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Concussion



Ovid: 5-Minute Sports Medicine Consult, The


Concussion
Daryl A. Rosenbaum
Anna G. Monroe
Basics
Description
  • “Concussion is defined as a complex pathophysiologic process affecting the brain, induced by traumatic biomechanical forces” (1).
  • Common features include the following:
    • The blow may be directly to the head, face, or neck, or the force may be transmitted indirectly after a blow elsewhere on the body.
    • Neurologic signs and symptoms present quickly and disappear spontaneously, although in a small number of cases the symptoms may be prolonged.
    • Symptoms result from a functional disturbance in the absence of structural pathology, and imaging studies are usually normal.
    • Concussion symptoms may or may not include loss of consciousness (LOC).
  • Synonym(s): “Bell ringer”; “Ding”; Mild traumatic brain injury (TBI); Minor head trauma; Commotio cerebri
Epidemiology
  • 207,830 ED visits for nonfatal sports-related traumatic brain injuries per year between 2001 and 2005 (2)
  • Children ages 5–18 yrs represented 65% of those ED visits (2).
  • Estimated 1.6–3.8 million sports-associated traumatic brain injuries (2)
  • Incidence likely higher because athletes, coaches, or medical providers may fail to recognize the signs and symptoms of a concussion or athletes try to minimize the symptoms in order to continue to play (3,4).
  • In a study of high school football players, only 47.3% reported their concussion. 2/3 withheld information because they did not think their symptoms needed medical care. Almost 1/2 wanted to avoid being withheld from play, and a little more than 1/3 simply lacked understanding of concussion (5).
  • Possible underreporting of concussion especially in children because many do not seek medical care (4)
  • Some evidence of a higher incidence of concussion in female high school and college athletes even when comparing the same sports; the reason is unclear but could be due to more honest reporting of concussion in females (4,6).
  • 572 concussions per year for college athletes between 1988 and 2004 (7)
  • 54.8% of the total concussions during that period of time occurred in football (7).
  • Women's soccer, men's ice hockey, men's soccer, and women's basketball each represented between 5% and 7% of total college concussions for the same time period (7).
Risk Factors
  • Participation in contact and collision sports (2,3,4,7)
  • An athlete with a previous concussion may be more likely to have a repeat concussion than an athlete without a history of a concussion (3).
  • Improper technique (eg, leading with the head, or “spearing,” in football) (7)
Genetics
Investigations ongoing as to the significance of apolipoprotein (Apo) E4, ApoE promoter gene, tau polymerase, and others in concussion (1,8)
General Prevention
  • Evidence does not support prevention of concussion in football or rugby with current helmet technology, but helmets do prevent skull fractures and other head injuries. Likewise, while mouth guards do not prevent concussion, they do decrease dental and orofacial injuries (1,4,9).
  • Rules that promote safe and proper techniques (eg, outlawing “spearing” in football, leading with the head, and head-to-head contact) should be coached and enforced to limit concussion (1,7,10).
  • Encourage fair competition but discourage violent behavior in sports, especially among young athletes (1).
Etiology
  • Complicated pathophysiology that is incompletely understood (1,4,8)
  • Impact and resulting forces create shear injury to vessels and neurons (4,8).
  • Biochemical chain reactions are set in place, some of which may involve the release of excitatory amino acids (4,8,10).
  • Resulting decrease in cerebral metabolism occurs (4,8,10).
  • Alternatively, the blow may create immediate neuronal depolarization followed by a refractory period where neural transmission does not happen (8).
Diagnosis
  • Historically, numerous classification systems for grading severity have existed (4).
  • Systems were based mainly on the presence of LOC and/or amnesia (4).
  • More recent consensus statements recommend against concussion grading systems (1,10,11,12)[C].
  • Judge treatment for and severity of concussion on an individual basis according to the burden, nature, and duration of symptoms.
  • The presence of certain “modifiers” also may indicate the need for a more detailed workup or different management strategies (1)[C].
  • Modifiers include the following: Number, duration, or severity of symptoms; LOC for more than a minute; amnesia; concussive convulsions; frequent concussions or those occurring in close proximity; sustaining subsequent concussions with less impact; concussions in those <18 yrs of age; the presence of other comorbid or premorbid conditions such as mental health or learning disorders, including attention deficit hyperactivity disorder (ADHD); taking psychoactive drugs or anticoagulants; having a dangerous style of play; or participating in high-risk activities (1)[C].
Pre Hospital
  • Address airway, breathing, and circulation (ABCs) (4)[C].
  • Consider cervical spine (C-spine) immobilization (all unconscious athletes should have C-spine immobilization) (4)[C].
  • Do not remove the helmet in football or ice hockey players if C-spine injury is suspected (13)[C].
