We have all heard the term “concussion,” any many of us have had personal experience with concussions through years of involvement in athletics. But, just what exactly is a concussion? How do you know if you are suffering from one? And, most importantly, how should a concussion be managed? Whether you are a parent with kids involved in sports, or you yourself are on the ice/hitting the slopes this winter, concussion injuries are an important topic for all of us to be aware of. Concussion is most commonly defined as a “trauma-induced alteration of mental status that may or may not involve loss of consciousness.” This highlights the important fact that you can sustain a concussion injury without any loss of consciousness, or even in the absence of a direct blow to the head. These are two common misconceptions. Concussion can also be defined as a “biomechanically induced brain injury characterized by the absence of gross anatomic lesions.” More simply put, there will often be no detectable injury observed with conventional neuroimaging techniques (MRI, CT etc.) suggesting a functional rather than structural disturbance. Concussion injury results in the rapid onset of short-lived neurological impairment that usually resolves spontaneously within 7 to 10 days.
Signs and symptoms of acute concussion:
The diagnosis of acute concussion usually involves the assessment of a range of domains including clinical symptoms, physical signs, cognitive impairment, neurobehavioural features and sleep disturbance. A detailed concussion history is an important part of the evaluation, both in the injured athlete, and when conducting a pre-participation examination.
The suspected diagnosis of concussion can include one or more of the following clinical domains:
1) Symptoms—somatic (e.g. headache), cognitive (e.g. feeling like in a fog) and/or emotional symptoms (e.g. lability) 2) Physical signs (e.g. loss of consciousness, amnesia) 3) Behavioural changes (e.g. irritability) 4) Cognitive impairment (e.g. slowed reaction times) 5) Sleep disturbance (e.g. insomnia) If any one or more of these components are present, a concussion should be suspected and the appropriate management strategy instituted.
Concussion in sport:
Sport-related concussion is a leading public health problem with an estimate of 1.6 to 3.8 million cases each year in the United States alone. While 85% of these injuries are considered to be mild, a proportion of them may have long-term effects, and there is increasing awareness regarding the personal, medical, and societal costs of concussion. While most patients who suffer a concussion experience resolution over the course of 7–10 days, up to 10% of patients continue to have symptoms. Post concussion syndrome (PCS) is a constellation of physical, cognitive, and emotional symptoms that persist after concussion. Currently, there is no gold standard for the diagnosis of PCS, which has resulted in large discrepancies in the estimated prevalence of the syndrome.
When a player shows features of a concussion:
- The player should be evaluated by a physician or other licensed healthcare provider onsite using standard emergency management principles. Particular attention should be given to excluding a cervical spine injury.
- If no healthcare provider is available, the player should be safely removed from practice or play and urgent referral to a physician arranged.
- Once the first aid issues are addressed, an assessment of the concussive injury should be made using the SCAT3 or other sideline assessment tool.
- The player should not be left alone following the injury and serial monitoring for deterioration is essential over the initial few hours following injury.
- A player diagnosed with a concussion should not be allowed to return to play on the day of injury. It should also be noted that the appearance of symptoms or cognitive deficit might be delayed for several hours following a concussive episode, and that concussion should be seen as an evolving injury in the acute stage.
Concussion management:
The cornerstone of concussion management is physical and cognitive rest until the acute symptoms resolve, and then a graded program of exertion prior to medical clearance and return to play. With this stepwise progression, the athlete should only continue to proceed to the next level if asymptomatic at the current level. Generally, each step should take 24 hours so that an athlete takes approximately 1 week to proceed through the full rehabilitation protocol once they are asymptomatic at rest. If any post-concussion symptoms occur while in the stepwise program, the patient should drop back to the previous asymptomatic level and try to progress again after a further 24-hour period of rest has passed.
Graduated return to play protocol:
- No activity
- Light aerobic activity
- Sport-specific exercise (light sport drills)
- Non-contact training drills (more complex drills involving increased coordination and cognitive load)
- Full-contact practice
- Return to play
The bottom line:
- Concussion injuries are common in sports. They can happen in the absence of a direct blow to the head or without loss of consciousness.
- Immediate medical attention/assessment is crucial and the person should be monitored closely for the first several hours following injury for evolving signs and symptoms.
- A person diagnosed with a concussion should not be allowed to return to play on the day of injury.
- Complete physical and cognitive rest is recommended until symptoms resolve, and then a graduated return to play protocol should be initiated under the guidance of a qualified health care professional.
Keep your helmet on and see you on the slopes!
Dr. Steve
References: Baker et al. Return to full functioning after graded exercise assessment and progressive exercise treatment of post-concussion syndrome. Rehabilitation Research and Practice. (2012). Signoretti et al. The pathophysiology of concussion. American Academy of Physical Medicine and Rehabilitation. (2011). McCrory et al. Consensus statement on concussion in sport 3rd International Conference on Concussion in Sport held in Zurich, November 2008. Clinical J Sport Med. (2009). McCrory 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).