The Evaluation and Management of Concussions

 

What is a Concussion & How Often Does it Happen in Sports

• Concussion is a trauma-induced alteration of mental status due to head trauma  

   

  High School Football	20%
  Rugby	15%
  Soccer	10%
  Ice Hockey	9%
  College Football	8%

Concussion occurs as a result of external rotational acceleration & shearing forces to the brain form a blow to the head, neck back or face.

• "Double hit": blow to skull, causing the brain floating in cerebral spinal fluid within the skull to strike the opposite side of the skull. If a hard enough blow occurs, the brain will bounce back and strike the opposite side of the skull.
• This results in a shearing injury to neurons and nerve support cells in many areas of the brain
• Damage is in proportion to the degree of acceleration & deceleration
• Widespread disruption of brain function occurs because of damage to many areas

 

Changes are at the Nerve-Cellular Level

• Damage to nerve and support cells & vessels
• Similar to the body's response to a sprint, the injured brain cells demand more oxygen. The body's natural defense to injury is an initial decrease in blood flow to the injured area. In simple terms, this "oxygen debt" results in damage to the injured.

 

The area of cellular damage dictates the symptoms of concussion: however, most areas within the brain are capable of multi-tasking. Damage at one, or more areas can result in: a combination of

• Loss of consciousness (LOC)
• Amnesia & Confusion
• Slow mental processing of new information
• Behavioral changes
• Emotional changes 

Immediate evaluation of a suspected, series head injury

• Keep everyone away & only move if needed
• If the athlete remains unconscious: assume a cervical spine injury
• Do not let the head & neck move and begin basic CPR ABC process
• Airway present - often compromised in serious neck injuries
• Breathing - If not begin artifical respirations
• Circulation - If absent begin chest compressions & apply Automatic Electronic Defibrillator (AED) if available.
• Once ABCs are cleared, or normal, with controlled assistance, begin the process of securing the athletes to a backboard for transport to an emergency center.

 

The initial evaluation of less severe injuries

• No substitute for knowing the athlete
• Look at the facial expression - look for the "blank stare"
• Test orientation for confusion: place, date, score, quarter.
• Check for post-event and pre-event memory loss - athlete may ask repeatedly "what happened"
• Follow their behavior for atypical actions or emotions: anger, crying, etc.
• Once symptoms resolve at rest, they should also be checked after exertion on the sidelines.

Other symptoms at rest or with exercise include:

> Headache

> Slow Processing

> Easy confusion

> Slower decisions

> Decreased attention

> Decreased reflexes

> Poor judgment

> Poor problem solving

> Fatigue

> Slurred speech

> Dizziness

> Ringing in ear

> Nausea/vomiting

> Poor coordination

> Frustration

> Irritable

> Restless

No one should return to play if any symptoms are present at rest or with exercise.

  

"Grading" Concussions Based upon the combination of symptom severity & duration and most importantly, effects the decision to allow return-to-play.

• There is no universally accepted severity criteria
• Most conservative: Colorado Criteria

Adopted by NCAA, but used little by NCAA team physicians

• Most utilized: Cantu Criteria
• American Academy of Neurologists (AAN) or SAC evaluation - Recommended criteria by UIL
• Based upon time of any:

>Transient Confusion or amnesia or other mental status abnormalities

>Loss of consciousness

>Other Symptoms

AAN Grades & Return-To-Play

• Grade 1, least severe usually return-to-play the same day

All symptoms resolved in < 15 minute.

No loss of consciousness

No concussion in past 12 months

• Grade 2 moderate severity usually out for 1 week

Symptoms not completely resolved in 15 minutes and no loss of consciousness

A second Grade 1 concussion in < 12 months is a Grade 2 concussion

• Grade 3 is any loss of consciousness for seconds or more: out 1 week

If longer then for briefly or longer then out for 2 weeks.

A second Grade 2 concussion also results in no return for 2 weeks.

Multiple Grade 3 concussions result in a minimum of one month, or longer out of play

SAC Tests: The Sideline Evaluator for Concussions Several tests are utilized:

• Orientation to situation
• Concentration: spelling & ask the 12-months, backwards,
• Short-term memory: recall numbers- in- series 4-7 numbers: use portions of a phone number
• Exertion provocative symptoms need to be done, an athlete with "clear" symptoms at rest may have symptoms with exertion. Remember, the brain is responding to injury similar to a sprint, it has an oxygen debt which may worsen with exercise.
• Neurological exam

Pupils: dilate and contrict to light equally

Coordination: can stand with feet together and head extended backward and maintain balance with eyes open, closed and when the athlete is bumped lightly to offset balance.

