Concussion Evaluation and Management of Sports Related Concussions

Do I have a concussion? Does my child have a concussion? Concussion awareness continues to grow, so much so that a film has recently been released. However, this isn’t a fad and the growth in awareness is a positive force to bring knowledge to parents, students and their friends or teammates to assist each other in receiving proper evaluation and management of concussions.

A common misconception has been that if the athlete doesn’t get knocked out, then they didn’t receive a concussion. However, more often than being knocked out, athletes report a variety of symptoms including headache, dizziness, confusion, disorientation and even amnesia. This is where a friend or teammate can become an asset because of the confusion, disorientation and dizziness your child/student/friend may not realize right away that they’ve experienced a concussion. In a recent article discussing concussions, Doug Flutie states, “In San Diego, I came out of the game right away. At Boston College, I stayed in for another series and went five for five and a touchdown. But I threw the ball to the wrong receivers and still have no recollection of those plays. On the next series, I stood in front of the huddle with a blank stare and the players got me off the field. It was no one’s fault. I didn’t know and I didn’t bring it to anyone’s attention.” (Nih medlineplus the magazine, 2015). Being that symptoms can vary in occurrence and severity it is important to have concussions and injuries evaluated and managed by a specialist experienced with concussions. Each case should be treated individually and may progress from rest to activity as long as symptoms do not persist.

Are head injuries serious?

Most people recover from sport-related head injuries and have no lasting effects.  A concussion is a reversible injury to the brain that usually resolves in adults and adolescents within 7-10 days from injury, though some individuals take longer to recover than others.   In general, the younger the patient, the longer the recovery time.   Although concussions are not associated with bleeding in the brain, some injuries to the head can present with bleeding and may not be apparent right away.  Close observation for 24-48 hours after a head injury is important to ensure that trends are not worsening with time.

How can you tell how severe my injury is?

For the most part, the severity of a concussion is only determined in hindsight, once all symptoms have resolved and the athlete has been able to resume activity again.  In the Emergency Room, it is the job of the physician to confirm the diagnosis of concussion.   This involves looking at the athlete, speaking with them and screening their ability to process information.  In some instances, imaging of the brain with a CT or MRI is done to rule out associated bleeding.

Unfortunately there is no great way to accurately predict which athletes are going to do well and which are going to struggle.  Things that seem like they should predict longer recovery, such as seizures immediately after the head injury, or loss of consciousness for up to a minute at the time of injury, don’t necessarily predict a poor outcome.  On the other hand, things that don’t seem that severe at the time, such as memory loss, can be associated with longer recovery times.

When can I start playing sports again?

Because individuals vary in terms of symptoms and recovery, no one set of recommendations can be given.  In the ER, the most appropriate management is to arrange follow-up with your primary care physician or another physician trained in the management of concussion so that you can be monitored and a controlled return-to-play planned.

The management of concussion has evolved towards a return to full activity that is achieved in several sequences.  Typically, these are as follows:

1. No symptoms at rest or with mental exertion
2. No symptoms brought on with aerobic exercise in a supervised office setting
3. No symptoms brought on with aerobic exercise in a practice setting, with contact restricted
4. No symptoms with contact in a controlled practice setting
5. Return of physical exam and all testing results to normal, including computerized testing if baseline testing is available for comparison

Trying to rush this process will usually only delay return, as symptoms will tend to worsen if an athlete is pushed too fast.

What can I expect for the next day or two?

Symptoms of concussion vary greatly, but it is common to experience symptoms such as headache, dizziness or light-headedness, problems with focus (including problems retaining information) nausea, memory problems or unusual emotionality.

Even if a Cat scan is done in the emergency room and is read as negative, there is still a possibility of a small, slowly progressive bleed.  Because of this, we do not usually recommend the use of anti-inflammatories such as ibuprofen or naproxen for the day or two after a concussive injury.  If pain relievers are necessary, acetaminophen should be the first choice.

You should plan for follow-up in your designated physician’s office as soon as you can get in, preferably within 1-3 days after ER evaluation.  Expect to be seen in follow-up for a total of 1-2 additional visits if exercise testing in the office is going to be done.

Immediately after concussive injury, things that are mentally-challenging can aggravate your symptoms.  Unless your symptoms have completely resolved, consideration should be given to staying home from school for the first day or two after the injury, or until follow-up in your physician’s office can be arranged.

