para>Resolution of symptoms and return to neurocognitive baseline often take longer in pediatric and adolescent athletes (<18 years) (2)[B]. á
EPIDEMIOLOGY
- The CDC estimates 1.6 to 3.8 million concussions every year, although many go unreported.
- >1 million ER visits every year are due to TBIs (falls, MVAs, assault, sports, others); >1/2 of these visits are by children aged 5 to 18 years.
- High school and college athlete concussion rates have increased in the past 30 years, likely in part due to increased reporting.
- American football is associated with the highest number of TBIs.
- Concussions occur more often in games than practices.
- Female athletes have more reported concussions than male athletes in similar sports and more frequently suffer cognitive impairment.
Incidence
- The most common cause of TBI in the elderly (>65 years of age) is falls.
- Up to 1/3 of all sports-related concussions may go unreported or undiagnosed (3)[B].
- Sports (numbers per 1,000 athlete exposures, defined as one athlete playing in one game or practice) (4)[B]
- Football: college 0.61 (0.39 in practice, 3.02 in games); high school (HS) 0.47 (0.21 in practice, 1.55 in games)
- Basketball (college): males 0.16; females 0.22
- Ice hockey (college): males 0.41, females 0.91
- Lacrosse (college): males 0.26, females 0.25
- Soccer: college males 0.49, HS males 0.22; college females 0.63, HS females 0.36
- Skiing and snowboarding: 0.005 and 0.004, respectively. Snowboarders have a higher incidence of severe brain injuries than skiers.
ETIOLOGY AND PATHOPHYSIOLOGY
- Direct or indirect injury to the head
- Falls
- Sports-related injuries
- Motor vehicle accidents
- Assaults
- Identifiable metabolic changes include alterations in intra-/extracellular potassium, calcium, and glutamate with subsequent neuron dysfunction. Microtearing of cerebral blood vessels and a relative decrease in cerebral blood flow also occurs. An increased requirement for glucose by the brain, coupled with decreased blood flow, may result in cellular dysfunction and increased susceptibility to subsequent brain insults. Other biochemical changes are currently being studied.
- Structural abnormalities of the brain are typically absent based on imaging studies.
RISK FACTORS
- Patients at high risk for falls: elderly, intoxication
- History of previous concussion
- Young adolescents, female gender
- Contact sports (particularly football): activities such as bicycling, cheerleading, skiing, and snowboarding; organized sports > leisure physical activity
- There are no reported incidences of concussion associated with heading a soccer ball in a 6-year study (5)[B].
- Severity predictor
- Retrograde amnesia is better predictor than LOC for acute neuropsychological deficits (6).
GENERAL PREVENTION
- Educate athletes, coaches, parents, and officials about signs and symptoms of concussions.
- Preparticipation exams to identify risk factors in athletes
- Strength and conditioning (athletes and elderly)
- Rule enforcement in sports (e.g., penalties for spearing or head-to-head contact) and teaching athletes correct sports-specific techniques.
- Protective equipment, such as helmets and mouth guards, decrease injuries but have not been shown to decrease concussion rates.
DIAGNOSIS
HISTORY
- Cognitive signs and symptoms
- Confusion
- Posttraumatic amnesia
- Retrograde amnesia
- Loss of consciousness (LOC, occurs in <10%)
- Disorientation
- Feeling "in a fog,"Ł "zoned out"Ł
- Inability to focus (i.e., difficulty at work or school)
- Delayed verbal and motor responses
- Slurred/incoherent speech
- Excessive drowsiness
- Physical signs and symptoms
- Headache (most common symptom)
- Fatigue
- Disequilibrium, dizziness
- Visual disturbances
- Phonophobia
- Nausea
- Emotional signs and symptoms
- Emotional lability
- Irritability
- Personality changes
- Sleep disturbance
PHYSICAL EXAM
Variable and dependent on acuteness of assessment, degree of injury: á
- ABCs
- Evaluate for C-spine stability and possible serious head injury.
- Assess for focal neurologic signs and symptoms.
- Thorough neurologic exam, including
- State of alertness and orientation
- Cranial nerves
- 3- or 5-word recall at 5 minutes
- Concentration/attention (serial 3s or 7s)
- Cerebellar function (finger-to-nose, gait assessment) and postural stability assessment (Romberg test, single leg balance)
- Deep tendon reflexes
- Extremity strength
DIFFERENTIAL DIAGNOSIS
- Subdural hematoma
- Epidural hematoma
- Cerebral contusion
- Facial or skull fracture
- Seizure
DIAGNOSTIC TESTS & INTERPRETATION
- Serial cognitive and neurologic evaluations should be done by an experienced health care provider. Other assessment tools, such as the sport concussion assessment tool 3 (SCAT3), balance error scoring system (BESS), and computerized neurocognitive testing (CNCT) can also be used. However, a baseline test is needed for comparison, particularly in adolescents.
