Symptoms of concussion
Headache
“Don’t feel right”
Pressure in head
Difficulty concentrating
Neck pain
Difficulty remembering
Nausea or vomiting
Fatigue or low energy
Dizziness
Confusion
Blurred vision
Drowsiness
Balance problems
Trouble falling asleep
Sensitivity to light
More emotional
Sensitivity to noise
Irritability
Feeling slowed down
Sadness
Felling like “in a fog”
Nervous or anxious
In the past, severity of concussion was graded either numerically (grade 1, 2, or 3) or as mild, moderate, or severe. These grading systems were largely based upon the presence and duration of loss of consciousness with pre-prescribed times out of sports. However, the general consensus is to no longer use these types of grading scales, primarily because evidence now suggests that a brief loss of consciousness in association with concussion does not predict clinical course or long-term cognitive impairment [4–6]. In addition, it has become clear that duration of symptoms until full recovery and the timing for return to sports will be different for each athlete. An individualized treatment plan is necessary for each injury, and return to contact sports is restricted at least until there is a confirmation of full resolution of symptoms, full academic and exercise tolerance, and an estimation of full cognitive recovery [4, 10].
During initial evaluation, if the athlete has a loss of consciousness or there is any concern for potential concomitant cervical spine injury, then the principles of traumatology must be followed. Airway, breathing, and circulation must take priority. Athletes with possible cervical spine injury, including those with neck pain or neurologic symptoms (e.g., paresthesias, numbness, paralysis), should undergo cervical spine immobilization until spine injury is excluded clinically or radiographically. CT scan is considered to exclude serious intracranial injuries (e.g., epidural hematoma, subdural hematoma, parenchymal hemorrhage, or cerebral contusion) in athletes with posttraumatic seizure activity, loss of consciousness for longer than a minute, signs of skull fracture, persistent alteration in mental status, or focal neurologic abnormality [4, 10]. Patients with headache, vomiting, or a questionable loss of consciousness should have monitoring for the first several hours following the injury. Worsening of symptoms may warrant imaging, although this may be avoided if patients show improvement during observation. Because CT scan is often readily available and the results are rapid as well as sensitive for evaluating potential fractures or intracranial hemorrhages, it is the test of choice in the acute setting. However, it delivers a relatively large dose of ionizing radiation, so the decision as to if and when it should be used must be made carefully.
Recognizing and diagnosing concussion often begin with a subjective symptom survey, though other sideline tools are employed as well. These tools include a careful cervical spine and neurologic exam, along with balance and cognitive assessments. The 4th International Conference on Concussion in Sport produced the SCAT3 (and the Child SCAT 3). This evaluation tool includes simple methods for the sideline assessment of balance (the modified Balance Error Scoring System, or BESS) and cognitive function (the Standardized Assessment of Concussion, or SAC) [4]. Both the BESS and the SCAT 3 tests are best used when there are healthy, baseline scores that the athlete has completed before the injury for comparison is available, but they can still be useful in the absence of a baseline. Researchers have shown that compared with baseline, a 3.5-point drop in SCAT-2 score had 96 % sensitivity and 81 % specificity in detecting concussion. When examined to exclude baseline scores, a cutoff value of 74.5 was associated with 83 % sensitivity and 91 % specificity in predicting concussion versus controls [11]. “Normal” performance on sideline assessment tools does not necessarily rule out a concussion, and it should be recognized that symptoms may evolve over minutes to hours after a collision. If the athlete has new onset of concussion-like symptoms after a collision, then removal from the contest may be appropriate, even if sideline tests are normal. Particularly in younger athletes, the medical community as a whole has made a commitment to sit a player out if there is any doubt about their concussion status .
Management
Clinical management is based upon observational studies and clinical experience that have culminated in consensus guidelines. The majority of evidence is based on athletes over age 12, but the principals of management are the same for all ages [1, 4, 5, 10, 12–16].
Once the diagnosis of concussion is made, the top two priorities are to avoid additional injury and minimize the impact on the athlete’s academic life. If concussion is suspected, the athlete should be immediately removed from the contest with no plans to RTP the same day. This is a departure from previous management principles that were held years ago, where athletes who reported no symptoms after 15 or 30 min may be allowed to return to their sport. Athletes should also refrain from other activities that have a potential for injury, such as skateboarding, skiing, or climbing until a qualified licensed clinician confirms their full recovery [4, 5, 7].
Factors for emergency department (ED) assessment or for neuroimaging are discussed earlier in this chapter. If the patient is stable and the exam is reassuring, the patient may be allowed to recover at home if a responsible adult is available to transport and supervise them.
Cognitive and physical rest are the primary interventions [4, 12–17]. Frequent waking throughout the night is no longer part of current medical recommendations. However, if the patient’s status worsens throughout the night (e.g., recurrent vomiting, lethargy, worsening confusion), then urgent evaluation at an ED equipped with neuroimaging capabilities is warranted.
A treatment plan that ensures effective communication between athletic trainers, coaches, medical personnel, and parents should be in place before the start of the season to ensure effective handoff and monitoring of injured athletes.
The amount of rest required is different for each individual patient. But removal from high-risk activities is essential because during recovery, athletes suffering from concussions may be particularly vulnerable to worsening symptoms, additional concussions, or potential catastrophic outcomes, such as second impact syndrome if repeated injury occurs. Animal models and human observational studies suggest that these additional injuries may occur even with relatively low-energy collisions [10, 18–23].
Additionally, it is difficult to know how much cognitive rest is optimal. Care is taken to optimize recovery, but avoid unnecessary interruptions in the academic school year. Overdoing cognitive rest and academic restrictions can significantly affect a student athlete’s future school plans, increase the stress of trying to make up a large volume of school work (which by itself may increase symptoms), and can create unnecessary social isolation [24].
