Is It a Concussion?

Pediatric Pathways

Is It a Concussion?

Author

American Family Children's Hospital Pediatric Pathways: Dr. Greg Landry

Greg Landry, MD

Our Services

Sports Medicine

After reading this article and answering the review questions the reader will be able to:

  1. Diagnose concussions
  2. Treat the concussed athlete
  3. Provide return to play criteria for patients

Case Sam, a 16-year-old snowboarder, is brought to your office by his mother because she is worried he might have a concussion. Sam states that he fell yesterday on the slopes and hit the back of his head. He was wearing his helmet. He was a little stunned, but did not lose consciousness. He had a mild headache and some dizziness but he kept snowboarding. This morning he still has a headache, mild nausea, and is sensitive to light and noise. His mother asks you if Sam has a concussion.

Diagnosing Concussion

The subject of concussions in athletes has received a lot of media attention in the past few years. Because of all the publicity, athletes and their families are more aware of the problem and are more likely to seek help from their primary care provider when suffering a head injury. There are still some old textbooks that define a concussion as loss of consciousness due to head trauma, but it is now well known that an athlete can suffer a concussion without any loss of consciousness. It is estimated that about 90% of all concussions in athletes occur without any loss of consciousness. There are more complex definitions of concussion, but a simple one is any loss of mentation due to a traumatic event. Sometimes the concussion occurs with very little trauma to the head. The brain gets injured due to rapid acceleration and deceleration forces, which cause rapid movement of the brain within the skull. So the answer to mom’s question about her snowboarder is yes, he has sustained a concussion.

Athletes may not realize or won’t admit when they are injured. Fortunately, coaches and parents are aware of this and are getting better at identifying the concussed athlete. On the playing field, it is important for coaches, parents, and other players to be on the alert for athletes who are impaired, especially when there has been a significant blow to the head. If an athlete has any symptoms of a concussion, he must stop playing or practicing and rest. It is now required in Wisconsin that any athlete who is concussed be evaluated by a medical professional. This is sometimes the school’s athletic trainer, but can be any health professional who is familiar with the management of concussions.

When you see an athlete in the office, it important to ask the athlete if he remembers what happened. If he is having trouble remembering how it happened and events after the concussion, he has antegrade amnesia. It is also helpful to find out if he remembers events earlier in the day. If he can’t remember events earlier in the day, he has retrograde amnesia. Retrograde amnesia usually signifies a more severe concussion. It is important to find out if the athlete has had previous concussions, noting the severity and duration of the symptoms. In our office, we often use a symptom checklist (Figure 1) since the number of symptoms is variable and each athlete’s concussion tends to cause different symptoms. It also appears that athletes are more honest using a written score sheet than with verbal responses. These symptoms are not specific to a concussion, so it is important to ask the athlete if the symptoms reported are normal for him. We use a 0 to 6 scale with 0 meaning “no symptom” and 6 meaning “the worst you ever have had.” The total symptom score is also helpful in following athletes with a concussion to make sure there is improvement over time.

Figure 1: Concussion Symptom Checklist (score 0-6, with 0 meaning that symptom absent and 6 the worst ever)

Patient Name: __________________________

Date: _________________________________

Symptom Score
Headache   
Nausea   
Vomiting   
Balance problems   
Dizziness   
Fatigue   
Trouble falling asleep   
Sleeping more than usual   
Sleeping less than usual   
Drowsiness   
Sensitivity to light   
Sensitivity to noise   
Irritability   
Sadness   
Nervousness   
Feeling more emotional   
Numbness and tingling   
Feeling slowed down   
Feeling mentally “foggy”  
Difficulty concentrating   
Difficulty remembering   
Visual problems  
Total Symptoms Score=  

 

Sam completes a symptom checklist and reports a 2/6 headache, 2/6 nausea, 1/6 not getting enough sleep, 1/6 for sensitivity to light, 1/6 sensitivity to noise, 1/6 difficulty concentrating, and 1/6 feeling mentally “foggy.” His total symptom score is 9. He confirms that these symptoms are new for him. His neurological examination is normal. Should Sam get a head CT? The answer is no.

The vast majority of sports concussions are not associated with any anatomic change but rather they are due to functional disturbances in the brain. CT and MRI imaging are almost always normal. It was not until researchers examined functional tests like functional MRI or PET scans that abnormalities were detected. Imaging is indicated when there are focal findings on neurological examination or the athlete is having significant worsening of symptoms over time.

A good neurological examination should be performed with emphasis on balance and coordination. In most concussions the physical examination is totally normal. Simple cognitive tasks are helpful such as months of the year in reverse or having the athlete memorize 4 nonsensical items and report the list back in a few minutes. Serial sevens (100 minus 7, minus 7, etc.) were found to be difficult for 50% of uninjured high school students so should be used with caution. Ninety percent of these same students were able to do the months in reverse.

