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Guidelines for treatment of sport-related concussions

Proper recognition, initial management, and long-term clinical decision making are important aspects of treating concussive injury and allowing for a safe return to play.

Chad Martineau, PA-C, ATC; Jackie J. Kingma, MS, ATC, PA-C, PT; Laura Bank, PhD, PA-C; Tamara C. Valovich McLeod, PhD, ATC

Chad Martineau is a PA with Mountain Orthopaedics in Bountiful, Utah. Jackie Kingma is Associate Professor, Athletic Training Program, Department of Interdisciplinary Health Sciences; Laura Bank is Academic Coordinator, Department of PA Studies; and Tamara Valovich McLeod is Assistant Professor, Athletic Training Program, Department of Interdisciplinary Health Sciences; all at the Arizona School of Health Sciences, A.T. Still University, Mesa. The authors have indicated no relationships to disclose relating to the content of this article.

Sport-related concussion is a growing concern among health care providers in all specialties. The CDC reports approximately 300,000 sport-related concussions each year,¹ and some research suggests that these rates may underestimate the actual number of injuries by as much as 50%.^2-4

Several definitions of concussion exist within the literature. The Committee on Head Injury Nomenclature defined concussion as a clinical syndrome characterized by immediate and transient impairment of neural functions due to brain stem involvement.⁵ However, this definition is vague and does not precisely describe the mechanism, onset, or resolution of a concussive injury. An evidence-based definition, proposed at the International Conference on Concussion in Sport in 2001, is more comprehensive in identifying clinical, pathologic, and biomechanical features of concussion⁶ (see Table 1).

Recognizing and diagnosing a concussion can be difficult for a variety of reasons. The signs and symptoms are often vague and inconsistent. Also, symptoms may not appear immediately.^7,8 This delayed onset may put athletes at greater risk for a more serious injury, such as second-impact syndrome, if they are allowed to return to play too soon.

Second-impact syndrome occurs when the athlete sustains a second concussive injury while still recovering from the initial injury or while the athlete is still experiencing symptoms. Athletes are more susceptible to second-impact syndrome because of the inherent risk of a second injury when they return to play. This second injury can occur days or weeks following the primary concussion and can lead to acute brain swelling that results in a mortality rate of close to 50% and a morbidity rate of almost 100%.⁹ Although second impact syndrome is rare, young athletes seem to be at increased risk for it. There are 35 documented cases by the National Center for Catastrophic Sports Injury Research between 1980 and 1993, most of which occurred in athletes younger than 18 years.⁹

Whether the athlete reports the injury is another challenge inherent to concussive injuries.^3,10 Athletes with a concussion may think they can still perform at full capacity, and the fear of being removed from competition will keep them from seeking medical attention. It is easier to hide a concussion than to hide other sport-related injuries. In addition, athletes may not recognize the importance or significance of their symptoms. Thinking the injury is just a “ding,” the athlete may not seek medical attention.^2,3,10 It is important that health-care providers educate athletes that even a blow to the head that results in only a short, stunned, confusional state is a concussion. A recent study showed that athletes who presented with minimal symptoms at the time of injury demonstrated increased symptoms and cognitive deficits 3 days after the injury.¹¹ Thus, the notion that all concussions are potentially serious is substantiated, and all concussions should be managed as such, with clinicians making conservative decisions regarding when an athlete can return to play.

Recently published studies have stressed concerns regarding the effects of recurrent concussions.^7,8,12 This body of research supports the theory that athletes who sustain a concussion may subsequently have a lower threshold for future concussions. In addition, neurologic and cognitive recovery may be slower after subsequent concussions.^8,12 Once an initial concussion is diagnosed, the athlete should then be educated about the inherent risks associated with subsequent concussions. One risk is the potential for decreased cognitive function for months to possibly years after a subsequent injury. However, these findings are not conclusive.¹³

EVALUATION AND MANAGEMENT

A PA may be the first medical professional to examine an athlete who has sustained a concussive injury because the emergency department (ED) or family practice clinic is frequently where a concussion is diagnosed. PAs must be able to recognize the signs and symptoms of a concussion; counsel the patient, parents, and coaches regarding acute symptom monitoring, return-to-play criteria, and the risks of repeat concussions; consult with other medical professionals regarding management and return-to-play decisions; and be familiar with the various guidelines and assessment tools.

