Top 10 Facts You Need to Know: Sport-Related Concussion

S C I E N C E O F M E D I C I N E

Top 10 Facts You Need to Know About: Sport-Related Concussion

BRIAN J. TOLLEFSON, MD, CAQ-SPORTS MEDICINE; RICHARD L. GRANTIER, MD; PATRICK O’BRIEN

College football two-a-day practices appear to be ending. For safety reasons, the NCAA Sport Science Institute recommends eliminating the popular two-a-day preseason practices and reducing contact at all practices, including limiting full contact to once a week during the season. According to the NCAA's Sport Science Institute, 58 percent of the football practice concussions that occur over the course of a year happen during the preseason. Brian Hainline, the NCAA's chief medical officer, says August also is a peak month for catastrophic injuries resulting from conditioning rather than contact, such as heatstroke and cardiac arrest. [http://www.ncaa.org]

It is estimated that there are as many as 3.8 million sport-related concussions (SRC) annually in the United States. 1 This number may actually be much higher as many SRC go undiagnosed or unreported. It is important for all primary care providers to become familiar with the current literature, management guidelines, and state laws pertaining to SRC. Sports-related concussion is a potentially serious injury that requires prompt identification and proper management to ensure a safe return to play.

1. The Consensus Statement on Concussion in Sport is a peer-reviewed publication considered by many to be the gold standard for the diagnosis and management of sport-related concussion. The Consensus Statement on Concussion in Sport is the product of an international group of clinicians and researchers considered to be experts in the field of SRC. This Concussion in Sport Group (CISG) meets every four years to collaborate on a review of current literature and expert opinion related to SRC. The most recent meeting was held in Berlin in October 2016. The CISG consensus statement from that meeting was published in April 2017. The CISG consensus statement builds on the previously published Consensus statements. 2-5 The CISG consensus statement is not intended to be a legal standard of care. It is intended to be a guide consistent with the “reasonable practice of a healthcare professional”. 6

2. The definition of sport-related concussion is complex. The 2017 CISG consensus statement defines SRC as a traumatic brain injury induced by biomechanics forces with the following common features:

• Caused by a direct blow to the head or an impulsive force transmitted to the head from elsewhere on the body.

• Typically results in rapid onset and resolution of impaired neurological function.

• Exhibits clinical signs and symptoms due to functional disturbance rather than structural injury—no abnormality seen on standard neuroimaging.

• Results in a range of clinical signs and symptoms that often do not include loss of consciousness.

Although it is often done in practice and seen in literature, the CISG consensus statement guards against using the terms ‘sport-related concussion’ and ‘mild traumatic brain injury’ interchangeably. 6,7

3. Medical providers caring for athletes must be up-to-date on the diagnosis and management of Sport-Related Concussion. The diagnosis of SRC is not always straightforward, and the misdiagnosis or mismanagement of SRC can have devastating consequences for the injured athlete. The clinical signs and symptoms are often subtle and may even be delayed for hours or days after the initial injury. 8 It is important to be familiar with the signs and symptoms of SRC and maintain a strong index of suspicion for this often under recognized condition.

Medical providers can gain valuable up-to-date SRC training by reviewing the 2017 Consensus Statement on Concussion in Sports referenced above 6 and by completing the CDC HEADS UP to Health Care Providers online training modules. 9

4. Sport-Related Concussion should be suspected in an athlete that displays any of the following signs and symptoms after a direct or indirect impact to the head:

• Observable Signs—loss of consciousness, slowness to get up after a play, disorientation, blank stare, balance or coordination difficulties, head or facial injury, vomiting, emotional lability.

• Reported Symptoms—headache, dizziness, blurred vision, sensitivity to noise or light, irritability, anxiousness, drowsiness, feeling slowed down or “in a fog”.

Headache and dizziness are the most common post-SRC symptoms. 6

5. The Sports Concussion Assessment Tool version 5 (SCAT 5) should be used to help diagnose SRC. SRC is one of the most challenging injuries in sports medicine to accurately diagnose. Acutely, a SRC is an evolving injury with rapidly changing signs and symptoms. Adding to the diagnostic complexity, the athlete will often downplay or deny symptoms for fear of being pulled from the game.

