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Updated: Feb 11 2024

Concussions (Mild Traumatic Brain Injury)

Images
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  • Summary
    • Concussions are a subset of mild traumatic brain injury (mTBI) characterized by acute transient impairment of neurologic function secondary to an impulsive force transmitted to the head.
    • Diagnosis is made by careful neurological evaluation of an athlete following head trauma with a focus on cognitive function.
    • Treatment is immediate removal from play followed by cognitive and physical rest for 24-48 hours, and subsequent completion of a graduated return to play protocol.
  • Epidemiology
    • Incidence
      • 1.6-3.8 million sports-related concussions per year
        • increasing over the past decade, though possibly due to increased awareness
        • substantial rise in youth athletes is concerning
      • 5-9% of all sports injuries
    • Demographics
      • traumatic brain injury (TBI) is the leading cause of sport-related death
      • American football associated with the majority of concussions
      • occur in competition more often than practice
  • Etiology
    • Pathophysiology
      • direct blow to the head, face, neck or elsewhere with force transmitted to the head
      • complex neurometabolic cascade resulting in the typical signs and symptoms of a concussion
        • abnormal neuronal ionic flux -- headache, photophobia, phonophobia
        • altered release of neurotransmitters (glutamate) -- impaired cognition, amnesia, slowed reaction time
        • energy depletion, in an effort to correct the above underlying biochemical imbalances -- vulnerable to second injury (second-hit phenomenon)
      • may or may not experience loss of consciousness
        • not required for diagnosis of concussion
    • Risk factors
      • sports with player-to-player contact
        • football, wrestling, soccer, basketball at highest risk
      • prior concussion
        • 2-8x higher risk of sustaining another concussion
      • female
      • age < 18 years
      • mood disorders, learning disorders, history of migraines
        • mostly complicates diagnosis and recovery rather than predisposing to concussion
    • Guidelines
      • International Conference on Concussion in Sport
        • meeting held every 4 years
        • focuses on the prevention, diagnosis and management of sports-related concussion
        • generates a consensus statement summarizing the updated practice guidelines
          • consensus statement created at the first meeting in 2001
          • grading system for concussions removed in 2004
          • all classification systems removed in 2008
          • newer assessment tools and timing of return to play was the primary focus of the most recent meeting
  • Presentation
    • Symptoms
      • somatic symptoms
        • headache
          • most common symptom
          • present in 70% of concussed athletes
          • types
            • myofascial tension headache -- pain localized to posterior neck at base of skull
            • post-traumatic headache -- pressure localized to forehead and/or top of head
        • dizziness
        • balance problems
        • nausea and/or vomiting
        • vision changes
        • sensitivity to light (photophobia) or sound (phonophobia)
      • cognitive symptoms
        • feeling "in a fog" or slowed down
        • difficulty concentrating
        • forgetful
      • emotional symptoms
        • lability
        • irritability
        • sadness
      • sleep disturbance
        • change in amount of sleep (more or less)
        • difficulty falling asleep, insomnia
        • drowsiness
    • Signs
      • many sports have established "mandatory signs of concussion"
        • presence of these visible signs dictates further evaluation and often removal from play
        • note, the specific signs and subsequent recommended action differs between sports
      • loss of consciousness
        • occurs in only ~10% of cases
      • lying motionless > 5 seconds
      • slow to get up
      • confusion or disorientation
      • clutching the head
      • amnesia
      • vacant look
      • motor incoordination
      • ataxia
  • Evaluation
    • Sideline evaluation
      • primary survey
        • airway, breathing, circulation
        • assess for spinal cord injury
          • cervical collar and back board immobilization if needed
          • in an altered patient, assume cervical spine injury until proven otherwise
        • indications for transport to ER for advancing imaging
          • deteriorating mental status
          • increasingly restless, agitated or combative
          • severe or worsening headache
          • focal neurologic findings
            • unequal pupils
            • abnormal extraocular eye movements
            • motor and/or sensory deficit
          • neck pain or tenderness concerning for cervical spine injury
          • bloody otorrhea, mastoid ecchymosis, blepharohematoma
        • do not leave player alone after injury
      • secondary survey -- evaluate cognitive function
        • any athlete with symptoms or signs of a concussion should be removed from the playing field and undergo immediate cognitive evaluation by a licensed healthcare provider
          • if no healthcare provider is avaliable, the athlete should be removed from play entirely and urgently referred to a physician
        • sideline assessment tool that tests attention and memory
          • SCAT5 is the most commonly used
      • Sports Concussion Assessment Tool 5 (SCAT5)
        • standardized neuropsychological test for evaluating concussions in athletes aged 13 years or older
          • child SCAT5 can be used for younger athletes
        • composed of two parts
          • immediate on-field assessment
          • office or off-field assessment
        • immediate on-field assessment
          • red flags
          • observable signs
            • witnessed or on video review
          • Maddocks questions -- memory assessment
          • Glasgow Coma Scale (GCS)
          • cervical spine assessment
        • off-field assessment
          • should be done in a private, distraction-free area
          • Standard Assessment of Concussion (SAC) test
          • Balance Error Scoring System (BESS) test
  • Imaging
    • Advancing imaging
      • usually unnecessary
      • need for imaging is determined by the evaluating physician
      • indications
        • acute head trauma with
          • deteriorating mental status
          • increasingly combative, aggressive, restless
          • focal neurologic deficit
          • neck pain concerning for cervical spine injury
        • history of subacute/chronic head trauma with persistent symptoms
    • Computerized tomography (CT) head
      • most commonly used in the acute setting
      • findings
        • normal in vast majority
        • can identify fractures, intracranial hemorrhage, contusion, mass effect and herniation
    • Magnetic resonance imaging (MRI) brain
      • superior visualization of brain structures
      • diffusion-weighted imaging (DWI) most sensitive to shear injury
      • findings
        • standard MRI normal in vast majority
          • concussion is most often a functional rather than structural pathology
        • functional MRI can show increased cerebrovascular reactivity in the acute post-concussive period
  • Neuropsychological Assessment Tools
    • Standard Assessment of Concussion (SAC) test
      • evaluates
        • orientation (ex. What month is it?)
