Key points

Introduction

Each year in the United States there are an estimated 3.8 million concussions that occur as a result of sports and recreational injuries ; however, many more may go unreported because athletes may not recognize or report their symptoms, or there may be a lack of proper diagnosis. Motor vehicles remain the leading cause of concussions among individuals aged 15 to 24 years, with sports the second most common. Although this topic has drawn massive media attention, solid data are certainly lacking in many aspects of the management of adolescent athletes with concussions.

The passage of the Zackery Lystedt Law in Washington State on May 14, 2009 marked the beginning of a new era in the management of concussions, especially in youth athletes. Although clinicians strive for patient management based on empirical data, in actuality clinical practices are based on a combination of scientific evidence, recommendations provided by the Fourth International Consensus Conference on Concussion most recently held in Zurich in 2012, and anecdotal evidence derived from direct experience in patient care. As such, the goal of this article is to provide an updated review of the management of youth sports concussions. However, this is certainly a moving target as much work is currently under way to provide a structure for more evidence-based care.

Introduction

Each year in the United States there are an estimated 3.8 million concussions that occur as a result of sports and recreational injuries ; however, many more may go unreported because athletes may not recognize or report their symptoms, or there may be a lack of proper diagnosis. Motor vehicles remain the leading cause of concussions among individuals aged 15 to 24 years, with sports the second most common. Although this topic has drawn massive media attention, solid data are certainly lacking in many aspects of the management of adolescent athletes with concussions.

The passage of the Zackery Lystedt Law in Washington State on May 14, 2009 marked the beginning of a new era in the management of concussions, especially in youth athletes. Although clinicians strive for patient management based on empirical data, in actuality clinical practices are based on a combination of scientific evidence, recommendations provided by the Fourth International Consensus Conference on Concussion most recently held in Zurich in 2012, and anecdotal evidence derived from direct experience in patient care. As such, the goal of this article is to provide an updated review of the management of youth sports concussions. However, this is certainly a moving target as much work is currently under way to provide a structure for more evidence-based care.

Definition, demographics, epidemiology, pathophysiology

A concussion is a mild traumatic brain injury (mTBI) that occurs as a result of a direct impact to the head or an impact to the body that causes transmission of forces to the head and brain. Although every patient with a concussion presents differently, common features of a concussion typically include:

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  Rapid onset of symptoms that evolve within minutes to hours

  
  
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  Short-lived neurologic impairment

  
  
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  Functional, rather than structural, process

  
  
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  Only 10% of patients present with loss of consciousness (LOC)

  
  
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  Spontaneous resolution of symptoms (85% within 7–10 days)

The diagnosis of a concussion is based on the recognition of certain symptoms following an impact. These symptoms can be divided into 4 different categories: cognitive, somatic, affective, and sleep. The first 3 can be evaluated at the time of the initial injury, and the fourth category, sleep, should be included in subsequent evaluations ( Table 1 ). Serial evaluations are imperative because of the dynamic nature of concussion presentation, with possible emergence of symptoms minutes to hours after concussion.

According to the National Federation of State High School Associations, more than 7.7 million high school students (more than 3.2 million girls and 4.4 million boys) participated in sports during the 2012-2103 school year, which accounts for more than 50% of all high school students. In a recent study by Marar and colleagues, concussions represented more than 10% of all reported injuries, which is greater than rates reported in previous studies. Rates of concussion remain highest in football, followed by girls’ soccer, boys’ wrestling, and girls’ basketball. In all activities except for cheerleading, the rate of concussion is reported as higher in competition than in practice.

Of note, for all gender-comparable sports, girls had a higher rate of concussion than their male counterparts. In addition, several studies have suggested that female athletes report a higher number and greater severity of symptoms. Several hypotheses for this exist, including differences in head-neck segment mass contributing to increased forces on the head, hormonal factors, or self-reporting practices.

At present there is no way to accurately predict time to recovery after concussion. Impact seizures and brief LOC (<1 minute) have not been shown to predict prolonged recovery. However, there are several known risk factors for prolonged recovery ( Box 1 ).

Preseason planning

A formal Emergency Action Plan (EAP) should be in place before the beginning of practice for any sport. This EAP should include specific management guidelines pertaining to concussions, with a preassigned multidisciplinary treatment team. Preseason planning may include implementation of baseline assessment, particularly in high-risk sports. It may also include computerized neuropsychological (NP) testing, although, as discussed in a later section, this is not required. The preparticipation examination also offers a prime opportunity to discuss the risk of concussions and the importance of reporting with the athlete, and to modify behavior if appropriate. In addition, ongoing education of parents, coaches, and officials is necessary, as an EAP is only as effective as its implementation, and all involved parties need to be a part of the broader framework of concussion management and return to play (RTP) decision making.

