Physical
Cognitive
Emotional
Sleep
Headache
Feeling like “in a fog”
Irritability
Drowsiness
Nausea or vomiting
Difficulty concentrating
“Don’t feel right”
Sleep more than usual
Dizziness
Difficulty remembering
Sadness
Sleep less than usual
Loss of consciousness
Feels slowed down
Nervous or anxious
Hard to fall asleep
Seizures or convulsions
Forgets recent events
More emotional
Neck pain
Confusion
“Pressure in head”
Sensitivity to light
Repeats questions
Sensitivity to noise
Answers slowly
Balance problems
Amnesia
Blurred vision
Fatigue or low energy
Stunned or dazed
Numbness or tingling
Evaluation Tools
Physicians should use the “Recognize and Remove” concussion signs from the SCAT3 or SCAT5 tests to determine when an athlete should be removed from a game and evaluated [2].
Immediate Management
Concussion red flags
Red flags – call an ambulance | ||
|---|---|---|
Neck pain or tenderness | Severe or increasing headache | Deteriorating conscious state |
Double vision | Seizure or convulsion | Vomiting |
Weakness or tingling/burning in arms or legs | Loss of consciousness | Increasingly restless, agitated or combative |
Sideline Assessment
Concussion diagnosis can be difficult in an athletic environment due to time pressures and noise level [2, 16]. Physicians should never feel rushed to make a decision even at the explicit wish of the athlete or coaching staff [16]. Ideally, a quiet room should be used, but this may not be possible and is not required [1]. The key tenet of sideline assessment for concussion is the use of rapid screening rather than definitive diagnosis [1]. Rapid testing paradigms used on the sideline are not designed to replace a comprehensive neurological evaluation; however, studies have shown increasing the number and types of tests increases both the sensitivity and specificity of SRC diagnosis [1, 24]. Regardless, physicians should err on the side of caution acknowledging the possibility of sitting out an athlete who does not actually have a SRC [1–3, 6].
Evaluation tools for sideline assessment are designed to evaluate physical, cognitive, somatic, and affective symptoms of concussion [2–4]. Prior to formal concussion assessment, a physical exam should be performed including an evaluation of cranial nerves to rule out more severe spinal and brain injuries which would require immediate treatment [2, 4, 6]. If physical exam findings are negative, neurological assessments including the SCAT3 (or newly released SCAT5) test should be performed to assess attention and memory function [1]. This test contains the Maddocks questions which evaluate for orientation to time and place [25, 26]. Standard orientation questions are ineffective in the sporting context compared with memory assessment [25, 26]. The SCAT3/5 also contains the Standardized Assessment of Concussion (SAC) which evaluates orientation, immediate memory, concentration, and delayed recall [27]. The sensitivity of these tests increases when used in combination with symptom inventory and balance tests [28]. The Balance Error Scoring System (BESS balance test) is an assessment of balance and postural control clinically supported in the diagnosis of concussion due to the temporary balance deficits found in concussed athletes [28–33]. It is helpful to compare sideline results to baseline scores if available, but this is not required [1, 5, 6]. Baseline scores for sideline tests vary significantly based on age, sport, sex, and comorbidities making evaluation without personal baseline data challenging [6, 10, 34–36]. Similarly, there are multiple confounding factors in the diagnosis of concussion as sideline tests have been shown to vary with maturation, mood, and fatigue [6]. For this reason, appropriate baseline testing is recommended before each season particularly in youth and adolescent athletes who are still maturing.
Athletes suspected of having a concussion are not to be left alone until a diagnosis has been made [4]. If a concussion is diagnosed, a disposition decision should be made to send the athlete home with family or keep them on site [4]. If they remain on site, it is advised to take a required piece of playing equipment from the athlete to prevent inadvertent return to play as there is no same-day return to play following SRC [1, 4–6]. Before sending the athlete home, plans should be made with parent/guardian for follow-up evaluation with a physician [4, 6]. The family should also be given take-home instructions including signs of worsening symptoms which warrant taking the athlete to the emergency room [4, 6]. Even if sideline screening is negative and the athlete returns to play, they should undergo follow-up evaluation after the game as some patients experience delayed-onset of concussive symptoms [1].