Injury recognition At presentation, an athlete may not be experiencing the obvious signs of an acute concussion because many of the signs and symptoms may have already resolved. A thorough history, including the mechanism of injury, any previous concussions, the acute symptoms experienced, and any residual symptoms, is crucial. The clinician may have to question the athlete’s parents, coaches, and teammates regarding objective symptoms they observed. The signs and symptoms of a concussion include, but are not limited to, those presented in Table 2.^6,7,14

Loss of consciousness (LOC) and amnesia are not required to make a diagnosis of concussion.^7,15 While no specific symptoms are required, some symptoms have been recognized as being more serious. Headache lasting for more than 3 hours, difficulty concentrating for more than 3 hours, retrograde amnesia, and LOC are symptoms that may indicate a more serious injury.¹⁶ Athletes with these symptoms should be evaluated for a more serious trauma such as cerebral contusion, intracerebral hematoma, epidural hematoma, acute subdural hematoma, or cervical spine injury. Additionally, PAs should be able to recognize the symptoms of these more serious injuries, including worsening symptoms over time, LOC, cranial nerve deficits, and deterioration in mental status, to rule them out in the differential diagnosis. In these cases, CT is indicated and has been recommended by the American Academy of Pediatrics.¹⁷

Studies performed on collegiate athletes show that headache was the most commonly reported symptom, occurring in 85% to 92% of cases.^8,14 Headache alone may not indicate a concussion; however, the prevalence of headache following a blow to the head should increase suspicion of a concussion. Additionally, a postconcussion headache lasting for more than 7 days has been related to incomplete neurocognitive recovery.¹⁸

Counseling Once the patient has been medically cleared to return home, specific instructions should be given to the patient and/or parents regarding follow-up care and symptom monitoring. Such instructions should be directed toward medications, identifying any symptoms of deterioration, appropriate and inappropriate activities, whether rousing the patient from sleep is needed, and return-to-play criteria. Instructions should make it clear that follow-up evaluations with a medical professional are needed to track the patient’s recovery, to monitor for more serious complications, and to evaluate for a safe return to activity.

A 3-week window from initial injury has been recommended before pharmaceutical interventions are started.¹⁹ Aspirin products and NSAIDs should be avoided in the acute stage because they may enhance any intracranial bleeding and mask some concussion-related symptoms, such as headache. Other medications, such as sleep aids, CNS stimulants, selective serotonin reuptake inhibitors, or anxiolytics, may be used at the discretion of the clinician for symptomatic treatment.^19,20 Care should be taken to ensure that any medications administered do not skew cognitive testing scores, should these tests be used as part of the recovery and return-to-play decision-making process.

The patient and/or parents should be instructed to be aware of and monitor for any symptoms that may indicate a deteriorating condition. Such symptoms may include increasing headache, vomiting, and a change in the level of consciousness. If the athlete has experienced LOC or amnesia or is currently experiencing symptoms, he or she should be awakened every 3 to 4 hours to monitor any symptom changes.⁷ All patients should be instructed to go to the ED if symptoms worsen, as the worsening symptoms may be a sign of a more serious injury.

The PA should discuss with the patient and/or parents which types of activities are inappropriate. Activities that should be avoided include those that place the athlete at risk for further head injury, will elevate the heart rate, and require moderate to high levels of cognition. These activities may exacerbate postconcussion symptoms. Rest is good, but excessive sleep should be avoided,⁷ and a return to normal activities of daily living is encouraged. Recent literature identifies a need for cognitive rest among children while they are still symptomatic.²⁰ This may include avoiding any difficult testing or other cognitive activities that may delay recovery. Recommendations should be individualized, so it may be wise to discuss each upcoming activity to assess whether an appropriate amount of cognitive rest can be achieved. This may or may not include absence from school. In addition, an athlete’s school grades may decline during the semester in which they sustained the concussion. However, if grades continue to decline or do not improve in subsequent semesters, referral to a neuropsychologist is indicated.

Consultations with other medical professionals The PA should understand and be familiar with the other medical professionals who may be involved in managing the patient with a sport-related concussion. If the athlete has a certified athletic trainer (AT) who covers the particular school and/or team, the AT should be consulted regarding the athlete’s injury and care.

The AT and/or team physician can be a valuable resource regarding the mechanism of injury, immediate signs and symptoms, and previous care rendered. The AT may be familiar with the athlete’s personality and other habits that will help in the evaluation of any postconcussive symptoms. The AT may also have preseason baseline scores that can be compared to scores indicating the athlete’s current status. Other medical professionals who may be valuable consultants include a neurologist, who can help manage any persistent signs and symptoms and sleep disturbances, and a neuropsychologist, who can help with any extensive cognitive testing and return-to-school difficulties.⁷

Assessment of recovery Many times the athlete who has experienced a concussion will have to be cleared to return to play by a physician or PA. It is imperative to understand the return-to-play guidelines before clearing an athlete for full participation. Several postconcussive symptom scales are available as references; the AT, PA, and physician should agree on which one to use and use that one consistently.^6,7

Concussion grading scales have effectively raised awareness of concussive injuries and have promoted further research, but few scales are evidence-based and some have been found to over emphasize LOC.^7,15 Additionally, the use of adjunct assessment tools such as graded symptom scales, neurocognitive testing, and balance testing may provide better recovery indicators and allow for a more objective return-to-play decision. The most commonly used concussion grading scales are presented in Table 3.

RETURN-TO-PLAY PROGRESSION

Although several return-to-play guidelines exist, the return-to-play process should begin only after the athlete is asymptomatic, regardless of the scale used (see “Table. Common return-to-play guidelines” only in the online version of this article). A recurring recommendation made throughout many guidelines is that in an absence of objective data (balance and neuropsychological testing) athletes should wait 7 days, beginning on the first asymptomatic day, before attempting to return to play.⁷ This waiting period will help reduce the risk of recurrent concussions and, possibly, second-impact syndrome.