On-the-field management

Any athlete suspected of having suffered a concussion should be removed from practice or play immediately. In a collapsed or unconscious athlete, assessment must begin with the ABCs (airway, breathing, circulation) and determination of cervical spine status before dedicated neurologic testing. Initial disposition for emergency transport or sideline evaluation must be determined.

On the sideline, injured athletes should be supervised at all times and continually reassessed to ensure there is no deterioration of mental status. In addition to a more in-depth history and neurologic examination, the Sport Concussion Assessment Tool 3 (SCAT3) or NFL Sideline Concussion Assessment Tool can be used to evaluate a concussion. These tools may be even more valuable if baseline testing data have been obtained before the season. If the athlete is to be discharged home, detailed instructions and precautions should be reviewed with the athlete and the caregiver and follow-up care should be coordinated.

There should be no same-day RTP for any athlete suspected of sustaining a concussion, at any level (youth, collegiate, professional), even if initial symptoms resolve quickly. Concussions continue to evolve, and in some cases symptoms may not be fully present until several hours after the initial insult. In addition, although the athlete may appear asymptomatic at the time of the impact, he or she may actually experience cognitive deficits that are not readily apparent on immediate sideline evaluation. The adage “when in doubt, sit them out” becomes even more paramount in these situations.

Younger athletes face additional risks related to head trauma and concussions. In comparison with their older counterparts, research has shown that younger athletes are more vulnerable to both concussions and potentially catastrophic outcomes of mismanagement. Consensus statements and legislation that require immediate removal from play until a player has returned to baseline have been put in place, at least in part, to help eliminate the occurrence of second impact syndrome (SIS) and other catastrophic injuries. SIS is thought to occur when an athlete suffers a second head injury while still symptomatic from an earlier head injury, resulting in either death or severe disability. This problem seems to occur primarily in adolescents, and is thought to stem from a loss of cerebral autoregulation, leading to rapid cerebral vascular congestion, increased intracranial pressure, and brain herniation. SIS usually progresses rapidly, and the athlete may walk off the field only to be comatose and in respiratory arrest several minutes later. In its original description, there is no associated intracranial hemorrhage. More recent descriptions, however, do demonstrate cases of SIS with a concomitant thin subdural hematoma. The extent of the mass effect and midline shift in these cases is disproportional to the volume of the subdural hematoma, and is thought to be consistent with the loss of autoregulation that is a hallmark of SIS.

Clinical management

Beyond initial physical and relative cognitive rest, there is no effective treatment for curing a concussion. Excessive exertion, however, may delay recovery. In addition, as previously discussed, premature return to contact activity could result in catastrophic brain injury. Clinical management should be performed by a medical professional trained in the diagnosis and management of youth sports concussions. Initial identification is often performed by athletic trainers on the field, and a team approach is often necessary for comprehensive and proper management, especially for those with persisting symptoms. This multidisciplinary team includes physicians, athletic trainers, neuropsychologists, physical therapists, school counselors, and others.

The initial clinic visit should include a detailed history and physical examination ( Boxes 2 and 3 ).

Unfortunately, there is no definitive test for diagnosing a concussion. In certain scenarios, however, imaging, laboratory testing, and/or NP testing may be used as part of the workup or management of the postconcussive athlete.

Imaging is not typically indicated for athletes who have sustained a sports-related concussion, especially those with an uncomplicated recovery pattern. Standard imaging, such as magnetic resonance imaging (MRI) or computed tomography (CT), is expected to be normal given the predominately functional, rather than structural, etiology. In the acute setting such as the emergency department, imaging, typically CT, should be pursued if there is suspicion of a skull fracture or an intracranial bleed, and should be considered in cases where there has been a prolonged LOC, focal neurologic deficits, or other concerning findings. In the postacute setting, brain MRI may be used in cases where focal neurologic deficit is identified on physical examination. In addition, MRI may be used if there is a prolonged course with persistent symptoms, or if underlying abnormality such as tumor, arteriovenous malformation, or Chiari malformation is considered. Other imaging modalities, such as positron emission tomography, single-photon emission CT, functional MRI, diffusion tensor imaging, and magnetic resonance spectroscopy have demonstrated findings of structural and physiologic changes and should currently be considered research tools, with hopes for future use in the clinical setting.

NP testing can be a very useful adjunct with many aspects of management, including diagnosis, scholastic issues, and RTP timing. Full cognitive recovery should occur before RTP, although this may lag behind resolution of clinical symptoms. NP testing should not be solely relied on for RTP decisions, especially in the infrequent cases where cognitive function returns to baseline before full resolution of clinical symptoms. According to Zurich guidelines, NP testing is not required; however, several investigators have proposed that baseline NP testing be obtained in all athletes participating in contact sports as part of their preparticipation assessment. In the realm of youth athletes, this is typically done in the form of easily accessible computerized testing. This testing may be very helpful in the case of subsequent concussions, in that it can be used to assist with the timing of RTP. Before an athlete becomes clinically asymptomatic, NP testing may be used to evaluate for deficits initially after injury, and may be useful in assisting with return to school issues and guidelines for teachers. Regardless of the form of testing, it is the opinion of the authors that all NP testing is best interpreted with the involvement of a well-trained neuropsychologist.

