Approach Considerations
In March 2013, the American Academy of Neurology (AAN) updated its 1997 guidelines on the evaluation and management of sports concussion. A major change is the removal of return-to-play recommendations. The current recommendation for athletes who have sustained a concussion is immediate removal from play. Return to play should not be allowed until after assessment by a healthcare professional. Young athletes should be managed even more conservatively; their symptoms and neurocognitive performance take longer to improve after a concussion.
Highlights from the revised recommendations include the following [13, 65] :
-
There is no evidence that medication improves recovery after concussion
-
The risk for concussion is greatest in football and rugby, followed by hockey and soccer; for young women and girls, the risk is greatest in soccer and basketball
-
An athlete who has a history of 1 or more concussions is at greater risk for being diagnosed with another concussion
-
The first 10 days after a concussion appears to be the period of greatest risk for being diagnosed with another concussion
-
Evidence suggests that use of helmets may prevent concussion versus no helmet, but there is no clear evidence that one type of football helmet can better protect against concussion over another kind of helmet
-
Licensed health professionals trained in treating concussion should look for ongoing symptoms, history of concussions, and younger age in the athlete
-
Risk factors linked to chronic neurobehavioral impairment in professional athletes include prior concussion, longer exposure to the sport, and having the ApoE4 gene
-
Symptom checklists, the Standardized Assessment of Concussion (SAC), neuropsychological testing (paper-and-pencil and computerized), and the Balance Error Scoring System may be helpful tools in diagnosing and managing concussions but should not be used alone for making a diagnosis
-
Although an athlete should immediately be removed from play after a concussion, there is insufficient evidence to support absolute rest after concussion
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. [11] 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.
Updated guidance from the AAP continues to recommend immediate removal from play; however, athletes do not need to avoid all activity while they have symptoms but should instead limit their physical exertion to brisk walking. Similarly, although a reduction in academic workload is recommended, prolonged absence from school should be discouraged. [66]
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.
Use of standardized tools in ED management of concussion
In a study of 164 patients 5 to 21 years old, use of the CDC’s Acute Concussion Evaluation (ACE) tools modified for use in a pediatric emergency department (ED) increased patient follow-up and improved recall of, and adherence to, ED discharge recommendations. [67, 68] With implementation of the tools, the percentage of patients following up with their primary care provider increased from 23% to 39% in the first week following discharge; from 31% to 55% in the second week; and from 32% to 61% in the fourth week. [67, 68]
Failure on validity tests has been shown to help detect exaggerated or feigned problems in adults with mild traumatic brain injury (TBI), and a study by Kirkwood and colleagues suggests that validity testing may also help identify noninjury effects in children and adolescents. [69] In their study of 191 patients aged 8 to 17 years with mild TBI, the 23 patients (12%) who failed the Medical Symptom Validity Test endorsed significantly more postconcussive symptoms than those who passed the test, with a large effect size (P< .001). [69]
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.
A retrospective case-control study indicated that children with a personal or family history of mood disorders who sustain a sports-related concussion have a significantly increased risk for developing postconcussive syndrome. [70]
A study that included 2413 participants by Grool et al reported a lower risk of persistent postconcussive symptoms in those who participated in early physical activity compared to those with no physical activity (24.6% vs 43.5%; Absolute risk difference, 18.9% [95% CI,14.7%-23.0%]). However, further clinical studies are needed to examine this association. [71]
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 double-blind study by Miller and colleagues indicated that hyperbaric oxygen (HBO) is no better than sham therapy in the treatment of postconcussive syndrome. The study involved 72 persons, 94% of whom were enlisted in military service, with participants experiencing ongoing postconcussion symptoms for a period of at least 4 months after sustaining an MTBI. Patients received HBO treatment, sham air-compression therapy, or routine care alone. [72, 73]
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. [3] 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. [23]
Concussion information from the NFL Players' Association, the American Academy of Neurology, and the American College of Emergency Physicians can be found here.
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.