Clinical Assessment
Comparison of concussion assessment tools
Test | Advantages | Disadvantages |
|---|---|---|
PCSS | Large battery of concussion-related symptoms tests | Subjective self-reported questionnaire; possible wide variability in results |
SAC | Ease of administration (paper and pencil); high sensitivity and specificity | Cannot be used for continued monitoring due to rapid return to baseline (usually within 48 h post-concussion) |
SCAT3 | Wide variety of symptoms tested (including all symptoms in PCSS); separate version for children | Not a comprehensive neuropsychological test and therefore cannot be used alone |
ImPACT | Comprehensive test with high sensitivity and specificity; can be used as a standalone test; can identify athletes attempting to hide symptoms; can be used for longer-term monitoring; separate version for children | Athletes more forthcoming with symptoms may display more normal behavior and decrease sensitivity of test |
CRI | Highly sensitive and resistant to retest effects | Cannot be used for longer-term monitoring (many false positives on later tests) |
CogSport | High correlations with paper and pencil neuropsychological tests | Reportedly high variability in sensitivity and specificity |
KD | Easy to administer; tests eye movement and brainstem functions that other tests do not; able to identify events in athletes without symptoms of concussion (unrecognized concussions) | Not a comprehensive neuropsychological test; does not test many of the classic concussion symptoms |
Balance Error Scoring System (BESS Balance Test)
The BESS balance test is also used during sideline evaluation of athletes with suspected concussion [31]. The test involves having the athlete perform a double-leg stance for 20 s, a single-leg stance on each leg for 20 s, and a tandem stance for 20 s [2]. This test is useful for determining balance deficits in concussed athletes but has a relatively short window of sensitivity as most balance deficits resolve within 24 h [2]. Regardless, this makes a useful part of the clinical assessment to rule out long-term balance issues which are possible [2].
Vestibular/Vision Assessment
The vestibular and vision assessment is comprised of two separate tests. The smooth pursuit test examines the ability to follow an object smoothly without effort, strain, or nystagmus. The convergence test evaluates the ability to follow a converging object without effort, strain, or diplopia [39, 40]. Both are useful in the evaluation of concussion as concussed patients may experience diplopia or other vision impairments [1, 2, 41].
Rivermead Post-Concussive Symptom Questionnaire (RPQ)
This test evaluates the clinical symptoms of concussion through a scaled questionnaire. The modified version separates scoring into two parts which allows the RPQ to be used clinically as a subjective test-retest assessment tool for concussion symptoms in patients experiencing symptoms over a more prolonged period of time [42].
Physical Evaluation of the Cervical Spine
Assessment of the cervical spine should be performed to rule out potential injuries which may be signs of a more severe injury [2, 43].
SCAT3/Child SCAT3
The SCAT3 is to be used for patients age 13 and over, while the Child SCAT3 is used in patients between the ages of 5 and 12 [44, 45]. As described in the sideline evaluation portion of this chapter, the SCAT3 incorporates the SAC and Maddocks questions as well as other assessments to provide a more sensitive and specific diagnostic tool for SRC [44, 45].
SCAT5/Child SCAT5
Following the 5th International Conference on Concussion in Sport, the Concussion in Sport Group released the SCAT5 and Child SCAT5 after systematically reviewing the most recent literature on SRC [19]. This version has several important changes to note including its duration, as the complete SCAT5 can no longer be performed in under 10 min. The new iteration also includes an immediate/acute assessment section which provides indications for emergency management [19]. Other modifications include the addition of questions comparing athlete’s post-injury presentation with preinjury behavior, a lengthened SAC immediate and delayed word recall, additional versions of the Digits Backwards test, and emphasis that the physical and cognitive rest should typically only last 24–48 h [19]. Additionally, the SCAT5 includes “Recognize and Remove” criteria to assist health-care professionals in determining when to remove an athlete from the game [19]. These include neck pain, double vision, weakness or tingling in the arms and legs, severe or increasing headache, seizure, loss of consciousness, deteriorating consciousness, vomiting and increasing restlessness, or becoming agitated or aggressive [19]. Although there are no formal validation studies supporting the SCAT5 test as a diagnostic tool for SRC, the authors feel comfortable recommending its use as a diagnostic tool in place of the SCAT3 given the rigorous and systematic nature of its development [19].
