Current Concepts in Concussion: Initial Evaluation and Management
Am Fam Physician. 2019 Apr 1;99(7):426-434
Author disclosure: No relevant financial affiliations.
Mild traumatic brain injury, also known as concussion, is common in adults and youth and is a major health concern. Concussion is caused by direct or indirect external trauma to the head resulting in shear stress to brain tissue from rotational or angular forces. Concussion can affect a variety of clinical domains: physical, cognitive, and emotional or behavioral. Signs and symptoms are nonspecific; therefore, a temporal relationship between an appropriate mechanism of injury and symptom onset must be determined. Headache is the most common symptom. Initial evaluation involves eliminating concern for cervical spine injury and more serious traumatic brain injury before diagnosis is established.
Tools to aid diagnosis and monitor recovery include symptom checklists, neuropsychological tests, postural stability tests, and sideline assessment tools. If concussion is suspected in an athlete, the athlete should not return to play until medically cleared. Brief cognitive and physical rest are key components of initial management. Initial management also involves patient education and reassurance and symptom management. Individuals recover from concussion differently; therefore, rigid guidelines have been abandoned in favor of an individualized approach. As symptoms resolve, patients may gradually return to activity as tolerated. Those with risk factors, such as more severe symptoms immediately after injury, may require longer recovery periods. There is limited research in the younger population; however, given concern for potential consequences of injury to the developing brain, a more conservative approach to management is warranted.
Mild traumatic brain injury, also known as concussion, accounts for 80% to 90% of traumatic brain injuries and is recognized as a major national health concern.1–7 Whereas 2.8 million traumatic brain injuries were reported in 2013,8 estimates suggest up to 3.8 million occur annually.4,7,9. Concussion diagnosis and management can be challenging, complicated by the lack of a universal definition.2,6,10 No single objective measure or combination of measures for diagnosis and no definitive evidence-based treatments exist. Return-to-activity and return-to-play decisions are limited by a shortage of prospective data.6 Physicians must rely on expert guidelines and available assessment tools with clinical judgment for diagnosis and treatment.
A quarter of Americans have had a concussion, and we’re still far from understanding its consequences.
At the end of the third quarter of the fantastic Notre Dame at Texas college football season opener on September 4, there were about 30 seconds left.
Irish wide receiver Torii Hunter Jr. leapt up to catch what looked like a touchdown pass that would have given Notre Dame the lead. But Texas defensive back DeShon Elliott slammed into Hunter with a hit that at least appeared to to make direct contact with his helmet. The ball fell to the ground and Hunter didn’t get up.
After several minutes of checking to ensure he could still move his arms and legs, the medical team helped him to his feet and walked him to the locker room. The redshirt junior team captain is now in what’s known as the concussion protocol, which means that he’s supposed to return to baseline levels of cognitive performance and balance before slowly ramping up physical activity again.
It’s unclear whether or not Hunter will be cleared to play in the Irish home opener against Nevada on September 10.
We now pay a lot more attention to head injuries in football and other sports, as we’re more aware now of the potential long term consequences than we have ever been. But that doesn’t mean we are anywhere close to figuring out what to do about these injuries.
Hunter’s return is unclear in part because every individual hit to the head is unique, as is the recovery process. But the issue is also something much larger: We still don’t understand nearly as much as we would hope to about brain injuries, despite the fact that they are astonishingly common.
“Part of the biggest problem that we have is that we still don’t know exactly what a concussion is,” Dr. Chad Asplund, medical director of athletics sports medicine at Georgia Southern University, tells Business Insider. We know how concussions happen and we’ve observed a number of different symptoms triggered by brain trauma, but we still don’t know exactly at what point these injuries (or smaller sub-concussive hits) lead to permanent damage.
Almost a quarter of Americans report having suffered a concussion, according to a recent NPR-Truven Health Analytics Health Poll.
In a certain sense, this should offer a bit of comfort to anyone terrified of wondering what a knock to the head — or several — mean for the future.
