Rider:
New guidelines for concussion mangement: from pre-season to on the field to sideline assessment, diagnosis, treatment and return to play
Management of sport-related concussion involves a step-by-step process say three recently issued concussion guidelines:[1-3]
1. Preseason
Preparation for the care of concussed athletes begins prior to any practice or competition with:
- A pre-participation exam (PPE): The PPE should include the taking of a detailed concussion history .[1,2]
- Baseline testing: The pre-season evaluation may include one or more of the following:
- paper-and-pencil or computerized neuropsychological/neurocognitive (NP) testing (Note, however, as indicated below, that whether baseline NP testing is necessary, and, if so, for what athletes, is controversial;[1,2,12,13]
- symptom scores on a concussion symptom scale
- balance testing
- a sideline evaluation tool testing neurocognitive function (memory, orientation to time and place etc.) (e.g. SCAT3 . SAC )
- a vision test (e.g. King-Devick ) [Note: While the Zurich consensus statement on concussion[1] and a related study[5] says more research is needed before King Devick can be recommended for use in sideline assessment of concussion, one leading concussion expert, Dr. Robert Cantu,[6] recommends that it be included as part of the baseline and post-concussion test battery.]
- Development of an emergency action plan (EAP): to ensure that appropriate care is provided in a timely manner, an EAP should
- include planning for responses to medical emergencies involving athletes, spectators, coaches, and officials;
- be developed with input from an athletic health care team, administrators, coaches, facilities managers, parents, and members of the local EMS;
- be reviewed before every sports season; and
- periodically rehearsed with EMS.[2]
2. On the field
The first step is to check an athlete's airway, breathing and cardiac function (ABCs) followed by a physical evaluation to exclude brain injury or cervical spine injury .[1,2]
- If a cervical spine injury cannot be eliminated, neck immobilization and immediate transfer to a hospital emergency department capable of advanced neurological imaging (CT/MRI )[2];
- Emergency transfer should also occur if there are signs of a more serious brain injury such as deteriorating mental status, focal neurological findings (abnormal or unequal pupil reaction, etc.) or worsening of symptoms.[1,2]
3. Sideline assessment
A standardized approach using one or more of the following sideline assessment tools is recommended:
- Standardized Assessment of Concussion (SAC) [1,5] (cognitive assessment of orientation, immediate memory, concentration, and delayed recall)
- Balance Error Scoring System (BESS) and modified BESS [1,2,5]
- Sport Concussion Assessment Tool 2/3 ( SCAT3) [1,4,5](includes Maddocks' questions , SAC , modified BESS , and Post-Concussion Symptom Scale );
- King-Devick test [Note: while several studies have shown the K-D Test to be helpful as a rapid sideline screening tool [7,8,9], the most recent meta-analysis states that "no conclusion can be drawn at this point regarding [its] eventual usefulness." [5]
- NFL Sideline Concussion Assessment Tool (based on SCAT2)
- Maddocks questions .[11]
Note: the sensitivity (the
likelihood that an athlete with concussion will be correctly identified)
and specificity (the likelihood that an athlete without concussion will
be correctly classified) of the diagnosis of concussion may increase
when multiple concussion assessment tools are used.
[2,10]
- Where available, sideline tests results should be compared to a reliable preinjury baseline.
- Because results can vary widely from athlete to athlete and the results depend on age, sport, sex and pre-existing medical conditions, use of sideline tests without baseline results is difficult.
- Note, however, that a pair of 2012 studies[12,13] suggest that comparing an athlete's post-concussion neuropsychological test
results to those of athletes of the same age and gender (e.g. 'normative
values') may be enough as a diagnostic tool, and that clinicians, can, in most cases, identify the same
cognitive impairments in a concussed athlete by using normative
neurocognitive values as by comparing their post-concussion performance
to individual pre-injury baselines.
