Concussions may be caused either by a direct blow to the head, face or neck or elsewhere on the body with an impulsive force transmitted to the head. The result is a rapid onset of short lived impairment of neurologic function that resolves spontaneously. Perhaps the term brain injury would better serve the entity of concussion.
Concussions are likely underreported by pediatric and adolescent athletes for obvious reasons. They result in 144,000 ER visits per year; however it was estimated in one recent review that up to 3.8 million recreation and sports related concussions occur annually in the U.S. Concussions represent 9% of all high school athletic injuries; however, data are significantly lacking about concussions in grade school and middle school athletes.
Football results in the highest rate of concussion for the high school male, while soccer and basketball have the highest rates for the high school female. Rugby, ice hockey and lacrosse also account for higher rates but data is limited as these are often club sports. Females have a higher rate of concussions than males in similar sports.
Concussion results in symptoms that interfere with school, social and family relationships and participation in sports. Signs and symptoms center around four aspects: 1) physical 2) cognitive 3) emotional and 4) sleep activity. Although loss of consciousness (10% occurrence) is an important sign that may lead to further intervention, headache is the most frequent reported symptom. Symptoms may not occur until several hours after the episode, and many young athletes may not be forthcoming of their symptoms as they fear activity restrictions. An unconscious athlete or one who regains consciousness quickly may be evaluated further on the sidelines. Tools of assessment include Maddocks questioner, Standardized Assessment of Concussion (SAC) and Balancing Error Scoring Systems (BESS). Question used in assessment include “what team did you play last week?” and “who won by what score?” If a concussion is identified, the athlete should be removed from the remainder of the practice or game(s) on that day and should continue to be monitored for several hours after the injury to evaluate for any deterioration of his or her condition.
Neuroimaging is obtained whenever suspicion of an intracranial structural injury exists. An objective measurement of brain function for a high school athlete with a concussion may lie with neuropsychological testing either computerized or with pencil and paper. Ideally a baseline or pre-injury test should be obtained before the start of the athlete’s season. If no baseline is available, results can often be compared with age established norms.
Management of the athlete with a concussion revolves around hastening recovery while avoiding activities and situations that may slow recovery stressing adequate time for both physical and cognitive recovery. Thus cognitive and physical rests are the mainstay of management. There is no evidence-based research regarding the use of any medication for treatment. Any athlete using any medication such as Ibuprofen or NSAIDs may not return to play until no medication is used and the athlete is symptom free. As a concussion is a functional not a structural brain injury, many athletes report increased symptoms with cognitive activities. Cognitive rest is recommended and may include a temporary leave of absence from school, shortening of the school day, reduction of workload, and an allowance of more time to complete assignments or take tests. Taking standardized exams are discouraged as lower than expected scores will likely occur. After reintegration into school, adequate time must be afforded to make up assignments. The volume of make-up work must be reduced. The use of videogames, television and computers must be discouraged as they may exacerbate symptoms. Until the athlete is totally symptom free a broad restriction of all physical activity is strongly recommended. A concussion can result in depression in part from the injury itself but also from the prolonged time away from sports, the difficulties in school and sleep disturbances.
Return to play for the athlete is individualized. “When in doubt, sit them out!” Under no circumstances should an athlete return to play the same day of the concussion. No athlete should return to play while still symptomatic at rest or with exertion. Most athletes will become asymptomatic within a week of their concussion; however there will always be a longer recovery of full cognitive function in the younger athletes when compared to the college aged athlete. A more conservative approach should be used with the pediatric and adolescent athlete. A graded return-to-play protocol or concussion rehabilitation is recommended. Once asymptomatic at rest, progression occurs in a step wise fashion and continues as long as the athlete is asymptomatic. Each step is about 24 hours and it should take 5 days to complete the rehabilitation. If symptoms occur while on the protocol, progress stops until the athlete is symptom free for 24 hours and then the last step is repeated.
In conclusion, although much has been talked of prevention such as the use of mouth guards, headgear, body armor and even genetic testing for possible predisposing risk factors, both education and recognition are the best tools we have of improving the care of the athlete with a concussion. Individuals that need to be targeted include the athletes themselves, their parents, the coaches, athletic directors and trainers, teachers, school administrators, physicians and all other health care providers.
Halstead, ME; Walter, KD; American Academy of Pediatrics, Council on Sports Medicine and Fitness. Sport-Related Concussion in Children and Adolescents. Pediatrics. 2010;126(3):597-615.
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