Sensation & motor strength is normal

• SAC plam card and test packets are available to carry for quick recall in case of emergency: 800-321-7037

Concussion Complications if returned-to-play too soon

• Second-Impact Syndrome: a rare, lethal complication of returning-to-play too soon and having a second blow to the head resulting in disproportionate brain swelling, coma, and death. Usually occurs in boxers and is very rare.
• Post-Concussive Syndrome (PCS): an unpredictable complication presenting as a cluster of concussion symptoms lasting longer then the typical recovery time. PCS is most common following higher-grade concussions, or multiple concussions, however they can occur unpredictably following a first Grade 1 concussion. Clues to post-concussion syndrome include:

Personality and behavioral changes

Cognitive deficiencies, or slower mental processing

Decreased abilities for reasoning and/or learning information

 

• It is possible to detect PCs on routine imaging such as x-rays, CT scan or MRI. The best diagnostic test utilizes neuropsychological tests: a series of tests measuring memory, new learning abilities, physical/mental reaction times and mental processing.

Most important, student athletes diagnosed with post-consussion syndrome will need academic assistance.

• Food for thought: Do we create the "concussion-prone" player by allowing them to return-to-play before concussion symptoms have resolved, thus lowering their "resistance" to having subsequent concussions?

• All suspected concussions should be evaluated by the team athletic trainer and team physician. All concussions get better soon after the initial evaluation - those that become worse need prompt evaluation. Conditions warranting more prompt or specialist evaluation include:
• Any LOC with initial concussion
• Any new neurological deficits
• Multiple concussions with memory loss involved with each event

How do doctors evaluate?

• The reported events, initial observations and symptoms are the most important information to the physician evaluating an athlete with a concussion.
• Neuropsychological exams are becoming more frequently used in athletes suffering from PCS. The information is best utilized if a baseline test was administered prior to the season and repeat following the concussion. A comparison of post concussion results with baseline results will be used by the physician to determine a safe time for return-to-play.
• A CT scan or MRI may be used acutely if serious intracranial bleeding is suspected, if symptoms worsen, or are prolonged. PET scans and functional MRI's are done at research centers now and may be more commonly available and affordable in the future.
• A blood test looking for an identified gene may be routinely used in the future to identify "concussion-prone" individuals. The gene has been found in boxers with severe PCS and in Alzheimer's disease patients.

Prevention of concussions and post concussion complications begin in the off-season and continues through the competitive season. These include:

• Improved conditioning and neck strengthening
• Improved protective equipment especially properly fitted helmets and mouthpieces
• Emphasizing proper skills throughout the pre- and competitive season
• Enforcement of protective rules by officials
• Recognition of concussive symptoms by coaching and medical staffs
• Have a proactive emergency plan for severe concussions and neck injuries

IN SUMMARY:

 

“Ready to go back in”

• No recent, previous concussion
• No LOC
• Complete resolution of symptoms in 15 minutes including no symptoms with mental or physical exertion.
• Normal neurological exam
• Follow-up exam later

"Not coming back today"

• LOC

Activate emergency plan if >seconds

• Symptoms > 15 minutes

Continued or worsened complaints

Cognitive disability below baseline

Exertional symptoms or complaints

• Second grade I, or greater, this season

All concussions get better - any worsening symptoms need immediate evaluation.

Neuropsychological testing is currently the most accurate way to determine if post-concussion syndrome is present. These results are best utilized if a baseline test was done prior to the concussion event and used for comparison. Accurate at identifying the presence of symptoms, the neuropsych tests are used in conjunction with other information to clear athletes for return-to-play.

**Special thanks to Jon Divine, M.D.., M.S., Memorial-Hermann Sports & Family Medicine, President-elect, Texas Chapter American College of Sports Medicine and Team Physicial, University of Houston, for preparing this article.

"Ready to go back in"

Look for PDC articles on pertinent athletic training medicine issues each month in Texas Coach Magazine. Send your comments and ideas for articles to Tinker Murray (tm05@swt.edu).

 

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