Concussion Identification, Evaluation and Management: A Step-By-Step Process

4. Follow-up evaluation

• Athletes with concussion should have a medical follow-up which should include:
  • the taking of detailed history of how the injury occurred;
  • periodic monitoring of symptoms using a standardized symptom scale to assess symptom resolution and progress towards and return to the athlete's pre-injury baseline (note: in the vast majority of concussions, balance is back to baseline in 3 days)^[2]
    • Worsening symptoms, pronounced amnesia, progressive balance problems, or focal neurological deficits (abnormal or unequal pupil reaction, abnormalities in eye movements, abnormalities on a screening motor/sensory exam) could be sign of intracranial bleeding and should prompt neurological imaging (CT/MRI).^[2]

5. Treatment  

• Physical and cognitive rest. Treatment of a concussion consists of physical and cognitive rest, especially in the early stages of a concussion recovery when they may make symptoms worse.  Most athletes recover spontaneously and become asymptomatic after concussion within a week,^[24] although younger adolescent athletes usually take longer to recover,^[25] and full return of cognitive function^[19] and cerebral blood flow^[26,27] may not occur until weeks or even months after athletes report that their symptoms have cleared (which is why studies suggest that recovery not be viewed as complete based solely on the athlete's self-assessment of their recovery^[28]).
  • Because a concussion impacts the brain's cognitive functions (those that involve thinking, concentrating, learning and reasoning), most concussion experts believe that limiting an athlete's scholastic and other cognitive activities to allow the brain time to heal helps in recovery. While strict bed rest is not necessary, and while the effect of physical activity on concussion recovery has not been extensively studied (indeed, there is some evidence to suggest that mild physical exertion may actually help concussion recovery, especially for those suffering from post-concussion syndrome), the consensus of experts recommends broad restrictions on physical activity in the first few days after a concussion, with the Zurich statement^[1] highlighting the "concept of 'cognitive rest' ... with special reference to a child's need to limit exertion with activities of daily living that may exacerbate symptoms," including school.
  • Such recommendations are not without dissenters, most notably Christopher Randolph, PhD of the Department of Neurology at Loyola University Medical Center in Maywood, Illinois, who continue to question the idea that the rest needs to be "complete" and last until an athlete is entirely asymptomatic. Writing in an editorial in the September 2012 issue of the Clinical Journal of Sports Medicine,^[20] Randolph and his co-authors point to the lack of empirical data to show that physical or cognitive rest after sport-related concussion exacerbates concussive injury, and cite to studies of athletes suggesting that re-engaging in activities in the days after injury is likely to have no detrimental effect or even a beneficial one; findings consistent with the view that total bed rest is generally contraindicated for most medical conditions.
  • A 2013 systematic review of the literature on the effects of rest and treatment following sport-related concussion^[21] takes a middle ground, noting that, while mental and physical rest in the initial days following a concussion have been strongly encouraged, and resting until symptom free widely recommended, there have been only three published studies evaluating the effects of rest in athletes who have suffered a sport-related concussion, and with specific reference to a 2012 study in the Journal of Pediatrics by MomsTEAM expert concussion neuropsychologist, Rosemarie Scolaro Moser, PhD,^[22]point to the absence of a control or comparison group, "so that improvements could have been attributed to a diverse range of factors."
    • The authors, however, identified three lines of evidence that indirectly support the value of rest:
      • "First, concussions can have a large adverse effect on physical and cognitive functioning in the first few days postinjury, as the brain is in a state of metabolic crisis,^[23] at which time increased energy demand may hinder the restorative process, and it is believed that rest might facilitate recovery.
      • Second, in animal injury models, there appears to be a 'temporal window' of vulnerability in which a second overlapping injury results in greater levels of traumatic axonal injury and magnified cognitive and behavioral deficits. Thus, a rest period will reduce the likelihood of the athlete experiencing an overlapping injury.
      • Finally, it has been demonstrated in rodent models that exercise appears to be good for the injured brain; however, animals that are allowed to exercise too soon after injury do not show the expected exercise-induced increases in molecular markers of neuroplasticity [the ability of the brain to rewire itself after injury]. For these reasons, it is believed that rest is very likely beneficial following injury. However, this is largely based on animal research, theory and expert consensus."^[21]
  • In the absence of further studies to evaluate the effects of a resting period and the optimal duration of this period, experts recommend taking a "sensible approach involv[ing] a gradual return to school and social activities (prior to contact sports) in a manner that does not result in a significant exacerbation of symptoms." (n. 2,4)

