Key points

Concussion in the athlete and return-to-play guidelines

Concussion can be a challenging diagnosis to make owing to a lack of objective binary data, often relying on self-reported history and symptoms that may be confused with or even overlap with other diagnoses. Concussion and mild or transient traumatic brain injury (tTBI) are terms that are multifaceted and multifactorial. These terms are often applied to a constellation of scenarios ranging from low-velocity occurrences (eg, running into a door) to high-impact events like car accidents and sporting injuries. The etiology is a spectrum of energy and ultimately inertia that affect the brain. Major trauma such as car accidents are probably the single most common cause of concussion. A high index of suspicion is critical to proper management of concussions. It is easy to overlook a trauma patient’s head injury, especially if there are no obvious cuts or abrasions in that area. Physicians evaluating trauma patients must avoid tunnel vision that focuses only on outwardly visible injuries to the body. After stabilization of the patient, starting with the ABCs (airway, breathing, and circulation), a comprehensive secondary survey should include an assessment for acute brain injuries.

An accurate initial neurologic evaluation of the patient can be challenging in the face of multiple injuries. Many patients with tTBI do not have loss of consciousness or acute neurologic deficits. In the assessment phase of these patients, multiple serial neurologic assessments of these patients are critical. Brain injury can be ever evolving. One of the first components of the evaluation will be assessing the patient’s cognitive function. Multiple neuropsychological tests are useful for this assessment.

Recognition of a patient’s concussion or tTBI is crucial so that treatment that is focused on directed therapy may be started. The severity of brain injuries varies; likewise, there are differing manifestations of symptoms. The definition of concussion has gone through extensive analyses. A central question is whether concussion lies on the TBI continuum, but is associated with lesser diffuse structural changes than seen in more severe TBI. Alternatively, concussion could be a distinct entity occurring only owing to reversible physiologic changes. The consensus statement on concussion in sport in Berlin (October 2016) has given the following definition of a sport-related concussion.

• 1.
  

  A direct cause by either a direct blow to the head, face, neck, or elsewhere on the body with an impulsive force transmitted to the head.

  
  
• 2.
  

  A rapid onset of short-lived impairment of neurologic function that resolves spontaneously.

  
  
• 3.
  

  A concussion can cause neuropathological changes, but the acute clinical signs and symptoms largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies.

  
  
• 4.
  

  A concussion results in various clinical signs and symptoms that may or may not involve a loss of consciousness. The resolution of symptoms (clinical or cognitive) typically follow a sequential course whether short or prolonged.

This challenging diagnosis can become even more difficult in the athlete population because additional obstacles are frequently present. Athletes may be motivated to not report the event and/or be unwilling to fully describe the symptoms so they can continue to play. To counter these challenges, it is important to keep the patient history and physical examination consistent and standardized as much as possible. Several groups across multiple sports agree that concussion guidelines and protocols should have consistent basic principles that are adhered to, but should also be flexible enough to adapt for the particular sport and level of sport. One of several tools available is the Sport Concussion Assessment Tool, 5th edition (SCAT-5). The SCAT-5 was developed in 2017 after the Berlin Concussion in Sport Consensus meeting. The SCAT-5 is designed to be used by medical professionals as an aid in diagnosing and later monitoring the progress of recovery from a concussion.

In the initial evaluation of concussion, it is important to understand that a concussion is an evolving event. The evolution is based on multiple factors, such as prior injury, location of the head impact, the velocity of the head impact, and the kinematics of the brain on impact within the skull. These factors are important in terms of the acute phase of traumatic brain injury and the subsequent evaluation of the patient hours and days after injury. Unfortunately, there are no definitive tests or markers to validate the grade of the injury or to predict short or long term outcomes after the injury.

