Concussion: Current Concepts of Assessment and Management

Concussions are a common sports injury, most often sustained by athletes involved in contact sports. Therefore, the sports physiotherapist will regularly assess, diagnose and subsequently manage this condition. Concussion is a potentially life-threatening condition, and thus appropriate evidence based assessment and management is crucial.

However, there is a broad and often confusing body of literature regarding concussion in sport. Hopefully the review below will assist the sports physiotherapist in making specific and evidence based decisions regarding concussion management.

WHAT IS A CONCUSSION?

There is no clear or universal definition for concussion. However a commonly accepted definition is:

A complex pathophysiological process affecting the brain,
induced by traumatic biomechanical forces (Aubry et al. 2001)

Despite the lack of universal definition, the condition is often characterised by the following conditions:

• An direct blow to head, face or neck OR an indirect blow to another part of the body which transfer impulse to the head.
• The symptoms are transient
• The neuropathic changes are associated with a functional disturbance only (no structural changes)
• Can occur with or without a loss of consciousness
• Typically neuro-imaging (XR, CT, MRI) is normal

WHAT TO ASSESS?

PHYSICAL EXAMINATION

The physical examination is often the primary assessment tool for concussion. This occurs when the athlete first walks (or is carried) off the field. Please remember if you are the first to the athlete on the field EXPECT a spinal condition until proven otherwise.

There are a few tools that exist to assist the sports physiotherapist in assessing the athlete on the sideline. A recently developed tool (and the one that I now use – if that counts for anything) is the Sports Concussion Assessment Tool (SCAT) (McCrory et al. 2005). The SCAT can be found for here for free – I recommend you print this out and keep it with your kit. The SCAT is a simple to use assessment tool for medical professionals, including sports physiotherapists, to implement following an athlete suffering a suspected concussion. The tool includes:

• A symptom checklist
• Simple concentration and memory tasks
• Neuro screening

RED FLAGS

As a sports physiotherapists you should be aware of ‘red flags’ following head injury/concussion. Any of these indicate immediate need for hospital referral:

• Significant drowsiness
• Repeated vomiting and nausea
• Seizures
• Neuro signs
• Bleeding or straw-coloured fluid (CSF) from the ears.
• A sudden change in neurological status
• Symptom progression or decline (i.e. headaches worsening)

ROLE OF IMAGING

In concussion X-ray, CT and MRI are unable to detect any changes, in the absence of gross structural changes. They may only be helpful in identifying situations that are potentially life threatening, and therefore are used as a precaution. When imaging is not possible, it is suggested that continual patient monitoring (for a period of 24 – 48 hours) can give relevant information.

OTHER TESTING (NEUROPSYCHOLOGICAL AND POSTUROGRAPHY)

These are more complex forms of testing, and often beyond the scope of your “weekend sports physiotherapist”. Neuropsychological testing, despite no validation, is considered the gold standard for concussion assessment. It is used to assess cognitive functioning of:

• Memory
• Attention
• Executive Function
• Speed and Flexibility of Cognitive Function

Whilst these tests are not related to a sideline assessment, they will assist in the RTP decision-making process (see below). Some examples of neuroychological tests are shown here. This is particularly useful when this testing has been implemented in the pre-season to establish baseline values. Posturography assesses the athletes ability to integrate the information from somatosensory, visual and vestibular inputs. There are standardised tests, such as the Balance Error Scoring System (BESS). Explained here: Concussion and Sports.

TREATMENTS

There are no specific medical therapies available. Most patients should fully recover with:

• Education: including reassurance and symptom information
• Cognitive Rest
• Time to recover

Pharmacological interventions have shown no clear evidence of benefit (Hunt & Asplund, 2010).

RETURN TO PLAY CRITERIA FOLLOWING CONCUSSION

There is no sound evidence basis for RTP criteria following concussion. However, the general consensus follows the following paradigm:

Day 1: Asymptomatic for 24 hours

Day 2: Light Aerobic Exercise

Day 3: Sport Specific Exercises

Day 4: Non-contact Training Drills

Day 5: Full Contact Training (given medical clearance)

Day 6: RTP

NB: Any increases/production of symptoms means you must start at Day 1 again. (McCrory et al. 2005).

CONCLUSIONS

Sports physiotherapists deal with concussed athletes frequently. Thus, a quick and effective sideline assessment is important. Following the diagnosis of concussion, providing evidence based decisions is crucial to the health of your athlete. Unlike ligament sprains and muscle strains – this can be a life-threatening condition!

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LINKS

Want to see how concussion effects the athlete and his future? Check out this vid

For more information regarding concussion assessment and management check out this text :

Aubry M, Cantu R, Dvorak J, et al. Summary and agreement statement of the First International Conference on Concussion in Sport, Vienna 2001. Recommendations for the improvement of safety and health of athletes who may suffer concussive injuries. Br J Sports Med 2002;36(1):6–10

McCrory P, Johnston K, Meeuwisse W, Aubry M, Cantu R, Dvorak J, Graf-Baumann T, Kelly J, Lovell M, Schamasch P. Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague 2004. Br J Sports Med 2005;39:i78-i86

Hunt T, Asplund C. Concussion Assessment and Management. Clinics in Sports Medicine 2010; 29 (1): 5 – 17