Diagnostic Testing
Imaging
Plain skull radiographs , head computed tomography (CT), and magnetic resonance imaging (MRI) have limited value as diagnostic tests for SRC as SRC typically develops due to functional brain disturbances rather than structural changes [1, 4, 5]. Indications for head imaging include concern for intracranial bleed, cerebral edema, or skull fracture. These clinical entities can present as worsening concussion symptoms, decreasing level of consciousness or persistent focal neurologic deficit; therefore imaging should be performed when experiencing any of these symptoms [4, 5]. Functional magnetic resonance imaging (fMRI), diffusion tensor imaging, and magnetic resonance spectroscopy are currently being used as research tools and may 1 day be clinically useful in the diagnosis of concussion [4].
Neuropsychological Testing
Neuropsychological testing (NP) by qualified neuropsychologists has clinical value in the evaluation of SRC but is not a requirement [4, 46–51]. Additionally, NP testing should not be used as a stand-alone tool in diagnosing concussion as symptoms do not necessarily correlate with NP scores [4]. As discussed in the sideline assessment portion of this chapter, NP testing data is more valuable in correlation with baseline test results for a specific athlete and is most valuable in conjunction with balance and symptom checklists [4]. Computerized NP testing may be used to test multiple athletes at once which is particularly helpful when performing baseline tests [4].
Biomarkers
Several blood biomarkers are being evaluated for their role in SRC including S-100 proteins, neuron-specific enolase, and tau proteins, but these are currently inconclusive in clinically diagnosing concussion [1, 4].
Event- and Evoked-Related Potentials
Electrophysiologic research has also been found to be inconclusive for the clinical management of concussion. Research is being conducted to determine the diagnostic utility of evaluating brain activity with quantitative electroencephalography (qEEG) and event- and evoke-related potentials for athletes suspected of suffering SRC [1, 4].
Genetic Testing
Specific genetic markers may contribute to increased risk of initial injury, prolonged recovery, or decreased long-term neurological health following SRC, but this research is not yet clinically relevant [1].
Referral Strategy
All athletes who suffer a SRC should be referred to a physician with experience managing athletic head injuries [16]. In some cases, it can take up to 72 h following a concussion for symptoms to develop; thus it is important to monitor injured athletes with serial exams for the first 48–72 h to ensure that appropriate diagnoses and follow-up is made [2]. Concussed athletes should not return to physical activity without being evaluated and cleared by a physician [16]. In general, there are three categories of SRC physician referrals: urgent referral, same-day referral, and post same-day concussion referral.
Patients presenting with red flag symptoms indicate a need for an urgent referral. Urgent referrals require immediate spinal immobilization with a cervical collar and transportation to the nearest trauma hospital by ambulance for further evaluation [6]. Red flag symptoms include but are not limited to Glasgow Coma Scale (GCS) score less than 13, mental status change from baseline, prolonged loss of consciousness, decreased neurological function or neurological deficit, persistent vomiting, seizure, severe or worsening headache, slurred speech, visual changes, unequal or unreactive pupils, confusion, or agitation.
A same-day referral is recommended when an athlete’s symptoms meet the criteria for a same-day referral in the absence of red flag symptoms [2]. Berrigan et al. outline criteria for same-day referrals, which includes the following: no loss of consciousness, normal neurological exam, mild nausea, mild memory issues, headache that does not increase in intensity, and no other urgent indicators as listed above. It is important to note that an athlete should be monitored for at least 4 h before making the decision whether to refer as a same-day or post same-day concussion referral [2].
In the absence of symptoms meeting urgent or same-day referral criteria, it is recommended that an athlete be assessed by a physician for a post same-day concussion referral within 3–7 days of the concussive injury [2]. Post same-day concussion referral criteria include mild headache with the resolution of all other associated symptoms within 15 min of the initial injury. The goal of this visit is to monitor for symptom improvement, new signs or symptoms, or a change in the severity of symptoms [4].
Home Care
Athletes diagnosed with a concussion should be carefully monitored for the first 24–72 h following a SRC injury in order to identify an evolving issue. Concussed athletes should be provided with education on the signs and symptoms of concussion, symptom management strategies, and the risks of returning to sport without medical clearance [3]. The National Athletic Trainers Association recommends using an agreed-upon standard concussion home-instruction form for all concussed patients [16]. It is also recommended to give oral and written home care instructions to both the patient and a responsible adult who will be observing the patient in the acute post-concussion setting [52, 53].
