Accurate on-field identification of concussion entails education of athletic trainers, coaches, health-care professionals, parents, and athletes to ensure that common acute symptoms are readily recognized.
In cases of suspected head injury, an instrument such as the Sport Concussion Assessment Tool (SCAT2) should be used to evaluate the athlete.13 The SCAT2 is a standardized method of evaluating injured athletes for concussion and can be used in individuals aged 10 years and older.
Any sports participant that is suspected of having a concussion must be removed from play. Other assessment tools that can be used on the field include testing for orientation (“What team are you playing? What is the score?”), concentration (word/number recall), and neurologic defects (speech, eye movement, balance).
Any athlete that elicits signs of neurologic deterioration must undergo a detailed evaluation in the ED. This examination should include a thorough neurologic history. The clinician should obtain information from the athlete, parents, and any teammates that can add pertinent facts to your assessment. The need for emergent neuroimaging to exclude severe brain injury must be determined; not every athlete who sustains a TBI requires imaging. In general, imaging is required if there is a suspicion of intracerebral structural lesions, prolonged loss of consciousness lasting longer than one minute, focal neurologic deficits, worsening of symptoms, repeated and uncontrolled vomiting, or persistent cognitive symptoms.7 There has been recent research on the use of functional MRI, positron emission tomography (PET) scans and diffusion tensor imaging of sports-related concussion in adolescents.14 Unfortunately, there are no imaging techniques that can diagnose a concussion.
When to return to play
The cornerstone of concussion management is physical and cognitive rest. Activities that require attention and concentration must be limited so not to exacerbate symptoms. Cognitive rest activities include limiting use of computers, cell phones (texting), video games, watching television, and even socializing with friends.
At the Third International Conference on Concussion in Sport, a stepwise protocol for return to play was recommended (Table 2).7 The protocol begins with no activity or complete rest until the concussed athlete is asymptomatic. Once asymptomatic, light aerobic exercise with no resistance training is allowed. If the athlete continues to be asymptomatic, he or she is allowed to move on to the next step. Each remaining stage must be completed without symptoms returning over a 24-hour period. If symptoms reappear, the athlete must go back to the preceding stage until asymptomatic and then restart the stepwise progression. Once the athlete can complete noncontact drills without experiencing symptoms, he or she is medically cleared to begin full contact drills and return to competition.16
What else can clinicians do?
Above all, educate the athlete and his or her parent on the serious nature of concussions. Explain the facts about the injury and provide realistic expectations. Emphasize the fact that activities that require concentration and attention (e.g., schoolwork, videogames, television, text messaging) may exacerbate concussion symptoms and possibly delay recovery. Provide a reminder that an injury to the developing brain may increase the risk of long-term effects in children and adolescents. No athlete who suffers even a mild concussion should ever return to play on the same day of an injury. When in doubt, sit them out.
Nancy J. Denke, MSN, FNP-BC, ACNP-BC, is a family and acute care nurse practitioner for trauma services at Scottsdale Healthcare-Osborn in Scottsdale, Ariz.
- Luke A, Lazaro RM, Bergeron MF, et al. Sports-related injuries in youth athletes: is overscheduling a risk factor? Clin J Sport Med. 2011;21:307-314.
- National Federation of State High School Associations. High school sports participation achieves all time high. Available at www.nfhs.org/CoachingTodayContent.aspx?id=7728.
- Centers for Disease Control and Prevention. Concussion in sports and play: Get the facts. Available at www.cdc.gov/concussion/sports/facts.html.
- Marar M, McIlvain NM, Fields SK, Comstock RD. Epidemiology of concussions among United States high school athletes in 20 sports. Am J Sports Med. 2012;40:747-755.
- Lincoln AE, Caswell SV, Almquist JL, et al. Trends in concussion incidence in high school sports: a prospective 11-year study. Am J Sports Med. 2011;39:958-963.
- Guskiewicz KM, Valovich McLeod TC. Pediatric sports-related concussion. PM R. 2011;3:353-364.
- McCrory P, Meeuwisse W, Johnston K, et al. Consensus statement on concussion in sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008. J Athl Train. 2009;44:434-448. Available at www.ncbi.nlm.nih.gov/pmc/articles/PMC2707064/.
- Halstead ME, Walter KD. Clinical report–sport-related concussion in children and adolescents. Pediatrics. 2010;126:597-615.
- Collins MW, Iverson GL, Lovell MR, et al. On-field predictors of neuropsychological and symptom deficit following sports-related concussion. Clin J Sport Med. 2003;13:222-229.
- Johnson EW, Kegel NE, Collins MW. Neuropsychological assessment of sport-related concussion. Clin Sports Med. 2011;30:73-88.
- Bernhardt DT, Roberts WO, eds. Preparticipation Physical Evaluation. 4th ed. Elk Grove Village, Ill.: American Academy of Pediatrics; 2010.
- Womack J. Give your sports physicals a performance boost. J Fam Pract. 2010;59:437-444.
- Jinguji TM, Bompadre V, Harmon KG, et al. Sport Concussion Assessment Tool-2: baseline values for high school athletes. Br J Sports Med. 2012;46:365-370.
- Virji-Babul N, Borich MR, Makan N, et al. Diffusion tensor imaging of sports-related concussion in adolescents. Pediatr Neurol. 2013;48:24-29.
- Aubry M, Cantu R, Dvorak J, et al. Summary and agreement statement of the 1st International Symposium on Concussion in Sport, Vienna 2001. Clin J Sport Med. 2002;12:6-11.
- Covassin T, Elbin R 3rd, Stiller-Ostrowski JL. Current sport-related concussion teaching and clinical practices of sports medicine professionals. J Athl Train. 2009 Jul-Aug;44(4):400-404. Available at www.ncbi.nlm.nih.gov/pmc/articles/PMC2707074/.
This article originally appeared on Clinical Advisor