- CNCT 1 week after concussion consistently shows negative effects on code substitution, visual memory, processing speed, and memory, with young adolescents showing greatest effects (7).
- SCAT3 testing is appropriate for patients >13 years of age. The Child-SCAT3 was developed for children 5 to 12 years of age (8).
- The gold standard is a thorough evaluation and individualized treatment by a trained physician. Studies have not yet validated computerized testing as either improving outcomes or being cost effective.
Initial Tests (lab, imaging)
- C-spine x-rays for midline cervical tenderness, abnormal neurologic findings, or dangerous mechanism. Structural neuroimaging is usually normal in the setting of concussion.
- CT head or MRI is indicated with loss of consciousness, amnesia, focal neurologic deficit, age >65 years, coagulopathy, GCS score <15, seizure, evidence of skull fracture, persistent vomiting, or overall worsening symptoms.
- Various clinical decision rules for imaging exist including the NEXUS and Canadian CT head and C-spine rules and PECARN.
Diagnostic Procedures/Other
- Monitoring for several hours after injury is paramount, as signs and symptoms may worsen.
- EEG testing is not commonly used; however, in studies, electrophysiologic abnormalities have been identified in concussed athletes for days after injury.
TREATMENT
GENERAL MEASURES
- There are no specific treatments for concussion. Current guideline recommends physical and cognitive rest as the mainstays of initial management, but limited evidence.
- Research being done on exercise therapies.
- Sunglasses, ear plugs if needed
- Consider no texting, video games, school, work, play, exercise, or sexual activity until symptoms begin to improve.
- A graded, individualized return to play and return to school/work plan can be initiated after complete resolution of all signs and symptoms (see "Follow-Up Recommendations"Ł).
MEDICATION
- Ibuprofen or acetaminophen may be used for headache once structural brain injury ruled out; limit use to a few days to reduce risk for rebound headache.
- Prolonged symptoms such as sleep disturbance, depression, or anxiety may benefit from appropriate pharmacologic treatment for symptom relief (i.e., SSRIs, amitriptyline, etc.).
- Preclinical animal studies showing potential benefit of DHA (9).
ISSUES FOR REFERRAL
- Most concussions can be managed by primary care physicians; referral to a specialist is not mandatory.
- Patients with prolonged signs and symptoms of concussion, or who have suffered recurrent concussions, should be referred to a sports medicine physician or neurologist for management and clearance prior to returning to sports activities.
SURGERY/OTHER PROCEDURES
Not indicated, unless signs of more severe TBI are present with increased intracranial pressure or large bleeding á
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
ABCs take priority over head injury and concussion. á
- C-spine immobilization should be considered in all head trauma, especially for GCS <15, neck pain or tenderness, or focal neurologic deficit.
- Admit for progressive neurologic symptoms, including deterioration of mental status, seizures, and focal neurologic signs, or when no competent adult at home.
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
- Any athlete with a suspected concussion should not be allowed to return to play on the same day.
- Return to play guidelines: Decisions for athletes should be individualized, graded, and not made without follow-up evaluation(s). This includes the following:
- Complete rest until symptom-free
- Gradual reintroduction of activity as long as symptom-free. Each step should generally be done 24 hours apart (10)[C]:
- Light aerobic exercise
- Sports-specific exercise
- Noncontact training drills
- Full-contact training
- Game play
- If any signs or symptoms recur (i.e., exertional headache, visual disturbance, or disequilibrium), stop all activity until again asymptomatic for 24 hours. Restart return to play protocol at last step that the patient was asymptomatic.
- For student athletes, the period of time away from class and homework should be individualized and symptom-based.
- Athletes at high risk for prolonged recovery include pediatric athletes and athletes with mood disorders, learning disabilities, or migraine headaches. These athletes should have a slower return to play progression and may require more intensive evaluation (formal neuropsychologic, balance, symptom testing).
- Athletes with multiple concussions should have slower return to play and may benefit from sports medicine consultation or neurology referral.
Patient Monitoring
- Written instructions regarding postconcussion management should be given to a competent adult, describing signs to watch for and when to bring the patient back for further evaluation.
- Have a follow-up plan prior to discharge to home, ideally to be seen within a few days.
- Instruct patients and families regarding postconcussive signs and symptoms.