A tTBI is typically caused by a rapid acceleration/deceleration of the brain by a blow or mechanical force that causes disruption of the cell membrane and axonal integrity, triggering a complicated molecular cascade. Although a direct blow to the head can cause an tTBI, it is not the only mechanism of action to look for. It is this disruption at the cellular level that accounts for the signs and symptoms of concussion. This cascade is not fully understood or delineated currently, but in the future a better understanding of the molecular processes involved could provide breakthroughs in diagnosis, prognosis, and differentiating between tTBI and more complicated diagnoses. Universally accepted criteria for the diagnosis are still not present, but all stakeholders agree that recognition and early removal from harmful situations and environments is essential for the athlete to return to normal health. Some sports and sporting organizations employ a spotter who is trained to monitor for events that may cause an tTBI and to recognize signs and symptoms of an altered mental status. Regardless of whether there is a dedicated spotter or not, all coaches, staff, and players need to be educated on the signs and symptoms of tTBI. They must also feel the freedom to point these signs and symptoms out during practices and games.

Once a potential mechanism of injury has been identified, the athlete should be evaluated for any red flag signs or symptoms that may indicate a need for transportation to a medical facility for emergent care. This process may include findings of double vision, seizure, increasing headache, vomiting, neck pain, or weakness in the legs and arms. This list is not a complete list of signs or symptoms that should be monitored and no list can replace sound medical decision-making after a thorough evaluation of the entire situation and circumstances.

After the athlete’s immediate safety is ensured, the medical team can proceed with additional evaluation for tTBI. The mainstay of tTBI diagnosis and subsequent follow-up is evaluating signs and symptoms. To maintain standardization, a list of symptoms is given, and the athlete is asked to rate the severity of the symptom instead of providing a simple yes or no response. The athlete, not the evaluator, should be the one to fill out the checklist, including to give a severity score. In addition to being a part of the diagnostic process, the symptom score can be used to track progress throughout the recovery. Although further studies need to be done, some symptoms can be predictive of timeline to return to activity. It is also important to remember that signs and symptoms of tTBI can and often do evolve over time, so repeat questioning can be a valuable part of the history.

An evaluation of cognitive abilities is also important in making the diagnosis of tTBI. The evaluator has multiple areas that can be tested to assess cognition, including orientation, concentration, and immediate memory. Testing of these areas should involve consistency and several trials to provide reliable results. For the SCAT-5, a list of 10 words is read by the evaluator. The athlete then repeats as many words as possible that can be recalled. Three trials are done using the same list of 10 words to get an accurate evaluation of immediate memory.

A neurologic evaluation is a critical element of the diagnosis as well. This assessment includes a physical examination as well as balance testing. The physical examination should include an evaluation of the cranial nerves, as well as a thorough head, ears, eyes, nose, and throat examination. Evaluation of the temporomandibular joint and teeth are an important aspect owing to the potential for revealing a mechanism of injury. The neck examination should involve passive and active range of motion testing, as well as palpation of the bony vertebrae and paraspinal muscles. An evaluation for nerve involvement should include Spurling’s testing, also known as the maximal cervical compression test and foraminal compression test, to look for cervical radiculopathy. Upper extremity strength, gross sensation, and deep tendon reflexes should also be tested. One way to test balance is using the modified Balance Error Scoring System. This test measures postural stability that is often affected in the concussed athlete. Several maneuvers are performed by the athlete, and the evaluator is looking for specific errors that may indicate a deficit.

A long list of additional special tests are available to further assist the evaluator in assessing the vestibular and oculomotor system. The medical professional should decide which test is best for their situation and experience. Regardless of the test chosen, the evaluator should be able to correctly instruct the athlete on how to do the test, know what the maneuver is testing, and know what makes it a positive or negative test. Additionally, the evaluator should always use the same tests on repeat evaluations to mark progress effectively.

Saccades are a test that evaluates the ability of the athlete to move quickly between 2 targets. Two versions are typically done, horizontal and vertical. The examiner should be looking for the athlete to give indications of difficulty in doing the maneuver, including slowed speed of eye movement as the test continues. Reproduction of symptoms, such as headache and dizziness, should be recorded as well.

The Vestibular-Ocular Reflex Cancellation test is a higher-level test that evaluates the ability to inhibit vestibular-induced eye movements. This test can also be done in 2 versions, horizontal and vertical. The evaluator monitors for the athlete and notes if they are unable to complete the test owing to dizziness or balance disruption. After the test is complete, after a 10-second pause, the evaluator should inquire about provocation of symptoms like dizziness, fogginess, photophobia, and headaches.