  • Assess level of consciousness with the Glasgow coma scale (GCS) (13)[C].
  • Evaluate for other trauma such as skull fractures (including basilar skull fractures) or lacerations (13)[C].
  • Perform a neurologic exam including cognitive evaluation and balance assessment (13)[C].
  • Conscious athletes in whom C-spine trauma is not suspected may exit the field and undergo a more thorough exam (13)[C].
  • Immediately transfer athletes with prolonged LOC, focal neurologic deficits including asymmetric pupils and declining GCS or worsening symptoms, athletes with comorbidities (eg, hemophiliacs), and those with persistent vomiting (3)[C].
History
  • Direct blow to the head, sudden rotational or acceleration-deceleration force to the head in the absence of direct trauma, or transmitted force to head (13)
  • Athletes often fail to recognize or report their symptoms. Concussion should be considered in anyone demonstrating signs of a concussion (4).
  • Standardized symptom checklists such as the one found in the Sport Concussion Assessment Tool 2 (SCAT 2) that allow the athlete to score his or her complaints on a scale of 0–6 may be useful when evaluating the concussed athlete (1)[C].
  • Athletes may complain of any of the following: headache (HA) or neck pain; feeling off-balance or dizzy; nausea or vomiting; problems with vision or hearing including ringing in the ears; confusion; slowness, fatigue, or sleepiness; irritability or other emotional problems; concentration difficulty; memory problems; “dinged”; “dazed”; or “don't feel right” (3)[B].
  • Prospectively validated symptoms include HA, dizziness, blurred vision, attention deficit, memory problems, and nausea (3)[A].

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Physical Exam
  • Physical signs: LOC, amnesia, or balance problems (1,3)[A]
  • Behavioral changes such as irritability (1,3)[B]
  • Cognitive problems such as slowed reaction times (1,3)[B]
  • Sleep disturbances such as drowsiness (1,3)[B]
  • After addressing emergency medical issues, formal concussion assessment should occur (1)[C].
  • Perform a detailed neurologic exam including cognitive evaluation and balance assessment (13)[C].
  • Consider administering the SCAT 2 or other standardized test (1)[C].
  • The SCAT 2 was developed by the 3rd International Conference on Concussion in Sport and incorporates 2 prospectively validated tests, the Maddocks Score and the Standardized Assessment of Concussion (SAC), into a comprehensive tool (1,3).
  • The SCAT 2 contains 8 sections and assesses the following domains: Subjective rating of symptoms; physical signs; GCS; Maddocks score (which assesses recent memory about the game but is not used in the final score); cognitive testing such as orientation, immediate memory, and concentration; balance examination using the modified Balance Error Scoring System (BESS); coordination test (finger to nose); and repeated cognitive testing focusing on delayed memory (1).
  • An overall score is calculated out of 100 possible points (1).
  • Cut-off scores are not currently known, and the test has not yet been validated (1).
  • Score is useful with repeat testing or with known baseline (1)[C].
  • The SCAT 2 should not be used as the only tool to diagnose concussions, determine whether recovery has occurred, or decide when to allow an athlete to return to play (1)[C].
Diagnostic Tests & Interpretation
Lab
  • Research conducted on more severe head injury suggests that many genetic and cytokine factors are induced (1).
  • These include insulin-like growth factor 1 (IGF-1), IGF-binding protein 2, fibroblast growth factor, copper-zinc superoxide dismutase 1 (SOD-1), nerve growth factor, glial fibrillary acidic protein (GFAP), and S-100 (1).
  • As yet, the significance of these factors in concussion is not fully known, and no routine laboratory testing is occurring (1).
Imaging
  • Cranial CT scan: Useful in acute imaging to rule out intracranial bleed. Consider if prolonged LOC or if symptoms are worsening or failing to resolve in a timely manner (1,3)[C].
  • Imaging usually contributes little to routine concussion management (1,3).
  • MRI modalities such as gradient echo and perfusion and diffusion imaging may diagnose structural lesions better than CT scan, but again, routine use of MRI does not add to concussion evaluation (1)[C].
  • Functional MRI (fMRI) may illustrate degree of symptoms and their resolution but is not yet part of standard concussion management (1).
  • Experimental imaging technology includes positron emission tomography (PET), diffusion tensor imaging, MRI spectroscopy, and functional connectivity (1).
Diagnostic Procedures/Surgery
  • Neuropsychological (NP) testing is used to assess cognitive function and help with return to play (RTP) decisions (1)[A].
  • Usually conducted when the athlete is asymptomatic as a final measure before clearance for RTP (3)[C]
  • Cognitive function often resolves after other symptoms, so NP evaluation can add helpful information (1)[A].
  • Should never be used as the only factor in deciding if an athlete should RTP (1,3)[C]
  • Consider in the case of a concussion with modifiers (1)[C].