- Ensure adequate cognitive and physical rest and symptom-free return to school, work, and sports-related activities.
- Some states now require specific training in order to provide medical clearance for return to sport after concussion.
COMPLICATIONS
- Subdural hematomas can be present minutes to hours after initial injury, necessitating serial neurologic checks and close observation.
- Second-impact syndrome describes rare but life-threatening cerebral edema that occurs after repeated head injury before the brain has had adequate time to completely recover (highest susceptibility within first 7 to 10 days of initial concussion). The etiology is thought to be due to loss of regulation of either cerebral circulation or glucose metabolism in the concussed brain.
- Recovery can be prolonged or complicated by concussion history, age (youths need more time to heal than adults), and preexisting conditions (migraines, depression, ADHD, anxiety, learning disabilities).
- Postconcussion syndrome occurs when symptoms of concussion, such as headache, fatigue, memory changes, or emotional lability, are persistent and last at least 1 to 3 months or longer.
- Chronic traumatic encephalopathy (CTE) with chronic cognitive, mood, and potential Parkinson-type symptoms is a distinct neurodegenerative disease that may be related to repeated concussions, although causality has not been proven.
REFERENCES
11 Carney áN, Ghajar áJ, Jagoda áA, et al. Concussion guidelines step 1: systematic review of prevalent indicators. Neurosurgery. 2014;75(Suppl 1):S3-S15.22 Zuckerman áSL, Odom áM, Lee áYM, et al. Sport-related concussion and age: number of days to neurocognitive baseline. Neurosurgery. 2012;71(2):E558.33 Meehan áWPIII, Mannix áRC, O'Brien áMJ, et al. The prevalence of undiagnosed concussions in athletes. Clin J Sport Med. 2013;23(5):339-342.44 Daneshvar áDH, Nowinski áCJ, McKee áAC, et al. The epidemiology of sport-related concussion. Clin Sports Med. 2011;30(1):1-17, vii.55 Fuller áCW, Junge áA, Dvorak áJ. A six year prospective study of the incidence and causes of head and neck injuries in international football. Br J Sports Med. 2005;39(Suppl 1):i3-i9.66 Dougan áBK, Horswill áMS, Geffen áGM. Do injury characteristics predict the severity of acute neuropsychological deficits following sports-related concussion? A meta-analysis. J Int Neuropsychol Soc. 2014;20(1):81-87.77 Kontos áAP, Braithwaite áR, Dakan áS, et al. Computerized neurocognitive testing within 1 week of sport-related concussion: meta-analytic review and analysis of moderating factors. J Int Neuropsychol Soc. 2014;20(3):324-332.88 Guskiewicz áKM, Register-Mihalik áJ, McCrory áP, et al. Evidence-based approach to revising the SCAT2: introducing the SCAT3. Br J Sports Med. 2013;47(5):289-293.99 Barrett áEC, McBurney áMI, Ciappio áED. ¤ë-3 fatty acid supplementation as a potential therapeutic aid for the recovery from mild traumatic brain injury/concussion. Adv Nutr. 2014;5(3):268-277.1010 McCrory áP, Meeuwisse áW, Aubry áM, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Phys Ther Sport. 2013;14(2):e1-e13.
ADDITIONAL READING
- Almasi áSJ, Wilson áJJ. An update on the diagnosis and management of concussion. WMJ. 2012;111(1):21-27; quiz 28.
- Garcia-Rodriguez áJA, Thomas áRE. Office management of mild head injury in children and adolescents [in English, French]. Can Fam Physician. 2014;60(6):523-531, e294-e303.
- Grady áMF. Concussion in the adolescent athlete. Curr Probl Pediatr Adolesc Health Care. 2010;40(7):154-169.
- Halstead áME, McAvoy áK, Devore áCD, et al. Returning to learning following a concussion. Pediatrics. 2013;132(5):948-957.
- Halstead áME, Walter áKD, Council on Sports Medicine and Fitness, American Academy of Pediatrics. Clinical report-sport-related concussion in children and adolescents. Pediatrics. 2010;126(3):597-615.
- Herring áSA, Kibler áWB, Putukian áM. Team Physician Consensus Statement: 2013 update. Med Sci Sports Exerc. 2013;45(8):1618-1622.
- Jinguji áTM, Bompadre áV, Harmon áKG, et al. Sport Concussion Assessment Tool-2: baseline values for high school athletes. Br J Sports Med. 2012;46(5):365-370.
- Khurana áVG, Kaye áAH. An overview of concussion in sport. J Clin Neurosci. 2012;19(1):1-11.
