Laurel Rudolph, MD
Medical Director Marshfield Clinic Sports Medicine
Millions of children, adolescents, and adults throughout the United States participate in organized sports. Sport participation has many physical and social benefits; however, playing sports is not without risk. Musculoskeletal injuries are common in all sports and often the focus of media reports in the professional athletic arena. Yet, in recent years, mild traumatic brain injuries (mTBI), more commonly referred to as concussions have gained significant awareness. Increased knowledge and understanding of the diagnosis, evaluation and management of concussions is important for all healthcare providers, especially EMS professionals.
According to the 2012 Zurich Consensus Statement on Concussion in Sport (McCrory et al 2013), a concussion is a functional injury to the brain, NOT a structural injury. A concussion may be caused by a direct blow to the head or neck, or another part of the body with an impulsive force transmitted to the head. Thus, an athlete does have to strike his/her head to suffer a concussion. Typically, a concussion results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously. However, for some athletes, symptoms may evolve over a period of minutes to hours. A graded set of clinical symptoms are present, and resolution of the clinical and cognitive symptoms normally follows a sequential course. A concussion may or may not involve loss of consciousness and for some athletes, symptoms may be prolonged.
It is important that the signs and symptoms of a concussion are recognized early and that the athlete is not allowed to return to participate without a formal medical evaluation. Many states and sport organizations have defined guidelines in regards to return-to-play. In April, 2012, Wisconsin Act 172 was signed into law. The law requires that all athletes under the 19 years of age in all organized sports receive and acknowledge an informational sheet regarding concussions and head injuries. In addition, any athlete determined to have a concussion must be removed from play and is not allowed to return to practice or play that same day. In Wisconsin, prior to returning to sports, all athletes must received written medical clearance from a healthcare provider who is experienced in the evaluation and management of concussions. Decisions in regards to return to- play and formal neurocognitive testing should be left to healthcare providers with such experience. However, coaches, officials, parents, and athletes, and healthcare providers should all be attentive to the signs and symptoms of a concussion. It is extremely important that EMS professionals are experienced in both evaluation and initial management of a patient deemed to have a concussion, whether that person is participating in sports or not.
Common signs of a concussion are loss of consciousness, amnesia, irritability, cognitive impairment such as slow reaction times, and insomnia. The most frequently experienced symptoms include complaints of headaches, dizziness, light and noise sensitivity, poor balance and “fogginess”. Feeling like one’s brain is “foggy’ is a common and recognized symptom in the concussion literature. Some student-athletes have described the feeling like “watching TV or a movie” without HD. Hence, if a patient is deemed to have suffered a concussion, they should be immediately removed from the activity, whether a practice or competitive event, and undergo a thorough exam. A medical assessment which includes a comprehensive history and detailed neurological exam should be performed to include a thorough evaluation of mental status, cognitive functioning, gait, and balance. If any significant neurological deficits are noted such as pupil asymmetry, limb weakness, altered reflexes, or the athletes is unable to respond appropriately, the athlete should be transported for emergent medical evaluation. Imaging studies, such as a CT scan or brain MRI, are only indicated if the patient is experiencing neurological deficits or worsening of symptoms. Brain imaging should be employed whenever there is suspicion for an intracerebral hemorrhage or structural lesion Many athletes who have suffered a concussion do not require emergent referral, and since a concussion is a functional injury of the brain, not a structural injury, costly imaging studies do little to change the evaluation or treatment plans.
An athlete with a normal physical exam, without any focal neurological deficits, who is responsive, should undergo neurocognitive evaluation. A commonly used sideline tool is the SCAT3 which is even available as an electronic application. The SCAT3 is a standardized tool for evaluating athletes with a suspected concussion and can be used in athletes aged from 13 years and older. For younger persons, ages 12 and under, the Child SCAT3 can be utilized.
