KEYS TO CONCUSSION MANAGEMENT

Goals

  • Recognize that a concussion has occurred.
  • Remove athlete from activity.
  • Treat the athlete.
  • Determine when it is safe to return to activity.

Recognition

What is a concussion?

  • “A concussion, or mild traumatic brain injury, is a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces secondary to direct or indirect forces to the head. Disturbance of brain function is related to neurometabolic dysfunction, rather than a structural brain injury, and is typically associated with normal structural imaging findings (CT scan, MRI).
  • Concussion may or may not involve loss of consciousness.
  • Concussion results in a constellation of physical, cognitive, emotional, and sleep-related symptoms. Symptoms may last from several minutes to days, weeks, months, or even longer in some cases.” – CDC tool kit (cdc.gov/headsup/index.html)

Sign & Symptoms

Signs: Things observed by others.

  • Dazed or stunned
  • Vacant stare
  • Confusion
  • Amnesia
  • Unsure of surroundings
  • Answers questions more slowly
  • Repeatedly asks the same questions
  • Balance problems
  • Loses consciousness (even briefly)
  • Shows behavior or personality changes
  • Retrograde amnesia (unable to recall events prior to hit or fall)
  • Antegrade amnesia (unable to recall events after the hit or fall)

Symptoms: Complaints experienced by the athlete.

  • Headaches
  • “Pressure in head”
  • Neck Pain
  • Nausea or vomiting
  • Dizziness
  • Blurred vision
  • Balance problems
  • Sensitivity to light
  • Sensitivity to noise
  • Feeling Slowed Down
  • Feeling like “in a fog”
  • “Don’t feel right”
  • Difficulty Concentrating
  • Difficulty Remembering
  • Fatigue or Low Energy
  • Confusion
  • Drowsiness
  • Trouble Falling Asleep
  • More Emotional
  • Irritability
  • Sadness
  • Nervous or Anxious

Treat the Athlete

MANAGEMENT

The brain is the most complicated organ in the body therefore it’s functioning and recovery from injury is not fully understood. The last several years, millions of dollars have been spent on research regarding brain injury this has resulted and a better understanding of the injury and recovery. New information from this research guides our treatment and precautions regarding concussion. The most robust research has been done in athletes. Education for athletes, parents, coaches, athletic trainers, school administrators, and teachers is vital for successful management of concussion. Each person’s brain is different than any other and each injury is different. The management of this injury therefore needs to be individualized and is often somewhat different from one athlete to another. A very large percentage of athletes who sustain a concussion recover completely, usually in a relatively short period of time. However, some athletes may experience prolonged symptoms and rarely permanent injury. The brain during recovery is trying to repair the injury to the cells in addition to performing all the other functions required on a day-to-day basis. During the recovery phase certain restrictions or limitations may be necessary to allow that recovery.

-Physical Restrictions

Recovery from a concussion requires limitation of physical activity, especially sport activity such as practice, drills, games, and physical education classes. A return to activity must be gradual, starting slowly and increasing in intensity without recurrence of symptoms.

-Academic Accommodations 

In significantly symptomatic athletes, mental cognitive activities should also be limited to allow the brain time to heal. These activities may include limiting assignments, allowing greater time to complete quizzes and tests or assignments. The athlete may have to be absent from school or attend on a limited basis. Limited texting, video games and watching television and movies may be necessary. In the past complete rest from physical and cognitive activity was recommended but more current research shows that return to limited physical and cognitive activity and return to school are important to recovery of the brain and to help prevent anxiety and depression. Treatment should always be individualized for each athlete.

-Neuropsychological Testing

It is well recognized that valid neuropsychological testing can be helpful to uncover cognitive or other neuropsychological disorders related to the concussion. Computerized baseline neurocognitive testing and compared post injury testing has been advocated and used over the last several years. More recent data show that the sensitivity and specificity of these computerized tests and the difficulty of administering the tests in a group environment do not meet the scientific level of evidence for validity. Baseline and post injury testing with the SCAT 5 and vestibular and ocular motor screening (VOMS) can give us some indication of performance and help to make the diagnosis of concussion. The ISCN physicians have collaborated with multiple healthcare systems in central Indiana who have experience in treating sports concussions. This new organization is the Indiana Sports Concussion Alliance (ISCA) and the rationale for not recommending routine baseline testing is as follows: The Indiana Sports Concussion Alliance (ISCA), a group of sports medicine, rehabilitation, and neurosurgery physicians in Indiana who advocate for the proper prevention, diagnosis, and care of sport-related concussion, has recently conducted a thorough review of the use of baseline computerized neurocognitive testing as a “standard of care” among middle- and high school-aged athletes.

The goal of baseline testing is to improve the accuracy of concussion diagnosis, leading to more timely treatment and speeding the athlete’s return to normal activities. A scientific review of existing computerized neurocognitive tests casts doubt on their usefulness for this purpose. Specifically, both the reliability (i.e. how much a student’s score changes from one administration to the next) and validity (i.e. whether the use of baselines increases the likelihood of an accurate diagnosis) of existing tests are insufficient to recommend their standard use by middle and high school athletic departments1,2,3. As a result, the ISCA does not at this time endorse or recommend any computerized baseline neurocognitive testing.

