Concussion in Sport (International Conference on Concussion in Sport Guideline 2008)

Rational

Concussion is a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces.  It is a common presentation, and with more severe cases, can have significant consequences.  It is important to have a general approach to patients who present with a history of traumatic head injury.

The current guidelines have been agreed to apply to individuals over the age of 10 years.

Screening

Should be done on all patients who have sustained a head injury.

Diagnostic Criteria

  1. Concussion may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an ‘‘impulsive’’ force transmitted to the head.
  2. Concussion typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously.
  3. Concussion may result in neuropathological changes but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury.
  4. Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course; however it is important to note that in a small percentage of cases however, postconcussive symptoms may be prolonged.
  5. No abnormality on standard structural neuroimaging studies is seen in concussion.

Classification

Simple vs complex concussion has bee abandoned as a form of classification

Most concussion resolve in 7-10 days, but in adolescents and children it may be longer.

Risk Factors

Contact sports, high-velocity activities, previous concussions

Evaluation of Patient

Sx: H/A, cognitive difficulties (feeling like in a “fog”, delayed reaction times), and emotional lability may be present, sleep disturbance (i.e. drowsiness)

Signs: LOC (>1 min considered significant and should be taken into consideration with management), amnesia, irritability

If any of the above signs or Sx are present, a concussion should be considered.

PEx: Full Neuro exam, gait and balance testing (BESS Testing), mental status

It is important to determine the trajectory of the Sx.

Consider neuroimaging: prolonged disturbance of conscious state, FND, worsening Sx, Canada CT head rules +, concern of intracranial lesion

Neuroimaging currently contributes little to the management or prognosis of concussions, and should only be used to R/O other causes of the patients signs and Sx

Consider neuropsychiatric assessment

Investigations

Use the SCAT2 template for assessing concussion

For a sport-related concussion, game-side memory impairment post-concussion can be assessed by Maddock’s Questions:

  • Which field are we at?
  • Which team are we playing today?
  • Who is your opponent at present?
  • Which half/period is it?
  • How far into the half is it?
  • Which side scored the last touchdown/goal/point?
  • Which team did we play last week?
  • Did we win last week?

Another tool that is more involved is the Standardized Assessment of Concussion (SAC) tool

Management

Acute management:

  • ABCs, consider trauma, cervical spine injury
  • A medical professional should determine patient disposition
  • Concussion assessment utilizing the SCAT tool
  • Patient should not be left alone for the first few hours of assessment, with serial monitoring, so deterioration is not missed with potential significant consequences
  • A patient with diagnosed concussion should, at the very least, not return to play on the very same day as the injury

The cornerstone of concussion management is physical and cognitive rest until Sx have resolved and then a graded return to activity with eventual medical clearance to return to full play.

The graduated return to play has clearly defined steps, with each taking an indefinite amount of time.  The minimum time is 24hrs per step, for a total return-to-play of at least 7 days.

An example return to play schedule.  Most emergency departments, clinics, and sports teams have handouts with some version of this schedule.

Concussion management modifiers, that can signal larger concerns and reason for specialist assessment and W/U include:

  • Symptoms Number
    • Duration (.10 days)
    • Severity
  • Signs – Prolonged loss of consciousness (.1 min), amnesia
  • Sequelae – Concussive convulsions
  • Temporal
    • Frequency—repeated concussions over time
    • Timing—injuries close together in time
    • ‘‘Recency’’—recent concussion or traumatic brain injury
  • Threshold – Repeated concussions occurring with progressively less impact force or slower recovery after each successive concussion
  • Age – Child and adolescent (,18 years old)
  • Co- and pre-morbidities – Migraine, depression or other mental health disorders, attention deficit hyperactivity disorder, learning disabilities, sleep disorders
  • Medication – Psychoactive drugs, anticoagulants
  • Behaviour – Dangerous style of play
  • Sport – High risk activity, contact and collision sport, high sporting level

Treatment

Pharmacologic treatment of concussion Sx is typically in the realm of a specialist.  However, medications for sleep or antidepressants can be considered.

Prognosis

Always screen for depression in concussed athletes, as this is often a comorbid condition.

Post-concussion syndrome must be monitored for, and consists of Sx lasting for months with significant impact on the patients function.

Repeat concussion syndrome is another concern, as research has shown that repeat concussions without complete recovery in between can have synergistic detrimental effects on the athlete.

References

Consensus Statement on Concussion in Sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008.  McCrory et al. Br J Sports Med 2009;43(Suppl I):i76–i84.