Update on concussion: Here’s what the experts say

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Applied Evidence

Update on concussion: Here’s what the experts say

J Fam Pract. 2010 August;59(8):428-433

By

Shawn M. Ferullo, MD

Alysia Green, MD

The latest consensus statement—and handy assessment tool—from the sports medicine community will help you manage this all-too-common injury.

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References

1. Cantu R. Cerebral concussion in sport: management and prevention. Sports Med. 1992;14:64-74.

2. Centers for Disease Control and Prevention. Nonfatal traumatic brain injuries from sports and recreational activities. MMWR Morb Mortal Wkly Rep. 2007;56:733-737.

3. American College of Sports Medicine. Special communications: concussion (mild traumatic brain injury) and the team physician: a consensus statement. Med Sci Sports Exerc. 2006;38:395-399.

4. Van Kampen D, Lovell M, Pardini J, et al. The “value added” of neurocognitive testing after sports-related concussion. Am J Sports Med. 2006;34:1630-1636.

5. 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 I):i76-i84.

6. Powell J. Cerebral concussion: causes, effects and risks in sports. J Athl Training. 2001;36:307-311.

7. Cantu R. Posttraumatic retrograde and anterograde amnesia: pathophysiology and implications in grading and safe return to play. J Athl Training. 2001;36:244-248.

8. Oliaro S, Anderson S, Hooker D. Management of cerebral concussion in sports: the athletic trainer’s perspective. J Athl Training. 2001;36:257-262.

9. Concussion in sport group: Aubry M, Cantu R, Dvorak J, et al. Summary and Agreement Statement of the 1st International Symposium on Concussion in Sport. Vienna 2001. Clin J Sports Med. 2002;12:6-11.

10. McCrory P, Johnston K, Meeuwisse W, et al. Summary and agreement statement of the 2nd International Conference on Concussion in Sport. Prague 2004. Br J Sports Med. 2005;39:196-204.

11. Hoge C, McGurk D, Thomas J, et al. Mild traumatic brain injury in US soldiers returning from Iraq. N Engl J Med. 2008;358:453-463.

12. Harmon KG. Assessment and management of concussion in sports. Am Fam Physician. 1999;60:887-892.

13. American Academy of Neurology. Practice parameter: the management of concussion in sport (summary statement). Report of the Quality Standards Subcommittee. Neurology. 1997;48:581-585.

14. Cantu R. Guidelines for return to contact sports after cerebral concussion. Phys Sports Med. 1986;14:75-83.

15. Colorado Medical Society School and Sports Medicine Committee. Guidelines for the management of concussion in sports. Colo Med. 1990;87:4.-

16. Guskiewicz KM, Bruce SL, Cantu R, et al. Research based recommendations on management of sport related concussion: summary of the National Athletic Trainers’ Association Position Statement. Br J Sports Med. 2006;40:6-10.

17. Barth JT, Alves WA, Ryan TV, et al. Mild head injury in sports; neuropsychological sequelae and recovery of function. In: Levin HS, Eisenberg HM, Benton AL, eds. Mild Head Injury. New York: Oxford University Press; 1989:257–275.

18. Randolph C. Implementation of neuropsychological testing models for the high school, collegiate and professional sport settings. J Athl Training. 2001;36:288-296.

19. Maroon J, Lovell M, Norwig J, et al. Cerebral concussion in athletes: evaluation and neuropsychological testing. Neurosurgery. 2000;47:659-672.

20. Collins M, Lovell M, Iverson G, et al. Examining concussion rates and return to play in high school football players wearing newer helmet technology: a three year prospective cohort study. Neurosurgery. 2006;58:275-286.

21. Delaney J, Al-Kashmiri A, Drummond R, et al. The effect of protective headgear on head injuries and concussions in adolescent football (soccer) players. Br J Sports Med. 2008;42:110-115.

22. Viano D, Pellman E, Whitnall C, et al. Concussion in professional football: performance of newer helmets in reconstructed game impacts – Part 13. Neurosurgery. 2006;59:591-606.

23. Pellman E, Lovell M, Viano D, et al. Concussion in professional football: recovery of NFL and high school athletes assessed by neuropsychological testing – Part 12. Neurosurgery. 2006;58:236-274.