Is it true that the person must be kept awake after the injury?

No.  As long as symptoms are not noticeably worsening with time, concussed patients can be allowed to sleep, which will help them clear their symptoms more quickly.  If there is high concern that an athlete is clinically worsening after a concussion, consideration might be given to holding the patient in the hospital for observation.  Depending on the appearance of the patient and at the discretion of the ER staff, you may be asked to wake the injured person several times during the night and ask questions such as “what’s your name?” and “where are you?” to make sure everything is okay.

How do I know whether I should get additional help?

Get help if you notice any of the following:

• Any symptom that is getting worse, such as headaches, nausea or sleepiness
• Nausea that doesn’t go away
• Changes in behavior, such as irritability or confusion
• Dilated pupils (pupils that are bigger than normal) or pupils of different sizes
• Trouble walking or speaking
• Drainage of bloody or clear fluids from ears or nose
• Vomiting
• Seizures
• Weakness or numbness in the arms or legs

At Stadia Sports Medicine we evaluate and manage concussions for athletes and non-athletes after the incident, but we also offer a valuable tool which can provide data to best treat you or your child if a concussion occurs. This is a computer-based pre-concussion baseline test that we suggest to any athlete to take prior to the start of their sport season. Then we would have a baseline which we can compare results to in a post-concussion evaluation.

Computer-Based “Pre-Concussion” Testing

How to sign-up:

1.   Call Stadia: 515-221-1102

2.   Let us know: Patient’s name, date of birth, parent’s name, telephone number, email, address, etc.

3.   Schedule an appointment to take the computer-based test in our office.

4. Pre-concussion baseline testing is not covered by insurance and will require payment at the time of service.

What is computer-based concussion testing and why is it relevant? Over the years, several computer-based tests have been developed which are designed to assess mental function in athletes, measuring things such as processing speed, attention and memory.  Following a concussion injury, any of these variables can become impaired. For the most part, these tests are only clinically useful if an athlete’s performance after an injury can be compared with scores on the same test, taken earlier in a pre-injured state.  In general, these tests have a higher ability to detect changes in brain function than the clinical exam alone. The single largest barrier to use of this technology following an injury is lack of a prior valid baseline test.

Who is eligible? Typically discussed with athletes participating in contact sports, this test is a valuable tool for anyone participating in a variety of activities and non-contact sports.  This test has been useful in injuries sustained from car accidents, victims of domestic attacks, horseback riding, skateboarding and other leisure activities.

What is involved with the test itself? The test itself takes an average of 8-10 minutes to perform. Prior to taking the official test, each athlete should complete a practice test (available free-of- charge) to eliminate learning-related test improvements.  Total time to complete baseline testing averages 15-20 minutes.  Athletes will be informed if their test is considered an acceptable baseline. If unacceptable (approximately 10% of all test takers do not pass their initial test), the athlete will be instructed to repeat the test after a reasonable break.  There is no charge for repeated test attempts.

What happens with the test data once it has been obtained? Nothing, unless an athlete sustains a concussion injury during the course of his/her season.  All test data remains confidential.  If an injury does occur, we can arrange post-injury testing for the athlete at an appropriate time. This is typically done once an athlete’s other concussion symptoms have cleared, but is ultimately dependent on the judgment of the physician providing care. Although post-injury testing can be processed through insurance, no athlete at Stadia will be turned away from testing due to lack of insurance.

Is test performance the only factor used in return-to-play decisions? No. Athletes who have sustained concussion injury undergo periodic symptom surveys, balance assessment and, once clearly improving, graded exercise assessment, both on the treadmill and with agility testing on the exercise floor. Athletes also need to be able to demonstrate tolerance to their usual course load at school.  Computer-based testing however, adds another layer of safety to an athlete with a concussion injury and grounds medical decision-making in more objective data.

Why is Stadia Sports Medicine doing this? It’s in line with our core area of expertise, which is the care of injured athletes.  Concussion care is a somewhat specialized area of medicine, and although we already provide high-level services in this area, the widespread addition of baseline concussion testing to the student-athlete population in Des Moines would enhance our clinical capabilities when an injury does occur.

Bibliography

Nih medlineplus the magazine. (2015). Doug Flutie: “Be on the Safe Side”. Retrieved 27 January, 2016, from https://www.nlm.nih.gov/medlineplus/magazine/issues/summer15/articles/summer15pg12.html