Heads Up on Sports Concussions

A 16 yo female high-school soccer star was momentarily dazed after heading the ball awkwardly, and immediately felt nauseated.  However, after a rest, she only had a lingering headache.  She did not mention the headache to anyone, and played the rest of the game.  Her headache worsened and the nausea returned when she was running.  Somewhat distracted, she clunked heads with another player and was unconscious for a minute.  Her coach felt that she was soon oriented and coherent; he did a brief sideline check and saw no weakness, balance or eye movement abnormalities.  She was advised to rest, take the next day off, and see her doctor and to report back for practice when cleared.  

In a medical office two days later, her mother says that she has been unusually quiet.  She denies headache or nausea, but has not been eating as much as usual.   She tried to go to classes yesterday morning, but says she “learned nothing”.  She is concerned about upcoming final exams.  Her parents tell you that she is a soccer scholarship candidate and needs to be active when her school plays in the state championships in two weeks.  Her teammates think they have a good chance of winning if she plays.

Is additional testing/consultation needed?  What treatment beyond rest and common sense might there be?  Recommendations are needed about returning to practice and play.  Her parents would like to know about schoolwork and other activities. 

Recent, well-publicized sports-related head injuries have forced a reconsideration of our about management of sports concussion.
The American Academy of Neurology (AAN) Practice Parameter on this topic is 15 years old, and contains paradigms that have since become outdated.  Lately, the AAN has aired interviews with thought leaders, and made plans to update their Practice Parameter.   Much of what they have discussed comes from the 3rd International Conference on Sports Concussion, held in Zurich, 2008.  The interviews placed great emphasis on Second Impact Syndrome (SIS), and Chronic Traumatic Encephalopathy (CTE).

SIS follows a head injury to someone who has not yet recovered fully from a prior concussion, resulting in a more severe condition, associated with cerebral edema, coma and potentially fatal outcome.  Epidemiological studies have suggested an association between repeated sports concussions during a career and late-life cognitive impairment.  Case reports have noted instances where neuropathological evidence of CTE was observed in retired football players.  Family histories of degenerative CNS disease or dementia increase risk as well as the “dose” and frequency of trauma, i.e., higher for a starting linebacker who also plays tight end than for the backup kicker.

In my opinion, identification and grading of concussion, and Return to Play (RTP) guidelines for injured athletes really need our focus; appropriate guidelines can serve to prevent the occurrence of SIS and CTE.  Eleven states have passed laws mandating licensed health professional assessments and clearance for young competitors sustaining concussions, as well as education for parents and coaches.  

Identifying Concussion

In defining concussion as “a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces”, head injury experts are unanimous.  Emerging constructs are that:

1. Concussion need not involve direct head trauma, but can occur after injury to face, neck or elsewhere on the body where force can be transmitted towards the head.
2. Loss of consciousness is not required.
3. Functional disturbance rather than structural injury is the most common observation; further, the symptoms are generally short-lived and resolve spontaneously.

It is suggested that a concussion be suspected if one or more of the following is present:

• symptoms: somatic (e.g. headache), cognitive (e.g. feeling like in a fog) or emotional symptoms (e.g. lability)
• physical signs (e.g. loss of consciousness, amnesia)
• behavioral changes (e.g. irritability)
• cognitive impairment (e.g. slowed reaction times)
• sleep disturbance (e.g. drowsiness).

Players showing any features as above should be evaluated onsite, using emergency management principles with particular attention given to the cervical spine.  The treating health care provider must determine appropriate disposition.  If no provider is available, the player should be removed from practice or play and urgently referred to a physician. Once first aid has been given, an assessment should be made using the Sport Concussion Assessment Tool 2 (SCAT2) or similar test - www.cces.ca/files/pdfs/SCAT2[1].pdf The player should be monitored for deterioration over the first hours following injury.  A player with diagnosed concussion should generally not be allowed to Return to Play (RTP) on the day of injury.

Sideline evaluation of cognitive function, including brief assessments of attention and memory function (included with SCAT reference), has proven to be practical and effective.  Standard orientation questions (e.g. time, place, person) have been shown to be unreliable in the sporting situation when compared with memory assessment.  These are not meant to replace comprehensive neuropsychological testing, which is sensitive to detect subtle deficits that may exist beyond the acute episode.  It should also be recognized that the appearance of symptoms might be delayed several hours following a concussive episode.

Return to Play

The 1997 AAN Practice Parameter suggested that after a “simple” injury, RTP—i.e. resumption of competition-level activity--was possible the same day, with longer delays for more “complex” injuries.   The Zurich Conference statement argues for a graduated return to play protocol according to the adapted table - click here to see table

Additional Management Concerns

The Zurich Congress participants advise psychological treatment where depression or anxiety is an injury sequela.  Pharmacological therapy may be needed for specific prolonged symptoms, i.e., sleep disturbance or headache; however, concussed athletes need to be symptom-free without medications before RTP. A pre-participation concussion evaluation has become standard for some sports (amateur boxing), specifically getting at symptoms following prior head, neck and face injuries.  Important factors such as disproportionate symptoms relative to impact severity, family history of concussion, history of prior headache and affective disorders, athlete aggressiveness and recklessness (increased by use
of protective gear) all have a
potential place.

Other Issues

Loss of consciousness (LOC) greater than one minute remains a factor that may modify management, particularly prolonged LOC; briefer LOC has not been shown to correlate with injury severity.  Retrograde amnesia varies with the time of post-injury measurement and is poorly reflective of severity.  Immediately occurring seizures or posturing are benign and require no special considerations. Although most concussions in adults resolve in 7 to 10 days, children and adolescents may take longer to recover.  Once identified, it is important that young concussed athletes have a period of rest, both cognitive and physical. The concept of ‘‘cognitive rest” involves a (child’s) need to limit exertion with activities of daily living and to limit scholastic and other cognitive stressors (e.g. text messaging, video games) while symptomatic.  Many further recommendations are pertinent to children, especially those less than ten years old who may report and manifest concussion differently from older children.

Dr. Siegel is a Neurologist practicing in San Mateo.