Concussion

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Introduction

Concussive head injuries have recieved recent media and medical attention, not only in the pediatric setting but also in professional contact sports such as football and boxing as well.  The immediate and long term physical and neurophysicatric sequela are an active area of current research and interest.

Because of the increasing prevalance of competitive sports and the importance of early recognition of a concussive head injury, it is important for patients, parents, coaches and providers alike to be aware of the symptoms and initial steps in management.

 

Concussion Evaluation

The Sport Concussion Assessment Tool (SCAT2) offers a standardized method of evaluating athletes aged 10 years and older for concussion. It is a component of the 2008 Zurich Consensus Statement on Sport Concussion and is a screening evaluation tool designed for use only by qualified first responders or medical professionals.

The SCAT2 score does not independently determine the diagnosis of a concussion, nor does it independently determine the injured athlete’s recovery or return to play status. Such determination can only be made by a medical professional who has experience in the treatment of sport concussion

SCAT 2 is not a validated tool but is most commonly used and it combines many other evaluation tools such as:                  

  • Symptom checklist
  • Maddock’s questions of concentration and memory
  • Standardized Assessment of Concussion (SAC) sideline screening tool
  • Balanced Error Scoring System (BESS) for postural stability testing
  • Glasgow coma scale

SCAT2 is only designed for patients older than ten years

  • In younger children may need input from parents, coaches, teachers as well as patients to evaluate symptoms
  • Providers can use SCAT2/SAC if they are aware of the limitations in younger children and use their clinical judgment

Click on the logo below to access the SCAT2 tool 

scat2_0.png

 

Post-Concussion Management

  • Children take up to 7-10 days to recover, which is significantly longer than adults
  • Never allow children to return to play on the day of the injury
  • Cognitive rest
    • Activities that require concentration can exacerbate symptoms and may prolong recovery, patients may also perform poorly
    • Keep out of school or decrease school hours and homework
    • Avoid text messaging, video games, television, computers, reading
  • Physical rest:
    • If an activity worsens symptoms it should be avoided
    • Exercise, strenuous chores, and sexual activity should be limited
    • May be a role for light cardiovascular training as a form of treatment, but always below the level that induces symptoms, this is currently being investigated
  • Medications
              
    • NSAIDS can theoretically increase the risk of intracranial bleeds when used immediately after the injury, but no increased risk has been shown
    • Medications could include NSAIDS/acetaminophen/amitryptyline for headaches, SSRIs for depression or anxiety symptoms, zolpidem for insomnia, etc.
    • Patients should be symptom free without medications before they return to normal activities as medications can mask post-concussive symptoms
  • Other interventions:
                    
    • Sunglasses for photophobia, earplugs and avoidance of headphones for phonophobia
    • May need to avoid driving due to slowed reaction times

 

Long Term Management

  • Long term sequela may not be readily visible after the injury, so reevaluation and a hightened sensitivity to depressive symptoms and  continued academic issues particularly for repeated concussions is important months to years afterwards

 

High-Risk Management

  • Patients are high risk if they have:
    • More than 3 symptoms at presentation
    • Headache lasting >60 hours
    • Loss of consciousness for >60 seconds
    • Amnesia
    • History of prior concussion (concussions can occur with more minor impact, have more lasting effects)
    • Comorbid conditions
  • These high risk patients may need formal neuropsychiatric testing, and referral to a concussion expert

 

Return to Activies

  • Return to school
    • Slowly add back school activities, make sure that all teachers and administrators are aware of their deficits so they can monitor the child's performance and behavior as well
    • May need some short term adjustments such as decreased homework, extra time on tests, extra breaks, note takers, and forgiveness of makeup work, individualized education program (IEP) in more severe cases
    • Be aware that the most difficult subjects may be math, science, foreign languages
    • Standardized testing should be avoided until recovery is full so that they do not perform poorly
                     
  • Return to Play Protocol
                           
    • Only begin after complete resolution of symptoms at rest, without medications
    • Return to play protocol: at least 24 hours for each step, if they develop symptoms stop the protocol and wait 24 hours before returning to the last asymptomatic step
      • Day 1: Nonimpact aerobic exercise
      • Day 2: Nonimpact drills
      • Day 3: Noncontact drills
      • Day 4: Full contact practice
      • Day 5: Normal play

 

Post-Concussion Syndrome

  • According to the DSM IV: 3 months of 3 or more of the following symptoms: fatigue, disordered sleep, headache, dizziness, vertigo, irritability, aggressiveness, anxiety, depression, personality changes, apathy.
    • Other groups make this diagnosis after as little as 1 week of prolonged cognitive, physical, or psychological difficulties
  • May consider prolonged time away from sports in some cases, including 3 concussions in one year or post-concussion syndrome for more than 3 months
  • When post-concussion syndrome is suspected, formal neuropsychiatric testing and referral to a neurologist is indicated to assist in management.

 

Second Impact Syndrome

  • If return to play while still symptomatic and sustain another injury, there is an increased risk of second impact syndrome
  • All cases reported in individuals under the age of 20
  • The proposed pathophysiology in this syndrome is cerebral vascular congestion leading to cerebral edema, increased ICP, coma, or even death
  • These patients should be managed by a neurologist familiar with concussive head injuries and highlights the importance of not playing while symptomatic.

 

Long Term Effects

The long term effects of concussions and repeated concussions include persistent problems with processing complex visual stimuli.  Multiple concussions are associated with lower GPAs, confusion, amnesia, loss of consciousness, and future concussions.

There is currently research going on in this field in order to assess the severity of brain disease and the cummulative nature of injury.

 

Prevention and Legal Issues

Most states require school boards to develop concussion policies in order to minimize potential negative outcomes.  These include steps such as:

  • Requiring parents and athletes to sign consent forms prior to dangerous play
  • Requiring specialized protective gear to be worn at all times.
  • Requiring adult supervision at all times, even during practice.
  • Requiring athlete removal from play if there is suspicion of concussion, and allowing return only after evaluation by a qualified health care professional
  • Education of student athletes, their parents and coaches in terms of the serious nature of head injuries, the importance of reporting injuries without punative recouse, and the symptoms to watch for in concussive injury.
    • Click on the logo below to access the "Heads Up" concussion prevention program sponsored by the Centers for Disease Control.  The site contains useful information for providers, coaches, athletes and families in both English and Spanish.

heads up.jpg

 

Recently, there have been calls to limit the exposure to contact as well (click here for a recent news article) however this has been met by opposition including arguements that lack of practice in contact could in effect lead to more serious injury because athletes are not properly training in tackle procedures.

 

References

  1. McCrory P, Meeuwisse W, Johnston K, Dvorak J, Aubry M, Molloy M, Cantu R. Consensus Statement on Concussion in Sport-The 3rdInternational Conference on Concussion in Sport, Held in Zurich, November 2008. Journal of Clinical Neuroscience 2009; 16; 755-763.
  2. Halstead ME, Walter KD. Sport-Related Concussion in Children and Adolescents. Pediatrics 2010; 126; 597-611.
  3. Scorza KA, Raleigh ME, O’Connor FG.  Current Concepts in Concussion: Evaluation and Management. American Family Physician 2012; 85,2; 123-132.