• Symptoms.  There is no convincing evidence that any particular medication is effective in treating the acute symptoms of sports concussion specifically.^[2]
  • Headache: Treatment options in the first several days after concussion (the acute phase) for headache (far and away the most common symptom of concussion) are limited:
    • Acetaminophen (e.g. Tylenol®) offers a possible benefit without the risk of bleeding in the brain that are thought to be associated with aspirin or non-steroidal anti-inflammatory medicine(NSAIDs)(e.g. Ibuprofen/Advil®), which are not recommended for that very reason. ^[2]
    • An ice pack on the head and neck is okay as needed for comfort. ^[2]
    • A dim, quiet environment may help with headache, as well as symptoms of sensitivity to light and sound often experienced by student-athletes with concussion. ^[2]
    • Headaches that continue as part of a (symptoms lasting longer than 4-6 weeks) often require a multi-disciplinary approach. ^[2]
  • Sleep disturbances: A concussed student-athlete may experience either difficulty falling or staying asleep, or sleep longer.
    • While disturbed sleep is a common and important symptom experienced throughout the course of a concussion, and immediately after a concussion, sleep issues should be initially addressed without medications, and with particular attention to good sleep hygiene.
    • If sleep difficulties persist (e.g. your child is diagnosed with post-concussion syndrome), then medical and cognitive therapies may be considered.
    • The traditional rule has been to wake up a concussed athlete every 3 to 4 hours during the night to evaluate changes in symptoms and rule out the possibility of an intracranial bleed, such as a subdural hematoma. The new thinking is that there may be more benefit from uninterrupted sleep than frequent wakening, which may make symptoms worse. As a result, waking up your child during the night to check for signs of deteriorating mental status is no longer recommended. Indeed, if level of consciousness or deteriorating mental status is a concern, the athlete should undergo a CT scan or MRI. and be observed in a hospital setting. As Dr. Bill Meehan of Boston Children's Hospital observes, "As an emergency room doctor, if I was that concerned about a patient that I wanted their parents to check on em every hour or two, I would keep them in the hospital, I wouldn't send them home. Ideally if you're that worried about a bleed, you can either get some kind of imaging and find out is there blood in the brain, or you observe them, and you watch them get better and then you don't need it. All that waking them up every hour or two is gonna do is make them worse, right? You want them to sleep so they get better. So the real reason to [wake them up] is if you're not sure it's concussion, you're worried there's something else going on, and for me if I'm that worried about it, I don't send them home." ^[2]
  • Alteration in mood, such as depression are common manifestation of concussion, particularly in the acute phase, but there is no established role for medications in treatment of a concussion-induced mood disturbance. Again, if mood issues persist beyond 6-12 weeks, either as part of post-concussion syndrome, or as a result of a worsening of a pre-existing mood disorder, treatment with medication and/or cognitive therapy should be considered. ^[2] [For more on therapies for post-concussion syndrome, click here].
  • Cognitive difficulties. There is no established role for stimulant medication (eg., Adderall, Ritalin) in the treatment of acute attention difficulties following concussion. Academic accommodations should be considered for any significant decrease in cognitive performance. ^[2]
  • Balance problems and vertigo. Medications such as meclizine or diazepam may be helpful for acute attacks of vertigo, but should be used cautiously early in concussion management as they may affect cognitive function, cause fatique, and obscure the evaluation of a concussion recovery. Although only limited evidence exists, vestibular therapy may be considered for the treatment of dizziness or vertigo. ^[2]

6. Neuropsychological testing

Neuropsychological (NP) testing in athletes began in the 1980's and its use has expanded in the last decade with the availability of computerized testing in addition to traditional paper-and-pencil NP tests.

