Concussion knowledge and understanding continues to evolve as it maintains a pinnacle of focus in the research world. We continue to learn and have a greater understanding about not only the acute effects of concussion, but also the long term pernicious effects of repetitive head impacts. In this blog we will discuss how concussions are currently diagnosed both on and off the field/court and the management strategies for youth and adult athletes to safely return to sport, school, and work.
Defining a concussion, although seemingly trivial, is argued between many clinicians and researchers even when the diagnostic process is virtually synonymous. The definition I will use for today comes from the consensus statement on concussion in sport and was agreed upon by 78.6% of the panel(1). “Sport-related concussion is a traumatic brain injury caused by a direct blow to the head, neck or body resulting in an impulsive force being transmitted to the brain that occurs in sports and exercise-related activities. This initiates a neurotransmitter and metabolic cascade, with possible axonal injury, blood flow change and inflammation affecting the brain. Symptoms and signs may present immediately, or evolve over minutes or hours, and commonly resolve within days, but may be prolonged.
No abnormality is seen on standard structural neuroimaging studies (computed tomography or magnetic resonance imaging T1- and T2-weighted images), but in the research setting, abnormalities may be present on functional, blood flow or metabolic imaging studies. Sport-related concussion results in a range of clinical symptoms and signs that may or may not involve loss of consciousness. The clinical symptoms and signs of concussion cannot be explained solely by (but may occur concomitantly with) drug, alcohol, or medication use, other injuries (such as cervical injuries, peripheral vestibular dysfunction) or other comorbidities (such as psychological factors or coexisting medical conditions).” (1) I think one of the main takeaways from that definition is the fact that they use the phrase mild traumatic brain injury in the definition of concussion. For many years athletes and individuals would brush off a concussion and return to normal life as quickly as possible, but when you think about it as a “brain injury”, it should be treated as seriously, if not more seriously, than any other injury an athlete might experience.
One of the first steps in the management of a sport related concussion is prevention. There have been many rule changes and policies that have been put in place over the years to help reduce the incidence of concussion altogether. Things such as targeting penalties in football, body checking in child and adolescent ice hockey, policies that limit contact practices are a few effective methods that have limited concussion incidence. Equipment has also been progressing in ingenuity in an attempt to reduce concussion rates, but things that seem insignificant like wearing a mouthguard have even been shown to reduce concussions by 28% (1). Despite all the policies, rule changes, equipment, etc, concussions will continue to be an inherent risk when playing sports, and the management following a concussion is where healthcare providers can make a significant impact on the outcomes of our patients.
So now that we understand that not all concussions are preventable, step one in the management of concussion is recognizing that a concussion has just occurred. Even if there is suspicion of concussion the athlete should be immediately removed from play. Signs to look for include actual or suspected loss of consciousness, seizure, tonic posturing, ataxia, poor balance, confusion, behavioral changes, and amnesia(1,2). These signs all warrant further evaluation by a healthcare provider and the athlete SHOULD NOT return to play. Maddock’s questions that include questions such as what quarter is it, are we winning or losing, who scored the last goal, etc are questions to help ascertain potential confusion or amnesia being experienced by the athlete. One thing to note, concussion symptoms can begin to manifest over minutes, hours, and even days so constant evaluation may be necessary.
Returning to full activity in a safe and sequential manner is important to protect the healing brain from further damage. It was previously believed that strict rest until complete resolution of concussion symptoms was the most effective way in managing sport concussions, but this has since been shown to not be beneficial (1) It is now recommended that within the first 1-2 days following a concussion light aerobic exercise that does not exacerbate symptoms greater than 1-2 points on a 10 point scale can facilitate recovery(1). Another important recommendation is to limit screen time and other high cognitive demand activities during the first 48 hours following a concussion to allow the brain to rest and heal immediately following the injury(1). Physical activity and cognitive demand is then systematically progressed in intensity and duration in the subsequent days ensuring that symptoms are not exacerbated greater than 2 points as mentioned before. But these are general guidelines to follow, many athletes are eager to return to their respective sport and these guidelines can be more specific to athletes. Below is a table that is a typical sequence to follow when attempting to return to sport. Each step takes at least 24 hours to complete. One thing to note regarding return to play is that on average it takes 19.8 days for an athlete to fully return to play, so the below table should not be followed strictly day to day and return to play should be individualized to the athlete.
Most athletes are also involved in either school or work outside of their sport so it is also important to reintegrate back into their respective duties outside of sports play. Below is another table showing sequential steps regarding how to return to a school, but this can also be used in my opinion if your work involves a similar cognitive demand and is mostly sedentary.
One disclaimer I would like to make for this post is that these are recommendations and should not be substituted for medical treatment and guidance from a healthcare professional. However, this can be a great resource to use if you find yourself recovering from a concussion and can benefit from extra guidance in your journey. Sport related concussions continue to be a focus in the research world and these recommendations will likely change in the next 5-10 years. But for now, these are the most up to date research recommendations and should be followed as such at this time. For now, let’s get back to play safely and effectively and continue to have a love for the game.