“The reality of life is that mild brain injuries are a pretty common thing,” Dr. Christopher Giza, director of the UCLA Steve Tisch BrainSPORT program, tells NPR. “Mother Nature designed us, for the most part, to recover from these kinds of injuries.”
That’s not meant to say that getting hit in the head is okay or that we shouldn’t worry about it. But it’s good to acknowledge that they happen.
Some other interesting findings from the poll:
- 79% of respondents said they sought medical treatment for their concussion.
- 29% of people who have had a concussion say they’ve suffered long term effects, most commonly headaches.
- The numbers on long term effects vary based on demographic factors. People with a high school education or less were the most likely to say they’d suffered long term effects (43.3% of respondents).
- Young (under 35) and wealthy (people who make more than $100k a year) respondents were by far the most likely to say their brain injury occurred while playing a contact sport.
- 49% of people who have had a concussion say they had just one; 35% said two or three; 9.4% said four or five; and 7% said more than five.
What we should do about brain injuries
The scary unknown with concussions is the fact that we still have significant open questions about the long term effects of head injuries. We know that people who suffer a concussion are at risk of an even more serious brain injury if they receive another hit to the head before they recover. Some people experience persistent mood problems after these injuries. And according to the CDC, brain injuries increase the risk for degenerative brain illnesses that we associate with age.
But we don’t yet know how big of a role concussions play in the degenerative brain illness Chronic Traumatic Encephalopathy, or CTE, which has been found in the brains of a number of former athletes. Concussions may play a role in this illness, but it’s also possible that CTE is largely caused by milder knocks to the brain that don’t result in a concussion or more serious injury.
And as Asplund and researcher Thomas Best wrote in the medical journal BMJ in 2015, we don’t yet know “if brain damage is an inevitable consequence or an avoidable risk in American football.” That’s a key question that still needs answering, and if the answer is “inevitable consequence,” we need to pause and figure out what that means.
It’s impossible to completely eliminate all risk of brain injury in sports, and so many researchers, like Asplund, say that the goal should be to minimize harm. But honest research that openly acknowledges the potential long term risks of brain injury from sports is needed to say just how risky both regular hits and occasional concussions are.
There are still open questions. But as long as we’re asking players to potentially put their brains on the line, we need to try to find answers.
At least in Hunter’s case, he’s tweeted that he’s feeling better.
Which Youth Sports Cause the Most Concussions?
A Prospective 11-Year Study
Background: Understanding the risk and trends of sports-related concussion among 12 scholastic sports may contribute to concussion detection, treatment, and prevention.
Purpose: To examine the incidence and relative risk of concussion in 12 high school boys’ and girls’ sports between academic years 1997-1998 and 2007-2008.
Study Design: Descriptive epidemiology study.
Methods: Data were prospectively gathered for 25 schools in a large public high school system. All schools used an electronic medical record-keeping program. A certified athletic trainer was on-site for games and practices and electronically recorded all injuries daily.
Results: In sum, 2651 concussions were observed in 10 926 892 athlete-exposures, with an incidence rate of 0.24 per 1000. Boys’ sports accounted for 53% of athlete-exposures and 75% of all concussions. Football accounted for more than half of all concussions, and it had the highest incidence rate (0.60). Girls’ soccer had the most concussions among the girls’ sports and the second-highest incidence rate of all 12 sports (0.35). Concussion rate increased 4.2-fold (95% confidence interval, 3.4-5.2) over the 11 years (15.5% annual increase). In similar boys’ and girls’ sports (baseball/softball, basketball, and soccer), girls had roughly twice the concussion risk of boys. Concussion rate increased over time in all 12 sports.
Conclusion: Although the collision sports of football and boys’ lacrosse had the highest number of concussions and football the highest concussion rate, concussion occurred in all other sports and was observed in girls’ sports at rates similar to or higher than those of boys’ sports. The increase over time in all sports may reflect actual increased occurrence or greater coding sensitivity with widely disseminated guidance on concussion detection and treatment. The high-participation collision sports of football and boys’ lacrosse warrant continued vigilance, but the findings suggest that focus on concussion detection, treatment, and prevention should not be limited to those sports traditionally associated with concussion risk.