- Baseline test results may change as part of the normal maturation and development process (which is why a new baseline is recommended periodically, although there is no agreement on how frequently) and can be dependent on current mood, fatigue [14] and other factors .[15-18]
- The sensitivity, specificity, and the false-positive and false-negative rates vary for different sideline tests. With the current sideline tests, as sensitivity goes up, the specificity goes down, so some athletes without concussion may held out. Physicians evaluating concussions on the sideline are nevertheless encouraged to err on the side of safety ("when in doubt, sit them out.")
- Test results may change over the course of a concussion (for instance, balance typically returns to normal after 3 days, making balance testing a potentially useful sideline test but not useful for a later follow-up), and are important considerations in the evaluation process.
- Familiarity with an athlete is an important component in the sideline evaluation of a concussion, given the variability in the way concussion can present. This is one of the reasons why a certified athletic trainer should be on the sideline at every game and practice in a contact or collision sport.
Whatever sideline screening tools are used, it is important to remember that they are designed only for rapid concussion screening on the sports sideline and are not meant to replace comprehensive neuropsychological testing, which should ideally be performed by trained neuropsychologists, nor should they be used as a stand-alone tool for ongoing concussion management. [1-3]
- Sequester an essential piece of playing equipment as a safety precaution. When a player is being evaluated for or has been diagnosed with a concussion, it is a good safety strategy to take from the player an essential piece of equipment (e.g.helmet, glove, catcher's mask etc.) to avoid an 'inadvertent' return to the game. [2]
- Watch the player. A concussed athlete should not be left alone if the decision is made to keep the player on site, and regular monitoring for deteriorating physical status is essential.[1,2] If, after a complete sideline assessment determines that a concussion is not thought to have occurred, and the player is allowed to continue to play, the player should be periodically evaluated after their return to ensure the decision was correct.
- Send home with instructions or transfer to hospital where appropriate. The sideline medical staff should:
- arrange or discuss the follow-up evaluation with a parent/guardian [2,4]
- arrange for the athlete to be accompanied or monitored once allowed to leave the competition area. [1,2]
- provide 'take-home' information, ideally in written form, including:
4. Follow-up evaluation
- Athletes with concussion should have a medical follow-up which should include:
- the taking of detailed history of how the injury occurred;
- periodic monitoring of symptoms using a standardized symptom scale to
assess symptom resolution and progress towards and return to the
athlete's pre-injury baseline (note: in the vast majority of
concussions, balance is back to baseline in 3 days)[2]
- Worsening symptoms , pronounced amnesia ,
progressive balance problems, or focal neurological deficits (abnormal
or unequal pupil reaction, abnormalities in eye movements, abnormalities
on a screening motor/sensory exam) could be sign of intracranial
bleeding and should prompt neurological imaging (CT/MRI).[2]
5. Treatment
- Physical and cognitive rest. Treatment of a concussion consists of physical and cognitive rest , especially in the early stages of a concussion recovery when they may make symptoms worse. Most athletes recover spontaneously and become asymptomatic after concussion within a week,[24] although younger adolescent athletes usually take longer to recover, [25] and full return of cognitive function [19] and cerebral blood flow [26,27] may not occur until weeks or even months after athletes report that their symptoms have cleared (which is why studies suggest that recovery not be viewed as complete based solely on the athlete's self-assessment of their recovery[28]).
- Because a concussion impacts the brain's cognitive functions (those that involve thinking, concentrating, learning and reasoning), most concussion experts believe that limiting an athlete's scholastic and other cognitive activities to allow the brain time to heal helps in recovery. While strict bed rest is not necessary, and while the effect of physical activity on concussion recovery has not been extensively studied (indeed, there is some evidence to suggest that mild physical exertion may actually help concussion recovery, especially for those suffering from post-concussion syndrome), the consensus of experts recommends broad restrictions on physical activity in the first few days after a concussion, with the Zurich statement[1] highlighting the "concept of 'cognitive rest' ... with special reference to a child's need to limit exertion with activities of daily living that may exacerbate symptoms," including school.
