •
Eye or vision problems
- •
Dizziness
- •
Anxiety and/or depression
- •
Sleep difficulties
- •
Learning disabilities
- •
The number of prior concussions and recovery time of each injury
The physical examination of a sport-related concussion should at a minimum include a:
- •
Neurological examination
- •
Balance assessment using the Balance Error Scoring System (BESS). The BESS tests balance with eyes closed, on firm and soft surfaces, in three stances—feet together, tandem, and on only the nondominant foot
- •
Visuomotor examination to determine presence of nystagmus and saccades and to test the convergence and vestibular–ocular reflex
If needed, the SCAT5 can also be performed (Child-SCAT5 for those ages 5–12). Computerized testing is not recommended. It is important to note that early in the recovery, cognitive and emotional complaints are likely a result of the somatic symptoms experienced, which need to be prioritized for treatment.
A head CT or brain MRI is usually not recommended initially, because the majority are negative, and their use is limited to high suspicion for structural intracerebral injury, including intracranial hemorrhage, prolonged LOC, posttraumatic amnesia (PTA), persistently altered mental status (Glasgow Coma Scale [GCS] score <15), focal neurological deficit, evidence of skull fracture on examination, or signs of clinical deterioration.
Management and treatment
General guidelines
- 1.
Concussion management is always individualized.
- 2.
Protocols available can guide the management and treatment.
- 3.
Goal of recovery should focus on return to play, sports, work, and daily life activities.
- 4.
“When in doubt, sit them out.” No athlete should be allowed to return to play until they have been assessed for the presence of a concussion. Risk of reinjury is high when one experiences symptoms of a concussion, and reinjury during unresolved concussion symptoms can lead to worsened symptoms and a prolonged recovery.
- 5.
Provide education and reassurance about recovery, as it can be the most important step! Inform the athlete on the natural course of recovery and the importance of following the treatment recommendations so that symptoms improve in a timely fashion, while maintaining a healthy lifestyle—such as timely and nutritious meals, adequate hydration, reducing stress, and sleeping well.
General recommendations
- 1.
After 1 or 2 days of relative rest, reintegration of physical and cognitive activity should begin, as tolerated by the symptoms. No complete rest should be recommended because it leads to prolonged symptoms and unnecessary anxiety. In addition, inactivity can lead to iatrogenic symptoms, similar to a concussion.
- 2.
As a general rule, if one feels well performing an activity, they should be allowed to continue that activity. If one feels worse performing an activity, the individual should take a break and try again later. This can include electronics use and interactive video games to test tolerance. Such activities can provide relevant information for clinician guidance of the management. For instance, if a child can tolerate screen time but is not able to read a book in school, this may hint to an underlying psychosocial aspect of the injury that needs to be addressed.
- a.
Physical activities performed in the early stages should be limited to those that are noncontact in nature. For example, recommend slow or brisk walks and modify the intensity based on exacerbation of symptoms. The goal is to allow some form of activity because complete rest is not conducive to improving return to previous level of activity.
- b.
Cognitive activities should be limited to activities as tolerated by the symptoms. Students should not be removed from school unless there are significant symptoms. Trial of school with rest breaks and modifications is initially recommended. Normalizing previous activities is important for maintaining social interactions with friends while limiting the unnecessary anxiety related to schoolwork missed.
- a.
- 3.
Once an athlete is making progress with their symptoms and able to tolerate day-to-day activities, it is important to begin the return to sport strategy as recommended by the Consensus Statement in Sports ( Table 50.2 ). The athlete is progressed through each of the six stages of activity, with at least 24 hours between each stage of progression. If symptoms worsen at any stage, the athlete is downgraded to the previous stage and reassessed after at least 24 hours at the previous stage. The return to sport strategy should take a minimum of a week and should not be performed any faster to ensure that recovery is occurring. Return to school must successfully precede return to contact sports.
TABLE 50.2Related posts:
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