Physicians caring for athletes in the acute post-concussion setting should review the patient’s home medications and adjust them accordingly; there is Level C evidence supporting the discontinuation of all medications other than Tylenol in athletes suffering a concussive injury [54, 55]. Athletes should also be instructed to eat a well-balanced diet and drink fluids to stay hydrated [53]. In the home care setting, athletes should be counseled to avoid mental or physical exertion that exacerbates their concussive symptoms [4, 31, 56].
Any acute change in a concussed athletes’ symptom severity or deterioration in neurological status requires immediate physician evaluation [2]. Symptoms meeting the criteria for immediate physician evaluation in the post-concussion setting include but are not limited to the following: loss of consciousness, severe headache, increasing neck pain, dizziness, diplopia, repeated vomiting, focal weakness, confusion, seizure, slurred speech, or gait disturbances [2].
Special Considerations: Mood Disorders
SRC is often a challenging injury for student athletes ; unlike most musculoskeletal injuries, the timeline for return to full activity can be difficult to project. In addition, athletes reportedly have unpredictable psychological responses to concussive injury [18]. There have been multiple reports of athletes experiencing emotional distress when they are kept out of competition for prolonged periods of time following a concussion injury [16]. Thus, it is important to monitor concussed athletes for signs and symptoms of depression. Health-care providers must also keep in mind that prolonged concussion symptoms may present similarly to mood disorders [57]. The importance of depression screening in this patient population cannot be emphasized enough, as passive management of a concussive injury in a truly depressed patient can be counterproductive and delay treatment [18, 58].
Initial treatment for SRC typically involves prescribed cognitive and physical rest [18]. The consensus statement from the Conference on Concussion in Sport (2016) recommends a brief period of rest during the acute post-concussion phase (24–48 h), followed by progressively increasing an athletes’ activity level while ensuring to stay below the cognitive and physical symptom-exacerbation level [1]. There is emerging evidence from randomized controlled trials that targeted approaches for treating SRC in certain populations may, in fact, be more beneficial than previously believed [1, 46, 48, 59]. In fact, some evidence reports that prolonged rest following a concussive injury may lead to adverse effects including low self-esteem, academic difficulties, physical deconditioning, social isolation, and anxiety [18, 60, 61]. Given the potential adverse effects of prolonged rest in concussed patients, researchers are advocating for targeted treatments that match an athlete’s concussion symptoms (migraine, vestibular, oculomotor, cognitive function, etc.) [58, 62].
Recovery
Clinical recovery from concussion is defined in functional terms as a return to normal activities including work, school, and sport. This includes a resolution of post-concussion-related symptoms as well as a return to normal cognitive functioning status and balance ability. It has been well established in the literature that concussive injuries can have adverse effects on an athlete’s balance and cognitive functioning for the first 24–72 h after injury [1, 31]. With this in mind, it is important to note that the severity of an athlete’s initial symptoms has been proven to be the strongest predictor of a slower recovery time from concussion [1, 31]. Not surprisingly, having mild symptoms the day after a concussive injury is a favorable prognostic indicator [1, 31]. Risk factors for the development of persistent post-concussion symptoms lasting more than 1 month include concomitant migraine headaches or depression [1, 31]. Young adults with a pre-injury history of mental health problems have also been shown to be at a greater risk of developing persistent symptoms [1, 31]. Conversely, athletes with ADHD or learning disabilities have not been shown to be at a greater risk of persistent concussion symptoms [1, 31].
Establishing recovery from a concussive injury is a difficult task for physicians. To date, there is no gold standard for defining a physiological window of time for recovery from a concussion [1, 31]. Furthermore, determining recovery can also be clouded by subjective symptom scores and nonspecific clinical and neuropsychiatric testing. Often, physicians are tasked with making a difficult return to play decision with limited data to guide decision-making. In addition, recent literature suggests that physiological recovery time from a concussive injury may outlast clinical recovery [1, 31]; the consequence of these findings is currently unknown, but in theory, allowing athletes with ongoing brain dysfunction to return to play may expose them to additional risk.
Return to Sport
Stepwise return to play protocol
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