Concussion

Clinical Pearls of Wisdom Q&A Case

A concussion is a type of traumatic brain injury—or TBI—caused by a bump, blow, or jolt to the head or by a hit to the body that causes the head and brain to move rapidly back and forth. This sudden movement can cause the brain to bounce around or twist in the skull, creating chemical changes in the brain and sometimes stretching and damaging brain cells..

Concussion is more common than you might think. Being struck by another person or object is the leading cause of unintentional injury for teens and young adults ages 15 to 24, according to Injury Facts, and sports-related concussions are a significant contributor. An estimated 1.6 to 3.8 million athletes (both boys and girls) annually suffer concussion, according to the Brain Injury Research Institute.

Often, cases are underreported and undiagnosed. A study by the American Academy of Pediatrics shows the number of sports-related concussions is highest in high school athletes, but they are significant and on the rise in younger athletes.

The CDC created the HEADS UP program to help coaches protect their athletes from concussion related injuries, but clinicians will still see plenty of concussion cases.

Try this sports-related concussion board review question case and pick up another "pearl of wisdom" from Med-Challenger.

Concussion Case:

A 13-year-old girl presents with her parents after sustaining a concussion playing soccer the afternoon prior. She was playing in a game and had a collision with another player, striking her head against the other player. She momentarily lost consciousness but did not have any seizure or focal neurologic deficit. She was removed from play and evaluated on the sidelines by the athletic trainer and team physician.

On the sidelines, she had poor recall of the events prior to her injury and she had some global headache, light sensitivity, and difficulty concentrating. She stayed out of the remainder of the game and was recommended to have further evaluation the following day.

Now, she still has some symptoms of headache, concentration difficulty and she is sensitive to light and sound.

Her past medical history is unremarkable and she has no history of learning disability, migraines, depression, or anxiety.

On physical examination, she has no focal deficits. She mentions that her team has playoffs in four days, and that she is important to their possibility for success.

Question:

Which of the following is the most appropriate management approach for this athlete with a concussion?

Answer Options:

Refer for CT head to rule out intracranial hemorrhage as a source of symptoms

Recommend a day or two of physical and cognitive rest, followed by introduction of activities that don’t worsen symptoms

Given the history of brief loss of consciousness, recommend five days of rest with low lights and low sound, with avoidance of any cognitive or physical exertion

Recommend not resuming physical activity until symptoms of headache and difficulty concentrating have completely resolved

See the Answer:

The correct answer is:

Recommend a day or two of physical and cognitive rest, followed by introduction of activities that don’t worsen symptoms

Key Point:

Initially, recommend a day or two of relative physical and cognitive rest, then gradually reintroduce low-intensity aerobic activities and cognitive activities that don't exacerbate symptoms

Explanation:

Mild traumatic brain injury (mTBI) is the term that the WHO recommends to encompass concussion.

An mTBI is defined as an acute brain injury resulting from physical forces that includes confusion, disorientation, amnesia, or other transient neurological abnormalities, provided that the Glasgow Coma Score (GCS) is 13-15, thirty minutes post-injury.

The incidence of mTBI is highest in sports like rugby, football, hockey, lacrosse and soccer.

An athlete who sustains mTBI should be immediately removed from play and evaluated on the sidelines. Once cervical spine injury or more serious head injury is ruled out, the athlete should be evaluated using a standardized mTBI evaluation instrument such as the Standardized Assessment of Concussion (SAC) or the Sport Concussion Assessment Tool 5 (SCAT5).

Neuroimaging is not required in all cases of mTBI, and should be used selectively, given the known risks of ionizing radiation. In this case, though the athlete has continued symptoms, there are not high-risk symptoms such as seizure, prolonged loss of consciousness, vomiting or worsening headache to indicate a need for CT scan.

Historically, prolonged rest had been recommended after concussion and concussions were also graded in severity, depending partially on whether there was any loss of consciousness. Now, it is known that loss of consciousness and concussion severity are not tightly linked. Current evidence also shows that prolonged physical and cognitive rest are not helpful, and, in fact, prolong the duration of symptoms.

The most recent recommendations for mTBI/concussion management suggest a brief period (one to two days) of rest, followed by introduction of activities such as light aerobic exercise, if they don’t worsen symptoms. Then, further activities are introduced in stepwise fashion, if symptoms are not worsened by the activity.

There are five recommended steps of increased activity, and each is supposed to last at least 24 hours, with a return to prior step if any symptom worsening, meaning that there will be at least five days from concussion to return to play.

At the end of the return-to-play steps, the athlete can return to play, once they have no symptoms at rest or with activity.

Figures:

Concussion: Youth Sports Concussion Case MRI

Med-Challenger

References:

Lumba-Brown A, Yeates KO, Sarmiento K, et al. Centers for Disease Control and Prevention Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children. JAMA Pediatr 2018; 172:e182853

Halstead ME, Walter KD, Moffatt K, Council on Sports Medicine and Fitness. American Academy of Pediatrics. Clinical report--sport-related concussion in children and adolescents. Pediatrics 2018; 142:e20183074

Leddy JJ, Haider MN, Hinds AL, et al. A Preliminary Study of the Effect of Early Aerobic Exercise Treatment for Sport-Related Concussion in Males. Clin J Sport Med 2018

Thomas DG, Apps JN, Hoffmann RG, et al. Benefits of strict rest after acute concussion: a randomized controlled trial. Pediatrics 2015; 135:213

About the Author:

Gerard Kiernan, MD, FAAFP, FHM is a Dartmouth-Hitchcock Clinic hospitalist in Keene, NH. He attended the University of Rochester School of Medicine and Dentistry, followed by a Family Medicine residency at the University of Wisconsin, Madison, where he was a chief resident. Dr. Kiernan is a Lean Six Sigma Greenbelt and has led hospital medicine quality improvement efforts. He is a fellow of both the American Academy of Family Physicians and the Society of Hospital Medicine. He has achieved the Recognition of Focused Practice in Hospital Medicine offered through the AAFP and ABIM via their joint examination pathway.

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