Importantly, this recommendation relates only to baseline testing as a standard practice. Each individual physician must determine, in the context of emerging evidence and individual circumstances, the use of computerized neurocognitive testing for their patients.

The members of the ISCA have over 200 years of combined experience diagnosing and treating sport-related concussion. We represent the healthcare systems of Central Indiana, and provide advice and guidance to adolescents, parents, schools, coaches, the Indiana High School Athletic Association, and state lawmakers. We also review new and existing concussion-related tools and technologies and share this information with schools, healthcare systems, and policy-makers as appropriate.

1. McCrory et al 2017, 838-847 Br J Sports Med
2. Alsalaheen et al 2016, 1487-1501 Sports Med
3. Nelson et al 2016, 24-37 J Int Neuropsych Soc

Members :
Director – Daniel Kraft, M.D.
Witham Sports Medicine

Asst Director – Terry Horner, M.D.
Methodist Sports Medicine

John Baldea, M.D.
IU Health Sports Medicine

Mark Booher, M.D
Hendricks Regional Health Sports Medicine

Kile Carter, M.D.
Central Indiana Orthopedics

Joel Jaeger, D.O.
Major Health Partners Sports Medicine

Patrick Kersey, M.D.
Ascension St. Vincent Sports Performance

Joshua Kluetz, D.O.
Community Health Network Sports Medicine Care

Sachin Mehta, M.D.
Franciscan Health Indianapolis Neurorehabilitation

Greg Rowdon, M.D.
Franciscan Health Lafayette Sports Medicine

Henry Feuer, M.D.

Research Advisor – Nicholas Port, PhD
Indiana University School of Optometry (Neuroscience)

FAQ’s (ISCA)

  1. Why is the computerized neurocognitive baseline testing discontinued in athletes?
    Answer: Recent research on computerized neurocognitive baseline testing shows that it barely meets the sensitivity and specificity to be a reliable test. Also, it is done in a group setting often causing the athlete to be distracted. Also the motivation to take the baseline test is not the same as taking the post-injury test when the athletes know they have to pass as part of the return to play protocol.
  2. Will the post injury computerized neurocognitive tests still be done?
    Answer: There may be times that the post-injury test will be done in certain circumstances which will be left up to the discretion of the treating MD.
  3. Is neurocognitive testing necessary when evaluating an athlete after a concussion?
    Answer: Almost all athletes recover from a concussion without any side effects. However, in some instances where recovery is delayed or pre-existing conditions complicate the post injury course a more specific form of neurocognitive testing may be required. There is presently ongoing research to develop the best and most valid neurocognitive testing for concussions.
  4. Are there any instances where a computerized neurocognitive baseline test would be done?
    Answer: Pre-existing conditions such as a learning disability and sometimes ADD/ADHD might be necessary to have a baseline to compare to a post-injury test, again that would be at the discretion of the physician.
  5. If the NFL and college athletics are still using the computerized neurocognitive baseline testing, why aren’t middle school and high school athletes being tested?
    Answer: The governing body for the NFL and college athletics (NCAA) establish their own practices. In the NFL a hybrid baseline test which is not computerized is being compared to the ImPACT to decide which is the better test. The NCAA is still using computerized cognitive testing but we suspect that will change when data is reported from a very large concussion study funded by NCAA and DOD.
  6. As an athletic director, what should I do next in regards to computerized baseline neurocognitive testing?
    Answer: The letter from the ISCA is only a recommendation. We suggest that you speak directly with your sports medicine team (AT & Physician) to determine if your school will make any changes to your current concussion management protocols.

Consequences

Post-Concussion Syndrome

A very large percentage of athletes who sustain a concussion recover completely, usually in a relatively short period of time. However, some athletes may experience prolonged symptoms and rarely permanent injury. However, some athletes have persistent symptoms after the concussion has resolved. Resolution of these symptoms may require specialty consultation. These symptoms may be related to an underlying condition which has been exacerbated by the concussion. These may include a pre-existing psychological condition with anxiety and depression or others which often mimic the symptoms common to concussion. Treatment often requires neuropsychological consultation and/or medication as well and as neurocognitive therapy. Early recognition and treatment of concussion may lessen the likelihood of developing a Postconcussion Syndrome.

Determine Return to Play

There are necessary steps that are to be followed before an athlete should be allowed to return to full competition. To ensure full recovery of the brain, an integral progression of both physical and cognitive activity should be initiated in the first few days when symptoms begin to resolve symptoms as a guide to continue the activity. These steps should be followed by a healthcare professional trained in the treatment and management of concussions.

  • Athlete must be asymptomatic at rest.
  • A normal neurologic examination.
  • Athlete must be asymptomatic physically and cognitively with increased activity and pass an activity progression protocol.

Must have a written clearance from a healthcare provider trained in the management of concussion.
Unlike some other sports injuries where the athlete can return to play when they attain 75% or greater recovery without a significant risk of recurrent injury, a brain injury should be 100% recovered before returning to full activity.

Establish A Concussion Protocol For Each Organization

Each organization should establish their own concussion protocol outlining how concussions will be managed within their organization. The directors have created a set of guidelines on the state-of-the-art concussion management of student-athletes that can help create a policy for the organization as discussed in the Keys To Concussion Management.