Although observational, studies suggest that athletes suffering from concussions who engage in very high levels of cognitive and physical activity have longer recovery times than those who engaged in low to moderate levels of activity [25, 26], those same studies suggest that low levels of activity are not harmful. The recommendation for physical rest is primarily based upon expert consensus and observational studies that suggest physical rest is associated with fewer concussion symptoms, a shorter duration of symptoms, and a lower risk of repeat concussion [10, 14, 19].
Physical Rest
During the prescribed physical rest , activities that significantly increase heart rate and blood pressure should be avoided, such as running, weight lifting, or pushups. The athlete should perform activities of daily living, and basic exercise such as stretching and walking can be encouraged. It should be noted that young, motivated student athletes often feel better when they can be proactive in their recovery. Continuous passive waiting can be frustrating and uncomfortable. In particular, patients who remain home from school, with instructions to do nothing but rest, and refrain from their typical exercise patterns, often have disruption to their normal homeostasis. For instance, a pattern of sleeping during the day and insomnia at night will, by itself, quickly contribute to daytime fatigue, irritability, trouble concentrating, and several other symptoms that are being monitored on the post-concussion symptom survey. Simple and safe suggestions such as dedicated time for daily stretching and walking can give the athlete an opportunity to be more proactive and perhaps stave off some degree of physical deconditioning.
Physical rest should be prescribed until there is resolution of symptoms back to the patient’s personal pre-injury baseline, normalization of balance, and recovery of cognitive function. Cognitive assessments may be made with tools such as the SCAT 3 [4] or with computerized neuropsychological testing, but at the very least, the patient should demonstrate the ability to attend full days of school and perform normal study habits without return of symptoms.
In the minority of athletes with prolonged symptoms beyond 14 days after injury, a light, sub-symptom threshold level of aerobic exercise (e.g., light stationary bicycling for 10–15 min trials) may be introduced. This light to moderate exercise challenge can often be well tolerated and may improve symptoms [27], provide a psychological boost, and potentially help mitigate the effects of physical deconditioning .
Cognitive Rest
Although there is evidence that high levels of cognitive challenge may exacerbate symptoms and perhaps even prolong recovery [17], a priority is given to attempts at academic work for several reasons. The implications of several weeks or (rarely) months of missed school work, while waiting for all symptoms to resolve, can threaten the success of a student athlete’s semester or school year. In addition, there is no current evidence that cognitive demand, even at high intensity, would contribute to long-term or structural brain damage. This is an obvious difference from the concerns that exist for a return to contact sports before full symptom recovery. For these reasons, patients may attempt a return to school even before complete symptom resolution. In fact, if symptoms are resolved by the next day after injury, the patient may be able to continue with school uninterrupted. However, if significant symptoms persist, then staying home from school with full cognitive rest for 3–5 days, followed by potential temporary academic adjustments, should be considered. For these patients, often they will attempt half days of school with minimal cognitive participation for the first 2–3 days back to school if necessary. It has been suggested that a return to school should occur when the student can tolerate the length of a typical school period (30–45 min) of uninterrupted reading [28].
During cognitive rest, the athlete may engage in light mental activities, such as watching limited amounts of television and family interaction, if symptoms are not exacerbated [28, 29]. Social visits and trips should be limited in an effort to minimize opportunities for symptom exacerbation. Extended texting, video gaming, movie theaters, exposure to loud music, or computer use should be avoided [10].
Academic adjustments may include limited course load, shortened classes or school day, increased rest time, aids for learning (e.g., class notes or supplemental tutoring), or postponement of high-stakes testing [28, 30]. Other adjustments may be offered based on the most prominent symptoms [28]. Strategies to avoid symptom exacerbation are suggested as well, including optimization of sleep patterns, nutrition, and hydration status for the athlete. Frequent breaks from prolonged reading including potential visits to a quiet dark location like the nurse’s office may be necessary. For athletes who suffer prolonged recoveries, plans to make up incomplete work may include assignments during scheduled school breaks or summer vacation [23, 31–33].
Prolonged Recovery
Most young athletes will recover readily from sports-related concussions in a matter of days to weeks [1–4, 33, 34]. Over 90 % of high school athletes who sustain a sports-related concussion will be symptom-free and cleared for play within 1 month of injury [1, 2, 10]. Some athletes, however, will take several months to recover from their concussions.
A minority of patients will have prolonged post-concussion symptoms lasting more than 3–4 weeks, and a multidisciplinary approach is warranted that includes treatment by a physician with concussion management expertise, physical therapist, neuropsychologists, and, in selected patients, behavioral management by a psychologist or psychiatrist [30]. Although it appears that initial symptom load (i.e., more severe or numerous initial signs or symptoms) seems to be one of the only reliable predictors of prolonged recovery [12, 35], other features have been debated as contributing factors. These include premorbid conditions such as prior concussion, multiple collisions before concussion was recognized and treatment was initiated, preexisting headache history, learning disability, or psychiatric disorder (e.g., depression) [10, 33, 36].
Symptom Management and Prolonged Recovery
While acetaminophen or nonsteroidal anti-inflammatory medications (NSAIDs) are reasonable adjuncts to physical and cognitive rest during the first few days after injury, they may be ineffective. Although uncommon, rebound headaches after frequent and prolonged use can complicate treatment and recovery [13, 31, 37, 38].
Headache is the most common symptom of concussion and is the most common complaint in patients with prolonged recovery [2]. For patients who have a preexisting migraine history, they may have increased incidence of migraines after injury. In these cases, the patient may use their typical migraine abortive therapy.
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