  • Computerized tests such as the Automated Neuropsychological Assessment Metrics (ANAM), CogState, Concussion Recovery Index (CRI), Immediate Post-Concussive Assessment and Cognitive Testing (ImPACT), and HeadMinder, among others, facilitate administration and interpretation, especially among nonneuropsychologists (3).
  • In addition to a postconcussion symptom scale, the tests evaluate the following: attention, memory, processing speed, and reaction time (3).
  • The most effective use of NP testing involves comparing preinjury baseline testing with postinjury testing and using a test that accounts for confounding factors (eg, a practice effect) that occur with serial tests (3,10,14)[C].
  • The Reliable Change Index describes test-retest reliability and is a feature available with computerized tests (14).
  • A neuropsychologist may administer other formal NP testing if necessary, and neuropsychologists are often the most qualified to interpret any NP test (1)[C].
  • Balance testing adds valuable information to concussion assessment, especially when the athlete is having signs or symptoms of postural instability (1)[A].
  • The Sensory Organization Test is a computerized force plate system to evaluate postural sway under changing visual and somatosensory information (3).
  • The Balance Error Scoring Test (BESS) evaluates the ability of a person to hold without “error” 3 positions (legs together, single-leg stance, and tandem stance) with eyes closed and hands on the hips. The test is conducted on a firm and a foam surface (3).
  • BESS has been prospectively validated (3)[A].
  • A modified BESS is part of the SCAT 2 test.
Differential Diagnosis
  • Subdural hematoma, which may be acute or subacute (15)
  • Epidural hematoma, which can result in rapid deterioration after a “lucid interval” (15)
  • Intraparenchymal hemorrhage (15)
  • Diffuse axonal injury (DAI) or shear injury to white matter that leads to prolonged LOC and often causes residual deficits (15)
  • Second impact syndrome (SIS) is a rare yet often fatal process that occurs when an athlete who has not recovered completely from one concussion sustains a 2nd blow to the head. Cerebral edema and increased intracranial pressure result. The patient can decline rapidly as cerebral herniation occurs (4).
  • Trauma-induced migraine
Ongoing Care
  • A 6-step graduated RTP protocol is endorsed in the work of the Concussion in Sport Group and by the American College of Sports Medicine (1,10,11,12)[C].
  • Athletes progress through each step for a period of at least 24 hr. Before moving forward in the protocol, athletes must be asymptomatic and not taking any drugs that would change or hide their symptoms.
  • If symptoms develop at one stage, the athlete should go back one level. Another attempt to progress to the next level can occur after a 24-hr rest period.
  • The 6 steps are as follows: No activity, light aerobic exercise, sport-specific training, noncontact training drills, full contact practice, and return to play.
  • This protocol sometimes may be expedited in an adult athlete.
  • An augmented RTP protocol might be appropriate in the situation of a concussion with modifying features, including in children.
Follow-Up Recommendations
  • After sustaining a concussion, an athlete should be evaluated by a medical professional prior to RTP (13)[C].
  • Emergent follow-up should be sought in the case of any of the following: focal neurologic deficit, declining mental status or LOC, uncontrolled vomiting, or worsening headache (3,13)[C].
  • Tylenol may be used to treat HA or other pain, but NSAIDs and aspirin should be avoided initially.
  • Athletes also should avoid sedating medicines or substances such as alcohol that may affect cognitive function.
  • An athlete should rest from all physical and mental activity while still having symptoms of a concussion. Physical rest includes avoiding activities such as physical education class or riding a bike to school, and mental rest includes school work, video games, texting, computer usage, etc. (1)[C].
  • After all symptoms have resolved without the use of medicine to mask complaints and an athlete sees a medical provider, a gradual RTP prescription likely will be recommended. This program might include starting with light aerobic activity and progressing from noncontact drills to contact drills over at least a 24-hr period per step provided that no symptoms appear with the addition of exercise (1).
  • It is important to be honest about the presence of symptoms because there is some evidence that if someone is incompletely recovered from a concussion and sustains another blow to the head, SIS, a rare yet often fatal process, can occur (4).
Patient Monitoring
  • A patient should not be left unsupervised following a concussion (1)[C].
  • A patient should be monitored for the following: focal neurologic deficit, declining mental status or LOC, and uncontrolled vomiting (3)[C].
  • Emergent medical care should be sought if any of the preceding occur (3)[C].
Prognosis
80–90% of concussions resolve within 7–10 days (1).
Codes
ICD9
  • 850.0 Concussion with no loss of consciousness
  • 850.11 Concussion, with loss of consciousness of 30 minutes or less
  • 850.12 Concussion, with loss of consciousness from 31 to 59 minutes


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