Currently, there is no definitive test or marker for the diagnosis of SRC. The SCAT 5 used for individuals 13 years and older and child SCAT 5 used for individuals 12 years and younger represents the most well-established instrument for the sideline evaluation of concussion. A copy of the SCAT 5 and child SCAT 5 can be downloaded for free and without copyright infringement for use by the healthcare professional on the sideline. 11,12

6. An athlete displaying any signs or symptoms of sport-related concussion must be removed from play immediately. SRC is a clinical diagnosis. The sideline provider must maintain a high index of suspicion for this sometimes elusive diagnosis. Once a player is suspected of having sustained an SRC, the player must be removed from play immediately. Further evaluation can be conducted on the sideline or in the locker room using the SCAT 5. If, after further evaluation, the player is diagnosed with a SRC, the player is not allowed to return to play that day. Depending on the severity of symptoms, the concussed player should either be transported to the emergency room for further evaluation or observed on the sideline for progression of symptoms. At no time should the injured athlete be left alone. After a 1-2 day period of physical and cognitive rest, the athlete is allowed to enter the return-to-sport protocol which is described later in this article. 6,13

7. Look for “red flags” of more serious injury in athletes with suspected sports-related concussion. Any athlete suspected of having an SRC after a direct or indirect blow to the head must be quickly identified on the field. The injured athlete must be immediately evaluated for “red flags” that could indicate other potentially more serious injuries. Red flags with suspected SRC include:

• Significant neck pain or tenderness—suspect possible cervical spine injury.

• Double vision, weakness or tingling/burning in arms or legs—suspect intracranial hemorrhage or cervical spine injury.

• Severe or increasing headache, seizure, prolonged loss of consciousness, deteriorating conscious state, vomiting, and increasing restlessness, agitation or combativeness—suspect intracranial hemorrhage. 6

An injured athlete displaying any of these “red flags” should be immediately transported to the emergency room, potentially in full spinal injury precautions.

8. All 50 states now have a youth concussion law that mandates education and management of sport-related concussion. The law in Mississippi was enacted on July 1 st , 2014, and is known called the “Mississippi Youth Concussion Law”. The law is a three-page document that should be read in its entirety by all healthcare providers who care for young athletes in Mississippi. The law applies to all private and public school athletes in grades 7-12 involved in school-sponsored activities. Although most legislation is similar, each state has its own law with subtle differences. If caring for an athlete in another state, you must follow that State’s specific Law. In summary, the Mississippi youth concussion law mandates the following: 13

• School organization shall adopt and implement a concussion management and return-to-play policy.

• Parents or guardians shall receive and sign a copy of the school’s concussion policy before the start of the sport season.

• Athlete with a suspected SRC shall be removed from practice or game immediately; not allowed to return the same day; evaluated by a healthcare provider.

• Athlete diagnosed with SRC shall be referred to a licensed physician, preferably one with experience in managing SRCs.

• Athlete diagnosed with SRC may return to play only after full recovery and clearance by a healthcare provider.

• State Department of Health shall endorse online concussion recognition education course.

9. Following a sport-related concussion, the athlete must complete a supervised graduated return-to-sport (RTS) protocol. The graduated RTS protocol is ideally supervised by the team physician or athletic trainer. The RTS protocol consists of 6 progressive stages of activity that culminates in the athlete returning to full unrestricted play. The RTS protocol begins after a 24-48 hour period of physical and cognitive rest only if the athlete is completely asymptomatic. There should be at least 24 hours between each stage of the protocol. If any sign or symptom recurs during the progressive stages of exercise, the athlete should go back to the previous stage. The following table is a generic example of a graduated RTS protocol as detailed in the 2017 CISG consensus statement. 6 A more sport specific strategy should be tailored to the individual athlete and sport.

10. There are several potential long-term risks associated with repeated sport-related concussions. These sometimes devastating complications should be discussed with the athletes and guardians prior to returning to sports with high risk for repeat concussion.

• Second impact syndrome (SIS)—SIS is a rare and devastating consequence of returning to play too early after suffering a sport-related concussion. It is thought that the initial concussion leaves the protective auto regulatory mechanisms of the brain vulnerable to subsequent trauma. A second impact on the incompletely healed brain results in massive cerebral edema and herniation. The injured athlete often dies on the field within minutes of the injury or may survive with profound neurologic deficits. 14

• Post-concussive syndrome (PCS)—After a sport-related concussion, symptoms typically resolve within 1-2 weeks. A small percentage (less than 10%) go on to develop PCS remaining symptomatic for several weeks or months following the injury. Risk factors for PCS include repeated concussions, history of psychiatric illness, and migraine. 15,16 Although treatment guidelines commonly advocate complete rest following an SRC, there is no evidence that completely avoiding physical activity while symptomatic expedites recovery. A recent study suggests that physical activity within 7 days of the SRC may reduce the risk of PCS. 17 Ideally, management of PCS should take place in a multidisciplinary collaborative setting experienced in treating this condition. 18

• Chronic traumatic encephalopathy (CTE)—CTE is a progressive neurodegenerative brain disease associated with repeated head trauma. Pathologically, CTE results from a buildup of abnormal tau protein in the brain that disrupts neuropathways. 19,20 The resulting clinical symptoms may include aggression, memory loss, depression, anxiety, and suicidal behavior. A recent well-publicized study examined the brains of more than 100 former NFL football players and found that 99% of those examined had pathological evidence of CTE. 21

References

1. Mullally, W, Concussion. Am J of Med. 2017:130;885-892.

2. Aubry M, Cantu R, Dvorak J, et al; Concussion in Sport (CIS) Group. Summary and agreement statement of the 1st international symposium on concussion in sport, Vienna 2001. Clin J Sport Med. 2002;12:6–11.