SEE ALSO
Traumatic Brain Injury (TBI)-Long Term Care Brain Injury, Traumatic; Postconcussion Syndrome (Mild Traumatic Brain Injury); Seizure Disorders á
CODES
ICD10
- S06.0X0A Concussion without loss of consciousness, initial encounter
- S06.9X0A Unsp intracranial injury w/o loss of consciousness, init
- S06.0X9A Concussion w loss of consciousness of unsp duration, init
- S06.9X9A Unsp intracranial injury w LOC of unsp duration, init
- S06.0X5D Concussion w LOC >24 hr w ret consc lev, subs
- S06.0X5S Concussion w LOC >24 hr w ret consc lev, sequela
- S06.0X6D Concussion w LOC >24 hr w/o ret consc w surv, subs
- S06.0X7A Concussion w LOC w death due to brain injury bf consc, init
- S06.0X7D Concussion w LOC w death due to brain injury bf consc, subs
- S06.0X7S Concuss w LOC w death due to brain injury bf consc, sequela
- S06.0X8A Concussion w LOC w death due to oth cause bf consc, init
- S06.0X8S Concussion w LOC w death due to oth cause bf consc, sequela
- S06.0X6A Concussion w LOC >24 hr w/o ret consc w surv, init
- S06.0X9D Concussion w loss of consciousness of unsp duration, subs
- S06.0X9S Concussion w loss of consciousness of unsp duration, sequela
- S06.0X5A Concussion w LOC >24 hr w ret consc lev, init
- S06.0X8D Concussion w LOC w death due to oth cause bf consc, subs
- S06.0X2A Concussion w loss of consciousness of 31-59 min, init
- S06.0X6S Concussion w LOC >24 hr w/o ret consc w surv, sequela
- S06.0 Concussion
- S06.0X Concussion
- S06.0X0D Concussion without loss of consciousness, subs encntr
- S06.0X0S Concussion without loss of consciousness, sequela
- S06.0X1A Concussion w LOC of 30 minutes or less, init
- S06.0X4S Concussion w LOC of 6 hours to 24 hours, sequela
- S06.0X1S Concussion w LOC of 30 minutes or less, sequela
- S06.0X2D Concussion w loss of consciousness of 31-59 min, subs
- S06.0X2S Concussion w loss of consciousness of 31-59 min, sequela
- S06.0X3A Concussion w loss of consciousness of 1-5 hrs 59 min, init
- S06.0X3D Concussion w loss of consciousness of 1-5 hrs 59 min, subs
- S06.0X3S Concussion w LOC of 1-5 hrs 59 min, sequela
- S06.0X4A Concussion w LOC of 6 hours to 24 hours, init
- S06.0X4D Concussion w LOC of 6 hours to 24 hours, subs
- S06.0X1D Concussion w LOC of 30 minutes or less, subs
ICD9
- 850.9 Concussion, unspecified
- 854.00 Intracranial injury of other and unspecified nature without mention of open intracranial wound, unspecified state of consciousness
- 850.0 Concussion with no loss of consciousness
- 850.5 Concussion with loss of consciousness of unspecified duration
- 850.3 Concussion with prolonged loss of consciousness and return to pre-existing conscious level
- 850.12 Concussion, with loss of consciousness from 31 to 59 minutes
- 850.11 Concussion, with loss of consciousness of 30 minutes or less
- 850.1 Concussion with brief loss of consciousness
- 850.2 Concussion with moderate loss of consciousness
- 850.4 Concussion with prolonged loss of consciousness, without return to pre-existing conscious level
SNOMED
- Concussion injury of brain (disorder)
- traumatic brain injury (disorder)
- concussion with no loss of consciousness (disorder)
- concussion with loss of consciousness (disorder)
- concussion with less than 1 hour loss of consciousness (disorder)
- concussion with 1-24 hours loss of consciousness (disorder)
CLINICAL PEARLS
- Concussions occur from direct or indirect force to the head; loss of consciousness is not required.
- Any athlete with a suspected concussion should not be allowed to return to play on the same day.
- Monitor for several hours after concussion; frequent waking from sleep is controversial, and sleep deprivation can make symptoms worse.
- Complete resolution of concussion symptoms typically spontaneously occurs within 7 to 10 days. Pediatric and adolescent populations, those with certain medical conditions, and those with a previous history of concussion may take more time to fully recover.
- An individualized, graded return to play plan can be initiated after complete resolution of signs and symptoms of concussion. If symptoms recur during any step of the plan, the athlete should postpone activity until asymptomatic for 24 hours.