These tests are often later compared to the student-athlete’s baseline tests obtained prior to the onset of a sport season. In addition, it is becoming the standard of care for all studentathletes to undergo a baseline computerized neurocognitive tests such as ImPACT, Cogsport, etc. The SCAT3 test requires adequate time and ideally the exam and implementation is done in a quiet environment. However, this is often difficult during an athletic competition, where the medical coverage provider must also be available for other injuries. Thus, shorter versions of neurocognitive testing, such as the SAC test (a part of the SCAT3) can be utilized with serial monitoring. The SAC test is easy to administer as points are assigned for each correct response. It has proven reliability for use in the field and like the SCAT3 should be only be administered by healthcare professional with experience in evaluating and managing athletes with concussions. Another frequently utilized tool used in concussion evaluations is the Graded Symptom Scale Checklist where patients grade 26 symptoms as “0” meaning
no symptoms or “6” meaning they are experiencing severe. This tool is frequently used by school athletic trainers to monitor daily how the athlete is doing. If symptom scores are increasing, the athlete requires referral for additional care.
There are several important facts to note when evaluating a patient who may have suffered a concussion. First, the amount of impact or force suffered with a collision does not have any direct correlation with the potential severity of a concussion, Thus, an athlete who suffers what coaches and fans often describe as a “hard helmet to helmet to helmet hit” may have fewer symptoms than an athlete who falls and accidentally strikes their head. IMPORTANT – neither athlete is allowed to return to practice or competition that same day, and must seek formal medical evaluation for clearance to return.
The reason for baseline testing is that research had shown that even after physical symptoms associated with a concussion resolve, neurocognitive impairment may persist; the athlete may then be more likely to suffer a second concussion or a life threatening event such as Second Impact Syndrome. Though rare, Second Impact Syndrome may occur when an athlete suffers a second concussion before the symptoms and any neurocogntive dysfunction suffered from the first concussion have resolved. It can result from even a very mild concussion that occurs days or weeks after the initial concussion. The brain loses its ability to auto regulate intracranial and cerebral perfusion pressure, which made lead cerebral edema and brain herniation. A concussion causes ionic fluxes, acute metabolic changes, and cerebral blood flow alterations. All of these characteristics enhance the vulnerability of the brain and increase the risk of death, even if the second injury was less intense.
A concussion is a SIGNIFICANT injury – it is a BRAIN injury! Hence, all patients felt to have a concussion are deserving of a thorough evaluation and should be followed by a licensed healthcare provider who is knowledgeable in regards to management of concussive symptoms, the potential need for school accommodations and the social stresses experienced by an athlete who is not allowed to return-to-play. Studentathletes often experience social isolation since they appear “normal” despite the fact that they may be experiencing constant headaches, inability to concentrate on common school tasks, and difficulty sleeping.
Student-athletes are often very reluctant to report their symptoms in fear that they may be removed from competition or not allowed to return to sport competition. Despite advancing scientific data regarding concussions, there remain many myths, especially in the athletic arena. Therefore, more education is needed. For example, many athletes believe that if they have suffered 3 concussions, they will no longer be able to participate in sports. The truth is that every athlete who has suffered a concussion should be managed with an individualized treatment plan. The decision in regards to when a concussed athlete who has a past history of one or more concussions can safely return to sports is based on many factors, such as length of time to full recovery from previous concussion, amount of time elapsed since the last concussion, and other patient specific factors.
The good news is that the majority (80 - 90%) of concussion symptoms resolve in a short period of time (7 - 10 days); however, the recovery time may be longer in children and adolescents. Physical and cognitive rest until acute symptoms resolve remains the key to management of a patient who has suffered a concussion.
Once cleared by an experienced healthcare professional, an athlete should follow the graduated return to play protocol, a stepwise process outlined in Table 1. Each step should take 24 hours, and symptoms and cognitive function should be monitored during each increase of exertion. Athletes should only progress to the next level of exertion if they are not experiencing symptoms at the current level. If any postconcussion symptoms occur while progressing through the rehab protocol, the patient should drop back to the previous asymptomatic level and try to progress again after at least a 24-hour period of rest.
In summary, a concussion is just one of the many injuries that can occur while participating in sports; yet, it is one of the most significant. Mental health issues, such as depression, can be a consequence of a sports-related concussion. Research continues as to whether there exists a cause and an effect relationship between concussions and chronic traumatic encephalopathy (CTE). Thus, early diagnosis and management of a concussed patient is important. EMS personnel play an important role in providing high quality care to patients who have suffered a concussion. EMS professionals are an essential part of all sport medicine providers caring for athletes of all ages, whether in recreational or professional sports.