        • memory, immediate and delayed (ex. repeating 5 words over 3 trials and 1 trial at the conclusion of assessment
        • concentration (ex. repeating string of 5 numbers backwards)
    • Immediate Post-concussion Assessment and Cognitive Testing battery (ImPACT)
      • a computer-based test that assesses verbal and visual memory, processing speed, reaction time, impulse control and presence of concussive symptoms
      • comparison is made to baseline scores or historical controls
      • useful tool in guiding treatment and return to play decisions
    • Balance Error Scoring System (BESS)
      • tests balance and postural stability by having the athlete perform 3 stances for 10 seconds each
        • bipedal stance
        • unipedal stance
        • tandem stance
    • Sensory Organization Test (SOT)
      • assesses integrity of the entire balance system by testing the vestibular, visual and somatosensory systems, which are responsible for postural stability and maintenance of balance
    • King-Devick (K-D) Test
      • examines saccadic eye movements, language and concentration by having the athlete rapidly read numbers off a card from left to right for 3 successive tests
    • Sports Concussion Assessment Tool 5 (SCAT5)
      • reviewed under Sideline evaluation
  • Treatment
    • Nonoperative
      • immediate removal from play, same day return to play is NOT indicated
        • indications
          • athletes of any age with signs/symptoms concerning for concussion (see above)
            • if concerned at all, remove athlete from play!
          • athletes with head trauma and no medical provider experienced in concussion evaluation present
          • head trauma with history of concussion
          • loss of consciousness
          • amnesia
          • positive exertional stress test
          • symptoms lasting > 15 minutes
      • cognitive and physical rest x24-48H, graduated return to play protocol
        • indications
          • acute concussion
        • technique
          • same day return to play is contraindicated in patients diagnosed with a concussion
          • graduated return to play protocol highlighted in table below 
          • each step should take 24 hours, so an athlete should take one week to proceed through the full protocol and return to play
      • Graduated Return to Play Protocol
      • Stage
      • Activity 
      • Goal 
      • 1. Symptom-limited activity
      • Daily activities that do not provoke symptoms
      • Gradual reintroduction of work/school activities
      • 2. Light aerobic exercise
      • Walking, swimming, or stationary cycling to maintain HR at <70% of maximum. No resistance training.
      • Increase heart rate
      • 3. Sport-specific exercise
      • Running or skating drills. No head impact activities.
      • Add movement
      • 4. Non-contact training drills
      • More complex training drills (i.e. passing drills). May start progressive resistance/strength training.
      • Exercise, coordination, and improved cognition
      • 5. Full contact practice
      • Normal training activities.
      • Restore confidence, assess functional skills
      • 6. Return to play
      • Normal game play
  • Prevention
    • Protective equipment
      • head gear and helmets reduce impact forces to the brain
      • helmet use is associated with decreased rates of head and neck injuries in certain sports
        • youth hockey, alpine, equestrian, cycling and motor sports
      • risk compensation
        • use of protective equipment may paradoxically increase injury rates by enabling more dangerous playing techniques
    • Rules changes
      • beneficial when a clear cut mechanism is implicated in a particular sport
        • upper limb-to-head contact banned in American football
          • accounted for ~50% of concussions
        • strict enforcement of red cards for high elbows in professional soccer
    • Community education
      • players, coaches, athletic trainers, referees and the general public
      • focus on safe play, identification of concussion and appropriate graduated return to play
        • minimizing premature return to play decreases risk of long-term complications
    • Preparticipation concussion evaluation
      • number of previous concussions, type and severity of symptoms, length of recovery
      • mechanism of injury
        • low-impact injury but with disproportionately high symptom severity can indicate an athlete who is particularly vulnerable to injury
      • great opportunity for education and modification of high-risk behavior
    • Future research
      • energy-absorbing artifical turf fields
      • genetic tests -- apolipoprotein E
      • specific playing technique -- limited contact football, different tackling techniques
  • Complications
    • Second impact syndrome
      • second head trauma before symptoms of a concussion have resolved
      • catastrophic cerebral edema resulting from loss of autoregulation of the brain blood supply
      • high rate of death and disability
        • mortality rate ~50%
      • associated with male gender, young age and American football
    • Postconcussion syndrome
      • persistent symptoms of a concussion (i.e. headache, confusion)
        • > 10-14 days in adults
        • > 4 weeks in children
          • younger athletes at increased risk for prolonged return to sport 
      • return to play is contraindicated
      • should undergo formal neuropsychiatric evaluation
      • use of pharmacotherapy is controversial
    • Intracranial hemorrhage
      • subdrual hematoma most common
      • epidural hematoma
        • commonly have a lucid period before neurologic decline
        • neurosurgical decompression and seizure prophylaxis indicated
    • Chronic traumatic encephalopathy (CTE)
      • progressive neurologic deterioration resulting from repetitive brain trauma
      • symptoms
        • behavior changes -- loss of impulse control, aggression, irritability
        • mood changes -- depression, apathy, suicidal ideation
        • cognitive impairment -- difficulty with executive functions (i.e. carrying out tasks), memory loss, dementia
      • diagnosis
        • postmortem neuropathologic examination of the brain
          • cerebral atrophy
          • enlarged ventricles
          • diffuse senile plaques
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