Concussions — also known as mild traumatic brain injuries — are one of the most commonly encountered sports injuries. They result in temporary changes in an individual’s normal behavior and function. Studies vary, but rates are estimated at 2 million sport related concussions per year in the United States. Ongoing research has led to changes in the approach to the diagnosis and treatment of concussions.
A concussion is defined as a head injury caused by a sudden blow to the head that does not necessarily involve visible or easily diagnosed damage to the head and/or brain. They are most common in collision/contact sports but may also occur without contact such as in a tumbling fall or during non sporting-related activities.
Signs and Symptoms
You don’t have to be knocked out in order to have a concussion. In fact, this only occurs in about 10% of concussions. Typical symptoms may include a headache, dizziness, nausea/vomiting, amnesia and an inability to concentrate. Other symptoms may include fatigue, sensitivity to light or noise, and visual and balance problems. Sleep disturbance is also a common and important symptom experienced throughout the course of a concussion. Some of these symptoms may last from several days to several weeks. Most symptoms of a concussion resolve within a week, but it is especially important not to sustain another blow to the head during this time period. Rest is important in the initial stages of treatment.
The following is a list of other possible signs and symptoms of concussion:
- Balance Problems
- Visual Problems
- Sensitivity to Light
- Sensitivity to Noise
- Stunned Appearance
- Feeling Mentally “Foggy”
- Feeling Slowed Down
- Difficulty Concentrating
- Difficulty Remembering
- Forgetful of Recent Information and Conversations
- Confused about Recent Events
- Answers Questions Slowly
- Repeats Questions
- More Emotional
- Sleeping More than Usual
- Sleeping Less than Usual
- Difficulty Falling Asleep
Sports medicine physicians are frequently involved in the care of patients with sports concussions and are specifically trained to provide care geared toward the type of sports concussion — from the acute injury to return-to-play decisions. The care of athletes with sports-related concussions is ideally performed by healthcare professionals with specific training and experience in the assessment and management of concussion. This expertise is not determined by specialty, but by the experience of the healthcare professional.
The diagnosis of a concussion is based mainly on the individual’s history and physical examination. There is, unfortunately, no single test or exam discovery — except loss of consciousness — that definitely leads to the diagnosis of a concussion. Previous medical history is important to understand the contributing factors that may be present, such as mood or attention disorders, or an orthopaedic injury that may affect the physical examination.
Imaging, CAT scans or an MRI is generally not performed unless there is a concern for a more significant injury. Previous concussions, gender, age, type of sport played, and more are taken into consideration when evaluating a patient.
It is no longer recommended that health care providers attempt to grade the severity of the concussion. This is for several reasons, most importantly because it does not change our treatment recommendations, but also because early signs and symptoms do not correlate well with injury severity. In general, the more symptoms an athlete exhibits and the more severe they are, the longer the expected recovery.
Treatment and Symptom Management
When an athlete⁄individual is suspected of having a concussion, they should be removed immediately from competition. Symptoms should be monitored and the athlete⁄individual should not be returned to competition until they are evaluated and cleared for participation by a qualified medical professional.
Physical and cognitive rest are very important until symptoms appear to go away (or for at least the first few weeks). Because rest is so important, the practice of waking a concussed athlete⁄individual every few hours to “make sure they’re okay” is no longer advised after an initial observation period. Sleep should not be interrupted because it may aid recovery. Caretakers should be informed that it is recommended to let the athlete⁄individual sleep. If there is concern about the level of consciousness during initial or subsequent examinations, further evaluation is suggested where the athlete⁄individual may be given an MRI and observed in a hospital setting.
Cognitive rest means limiting reading, television, texting and most classwork. Generally, athletes may return to school relatively quickly as symptoms improve. Some, however, may require changes to their daily schedule and routine.
It is very important to remember that for any athlete⁄individual, each concussive injury sustained must be treated individually. Recommended treatments and timelines for recovery will vary from event to event.
Symptom Management in the Acute Setting
The appropriate management of concussion symptoms requires careful consideration of the timing and natural history of the injury. Symptoms such as a headache, neck pain or other pain may be treated with over-the-counter medications. Acetaminophen is the first choice but anti-inflammatories such as Ibuprofen can be used safely if needed. In general, medications that may cause drowsiness are to be avoided. In some circumstances — such as an athlete with a broken bone and a concussion — stronger pain medications may be used.
After the acute phase, medications may be considered for symptomatic relief. However, those that affect the central nervous system — stimulants, certain anti-nausea medications and anti-depressants — should be used with caution and may interfere or impair the physician’s ability to properly evaluate the possibility and degree of the concussion. When the athlete⁄individual is being considered for a return-to-participation, medications that may mask symptoms of concussion must be avoided. During the entire course of recovery, activities and environmental conditions that make the symptoms worse should be managed appropriately.
