Friday, January 24, 2014

The recognition and management of concussions

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.


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