A study by Guskiewicz and Register-Mihalik demonstrated significant disagreement between symptom severity total scores, computerized neurocognitive testing, and balance testing. Each of these measures may be sensitive to specific deficits that other tests are not able to capture, underscoring the importance of using multiple tools for each assessment. Regardless of the specific tools used, it is imperative that evaluation and management after concussion uses tools that evaluate multiple facets, including a symptoms checklist and measurement of symptom severity, cognitive function (including concentration, memory, delayed recall), and a thorough neurologic and musculoskeletal examination, including balance testing.

At present there are no specific biomarkers or laboratory data that can be used to diagnose or rule out a concussion. During the initial evaluation, checking laboratory data is not likely to be of use. In the setting of persistent postconcussion symptoms, however, it may be useful to rule out other confounding factors or potential causes that can cause similar symptoms, such as hypothyroid/hyperthyroid and anemia.

At present there is no pharmacologic therapy that can be used to cure a concussed athlete. Any medications should be used judiciously, especially in the acute setting (<24 hours), during which time any substance that may alter mental status should be avoided. During recovery, medications may be considered for symptomatic relief. However, attention should be directed to those with potential cognitive and neurologic side effects, as they may interfere with recognition of true symptoms. When considering timing of RTP, it is important to take into account that symptoms may be masked or underreported in the presence of certain medications. The management of headaches is discussed later in this article.

Many athletes report sleep disturbance after concussion, may have difficulty with sleep initiation and maintenance, and may report increased daytime somnolence. Medications should be avoided for several days after concussion, and good sleep hygiene should be encouraged. There is no evidence for the use of stimulants or sleep-promoting medications in the acute setting ; however, both medication and cognitive therapies may be considered for poor sleep associated with postconcussion syndrome (PCS).

Several medications that aim to modify underlying pathophysiology to decrease symptom duration have been investigated, such as drugs that inhibit arachidonic acid metabolism, calcium-channel antagonists, corticosteroids, thyrotropin-releasing hormone (TRH)/TRH analogues, free radical scavengers, antioxidants, and drugs that modify monoamine function. In addition, treatment such as hyperbaric oxygen therapy has been considered. Caution should be exercised when trialing therapies with limited supportive data, as they certainly can have unwanted complications, such as possible psychiatric side effects with cholinergic antagonists.

Rest, both physical and cognitive, is the cornerstone of the treatment of concussions. Iatrogenic complications from mandated rest should be considered. Although physical rest should be encouraged during the initial period after concussion, there is some evidence that subthreshold activity may be safe and useful in treating the athlete with persistent symptoms. A preliminary study by Leddy and colleagues in 2010 demonstrated that monitored and controlled subthreshold exercise improved PCS symptoms in a comparison with patients who did not exercise, without any adverse events reported.

In addition, it is the opinion of the authors that the term “relative mental rest” is preferable to the commonly used term “mental rest.” Complete mental rest is not even a possibility, and youth athletes should be educated that thinking is not going to harm their brains. There is no concrete evidence that cognitive activity will either prolong symptoms or have any impact on the ultimate course of recovery ; however, it is true that cognitive stressors such as video games, loud or bright TV/movies, and prolonged computer usage may worsen symptoms during the acute recovery period. School and schoolwork should be a priority, and students should be encouraged to continue school as tolerated. Missing school can create many unintended consequences, such as anxiety from having to make up lost time and incomplete projects, and altered mood arising from limited social contact. In addition, patients with moderate and severe traumatic brain injury who are admitted to inpatient rehabilitation programs are required to perform 3 hours of therapy per day, with the intention to augment, rather than inhibit, their recovery.

The recent publication of the Child SCAT-3 reminds us that children experience concussions differently than older adolescents and adults. Young children may have difficulty reporting symptoms, and input from parents is often essential. Health care providers may need to work more closely with teachers and school officials for return-to-school issues, and return to learning should be emphasized before return to sport. A more conservative approach to RTP is also recommended, which may include a longer asymptomatic period before adding physical activity, and/or a longer period of time at each stage of the graduated RTP protocol.

Children and adolescents may require accommodations for a successful return to school. For those with prolonged symptoms, this may take the form of a 504 plan or an Individualized Education Program. Informal adjustments and accommodations may include a shortened school day or scheduled breaks during the day, providing preprinted class notes, delaying graded work such as tests and projects until symptom improvement, and providing increased time for testing once it is reintroduced.