3. McCrory P, Johnston K, Meeuwisse W, et al. Summary and agreement statement of the 2nd international conference on concussion in sport, Prague 2004. Br J Sports Med. 2005;39:i78–i86.

4. McCrory P, Meeuwisse W, Johnston K, et al. Consensus statement on concussion in sport - the third international conference on concussion in sport held in Zurich, November 2008. Phys Sportsmed. 2009;37:141–59.

5. McCrory P, Meeuwisse WH, Aubry M, et al. Consensus statement on concussion in sport: the 4th international conference on concussion in sport held in Zurich, November 2012. Br J Sports Med. 2013;47:250–8.

6. McCrory P, Meeuwisse W, Dvorak J, et al. consensus statement on concussion in sport – the 5th international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med. 2017;0:1-10.

7. McCrory P, Feddermann-Demont N, Dvořák J, et al. What is the definition of sports-related concussion: a systematic review. Br J Sports Med. 2017;51:877-887.

8. Morgan, C., Zuckerman, S., Lee, Y., King, L., Beaird, S., Sills, A., & Solomon, G. (2015). Predictors of postconcussion syndrome after sports-related concussion in young athletes: a matched case-control study. J Neurosurg Pediatr. 1-10 DOI: 10.3171/2014.10.PEDS14356.

9. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention, HEADS UP to Health Care Providers. www.cdc.gov/headsup/providers/index.html. Accessed July 20, 2017.

10. Davis GA, et al. Br J Sports Med 2017;0:1–8. doi:10.1136/bjsports-2017-097506SCAT5 BJSM Online First, Concussion in Sport Group 2017. Sport Concussion Assessment Tool — 5th Edition http://bjsm.bmj.com/content/ bjsports/early/2017/04/26/bjsports-2017-097506SCAT5.full.pdf. Accessed July 20, 2017.

11. Davis GA, et al. Sport concussion assessment tool - 5th edition. Br J Sports Med. 2017;0:1-8.

12. Davis GA, et al. Child sport concussion assessment tool – 5th edition. Br J Sports Med. 2017;0:1–8.

13. Mississippi Legislature Regular Session 2014 Committee Substitute for House Bill No. 48. By: Representatives Mims, Crawford. http://billstatus.ls.state.ms.us/ documents/2014/pdf/HB/0001-0099/HB0048SG.pdf. Accessed July 20, 2017.

14. Bey T, Ostick B. Second impact syndrome. Western J of Emerg Med. 2009;10(1):6- 10.

15. Morgan C, Zuckerman S, Lee Y, et al. Predictors of postconcussion syndrome after sports-related concussion in young athletes: a matched case-control study. J Neurosurg Pediatr. 2015;15:589-98.

16. Bleiberg J, Cernich AN, Cameron K, et al. Duration of cognitive impairment after sports concussion. Neurosurgery. 2004;54:1073–78–78–80.

17. Grool A, Aglipay M, Momoli G, et al. Association between early participation in physical activity following acute concussion and persistent postconcussive symptoms in children and adolescents. JAMA. 2016;316(23):2504-2514.

18. Makdissi M, Schneider K, Feddermann-Demont N, et al. Approach to investigation and treatment of persistent symptoms following sport-related concussion: a systematic review. Br J Sports Med. 2017;51(12):958-68.

19. McKee AC, Stern RA, Nowinski CJ, et al. The spectrum of disease in chronic traumatic encephalopathy. Brain. 2013;136:43-64.

20. Omalu BI, DeKosky ST, Minster RL, et al. Chroinc traumatic encephalopathy in a national football league player. Neurosurgery. 2005;57(1):128-133.

21. Mez J, Daneshvar DH, Kiernan PT, et al. Clinicopathological evaluation of chronic traumatic encephalopathy in players of American football. JAMA. 2017;318(4):360-370.

Author Information: Program Director of the Primary Care Sports Medicine Fellowship at the University of Mississippi Medical Center (UMMC) in Jackson (Tollefson). PGY-2 emergency medicine resident at UMMC (Grantier). Primary Care Sports Medicine Fellowship Coordinator at UMMC (O’Brien).

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