Currently, imaging is not beneficial in diagnosing tTBI. Research is ongoing to find ways to reliably implement advanced MRIs, but no clear role has been identified to this point. Biomarkers are another area that researchers and laboratories are investigating as an aid for diagnosis and prognosis, but no role or protocol has yet been determined.

Challenges are not limited to the recognition of the inciting event, performing an accurate history and physical examination, and recording a symptom score. Additional challenges exist with making the formal diagnosis once data from tools like the SCAT-5 are combined with the physical examination and other test results. After the complete evaluation has been done, a tTBI is either diagnosed, is ruled, out or is considered to be indeterminate. If the diagnosis is made or testing is indeterminate, the athlete should be removed from play to the sideline, bench, or dugout.

The initial evaluation entails recognizing the injury, evaluating cranial nerve function, and assessing symptoms, cognitive function, behavioral signs, and balance. Multiple evaluations are usually necessary because of the possibility that symptoms may arise later. For reevaluation of the patient, the consensus statement on sports concussion in sport in Berlin (October 2016) (5) mentioned 3 key features.

• a.
  

  A medical assessment including a comprehensive history and detailed neurologic examination including a thorough assessment of mental status, cognitive functioning, sleep/wake disturbance, ocular function, vestibular function, gait, and balance.

  
  
• b.
  

  Determination of the clinical status of the patient, including whether there has been improvement or deterioration since the time of injury. This assessment may involve seeking additional information from parents, coaches, teammates, and eyewitnesses to the injury.

  
  
• c.
  

  Determination of the need for emergent neuroimaging to exclude a more severe brain injury (eg, structural abnormality).

The treatment of patients with tTBI is multifaceted. The 4 R s (rest, rehabilitation, refer, and recovery) are important. Rest has been controversial. Most agree that rest is important in the acute phase, although there is no solid evidence that rest will shorten the acute phase of recovery or lead to significantly better outcomes. Rehabilitation has been evolving as a critical component to concussion recovery. Cervical spine therapy along with vestibular therapy have been increasing used in the treatment algorithm of these patients with concussion. Patients with persistent symptoms after initial evaluation for a concussion (>14 days in adults and <4 weeks in children) require extra scrutiny and a more thorough evaluation. The assessment should include a comprehensive history and focused physical evaluation. There are times where special tests may be necessary such as a graded aerobic exercise test. Tests such as an electroencephalogram, brain biomarkers, or advanced neuroimaging have not yet been shown to be efficacious or add to the diagnosis. Cognitive–behavioral therapy can also help with mood or behavioral issues. Pharmacologic therapy can be helpful as well, but should be used with caution. Although medication can help with symptoms, it can also mask or even exacerbate symptoms. Recovery is considered as a return to normal activity and functioning. The timeline is very variable. Most adults see recovery at 2 weeks. Children may take up to 4 weeks for recovery. There are very few reliable preinjury predictors of either prolonged or shortened recovery. The most consistent predictor of a slower recovery is the severity of initial head injury. Some studies in children have shown that mental health issues or a history of migraine headaches can lead to a slower recovery.

Clinics care points

• •
  

  Physicians evaluating trauma patients must avoid tunnel vision that focuses only on outwardly visible injuries to the body. After stabilization of the patient, starting with the ABCs (airway, breathing, and circulation), a comprehensive secondary survey should include an assessment for acute brain injuries.

  
  
• •
  

  In the initial evaluation of concussion, it is important to understand that a “concussion” is an evolving event.

  
  
• •
  

  A tTBI is typically caused by a rapid acceleration/deceleration of the brain by a blow or mechanical force that causes disruption of the cell membrane and axonal integrity, triggering a complicated molecular cascade.

  
  
• •
  

  An evaluation of cognitive and neurologic abilities is also important in making the diagnosis of tTBI.

  
  
• •
  

  The 4 R s (rest, rehabilitation, refer, and recovery) are important in a patient’s return to baseline.

  
  
• •
  

  The timeline is very variable in terms of recovery. Most adults see recovery at 2 weeks. Children may take up to 4 weeks for recovery.

  
  
• •
  

  The most consistent predictor of a slower recovery is the severity of initial head injury.

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