- Such recommendations are not without dissenters, most notably Christopher Randolph, PhD of the Department of Neurology at Loyola University Medical Center in Maywood, Illinois, who continue to question the idea that the rest needs to be "complete" and last until an athlete is entirely asymptomatic. Writing in an editorial in the September 2012 issue of the Clinical Journal of Sports Medicine,[20] Randolph and his co-authors point to the lack of empirical data to show that physical or cognitive rest after sport-related concussion exacerbates concussive injury, and cite to studies of athletes suggesting that re-engaging in activities in the days after injury is likely to have no detrimental effect or even a beneficial one; findings consistent with the view that total bed rest is generally contraindicated for most medical conditions.
- A 2013 systematic review of the literature on the effects of rest and treatment following sport-related concussion[21] takes a middle ground, noting that, while mental and physical rest in the initial days following a concussion have been strongly encouraged, and resting until symptom free widely recommended, there have been only three published studies evaluating the effects of rest in athletes who have suffered a sport-related concussion, and with specific reference to a 2012 study in the Journal of Pediatrics by MomsTEAM expert concussion neuropsychologist, Rosemarie Scolaro Moser, PhD,[22]point to the absence of a control or comparison group, "so that improvements could have been attributed to a diverse range of factors."
- The authors, however, identified three lines of evidence that indirectly support the value of rest:
- "First, concussions can have a large adverse effect on physical and cognitive functioning in the first few days postinjury, as the brain is in a state of metabolic crisis,[23] at which time increased energy demand may hinder the restorative process, and it is believed that rest might facilitate recovery.
- Second, in animal injury models, there appears to be a 'temporal window' of vulnerability in which a second overlapping injury results in greater levels of traumatic axonal injury and magnified cognitive and behavioral deficits. Thus, a rest period will reduce the likelihood of the athlete experiencing an overlapping injury.
- Finally, it has been demonstrated in rodent models that exercise appears to be good for the injured brain; however, animals that are allowed to exercise too soon after injury do not show the expected exercise-induced increases in molecular markers of neuroplasticity [the ability of the brain to rewire itself after injury]. For these reasons, it is believed that rest is very likely beneficial following injury. However, this is largely based on animal research, theory and expert consensus."[21]
- In the absence of further studies to evaluate the effects of a resting period and the optimal duration of this period, experts recommend taking a "sensible approach involv[ing] a gradual return to school and social activities (prior to contact sports) in a manner that does not result in a significant exacerbation of symptoms." (n. 2,4)
- Symptoms. There is no convincing evidence that
any particular medication is effective in treating the acute symptoms of
sports concussion specifically.[2]
- Headache: Treatment options in the first several days after concussion (the acute phase) for headache (far and away the most common symptom of concussion) are limited:
- Acetaminophen (e.g. Tylenol®)
offers a possible benefit without the risk of bleeding in the brain that
are thought to be associated with aspirin or non-steroidal
anti-inflammatory medicine(NSAIDs)(e.g. Ibuprofen/Advil®), which are not
recommended for that very reason. [2]
- An ice pack on the head and neck is okay as needed for comfort. [2]
- A
dim, quiet environment may help with headache, as well as symptoms of
sensitivity to light and sound often experienced by student-athletes
with concussion. [2]
- Headaches that continue as part of a (symptoms lasting longer than 4-6 weeks) often require a multi-disciplinary approach. [2]
- Sleep disturbances: A concussed student-athlete may experience either difficulty falling or staying asleep, or sleep longer.
- While disturbed sleep is a common and important symptom experienced throughout the course of a concussion, and immediately after a concussion, sleep issues should be initially addressed without medications, and with particular attention to good sleep hygiene.
- If sleep difficulties persist (e.g. your child is diagnosed with post-concussion syndrome ), then medical and cognitive therapies may be considered.
