Sport-related concussion: Evaluation and management

Question 1

What is a concussion?

Answer 1

A brain injury defined as “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.”

Question 2

What are symptoms/physical signs of concussion?

Answer 2

Headache
Nausea/vomiting
Dizziness
Visual disturbances
Photophobia
Phonophobia
Loss of consciousness
Amnesia
Loss of balance or poor coordination
Decreased playing ability

Question 3

What are behavioral changes with sport-related concussion?

Answer 3

Irritability
Emotional lability
Sadness
Anxiety
Inappropriate emotions

Question 4

What are features of cognitive impairment seen with sport-related concussion?

Answer 4

Slowed reaction times
Difficulty concentrating
Difficulty remembering
Confusion
Feeling in a fog
Feeling dazed

Question 5

What are features of sleep disturbances seen with sport-related concussion?

Answer 5

Drowsiness
Trouble falling asleep
Sleeping more than usual
Sleeping less than usual

Question 6

What is malignant brain edema syndrome or second-impact syndrome?

Answer 6

Fatal diffuse cerebral swelling a rare complication of head injury in children and adolescents. Caused by a loss of autoregulation in the brain’s blood supply, causing rapid cerebrovascular congestion and increased intracranial pressure, with progression to brain stem herniation, coma, and death

Question 7

What patients are at higher risk for prolonged recovery?

Answer 7

1. Previous head and facial injuries (including diagnosed concussions)
2. History of headaches or migraines in the patient and in the family
3. Mental health issues
4. Sleeping difficulties
5. Learning disabilities or ADHD

Question 8

What are recommendations regarding initial monitoring of a concussed athlete?

Answer 8

1. Monitor by a responsible adult, ideally parent, for 24-48h for signs of deterioration:
   a) severe headaches
   b) persistent emesis
   c) seizure activity
2. Check throughout the night but do not wake unless concern about deterioration:
   a) emesis
   b) seizure activity
   c) difficulty breathing
3. Signs of deterioration require immediate evaluation in ED

Question 9

What assessment tools are available for medical evaluation of concussions in athletes?

Answer 9

1. Sport Concussion Assessment Tool 3 (SCAT3) for >13yo

2. Child-SCAT3 5-12yo

Question 10

What are the recommendations regarding diagnostic imaging for concussion?

Answer 10

1. Routine structural neuroimaging is not recommended unless a structural injury is suspected
2. Specialized imaging techniques (i.. PET, fMRI) may demonstrate physiological and functional abnormalities with concussion but are not routinely available or recommended

Question 11

What are the recommendations regarding neuropsychological testing (NPT) for concussion?

Answer 11

1. Routine baseline testing in children is not recommended given their rapid cognitive development
2. NPT should only be used in combination with repeated clinical assessment
3. Age-appropriate, detailed NPT by a trained neuropsychologist may be necessary for athletes who have sustained multiple concussions and/or who experience prolonged postconcussive symptoms, to identify specific cognitive deficits and, possibly, aid in educational planning

Question 12

What are the recommendations regarding medications for concussion?

Answer 12

Usually not recommended. NSAID have a theoretical bleeding risk.
Do not take medications that can mask signs or symptoms of concussion when returning to play
May require medications for specific, prolonged symptoms

Question 13

What is the graduated return to learn protocol?

Answer 13

1. Cognitive Rest: Decrease and limit cognitive tasks and screen time at home. No school.
2. Increase cognitive tasks: As symptoms improve, slowly increase cognitive tasks at home in 15 min to 20 min increments.
3. Resume modified school attendance: As symptoms continue to improve, resume school attendance. Start with half-days or only certain classes (avoid gym, music, shop). Limit homework assignments to 15 min to 20 min blocks.
4. Increase school attendance: Gradually increase school attendance to full days as symptoms allow. Specific accommodations may be required to avoid symptom exacerbation. Tests should be limited to one per day in a quiet area, with unlimited time and frequent breaks.
5. Return to Play protocol: Once symptom-free and back to full-time school attendance without accommodations, the student can start with graduated return to play

If symptoms worsen at any stage, decrease activity until they improve

Question 14

What are some academic accommodations for concussed students?

Answer 14

1. Headache –> difficulty concentrating: frequent breaks, quiet area, hydration
2. Fatigue –> decreased attention, concentration: Frequent breaks, shortened day, only certain classes
3. Photophobia/Phonophobia –> worsening symptoms (headache): Sunglasses, ear plugs or headphones, avoid noisy areas, limit computer work
4. Anxiety –> decreased attention or concentration, overexertion to avoid falling behind
5. Difficulty concentrating –> limited focus on school work: Shorter assignments, decreased workload, frequent breaks, having someone read aloud, more time to complete assignments and tests, quiet area to complete work
6. Difficulty remembering –> Difficulty retaining new information, remembering instructions, accessing learned information: Written instructions, smaller amounts to learn, repetition

Question 15

What is the Graduated Return to Play protocol for athletes with concussion?