Treatment of Concussion and Return to Activity

There is general consensus in the sports medicine community that any athlete who currently has symptoms from a concussion, needs to refrain from exercise. This was also the recommendation of the 3rd International Conference on Concussion in Sport held in Zurich in 2008. The initial treatment should be physical as well as cognitive rest. For example, if a high school football player sustains a concussion on a Friday night, he should go home, go to bed, and stay in his bedroom for the rest of the weekend. If still very symptomatic on Monday, he should not go to school. Athletes will often report that symptoms are made worse not only from physical stress but cognitive stress as well. Activities causing potential cognitive stress include video screen activities as well as texting. Sometimes the student will need to go to school to see if he can be productive and to see if the schoolwork makes the symptoms worse. If there is a significant worsening of symptoms, he should go home. Acetaminophen or ibuprofen can be taken as needed for a headache. If the athlete is sleepy, he should be allowed to sleep and there is no need to wake him during the night.

The treatment of concussions is a “wait and see” approach. The amount of time required to fully recover from a concussion is highly variable and there is no way to predict in any given athlete how long it will take. Recent studies have shown that the athlete who reports feeling “mentally foggy” or dizzy will tend to be symptomatic longer than other concussed athletes. There is evidence that high school athletes take longer to recover than college athletes and that females take longer than males. There is no clear explanation for these findings. There are a number of concussion grading scales in the literature, but experts now recommend that we abandon those scales as none were evidence-based and should not alter treatment.

Back to our case: The plan for Sam will be to follow his symptoms daily and ask him not to exercise until he is symptom-free. When his symptoms are gone, he will be asked to increase his physical activity in a stepwise fashion (Figure 2).

Figure 2: Graduated return to play protocol

Rehabilitation Stage Functional exercise at each stage of rehabilitation Objective 
1. No activity Complete physical and cognitive rest Recovery
2. Light aerobic exercise Walking, swimming or stationary cycling, keeping intensity <70% MPHR. No resistance training. Increase heart rate 
1. No activity Complete physical and cognitive rest Recovery
2. Light aerobic exercise Walking, swimming or stationary cycling, keeping intensity <70% MPHR. No resistance training. Increase heart rate 
3. Sport-specific exercise kating drills in ice hockey, running drills in soccer. No head impact activities. Add movement
4. Non-contact training drills Progression to more complex training drills (e.g. passing drills in football and ice hockey). May start progressive resistance training). Exercise, coordination, cognitive load
5. Full contact practice Following medical clearance, participate in normal training activities Restore confidence, assessment of functional skills by coaching staff
6. Return to play Normal game play NA

First released by the Canadian Academy of Sport Medicine, the plan for return to activity has been endorsed by other groups including the 3rd International Conference on Concussion in Sport. On the first day back, the athlete should do some light aerobic exercise like jogging or a stationary bike workout. If any of the symptoms return, the athlete should stop exercising and start over the next day. If there are no symptoms, the athlete may progress to more intense exercise. In general, each step should take 24 hours, so the return to play protocol should take 6 days. This is not an evidence-based recommendation and experienced practitioners will sometimes compress the timeline especially with adult athletes.

Since the neurological examination is normal, the practitioner has to rely on self-report of symptoms. This is a problem because athletes will lie in order to be allowed to play. To address this problem, short computerized neuropsychological examinations have been developed to allow non-neuropsychologists to assess more complex brain functions that may be affected by a concussion. The most popular product in the United States was developed in Pittsburgh and is called ImPACT for Immediate Post-concussion Assessment and Cognitive Testing. ImPACT examines memory, processing speed, reaction time and distractibility. Used in professional and college sports for over 10 years, this testing is now becoming available to high school and middle school athletes. In general, ImPACT testing is most helpful when the athlete is asymptomatic and evidence is desired that his function is back to normal. We generally do not do ImPACT testing when the athlete is still symptomatic as the stress of this 20 minute examination can make symptoms worse.

Case Follow-up

Sam’s mother is not sure if her insurance plan will pay for ImPACT testing so she passes on the offer to do ImPACT testing for Sam. Sam decides to return to school and has no exacerbation of his symptoms. Seven days after the concussion, Sam states he is back to normal. He is then asked to begin light exercise and progress as long as his symptoms do not recur. After several days of running, doing sit-ups and push-ups, as well as weight lifting with no symptoms, Sam is allowed to return to snowboarding.

Go to CME Questions

References

  1. Herring SA, Cantu RC, Guskiewicz KM, Putukian M, Kibler WB: Concussion (Mild Traumatic Brain Injury) and the Team Physician: A Consensus Statement – 2011 Update. Med Sci Sports Exerc 2011; 43(12):2412-2422
  2. 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 Switzerland Nov 2008 Br J Sports Med 2009;43:i76-84.
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