- The traditional rule has been to wake up a concussed athlete every 3 to 4 hours during the night to evaluate changes in symptoms and rule out the possibility of an intracranial bleed, such as a subdural hematoma. The new thinking is that there may be more benefit from uninterrupted sleep than frequent wakening, which may make symptoms worse. As a result, waking up your child during the night to check for signs of deteriorating mental status is no longer recommended. Indeed, if level of consciousness or deteriorating mental status is a concern, the athlete should undergo a CT scan or MRI. and be observed in a hospital setting. As Dr. Bill Meehan of Boston Children's Hospital observes, "As an emergency room doctor, if I was that concerned about a patient that I wanted their parents to check on em every hour or two, I would keep them in the hospital, I wouldn't send them home. Ideally if you're that worried about a bleed, you can either get some kind of imaging and find out is there blood in the brain, or you observe them, and you watch them get better and then you don't need it. All that waking them up every hour or two is gonna do is make them worse, right? You want them to sleep so they get better. So the real reason to [wake them up] is if you're not sure it's concussion, you're worried there's something else going on, and for me if I'm that worried about it, I don't send them home." [2]
- Alteration in mood, such as depression are common manifestation of concussion , particularly in the acute phase, but there is no established role for medications in treatment of a concussion-induced mood disturbance. Again, if mood issues persist beyond 6-12 weeks, either as part of post-concussion syndrome , or as a result of a worsening of a pre-existing mood disorder, treatment with medication and/or cognitive therapy should be considered. [2] [For more on therapies for post-concussion syndrome, click here] .
- Cognitive difficulties. There is no established role for stimulant medication (eg., Adderall, Ritalin) in the treatment of acute attention difficulties following concussion. Academic accommodations should be considered for any significant decrease in cognitive performance. [2]
- Balance problems and vertigo. Medications such as meclizine or diazepam may be helpful for acute attacks of vertigo, but should be used cautiously early in concussion management as they may affect cognitive function, cause fatique, and obscure the evaluation of a concussion recovery. Although only limited evidence exists, vestibular therapy may be considered for the treatment of dizziness or vertigo. [2]
6. Neuropsychological testing
Neuropsychological (NP) testing in athletes began in the 1980's and its use has expanded in the last decade with the availability of computerized testing in addition to traditional paper-and-pencil NP tests.
- data suggests that cognitive impairment after concussion may last longer than subjective symptoms. [2]
- NP testing is a tool that can identify cognitive impairment and may also aid in documenting an athlete's recovery from concussion, [1-3] although whether the use of NP testing reduces the short-term risks (recurrent or catastrophic injury) or potential long-term complications is currently not known. [2]
- Paper-and-pencil NP testing has the advantage of testing additional cognitive domains ,[19] which may identify other conditions masquerading as concussion or post-concussion syndrome or identify continued cognitive deficits, such as the ability for high level thinking (so-called 'executive function'),[19] which a recent study shows may be impaired in concussed adolescents for as long as 2 months after injury. The disadvantage of paper-and-pencil NP testing, of course, is that it is more expensive than computerized NP and require significantly more time to administer and requires a licensed neuropsycholgist to intepret the results. [2]
- Computerized NP has advantages in the athletic setting in that it is less expensive, takes less time to administer, may be administered to groups of athletes, provide instant information to the provider, has more precise measures of reaction time, has multiple forms and may be used for serial assessment. [2]
- Both types of NP tests have significant individual variability with regard to the cognitive domains measured and performance measures. [2]
- NP testing has not been validated as a tool to diagnose concussion; rather, it is a tool to use in monitoring recovery from concussion [1,2] and making the all-important return-to-play decision.