Answer 15

1. No activity: symptom limited physical and cognitive rest until symptom free for several days (optimal 7-10d)
2. Light aerobic exercise: Walking, swimming or stationary cycling. No resistance training.
3. Sport specific exercise: skating drills in ice hockey or running drills in soccer. No impact activities
4. Non-contact training drills: Progression to more complex training drills
   May start progressive resistance training
5. Full contact practice: Following medical clearance, participate in normal training activities
6. Return to play: Normal game play

Question 16

What are modifying factors in concussion management?

Answer 16

1. Younger age
2. History of multiple concussions
3. LD
   4, ADHD

Question 17

When should consideration be given to retiring from a particular sport or changing to a less risky position to reduce risk of recurrent head injury ?

Answer 17

When a concussion:

1. occurs with less force;
2. results in more severe symptoms;
3. is more likely because of an athlete’s playing style, position or sport
4. occurs in the setting of a concomitant learning disability or persistent cognitive symptoms

Question 18

What are targeted treatment for persistent postconcussion headache?

Answer 18

Lifestyle adjustments (proper hydration, adequate sleep, regular exercise)
Avoidance of acetaminophen/ibuprofen overuse
Prophylactic medications (eg, for migraines)
Neurology referral

Question 19

What are targeted treatment for persistent postconcussion neck pain?

Answer 19

PT

Question 20

What are targeted treatment for persistent postconcussion balance problems/dizziness?

Answer 20

Vestibular rehabilitation

Question 21

What are targeted treatment for persistent postconcussion sleep disturbances?

Answer 21

Sleep hygiene reinforcement

Medications (eg, melatonin)

Question 22

What are targeted treatment for persistent postconcussion depression/anxiety?

Answer 22

Referral to a mental health professional; addressing social isolation or withdrawal
Medications

Question 23

How can concussions be prevented?

Answer 23

1. Learn and practice proper sport techniques
2. Foster atmosphere of respect, fair play, and good sportsmanship
3. Helmets do not prevent concussion
4. Discourage boxing
5. Reform hockey rules

Question 24

What are the CPS recommendations concerning the evaluation and management of sport-related concussion in children and adolescents?

Answer 24

1. An athlete who has sustained a head injury during sport should be removed from play immediately and not allowed to return to play (RTP) that day. The athlete should be closely monitored for any signs of deterioration and should not be left alone.
2. An athlete who sustains a head injury should be medically evaluated as soon as possible.
3. Diagnostic imaging is not routinely recommended unless a structural injury is suspected.
4. A concussed athlete should rest, physically and cognitively, until all symptoms have resolved.
5. A temporary absence from school, followed by a gradual return, may be necessary after a concussion. Academic accommodations may be needed until symptoms resolve.
6. Return to learn should precede return to sport.
7. Only after an athlete has been symptom free for seven to 10 days and has fully returned to school should she or he begin a medically supervised, stepwise RTP protocol.
8. RTP decisions for paediatric athletes should be conservative, cautious and individualized.
9. Athletes who have concussions with modifying factors or prolonged symptoms may require management by a multidisciplinary team including physicians with specific concussion expertise.

Question 25

What does the CPS recommend regarding concussion prevention?

Answer 25

1. Approved helmets should be worn in all contact sports and activities in which there is a risk for head injury. Protective equipment should be well fitted, properly worn, well-maintained and replaced according to manufacturers’ recommendations.
2. Athletes should be taught appropriate skills and techniques as well as good sportsmanship to help reduce injuries.
3. Sport rule changes that decrease the risk and incidence of concussive injuries should be adopted and enforced by sporting organizations and officials.
4. Anyone involved with child and youth sport, including athletes, parents, coaches or trainers, teachers and officials, should be educated regarding the signs and symptoms of sport-related concussion.
5. Medical school and paediatric residency curriculums should include concussion education.
6. All provinces and territories should require by statute that regional sporting associations and school boards have a written policy on concussion recognition and management.

Question 26

How should physicians advocate for their patients?

Answer 26

1. Discouraging participation in sports that involve intentional blows to the head, such as boxing.
2. Educating coaches and trainers, parents, athletes, school staff and policy makers in sport about the signs and symptoms of concussion and the need for a medical evaluation and clearance before an injured athlete returns to play.
3. Supporting the mandate that all coaches and trainers in sports organizations be educated about concussion risks, recognition and management.
4. Supporting the development of policies on concussion in schools and sports organizations.
5. Supporting legislation to make wearing a certified helmet mandatory for sports and activities for which there is a significant risk of head injury.
6. Urging researchers and manufacturers to develop and improve protective equipment.