Concussion Treatment & Management

  • Author: David T Bernhardt, MD; Chief Editor: Sherwin SW Ho, MD   more...
 
Updated: Nov 15, 2011
 

Acute Phase

Rehabilitation Program

A clinical report by the American Academy of Pediatrics (AAP) provided information regarding the diagnosis and management of sports-related concussions in adolescents and children.[39] The recommendations explained that appropriate management is essential in order to reduce the risk of long-term symptoms and complications. The team physician and athletic trainer must maintain a high index of suspicion to detect more mild concussions. The report also noted that cognitive and physical rest is the mainstay of management after diagnosis in these patients, and ongoing neuropsychological testing is a helpful tool during management.

The AAP report notes that a return to sports and physical activity should not occur the same day as a concussion. Return to sports and physical activity requires a progressive exercise program, a complete absence of symptoms, successful completion of a standardized neuropsychological test, and continuing evaluation for any recurring signs or symptoms. The recovery for pediatric and adolescent athletes is generally longer than for older athletes.

Medical Issues/Complications

Most of the complications listed below probably already existed when the athlete sustained the initial head injury; in other words, they are not caused by an MTBI. These conditions may be associated with what was thought of as an MTBI. Therefore, the reader should not think of these conditions as a complication of an MTBI but must consider these other conditions when evaluating an athlete with a head injury.

A subdural hematoma is a rare injury in the athlete who presents with a presumed concussion. The classic presentation of a subdural hematoma is an acute and persistent LOC associated with the initial injury.

No association between epidural hematoma and brain injury exists. This condition classically presents with a brief period of unconsciousness, followed by a lucid period, and then a subsequent deterioration over 15-30 minutes. Tearing of the middle meningeal artery secondary to an associated temporal skull fracture is the usual cause of an epidural hematoma.

Subarachnoid bleeding may also occur with a head injury of any type. Worsening headache and other signs of increasing intracranial pressure will gradually grow after the initial event.

Second impact syndrome has been described in many review articles. In this condition, fatal brain swelling occurs after minor head trauma in individuals who still have symptoms from a previous minor head trauma. Thus far, all cases of second impact syndrome have been described in relatively young patients (age < 20 y). Significant controversy exists over the etiology of this condition, although it is thought to be secondary to loss of autoregulation of cerebral blood flow in an already injured brain.

Authors have questioned the validity of second impact syndrome due to problems with the documentation of the (1) initial event, (2) persistent symptoms, and (3) severity of the second impact. Despite these problems, practitioners should be aware of this possible complication, especially when treating the relatively immature brain of a young athlete. Treatment of second impact syndrome requires immediate recognition and immediate treatment with hyperventilation and osmotic agents. Surgical treatment for this condition is ineffective. The overall prognosis is usually grim.

Postconcussive syndrome consists of prolonged symptoms that are related to the initial head injury. Unfortunately, the severity of the concussion does not necessarily predict who will experience prolonged symptoms. Similarly, the number of concussions is not necessarily predictive of future problems. Symptoms usually consist of persistent recurrent headaches, dizziness, memory impairment, loss of libido, ataxia, sensitivity to light and noise, concentration and attention problems, depression, and anxiety.

Most patients with MTBI recover in 48-72 hours, even with detailed neuropsychologic testing, and are headache free within 2-4 weeks of the injury. Obtain a more detailed history of emotional, concentration, and associated symptoms for patients who have persistent symptoms that last longer than 1 week.

A study of retired professional football players (average age 53.8 +/– 13.4 y) by Guskiewicz et al reported significant memory changes in those players with a history of recurrent concussions.[8] Another report by the same authors of these retired football players suggested a link between recurrent sports-related concussions and an increased risk of clinical depression.[19]

Consultations

Consultation with a neurologist or primary care sports medicine physician is indicated for patients who have prolonged symptoms. Neuropsychologic consultation may also be considered to document any deficits that may interfere with the athlete's return to sport, school, or work.

Proceed to Medication
 
 
Contributor Information and Disclosures
Author

David T Bernhardt, MD  Director of Adolescent and Sports Medicine Fellowship, Associate Professor, Department of Pediatrics/Ortho and Rehab, Division of Sports Medicine, University of Wisconsin School of Medicine and Public Health

David T Bernhardt, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Sports Medicine, and American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Joseph P Garry, MD, FACSM, FAAFP  Associate Professor, Sports Medicine Faculty, Department of Family and Community Medicine, University of Minnesota Medical School

Joseph P Garry, MD, FACSM, FAAFP is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Heart Association, American Medical Society for Sports Medicine, and North American Primary Care Research Group

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Jon B Whitehurst, MD  Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital

Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America

Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD  Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine

Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, and Herodicus Society

Disclosure: Breg, Inc. Consulting fee Consulting; Biomet, Inc. Consulting fee Consulting; GMV, Inc. Arthroscopy Simulator Evaluation and teaching; Smith and Nephew Grant/research funds Fellowship funding; DJ Ortho Grant/research funds Course funding; Athletico Physical Therapy Grant/research funds Course, research funding

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