PRACTICE RECOMMENDATION

• Don’t allow an athlete who has symptoms at rest or with exertion to return to play. C

• Consider neuropsychological testing in conjunction with continued clinical assessment for objective measurements to assist in managing concussion. B

• Recommend up-to-date protective equipment for athletes. Recent improvements, especially in football, have been shown to help decrease the incidence of concussion. A

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: Jeff, a 15-year-old high school ice hockey player, asks you to write a note for his coach, stating that he has recovered from his concussion and can return to play. He says that 2 days ago he collided with another player and was knocked unconscious for roughly 10 seconds. He had a headache for the rest of that evening, and complained that the light was hurting his eyes. Now he has no symptoms at rest, but activity gives him a slight headache.

How would you evaluate this patient to determine whether he can return to play?

Concussions like Jeff’s are common in sports-related activities, and family physicians are frequently asked to manage the condition and decide when the injured athlete can safely return to play.

Concussions occur in both helmeted and nonhelmeted sports, and are most common in collision sports.¹ A 2007 estimate from the Centers for Disease Control and Prevention (CDC) suggests that 1.1 million people are seen in emergency departments in the United States each year for concussion-related injuries, while nearly another 235,000 people are hospitalized.² As astounding as these numbers are, many experts believe they underestimate the true incidence of concussion, given the propensity for athletes not to report symptoms for fear of being held out of sporting events.^3,4

FAST TRACK

There is a propensity for athletes not to report symptoms for fear of being held out of sporting events.

Further complicating matters: There has historically been a lack of agreement over what, exactly, constitutes a concussion and how to manage these injuries.

Refining concussion terminology
Concussion has often been referred to as mild traumatic brain injury (MTBI), although more recent expert opinion suggests the terms refer to different injury constructs and should not be used interchangeably.⁵ Over the years there has been little agreement on the definition, grading, and treatment of these injuries.^6-8 On 3 occasions in the last decade, the sports medicine community has held symposia designed to refine an expert consensus on these issues: in 2001 in Vienna, in 2004 in Prague, and in 2008 in Zurich.^5,9,10 These recommendations provide a useful framework for caring for patients like Jeff.

A definition. According to the consensus statement that emerged from the most recent Zurich conference, sports concussion can be defined as a “complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces.” Common features may include:⁵

A direct blow to the head or elsewhere in the body with an impulsive force transmitted to the head.
Rapid onset of neurological impairments that resolve spontaneously over time.
Possible neuropathological changes, although the clinical symptoms reflect a functional disturbance rather than structural injury.
A graded set of clinical symptoms that may or may not involve loss of consciousness.
No abnormality on standard structural neuroimaging studies.

Athletes with concussion show a range of signs and symptoms

Athletes who suffer from a concussion may show signs of being dazed or disoriented, or experience retrograde amnesia (where they can’t remember things that happened before the traumatic event) or anterograde amnesia (where they can’t remember things that happened after the event). They may also suffer from poor coordination, decreased attention span, emotional lability, or loss of consciousness. After the traumatic event, they may complain of headache, dizziness, nausea or vomiting, photophobia, phonophobia, inability to concentrate, sleep disturbances, fatigue, and memory disturbances. Academic performance can also be severely impaired during the postconcussive period.

Symptoms of concussion may be short-lived or persist for many weeks. Postconcussive syndrome is a term used to describe the condition of prolonged and persistent concussive symptoms. Recent studies in military personal have also shown a strong association between post-traumatic stress disorder (PTSD) and clinical depression in soldiers who have suffered from a traumatic brain injury.¹¹

Start with the ABCs, then check the spine

If you are a team physician on the spot when the injury occurs, you can do the initial assessment on the field of play. A certified athletic trainer can also do this first assessment. Start by checking the basics: airway, breathing, and circulation. Once the ABCs have been completed, palpate the head and neck to rule out a head or cervical spine injury. If the player complains of neck pain or you can palpate bony tenderness or step-off over the spinous processes, suspect a possible cervical spine injury. Make sure the player is put onto a spine board with cervical spine precautions and transported to the nearest medical facility.