Sport-related concussion: Evaluation and management Flashcards
What is a concussion?
“A complex pathophysiological process affecting the brain, induced by biomechanical forces” and resulting “in the rapid onset of short-lived impairment of neurological function that resolves spontaneously”
A functional brain injury caused by either a direct impact to the head/neck or somewhere else in the body that transmits an impulsive force to the head.
What are the physical, behavioural and cognitive signs and symptoms of a concussion?
Physical: headache, N/V, dizziness/poor balance, visual disturbance, photo/phonophobia, LOC, amnesia
Behavioural: irritable, emotionally labile or inappropriate, sad, anxious
Cognitive: slowed reactions, poor concentration or memory, confusion, feeling dazed
Sleep disturbance
*May develop in minutes/hours or days, lasting 7-10 days in adolescents or weeks/months in younger children
What is a rare but fatal complication of head injury in children?
Fatal diffuse cerebral swelling = malignant brain edema syndrome = second-impact syndrome
Believed to be caused by a loss of autoregulation in the brain’s blood supply, causing rapid cerebrovascular congestion and increased ICP –> herniation, coma, death
What questions should you ask on PMHx/FHx in a patient who has a concussion?
Previous head and facial injuries (including diagnosed concussions)
History of headaches or migraines in the patient and in the family
Mental health issues
Sleeping difficulties
Learning disabilities or ADHD.
*The presence of these factors may identify patients at higher risk for prolonged recovery.
How should a child be evaluated/monitored within the first 24-48 hours after a concussion?
ABCs, if LOC use C-spine precautions
Assess for signs/symptoms
Medical (including neuro/cognitive) evaluation
NO return to sport until symptom-free and medically cleared (can have impaired response time/attention increasing risk of a second injury)
Close monitoring by a responsible adult for 24-48 hours for signs of deterioration (eg, severe headache, persistent vomiting, seizure activity). Sleep is important for recovery; therefore, a child or youth with concussion should be checked throughout the night but not awakened unless there is concern about deterioration –> ER
What are the indications for head imaging and neuropsychological testing (NPT)?
Head imaging only if structural injury is suspected (focal neuro deficit, seizure, prolonged LOC)
NPT with repeated clinical assessment can help guide return-to-play. Indicated if persistent symptoms, history of multiple concussions, PMHx of LD/ADHD. Routine baseline testing in athletes is not recommended (rapid cognitive development in kids means you’d need to repeat q6mos!).
What are the key principles of concussion management?
*Physical rest
*Cognitive rest (limiting activities that require mental exertion, including reading, texting, screen time and school)
Medications have not been studied. Tylenol/Advil might reduce symptom severity and duration post-concussion. Theoretical risk of bleeding with NSAIDs. Athletes should not take medications that can mask the signs/symptoms of concussion when returning to play
*decreases symptoms and improves performance on neuropsychological tests.
Describe return-to-learn (RTL)
Graduated protocol, advance as symptoms improve:
- Cognitive rest
- Increase cognitive tasks at home: 15-20 minute blocks.
- Modified school attendance: half-days, avoid gym/music, 15-20 minute blocks of homework
- Increased school attendance: to full days, may need accomodations like frequent breaks, reduced workload, quiet area
- Return-to-play: full return to academics must precede return to sports.
- If a prolonged absence from school (more than a couple of weeks) is necessary due to persistent symptoms, referral to a specialist with expertise in concussion, as well as a neuropsychologist, may be required.
- If symptoms worsen at any stage, decrease activity until they improve.
Describe return-to-play (RTP)
Graduated protocol, advance a minimum of every 24 hours only if symptom free:
- No activity: physical and cognitive rest until symptom free (ideally for 7-10 days)
- Light aerobic exercise: walk, swim, stationary bike to increase HR
- Sport-specific exercise: drills without impact
- Non-contact training drills: more complex drills, progressive resistance training
- Full contact practice after medical clearance
- RTP: normal game play
*If any symptom recurs, the individual should rest until it resolves (24-48 hours minimum) before trying again, starting with the last step at which they were asymptomatic.
What should you do if a child has persistent symptoms (weeks/months) post-concussion?
Multidisciplinary team management with expertise in concussions, may need formal neuropsychological testing and targeted treatments (i.e. physiotherapy for neck pain, sleep hygiene, lifestyle adjustments, prophylactic migraine medications, mental health referral)
What can we do to prevent concussions?
Ensure children wear approved helmets that are well-fitted
Coaches can ensure players learn appropriate techniques (i.e. heading, tackling, bodychecking) and foster good sportsmanship
Enforce sports rules and advocate for rule changes (i.e. CPS supports extending fighting ban to all junior league hockey)
Educate athletes, families, teachers, coaches on signs/symptoms of concussion and appropriate management
