What is it?
In sport, one of the most common injuries that a young athlete may endure is a concussion. In the United States, the Centers for Disease Control (CDC) estimates that 1.6 to 3.8 million concussions occur in sports and recreational activities annually. This is huge number – with an even larger economical burden. Recently, there has been great interest and concern regarding chronic traumatic encephalopathy, better known as CTE. This brain disease (for the time being) can only be diagnosed with an autopsy, and has been seen in collegiate and professional athletes. Because the hypothesized mechanism leading to CTE is repetitive head trauma, and the high incidence of concussion, there has been an even greater interest placed on the impact of concussion in youth athletes. So, what actually is a concussion, what are the symptoms, and how can it be managed or treated?
Concussion is an injury with complex pathophysiological processes that negatively affect the brain, induced by biomechanical forces. Concussion is caused either by a direct blow to the head, face, neck or elsewhere on the body where the force is transmitted to the head and brain. Typically, there is a rapid onset of neurological impairment that resolves spontaneously but sometimes symptoms may not arise immediately and may not involve any loss of consciousness. A vast majority (80-90%) of concussions will resolve in a short time period, usually 7-14 days.
In October of 2016, the 5th International Conference on Concussion in Sport was held in Berlin. They wrote a consensus statement that outlined signs and symptoms associated with concussion:
- Symptoms: headache, feeling like in a fog, emotional symptoms such as lability, slurred speech, glassy eyed stair.
- Physical Signs: possible loss of consciousness and amnesia
- Behavioral Changes: Irritability, restlessness, aggression, depression
- Cognitive Impairment: slow reaction times, difficulty concentrating
- Sleep Disturbances: Insomnia
The CDC has added symptoms such as balance disorders, dizziness, blurry vision, and sensitivity to light and sound.
The Berlin Consensus paper states that if concussion is suspected after on field injury, then evaluation and diagnosis be progressed in these steps:
- The player should be evaluated by a licensed healthcare provider onsite and attention should be taken to evaluate the cervical spine.
- Disposition of the player must be determined by the treating healthcare provider in a timely manner. If no healthcare provider is available, the player should be safely removed from practice or play and urgent referral to a physician arranged.
- Once the first aid issues are addressed, an assessment of the concussive injury should be made using the SCAT5 or other sideline assessment tools.1
- The player should not be left alone following the injury and serial monitoring for deterioration is essential over the initial few hours following injury.
- A player with diagnosed concussion should not be allowed to return to play (RTP) on the day of injury.
If the athlete is sent to the ER or follows up with their physician, then the evaluation to determine concussion should be focused on a neurological examination that looks at mental status, cognitive functioning, gait, and balance. They will determine the clinical status of the injury (improving or deteriorating) since time of onset. After this examination and evaluation, the physician (usually a neurologist) will determine if medical imaging is necessary to rule out possibility of a more severe brain injury.
Once a correct assessment has been made, the athlete will be directed about management of the concussion. This is a step-by-step process that needs to be followed to ensure that there is improvement in injury status, and that no further damage may be taking place.
Management and Return to Sport
Concussion, discussed in a previous post, is a head injury caused by a blow to the body or neck where force is transmitted to the head and ultimately injures the brain. It’s an extremely common injury, specifically for young athletes, which should not be taken lightly. Once an injury occurs and concussion is properly diagnosed, correct management of the injury is essential to ensure that the athlete/individual can safely return to both normal activities and sport.
Management for this condition is typically a relatively short process and can be accomplished through physician monitoring, with physical therapy, and in some cases – medication. Also discussed in the previous post, vestibular (balance) impairments as well as neck pain and headaches can accompany concussion. All of these symptoms can be treated well by physical therapy. There is evidence that after a concussion occurs there should be a period of complete rest, both mental and physical, for 24-48 hours. After this initial rest period, physical therapy can begin. There are 6 stages of management, each lasting 24-48 hours if there is no symptom provocation during and post treatment sessions.
- Stage 1: Symptom-limited activity with gradual reintroduction to work/school activities
- Stage 2: light aerobic exercise such as walking or stationary bicycle at a medium pace to increase heart rate
- Stage 3: Sport-Specific exercise to reintegrate different movement patterns. No head impact
- Stage 4: non-contact training drills to incorporate harder, more diverse training skills
- Stage 5: full contact practice following medical clearance
- Stage 6: return to sport
With each stage generally consists of 24-48 hours, conservative care will sideline the athlete for about two weeks before returning to sport. Combined with the initial rest period, this time period may be longer. This recovery time can be extended depending on how the individual is progressing. The strongest predictor for recovery is severity of symptoms the first day. If the concussion symptoms are very severe, then the athlete may be out of sport longer than the “typical” time frame. When in physical therapy, there is a very specific training program created depending on each person’s needs. With this protocol in mind, exercises may be prescribed for each stage, but will also incorporate balance and visual retraining to improve vestibular system function. If there are neck related symptoms, including cervicogenic headache, exercise and specific manual therapy techniques are used to decrease or eliminate these symptoms.
Children under the age of 18 should be managed with more caution. The evidence pertaining to child and adolescent concussion recovery is sparse. The consensus is that symptom duration in children and adolescents can last up to four weeks. Children should not return to sport until they can return to school. Returning to school should also be a gradual process due to the energy expenditure on cognitive tasks. A return-to-school protocol or strategy may look a little something like this:
- Stage 1: gradually build up typical at home activities without increasing symptoms. This includes minimizing reading, texting, and screen time. Start with 5-15 minutes of normal household activity and then gradually increase the time as long as symptoms are not provoked.
- Stage 2: Perform school activities at home such as homework or reading to increase tolerance to cognitive work
- Stage 3: return to school part-time with breaks during the day to increase academic activities without aggravating symptoms
- Stage 4: return to school full time if tolerated
Physical therapy is an important part of rehabilitating concussion, but it takes a team approach to manage concussion. There should be consistent and valued contact between physician, therapist, athlete, and parent. If you suspect that your child or loved one may have a concussion, please have them examined and evaluated by your medical provider, and use this information to help guide you.
For additional information about concussions in youth sports, visit this site: https://www.cdc.gov/headsup/youthsports/index.html
1McCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med Published Online First: 26 April 2017. doi: 10.1136/bjsports-2017-097699.
1McCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med Published Online First: 26 April 2017. doi: 10.1136/bjsports-2017-097699
2Schneider KJ, Leddy JJ, Guskiewicz KM, et al. Rest and treatment/rehabilitation following sport-related concussion: a systematic review. Br J Sports Med 2017;51:930-934.