Fall 2006

Sports-Related Concussion: From the Sidelines to the Office
George C. Phillips, MD, FAAP, Department of Pediatrics
University of Iowa Hospitals and Clinics

Recent studies of NCAA football players suggest that about 6% will suffer concussion in a given season. The risk is likely higher for younger athletes, given the relative immaturity of the nervous system and cerebral circulation, and the lower levels of skill in this population. Of course, concussion frequently occurs in other sports as well, including basketball, ice hockey, soccer, and wrestling.

that sports-related concussions are often a functional as opposed to structural injury. This means that imaging with CT or MRI rarely reveals findings of significance; the few findings that are discovered are usually incidental and unrelated to the concussion. Symptoms that indicate the need for neuro-imaging include:

• Loss of consciousness for longer than 5 minutes

• Worsening of such symptoms as headache or nausea

• Possible skull fracture

• Focal neurological signs

Management of concussion
Appropriate management of concussion starts on the sidelines. In the pediatric population, a conservative approach is advised. Whenever concussion is suspected, the athlete should immediately be removed from competition, and NOT return to competition until he or she has been symptom-free for at least 24 hours. Any concussed athlete should be evaluated by their healthcare provider or team physician prior to beginning a gradual return-to-play program.

Second impact syndrome. One reason for a conservative approach is to avoid second-impact syndrome. A rare and somewhat controversial diagnosis, second-impact syndrome has been reported in young athletes who suffer a second concussion before the symptoms of the first concussion have completely resolved. The clinical course entails a rapid progression of neurological deterioration that almost uniformly results in coma and brain death. Research with animal models suggest that younger athletes may have immature regulation of cerebral blood flow in the face of recurrent injury, which may ultimately lead to increased intracranial pressure and the clinical course described.

Sideline care
Sideline assessment of the athlete should include questions that test orientation, short-term memory and recall, and concentration. Questions can be tailored to the athletic event itself, such as asking the athlete to give the location of the current game, the current game scenario, the most recent series of plays, and who scored last. Concentration can be tested by having the patient count backward by 7s, starting at 100, or recite the months of the year in reverse order, although a significant number of young athletes will have difficulty with these tests at baseline. Any sideline assessment is at best a tool to aid the health care provider’s judgment and not an absolute measure of function.

Symptoms of concussion should be documented during the sideline assessment to provide a benchmark for future evaluation. Athletes should be reassessed frequently on the sideline, as often as every 5-10 minutes. Any athlete with highly concerning findings, such as prolonged loss of consciousness or focal neurological signs, should be immediately referred for evaluation. At the 30-minute mark, any athlete whose symptoms have not abated in severity or seem to be worsening should be referred for evaluation.

Return-to-Play Guidelines
The following guidelines for return-to-play, recommended by international consensus statement guidelines on sports concussion, are used by most sports medicine specialists. Each step in the protocol takes 24 hours, and if an athlete has a recurrence of symptoms, they are required to stop the protocol until they are asymptomatic for another 24 hours. Then the protocol is restarted one step prior to where they were when the symptoms recurred. This protocol calls for:

• No activity until 24 hours without symptoms

• After 24 hours without symptoms: Light aerobic activity only (treadmill, stationary bike)

• After 48 hours without symptoms: Moderate speed, sport-specific activities (position drills)

•  After 72 hours without symptoms: Non-contact, scrimmage, or game-scenario activities

• After 96 hours without symptoms: Medical evaluation before resuming full-contact activities

• Ongoing monitoring for return of symptoms

Implementing this return-to-play protocol is facilitated by having a full sports medicine team. In the absence of a full-time athletic trainer at school, a health care provider may give written instructions describing the protocol to the athlete’s coach and parents, and use a combination of their reports and office visits to make a return-to-play decision.

Fortunately, most concussions fully resolve within seven days, and most can be managed by the athlete’s primary care provider. Athletes with prolonged symptoms, especially cognitive impairment, and athletes with a history of multiple concussions should be referred for further evaluation by a specialist with experience in managing sports-related concussions.

Research

Research in concussion management may one day provide more accurate assessment of brain injury and prognosis for recovery. Studies are investigating the correlation of functional MRI and PET scans with specific tests of cognitive function. Athletic teams are employing neuro-psychological testing more frequently for baseline assessments of cognitive function. While computerized versions of such testing make it more available, costs and the lack of trained personnel are obstacles for many community school systems.

Evidence is accumulating that the effects of multiple concussions are additive, and that a history of multiple concussions increases the risk of future concussions. While a definite “cutoff” number of concussions for removal from sport does not yet exist, a history of multiple concussions may warrant a discussion of the appropriateness of continuing in a particular sport. Evidence from studies of genetic markers and traumatic brain injury may also provide future information for an athlete’s risk of sports-related concussion and potential long-term effects.

For now, providers should use a conservative approach in caring for the patient with sports-related concussion. Pediatric and adolescent athletes who have been concussed should be withheld from competition for the remainder of the day and should not return to play until all symptoms have resolved and a protocol of gradually increasing activities is completed. While most concussions will resolve within a week, a significant percentage will result in prolonged symptoms that may include cognitive impairment. Health care providers should be diligent in identifying complex concussion and referring patients with this condition for appropriate evaluation and management.