There is no convincing evidence that any particular medication is effective in treating the acute symptoms of a sports concussion. Treatment should be based on common approaches to each specific symptom. Symptoms such as a headache, sleep difficulty and depression may either be direct results of the concussion or may be aggravated by an athlete⁄individual’s pre-existing conditions.
During the acute setting, treatment options for headache are limited. In addition to the previously mentioned over-the-counter medications, physical modalities (i.e., massage, ice, contrast therapy, manual therapy) may be considered, especially if there is neck pain. A dim, quiet environment may moderate head pain, as well as light and noise sensitivity. If headache continues after 3-4 days, treatment should be tailored to headache type (i.e., migraine, tension). Similarly, preventative treatment of worsening chronic or recurrent headache should be tailored appropriately. Headaches that continue as part of a post-concussion syndrome (generally symptoms lasting longer than 6 weeks) often require a multidisciplinary approach to their treatment.
Sleep disturbance is a common and important symptom experienced throughout the course of a concussion. Immediately after a concussion, patients may experience an increase in the amount of time it takes to fall asleep after the lights have been turned out, along with frequent wakening, or less time to fall asleep and longer sleep times. In either case, sleep issues in the first few days following the injury onset should be addressed conservatively, without medications, and with particular attention to good sleep hygiene. Excessive daytime sleeping is also common regardless of normal sleep times. Sleep difficulties may continue as part of a post-concussion syndrome. In these cases, both medical and cognitive therapies may be considered.
A change in mood and decreased attention are also common signs of concussion, particularly in the acute setting. While depression is usually the most common, any mood disturbance is possible. There is no established role for medications in the treatment of a concussion-induced mood disturbance or attention difficulties. If mood issues persist beyond 6-12 weeks, either as part of a post-concussion syndrome or as signs of a worsening mood disorder, treatment with medications and⁄or cognitive therapy should be considered. In the case of decreased attention, modified class schedules should be considered.
Symptoms of balance difficulties and vertigo should be carefully evaluated prior to treatment. Medications such as Meclizine or Diazepam may be helpful for acute attacks of vertigo, but should be used with caution early in concussion management as they may affect cognitive function, cause fatigue and complicate the evaluation of concussion resolution. Although only limited evidence exists, vestibular therapy (motions that are intended to make you dizzy while at the same time making you focus on your body position and coordination, helping your brain compensate for lost balance more quickly) may be considered for the treatment of dizziness or vertigo.
If symptoms last longer than expected, they are known as Post-Concussive Syndrome. The syndrome is simply defined as symptoms and signs of concussion that persist for weeks to months after the incident. Recovery from post-concussive syndrome can be a long and slow process that is often frustrating for patients and removes them from their normal endeavors in school and sport. Management of post-concussion syndrome is ideally done by a team of providers who work with concussion on a regular basis. Treatment options include formal exercise testing with an exercise program guided by the results, and speech⁄language and occupational therapy to help with specific deficits in function.
Our treatment for those with prolonged symptoms is aimed at restoring the controlling functions of the brain through carefully monitored exercise, balance, coordination and sport-specific skills. Fundamentally, the foundation of post-concussion syndrome management is time.
Return to School
There are no specific guidelines for returning the athlete to school. If the athlete develops increased symptoms with cognitive stress, student-athletes may require modified class schedules, extended test taking time, days off or a shortened school day. Some athletes have persistent emotional or intellectual shortfalls following concussion, despite appearing symptom free. Consideration should be made to withhold an athlete from contact sports if they have not returned to their normal academic levels following their concussion. The CDC developed educational materials for educators and school administrators that are available at no cost and can be obtained via the CDC website: http://www.cdc.gov/concussion/HeadsUp/high_school.html
Return to Play
Return-to-play (RTP) after concussion should be individualized, gradual, and progressive. Coaches must be aware of, and consider, individual factors that may increase vulnerability and⁄or prolong recovery after a concussive injury. The athlete should be free of concussion symptoms at rest, as well as, during and after physical exertion before returning to full participation. The athlete should also have a normal neurologic exam, including a normal cognitive and balance evaluation. Once the athlete is symptom free and has returned to normal, a gradual and medically supervised return to activity can be started. It should consist of a measured increase in physical demand and contact. This progression may take several days to weeks or months, depending on the individual. The severity of a concussion is based on the nature, burden and duration of symptoms, the frequency and past history of concussions, and the presence of prolonged symptoms. All should be considered when determining the symptom-free time required prior to starting the RTP progression.