• data suggests that cognitive impairment after concussion may last longer than subjective symptoms. ^[2]
• NP testing is a tool that can identify cognitive impairment and may also aid in documenting an athlete's recovery from concussion, ^[1-3] although whether the use of NP testing reduces the short-term risks (recurrent or catastrophic injury) or potential long-term complications is currently not known. ^[2]
• Paper-and-pencil NP testing has the advantage of testing additional cognitive domains,^[19] which may identify other conditions masquerading as concussion or post-concussion syndrome or identify continued cognitive deficits, such as the ability for high level thinking (so-called 'executive function'),^[19] which a recent study shows may be impaired in concussed adolescents for as long as 2 months after injury. The disadvantage of paper-and-pencil NP testing, of course, is that it is more expensive than computerized NP and require significantly more time to administer and requires a licensed neuropsycholgist to intepret the results. ^[2]
• Computerized NP has advantages in the athletic setting in that it is less expensive, takes less time to administer, may be administered to groups of athletes, provide instant information to the provider, has more precise measures of reaction time, has multiple forms and may be used for serial assessment. ^[2]
• Both types of NP tests have significant individual variability with regard to the cognitive domains measured and performance measures. ^[2]
• NP testing has not been validated as a tool to diagnose concussion; rather, it is a tool to use in monitoring recovery from concussion ^[1,2] and making the all-important return-to-play decision.
• Whether baseline testing is necessary is open to debate: it appears to have advantages over comparative normal values, but no studies have looked at this issue with regards to outcomes, and there are, as noted, some studies ^[12,13] that suggests that age-related norms may be adequate to assist with management decisions. ^[2]
  
• If testing is used, care should be taken to make the baseline and postinjury physiological variables (ie, fatigue) and environmental variables (ie. distractions) as similar as possible. ^[2]
• No optimum postconcussion monitoring interval has been established and reported intervals vary from every few days to only testing asymptomatic athletes prior to return to play. ^[2]
• While NP testing has become increasingly popular in concussion management, its use remains controversial. As a result, there are no universally agreed-upon recommendations for use of NP testing, with existing recommendations based on experts' opinion. ^[2]
  
• If anything, while the trend in recent years has been for more athletes, especially at the high school level, to undergo baseline NP testing, there appears to be some slight movement away from recommending routine testing of all athletes, or even all athletes in contact or collision sports with a high risk of concussion:
  • The American Medical Society for Sports Medicine's 2013 position statement ^[2] says that concussions can be managed appropriately in a majority of cases without the use of NP testing, although it recognizes that it may have "added value in some settings, especially high-risk athletes." 
  • The 2013 Zurich consensus statement on concussions ^[1] states that "[f]ormal NP testing is not required for all athletes," and that there was "insufficient evidence to recommend the widespread routine [or mandatory] use of baseline neuropsychological testing."
  • The American Academy of Neurology's 2013 concussion guidelines ^[3] states that it is "likely" that NP testing, whether paper-and-pencil or computerized, "is useful in identifying the presence of concussion." The AAN's language on baseline NP testing is equally equivocal, saying only that concussion management "might utilize individual baseline scores on concussion assessment tools, especially in younger athletes, those with prior concussions, or those with preexisting learning disabilities/attention-deficit/hyperactivity disorder, as doing so fosters better interpretation of postinjury scores."
• If NP testing is used, both the Zurich statement and the AMSSM position statement, as well as other recent studies,^[29-33] agree that it should not be the sole basis of management decisions but should only be seen as an aid to the clinical decisionmaking process in conjunction with a range of other assessments (e.g. concussion symptom scales, balance, clinical exam).
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