When an AT is not available to guide the athlete through a progressive workout program, the PA may need to rely on parents and coaches to help with this process. The specifics of a progressive workout program should be individualized to each athlete. In general, the program should begin with light exercise and progressively work up to sport-specific activities, leading up to game participation. Figure 1 illustrates the return-to-play progression for high school athletes endorsed by the National Federation of State High School Associations.²¹ After each step in the progression, the athlete should be reevaluated to determine whether symptoms reappear with the increase in activity. If symptoms reappear, the athlete is now symptomatic and must remain out of activity until they again become asymptomatic and can again attempt to follow the return-to-play progression.

PAs should also be familiar with the variety of assessment tools for concussive injuries, as more and more ATs are using them at the high-school level for baseline testing and postconcussion assessments. Such tools include balance testing, neuropsychological testing, and mental-status tests such as the Standardized Assessment of Concussion (SAC).^7,22,23 Ideally, athletes are tested in an uninjured state during the preseason, and their baseline scores on each of these tools are recorded. Postinjury comparisons with the baseline scores can then be used as an indicator of recovery.

Balance testing is commonly used to evaluate the postural stability of an athlete after sustaining a concussion. Studies into the effects of concussion on postural stability initially assessed balance with instrumented force platforms. These studies noted deficits in postural stability from 1 to 3 days postinjury.^14,24 It is thought that postural stability deficits are the result of concussed athletes not being able to effectively use their visual system to aid in balance.²⁴

Since instrumented force platforms are expensive and often not available to many health-care professionals, the Balance Error Scoring System (BESS) was developed as a clinical measure of balance to assess athletes following a concussion. The BESS consists of a series of clinical balance tests that use different Romberg positions on firm and foam surfaces (see Figure 2).²⁵ As the athlete attempts to maintain balance, errors are scored for compensatory motions such as opening the eyes, lifting hands off the hips, or stepping to maintain balance. Error scores can then be tracked to quantify improvement during the recovery process. The BESS has demonstrated excellent reliability compared to force platform measures²⁶ and can be scored with excellent intertester and intratester reliability.^26,27 Studies of concussed athletes utilizing the BESS have also found postural stability deficits through 3 days postinjury,²⁵ mirroring those previously done with instrumented equipment.

Neuropsychological testing is becoming more common in sports medicine as a means to assess cognitive function following a concussion. While most clinicians are accustomed to the lengthy tests that are performed by neuropsychologists, the batteries used for the assessment of sport-related concussion often last only 20 to 30 minutes.²⁸ These batteries are either paper-and-pencil tests or computerized tests, some of which have been developed specifically for sport concussion.^29-31 Sport-concussion batteries focus on assessing the domains of the brain that are often affected by concussion, including verbal and visual memory, attention, processing speed, reaction time, and continuous learning.²⁸

Neuropsychological testing is often performed during the preseason to establish baseline cognitive scores for each athlete and is repeated following a concussion to determine the severity of cognitive deficits as well as to track recovery. Although the computerized neuropsychological tests can be administered by ATs or team physicians and printed reports of the athlete’s current scores compared with the baseline scores, these tests should be interpreted by someone who is trained to do so, such as a neuropsychologist.³² Additionally, athletes who suffer from prolonged symptoms or a delayed recovery should be referred to a neuropsychologist for more formal testing and treatment. Despite some concerns regarding the validity of neuropsychological testing for sport concussion,³³ it is a valuable tool that can be used in conjunction with other assessment tools and sound clinical judgment.^6,7

While neuropsychological testing is often used in the later stages of recovery and as an aid when making return-to-play decisions, mental status testing is often conducted on the sideline to aid in recognizing the concussion. The SAC is a mental status test used to assess the athlete’s orientation, immediate memory, exertional deficits, neurologic deficits, concentration, and delayed memory and is most sensitive in acute injury (within the first 48 hours).²² The SAC takes about 5 minutes to administer and can be done without specialized training. There are three alternate versions of the SAC that can be used to help eliminate the practice effects of each test. Studies using the SAC have noted deficits in mental status during the first 48 hours after a concussive injury occurs.^22,23 Recently, the Concussion in Sport Group advocated using a similar tool, the Sideline Concussion Assessment Tool;²⁰ however, there have been no studies assessing the measurement properties of this tool or investigations involving concussed athletes.

CONCLUSION

Sport-related concussion is a growing concern among health-care providers. As the number of people participating in sports activities continues to increase, health care providers must be able to recognize, evaluate, and treat this unique injury. Additionally, PAs and other health-care providers need to be sensitive to the subtle and minor symptoms of concussion. PAs should be familiar with the various assessment tools available and with the other professionals who can be consulted or may be involved in delivering appropriate care to the athlete. As sport-related concussions become more widely recognized and managed in a more uniform manner, it becomes more likely that potentially disastrous short- and long-term effects can ultimately be avoided.

REFERENCES

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