Short Term Risks Associated with Premature Return to Play
There are potential health risks when an athlete with persistent symptoms returns to play. Second Impact Syndrome (SIS), an increased chance of a recurrent or more severe concussion, and a longer duration of symptoms is possible. SIS is described as occurring when an individual sustains a second head injury before the symptoms associated with the initial injury have fully cleared. While this condition appears to be rare and is not completely understood, it emphasizes the importance of not returning to high-risk activities while symptoms are present.
Long Term Complications of Sports-Related Consussion
Chronic Traumatic Encephalopathy (CTE) – Some case studies have led to the theory that repetitive brain trauma is associated with progressive neurodegenerative disease known as chronic traumatic encephalopathy. However, no scientific studies are available to help understand or clarify any link between recurrent concussion or sub-concussive impact and CTE. Because of its link to professional athletes, this condition has become highly publicized. Fortunately, most of our young athletes are not at risk of developing this condition. The best protection is to follow the proper steps to ensure the safety of all concussed athletes by immediate removal from competition and evaluation/management by a healthcare professional with concussion experience.
At the present time, there exists no specific methods or equipment available to prevent concussions from occurring. Although helmets appear to be effective at preventing serious injuries such as a skull fracture — and more serious traumatic brain injuries — they are not able to prevent concussions. Soft helmets and headbands — such as those used in soccer and rugby — do not reduce the chances of a concussion or aid in the decrease of severity. There is also no evidence that mouth guards protect athletes from concussions. Mouth guards are excellent at protecting athletes from dental injury and should be worn in sports where the possibility of dental injuries is high. Rule changes and proper technique in tackling, checking, etc., may be able to decrease the risk of sustaining a concussion. Purposeful heading in soccer does not cause concussion and there is no reliable evidence that repetitive heading leads to long-term damage. However, it is important that young players are taught the proper technique for both heading and challenging. Preventing a second or recurrent injury may be best attained through the proper protocol of immediate removal from competition and adequate rest.
Concussion is a concerning and complicated problem in sports. It requires a versatile approach in diagnosis and management. Athletes, coaches, officials and parents need to be made aware of the signs and symptoms of concussion to better recognize the injury on the field of play and seek appropriate evaluation. It is critical that athletes are forthcoming regarding their symptoms as this is often the only noticeable indication of concussion. A physician or other health professional trained in the evaluation and management of concussion who knows the athlete well is in the best position to correctly diagnose a concussed athlete. Standardized sideline tests provide a helpful, uniform approach for examination, but further studies are needed to increase their accuracy. No athlete diagnosed with a concussion should return to play on the same day or while symptomatic. The return-to-play decision is a medical one. Additional research is needed to validate current assessment tools, further define the role of neuropsychological testing and balance testing, validate return-to-play guidelines, and to improve the identification of those at risk for prolonged concussive symptoms or other short⁄long-term complications.
Pre-season evaluation is available at the Concussion Clinic at VOC. Preparation for the care of concussed athletes begins prior to any practice or competition with a pre-participation exam (PPE) and the development of an emergency action plan. The pre-participation exam (PPE) includes concussion related questions including a past history of concussion (number, frequency, severity, and recovery) and the presence of mood, learning, and attention or migraine disorders. This information can be used to assess risk and for reference in the case of injury.
Pre-season testing requires an honest effort on the part of the athlete. Balance testing is time intensive but can be done by non-physician personnel. Computerized NP testing requires adequate resources and a quiet environment for best results, but can be done in large groups. NP testing requires health professionals competent in test interpretation.
Computerized Neuropsychological Testing
Computerized testing is offered through the Concussion Clinic at VOC. It is important to discuss whether this testing is appropriate for a concussion or screened athlete because its conclusions are not as definitive as once thought.
There are several variations of computerized neuropsychological testing available today. It was initially intended that by pre-screening athletes, a safer approach to a return-to-play could be determined. Recent recommendations, however, question the usefulness of pre-season testing and the overall benefit of this type of testing in the return-to-play decision. Testing may play a role in some cases but it should never be used in isolation.
Balance assessments have been recommended to use as part of a comprehensive concussion evaluation and management plan. These tests are relatively inexpensive to perform and are generally done by athletic trainers. Balance issues tend to resolve relatively quickly after concussive injuries (3-5 days). However, these tests can be useful in both the initial evaluation and subsequent follow up.
Acute Evaluation and Management
Through our sports injury hotline, 802.236.4117, our sports medicine providers and athletic trainers are available for consultation after an acute concussive injury. These providers will offer pre-examination advice and will expedite office evaluations whenever necessary.