By: Joe Ackerson, Ph.D.
Chair Alabama Statewide Sports Concussion Taskforce (ASCT)
This second of two articles
is designed to provide specific information on the recognition and management
of concussions for your medical practice. It has been estimated that up to 3.8
million sports- and recreation-related traumatic brain injuries occur in the
United States yearly with the highest rates of emergency department visits for
sports concussion occurring for young people from ages 10 to 19. Youth athletes
appear to be especially vulnerable to the effects of concussion, including
cognitive difficulties such as memory and attention problems.
However most concussions
occur OUTSIDE of organized sports such as football, soccer, and basketball and
can affect athletes in all sports, including cheerleading, volleyball, and
lacrosse. Therefore it is important that all primary care physicians, as well
as specialists in Sports Medicine, Physiatry, Neurosurgery, Neurology, and
Psychiatry, familiarize themselves with the proper recognition and management
of concussions. Dr. Ackerson and the rest of the ASCT have provided concussion
training for physicians, psychologists, schools, coaches, athletic trainers,
nurses, teachers, school administrators, athletes, and parents. We have helped
the Alabama High School Athletic Association, The Children’s Hospital of
Alabama, the University of Alabama at Birmingham (UAB), Andrew’s Sports
Medicine Clinics, and numerous school systems and athletic teams develop their
guidelines and clinical procedures for the recognition and management of concussion.
With the assistance of
Alabama State Representative Paul DeMarco and the sponsorship of State
Representative Ron Johnson and State Senator Greg Reed, and the advocacy
efforts and of Steve Savarese, director of the Alabama High School Athletic
Association (AHSAA) 2011-541 HB 108 was passed and signed into law in 2011 (with
a technical amendment added in 2012). This law helps to prevent the long-term
adverse consequences of youth concussions by requiring all schools and athletic
organizations to: provide information on sports concussions to all athletic
participants and their families; ensure that all coaches have training in the
recognition of concussions; the immediate removal of any athletic participant
suspected of having a concussion from participation and not allow him/her to
return the same day they are injured and
until cleared by a physician.
As a result of this law many
physicians are seeing a dramatic increase in the number of concussion cases
presenting for medical evaluation and management. Concussion symptoms can be
broken down into four major areas. 1) Mental- any change in their usual mental
state (feeling woozy, confused, in a fog, disoriented, problems with memory or
concentration, declining school performance),
2) Emotional- change in personality, irritability, nervousness,
unexplained or sudden sadness, or extreme moodiness, 3) Arousal- chronic
fatigue or lethargy, reduced endurance or tolerance for physical exertion,
sleep disturbance, and 4) Physical- blurred or double vision, dizziness,
problems with balance or coordination, headache, nausea, overly sensitive to
light or sound. It is critical to point out that loss of consciousness IS NOT
required to make a diagnosis of concussion and in fact occurs in less than 10%
of all cases. In the vast majority of cases neuroimaging (CT, MRI) will yield
normal results. Use of a standardized approach for assessment of
post-concussive symptoms, such as the SCAT-3, is highly recommended.
Once it has been determined
that a concussion has occurred, the physician should also attempt to determine
the severity of the injury. Any hard neurological signs should generate a
referral to the appropriate medical specialist (neurologist, neurosurgeon,
etc.). However for the routine concussion the most important element is to
prevent an additional concussion before the individual has fully recovered from
their current brain injury. During the post-concussive period the patient
remains especially vulnerable to additional neurological injury and possible
long-term complications. Therefore no athlete should return to play the same
day they have a concussion, and should not return to play or other high risk
activity, including activities that involve significant physical exertion,
until such time that a physician trained in the assessment and management of
concussion can perform an independent evaluation.
Return to play (RTP)
decisions should made by a physician trained in the assessment and management
of concussion. The physician’s decision regarding RTP may be enhanced by
including ATCs, neuropsychologists, and/or other qualified medical experts
whose knowledge, techniques, and experience can provide valuable additional
information. The final decision regarding the athlete’s ability to return to
play should be a medical decision. There are many unknown variables and no one,
including the treating or consulting physician, can guarantee that the
athlete’s return to play would not continue to present a health risk for the
athlete. However, we (the ASCT) believe that by following established
guidelines, as well as the information and resources developed by this
taskforce, the risk of immediate or long-term adverse consequences from the
concussion will be significantly reduced.
Given the established need
for cognitive or brain rest following concussion, and the fact that young
athletes’ most important task is academic achievement, it is increasingly
appreciated that in addition to RTP decisions, we need to formulate Return to
Think (RTT) protocols. Once an athlete has incurred a concussion, his or her school
should be notified as soon as possible in order for proper planning and
monitoring to occur, including appropriate accommodations in the academic
program. Every school that has an athletic program must provide a designated
contact person to receive and disseminate medical and neuropsychological
information required to guide RTT decisions in the academic setting. This
contact person at each school, and the treating physician, should have access
to a neuropsychologist that will be critical for guiding RTT decisions. In more
complex cases a neuropsychological evaluation may be necessary.
Neuropsychologists are
trained in the diagnosis and treatment of brain disorders, including
concussion. While they are licensed and operate at an independent level, they often
work closely with physicians in the diagnosis and treatment of brain injury.
While it is up to the physician’s individual discretion regarding whether and
when to refer to a neuropsychologist, many will choose to do so if their
patient seems to be taking longer than typical to clear, there are pressing
academic needs and challenges that require an expert, the patient has a
complicated premorbid history (such as ADHD, psychiatric illness, or learning
problems), or other factors that may place them at higher risk for a complicate
or prolonged recovery.
It is also important to
distinguish between the comprehensive evaluation, management, and treatment
services offered by a neuropsychologist and the brief, computerized cognitive
testing (such as IMPACT) that are sometimes erroneously referred to as a
neuropsychological assessment. Some
physicians utilize baseline (and follow-up) computerized cognitive testing to
enhance their practice, and some have found this approach can be quite useful.
However physicians are rarely trained in the intricacies of interpreting
neuropsychological test results and can make significant errors if they
over-rely on such measures without the benefit of a consulting
neuropsychologist.
While brain rest and time to
allow for full recovery are the primary treatments for concussion, there are
other interventions that can be considered. We often encourage the adoption of
a healthy lifestyle to promote brain wellness, including following an
appropriate diet, light exercise (such as walking), and engaging in low key
pleasurable activities (such as arts and crafts or pursing a favorite hobby).
Medications such as amantadine, amitriptyline, stimulants, anti-depressants,
migraine medications, etc. are sometimes employed to target specific symptoms that
persist past the expected time for recovery, but are
usually reserved for those cases that are sent to a specialist experienced in
concussion management. Finally psychological interventions can be particularly
useful for managing chronic pain, dealing with the sense of
loss/depression/anxiety, addressing family dynamics, the acquisition of healthy
behaviors, and promoting general recovery.