- Whether baseline testing is necessary is open to debate: it appears to have advantages over comparative normal values, but no studies have looked at this issue with regards to outcomes, and there are, as noted, some studies [12,13] that suggests that age-related norms may be adequate to assist with management decisions. [2]
- If testing is used, care should be taken to make the baseline and postinjury physiological variables (ie, fatigue) and environmental variables (ie. distractions) as similar as possible. [2]
- No optimum postconcussion monitoring interval has been established and reported intervals vary from every few days to only testing asymptomatic athletes prior to return to play. [2]
- While NP testing has become increasingly popular in concussion management, its use remains controversial. As a result, there are no universally agreed-upon recommendations for use of NP testing, with existing recommendations based on experts' opinion. [2]
- If anything, while the trend in recent years has been for more athletes, especially at the high school level, to undergo baseline NP testing, there appears to be some slight movement away from recommending routine testing of all athletes, or even all athletes in contact or collision sports with a high risk of concussion:
- The American Medical Society for Sports Medicine's 2013 position statement [2] says that concussions can be managed appropriately in a majority of cases without the use of NP testing, although it recognizes that it may have "added value in some settings, especially high-risk athletes."
- The 2013 Zurich consensus statement on concussions [1] states that "[f]ormal NP testing is not required for all athletes," and that there was "insufficient evidence to recommend the widespread routine [or mandatory] use of baseline neuropsychological testing."
- The American Academy of Neurology's 2013 concussion guidelines [3] states that it is "likely" that NP testing, whether paper-and-pencil or computerized, "is useful in identifying the presence of concussion." The AAN's language on baseline NP testing is equally equivocal, saying only that concussion management "might utilize individual baseline scores on concussion assessment tools, especially in younger athletes, those with prior concussions, or those with preexisting learning disabilities/attention-deficit/hyperactivity disorder, as doing so fosters better interpretation of postinjury scores."
- If NP testing is used, both the Zurich statement and the AMSSM position statement, as well as other recent studies,[29-33] agree that it should not be the sole basis of management decisions but should only be seen as an aid to the clinical decisionmaking process in conjunction with a range of other assessments (e.g. concussion symptom scales , balance, clinical exam).
7. Return to school
- Because of the dearth of research in this area, and the fact that each athlete's response to and recovery from concussion is different, there are no standardized guidelines for returning a concussed student-athlete to school, although the most recent Zurich consensus statement [1] and accompanying Child-SCAT3 [4] suggest that taking a couple of days off from school after a concussion may be beneficial.
- If the athlete develops increased symptoms with cognitive stress, he or she may require academic accommodations , such as reduced workload, extended test-taking time, days off or a shortened school day.
- Expert advice varies on whether an athlete should be allowed to return to sports if they have not returned to their academic baseline after concussion. The Zurich consensus statement [1] and a majority of concussion experts, take the view that "no return to sport or activity should occur before the child/adolescent has managed to return to school successfully." The AMSSM position statement [2] is couched in more ambiguous language: "Consideration should be made to withhold an athlete from contact sports if they have not returned to their 'academic baseline' following their concussion." (emphasis supplied).
8. Return to play (RTP)
- RTP after concussion should be individualized, gradual and progressive and should consider factors that may affect individual risk and outcome. [1,2]
- The athlete should be free of concussion symptoms at rest as well as during and after exertion before returning to full participation.[1,2]
- The athlete should also have a normal neurological exam, including a normal cognitive and balance evaluation, ideally compared to a preinjury baseline.
- Once an athlete is symptomatic and has returned to their baseline measures (if available), a gradual and medically supervised incremental return to activity should be initiated and include a stepwise increase in physical demands, sports-specific activities and physical contact. [1,2] This progression may take days to weeks to months depending on the individual responses and modifying circumstances. For more on the recommended return-to-play protocol, click here.
- The RTP progression should be individualized, with symptoms, cognitive, and balance exams used for tracking recovery.
- A final RTP/practice determination should occur with documented medical clearance from a licensed healthcare provider trained in the evaluation and management of concussion (as is now required by law in all but a handful of states).
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Posted May 28, 2013; substantially revised August 10, 2013, April 2, 2015
Teaser title:
Concussion Identification, Evaluation and Management: A Step-By-Step Process
Teaser text:
Management of sport-related concussion involves a step-by-step process beginning before a sports season even starts, say the three newest concussion guidelines, and continuing through on-the-field evaluation, sideline assessment, diagnosis, treatment, and return to play.