Sports concussion: A return-to-play guide

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Applied Evidence

Sports concussion: A return-to-play guide

J Fam Pract. 2012 June;61(6):323-328

By

Minh-Ha Hoang, DO

Aaron M. Lear, MD, CAQ

These evaluative methods can help you optimize a patient’s treatment and return to activity.

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References

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2. CDC. Brain injury awareness month—March 2010. MMWR Morb Mortal Wkly Rep. 2010;59:235.-

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4. Kliff S. Heading off sports injuries. Newsweek. February 4, 2010. Available at: http://www.newsweek.com/2010/02/04/heading-off-sports-injuries.html. Accessed February 9, 2011.

5. Kluger J. Headbanger nation. Health special: kids and concussions. Time. February 3, 2011. Available at: http://www.time.com/time/specials/packages/article/0,28804,2043395_2043506_2043494,00.html. Accessed February 9, 2011.

6. American Academy of Neurology. Practice parameter: the management of concussion in sports (summary statement). Report of the quality standards subcommittee. Neurology. 1997;48:581-585.

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8. Kelly J, Nichols J, Filley C, et al. Concussion in sports. Guidelines for the prevention of catastrophic outcome. JAMA. 1991;266:2867-2869.

9. American Academy of Neurology. Position statement on sports concussion. October 2010. AAN policy 2010-36. Available at: http://www.aan.com/globals/axon/assets/7913.pdf. Accessed February 23, 2011.

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11. Herring SA, Cantu RC, Guskiewicz KM, et al. Concussion (mild traumatic brain injury) and the team physician: a consensus statement—2011 update. Med Sci Sports Exerc. 2011;43:2412-2422.Available at: http://journals.lww.com/acsm-msse/Fulltext/2011/12000/Concussion__Mild_Traumatic_Brain_Injury__and_the.24.aspx. Accessed February 23, 2011.

12. McCrory P, Meeuwisse W, Johnston K, et al. Consensus statement on concussion in sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008. Br J Sports Med. 2009;43(suppl 1):i76-i90.

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20. Collie A, Maruff P, Makdissi M, et al. CogSport: reliability and correlation with conventional cognitive tests used in postconcussion medical evaluations. Clin J Sport Med. 2003;13:28-32.

21. Erlanger D, Saliba E, Barth J, et al. Monitoring resolution of postconcussion symptoms in athletes: preliminary results of a web-based neuropsychological test protocol. J Athl Train. 2001;36:280-287.

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PRACTICE RECOMMENDATIONS

• Prohibit sports participation as long as a patient exhibits concussive symptoms after a head injury. C

• Evaluate a patient’s balance and cognitive function to help gauge the severity of concussion and the likely delay in a return to sports activity. C

• Use a stepwise protocol in returning an asymptomatic patient to full sports activity. C

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

CASE KD is an 18-year-old high school basketball player who was knocked backwards during a game, hitting her head on the floor. She had immediate head and neck pain but no loss of consciousness; she was transported by EMS to the local emergency department (ED) for further evaluation. Results of head and neck CT scans were normal, and she was discharged home. Four days later, KD’s parents brought her to our office because she was experiencing ongoing headache, phonophobia, nausea, light-headedness, poor balance, increased sleepiness, and irritability.

The Centers for Disease Control and Prevention estimate that approximately 300,000 sports concussions occur yearly in the United States,¹ and that 135,000 of these cases are treated in EDs.² These numbers have not gone unnoticed in the consumer press. Over the past 18 months, Sports Illustrated, Newsweek, and Time^3-5 have published stories on sports-related concussion, helping to raise public awareness of its risks.

Recommendations for practitioners have changed. In 1997, the American Academy of Neurology⁶ published one-size-fits-all guidelines on managing concussion, using levels of symptomatology and loss of consciousness to grade the severity of concussion from 1 to 3. These guidelines were similar to the Cantu and Colorado guidelines of the early 1990s.^7,8 Since then, however, the diagnostic criteria and expert opinion about treatment and return to physical activity have changed. Indeed, several medical organizations^9-12 now recommend a more individualized approach to evaluation and management, which we describe here.

It begins with a definition

While there is no single agreed-upon characterization of “concussion,” the 3rd International Conference on Concussion in Sport (ICCS)¹² provides this definition:

Concussion is defined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. Several common features that incorporate clinical, pathologic, and biomechanical injury constructs that may be utilized in defining the nature of a concussive head injury include:

Concussion may be caused either by a direct blow to the head, face, or neck or a blow elsewhere on the body with an ‘‘impulsive’’ force transmitted to the head.
Concussion typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously.
Concussion may result in neuropathological changes but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury.
Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course.… In a small percentage of cases, however, postconcussive symptoms may be prolonged.
No abnormality on standard structural neuroimaging studies is seen in concussion.

Office evaluation
Obtain a thorough history and conduct a neurologic evaluation and musculoskeletal examination of the head and neck.

Clues to expected length of recovery

A patient with a concussion may lose consciousness after the impact, or have a brief convulsion that is not a seizure.¹³ In the periodimmediately after the injury, the patient may exhibit a constellation of such signs and symptoms as headache, confusion, a dazed look, dilated pupils, amnesia, poor balance, nausea, or vomiting. These features typically resolve over time, but may persist for weeks or months. Anterograde or retrograde amnesia may also occur. TABLE 1 details a more complete list of concussion symptoms. If the patient is a child or young adult, it is useful to have a parent present at the office visit to describe the patient’s mood, sleep, appetite, and overall health after the injury.

Factors that may portend a longer recovery include a previous concussion, retrograde or anterograde amnesia, younger age, and female sex.¹⁴

FAST TRACK

History of concussion, retrograde or anterograde amnesia, younger age, and female sex may herald a longer period of recovery from a concussion.

Dire problems beyond concussion. Complaints or historical elements inconsistent with concussion that should be considered red flags include any focal neurologic complaints, vomiting or headache that worsens after a period of improvement, or obtundation or disorientation that has worsened since the injury. With such findings, consider more serious head injuries and arrange for a more complete immediate neurologic work-up.