Sport-related concussion: Evaluation and management Flashcards
What is a concussion?
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.”
What are symptoms/physical signs of concussion?
Headache Nausea/vomiting Dizziness Visual disturbances Photophobia Phonophobia Loss of consciousness Amnesia Loss of balance or poor coordination Decreased playing ability
What are behavioral changes with sport-related concussion?
Irritability Emotional lability Sadness Anxiety Inappropriate emotions
What are features of cognitive impairment seen with sport-related concussion?
Slowed reaction times Difficulty concentrating Difficulty remembering Confusion Feeling in a fog Feeling dazed
What are features of sleep disturbances seen with sport-related concussion?
Drowsiness
Trouble falling asleep
Sleeping more than usual
Sleeping less than usual
What is malignant brain edema syndrome or second-impact syndrome?
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
What patients are at higher risk for prolonged recovery?
- 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
What are recommendations regarding initial monitoring of a concussed athlete?
- Monitor by a responsible adult, ideally parent, for 24-48h for signs of deterioration:
a) severe headaches
b) persistent emesis
c) seizure activity - Check throughout the night but do not wake unless concern about deterioration:
a) emesis
b) seizure activity
c) difficulty breathing - Signs of deterioration require immediate evaluation in ED
What assessment tools are available for medical evaluation of concussions in athletes?
- Sport Concussion Assessment Tool 3 (SCAT3) for >13yo
2. Child-SCAT3 5-12yo
What are the recommendations regarding diagnostic imaging for concussion?
- Routine structural neuroimaging is not recommended unless a structural injury is suspected
- Specialized imaging techniques (i.. PET, fMRI) may demonstrate physiological and functional abnormalities with concussion but are not routinely available or recommended
What are the recommendations regarding neuropsychological testing (NPT) for concussion?
- Routine baseline testing in children is not recommended given their rapid cognitive development
- NPT should only be used in combination with repeated clinical assessment
- 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
What are the recommendations regarding medications for concussion?
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
What is the graduated return to learn protocol?
- Cognitive Rest: Decrease and limit cognitive tasks and screen time at home. No school.
- Increase cognitive tasks: As symptoms improve, slowly increase cognitive tasks at home in 15 min to 20 min increments.
- 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.
- 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.
- 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
What are some academic accommodations for concussed students?
- Headache –> difficulty concentrating: frequent breaks, quiet area, hydration
- Fatigue –> decreased attention, concentration: Frequent breaks, shortened day, only certain classes
- Photophobia/Phonophobia –> worsening symptoms (headache): Sunglasses, ear plugs or headphones, avoid noisy areas, limit computer work
- Anxiety –> decreased attention or concentration, overexertion to avoid falling behind
- 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
- Difficulty remembering –> Difficulty retaining new information, remembering instructions, accessing learned information: Written instructions, smaller amounts to learn, repetition
What is the Graduated Return to Play protocol for athletes with concussion?
- No activity: symptom limited physical and cognitive rest until symptom free for several days (optimal 7-10d)
- Light aerobic exercise: Walking, swimming or stationary cycling. No resistance training.
- Sport specific exercise: skating drills in ice hockey or running drills in soccer. No impact activities
- Non-contact training drills: Progression to more complex training drills
May start progressive resistance training - Full contact practice: Following medical clearance, participate in normal training activities
- Return to play: Normal game play
What are modifying factors in concussion management?
- Younger age
- History of multiple concussions
- LD
4, ADHD
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 ?
When a concussion:
- occurs with less force;
- results in more severe symptoms;
- is more likely because of an athlete’s playing style, position or sport
- occurs in the setting of a concomitant learning disability or persistent cognitive symptoms
What are targeted treatment for persistent postconcussion headache?
Lifestyle adjustments (proper hydration, adequate sleep, regular exercise) Avoidance of acetaminophen/ibuprofen overuse Prophylactic medications (eg, for migraines) Neurology referral
What are targeted treatment for persistent postconcussion neck pain?
PT
What are targeted treatment for persistent postconcussion balance problems/dizziness?
Vestibular rehabilitation
What are targeted treatment for persistent postconcussion sleep disturbances?
Sleep hygiene reinforcement
Medications (eg, melatonin)
What are targeted treatment for persistent postconcussion depression/anxiety?
Referral to a mental health professional; addressing social isolation or withdrawal
Medications
How can concussions be prevented?
- Learn and practice proper sport techniques
- Foster atmosphere of respect, fair play, and good sportsmanship
- Helmets do not prevent concussion
- Discourage boxing
- Reform hockey rules
What are the CPS recommendations concerning the evaluation and management of sport-related concussion in children and adolescents?
- 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.
- An athlete who sustains a head injury should be medically evaluated as soon as possible.
- Diagnostic imaging is not routinely recommended unless a structural injury is suspected.
- A concussed athlete should rest, physically and cognitively, until all symptoms have resolved.
- A temporary absence from school, followed by a gradual return, may be necessary after a concussion. Academic accommodations may be needed until symptoms resolve.
- Return to learn should precede return to sport.
- 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.
- RTP decisions for paediatric athletes should be conservative, cautious and individualized.
- Athletes who have concussions with modifying factors or prolonged symptoms may require management by a multidisciplinary team including physicians with specific concussion expertise.
What does the CPS recommend regarding concussion prevention?
- 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.
- Athletes should be taught appropriate skills and techniques as well as good sportsmanship to help reduce injuries.
- Sport rule changes that decrease the risk and incidence of concussive injuries should be adopted and enforced by sporting organizations and officials.
- 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.
- Medical school and paediatric residency curriculums should include concussion education.
- All provinces and territories should require by statute that regional sporting associations and school boards have a written policy on concussion recognition and management.
How should physicians advocate for their patients?
- Discouraging participation in sports that involve intentional blows to the head, such as boxing.
- 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.
- Supporting the mandate that all coaches and trainers in sports organizations be educated about concussion risks, recognition and management.
- Supporting the development of policies on concussion in schools and sports organizations.
- Supporting legislation to make wearing a certified helmet mandatory for sports and activities for which there is a significant risk of head injury.
- Urging researchers and manufacturers to develop and improve protective equipment.
