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Post-Concussion Management

Concussions in Contact Sport: What You Need to Know

2 out of 10 high school athletes who play contact sports will suffer a concussion this year (1). According to the CDC, 1.6 - 3.8 million sports related concussions occur each year (2). Perhaps the most disturbing statistic, 5 out of 10 concussions go unreported or undetected (1). The Brain Injury Research Institute defines a concussion (AKA Mild Traumatic Brain Injury) as any bump, jolt, or blow to the head or body that causes the brain to move rapidly inside the skull. Even a seemingly mild blow to the head can have detrimental effects. With the recent discovery of Chronic Traumatic Encephalopathy (CTE), a progressive degenerative disease of the brain in people who have suffered repeated concussions, we are becoming more and more informed about the long terms effects that concussions have on the brain. We are now seeing safer concussion protocols among college and professional athletics as a direct result of the latest revealing evidence regarding the importance of proper post concussion management . We are hopeful that the advances made with post-concussion management in the collegiate and professional realm will trickle over to adolescent and child athletics. All contact sports teams should have a post-concussion management protocol in order to protect their athletes from what could be a lifetime of negative consequences.

Absence of a post-concussion management protocol is problematic due to the cumulative effect that concussions have on the brain if an athlete returns to sport prior to complete recovery (2). Combine that with the fact that an athlete who sustains a concussion is 4-6 times more likely to suffer a second concussion and you have an unfavorable situation for the athlete. It is imperative that we educate the athletes who participate in contact sports as well as their parents and coaches, as much as possible, regarding the importance of an appropriate post-concussion management protocol as well as the short term and long term effects that a concussion can have on the brain.

Post Concussion Symptoms

  • Headache: 59 - 90% of individuals who suffer from a concussion will experience a post- concussion headache (3). The more concussions an individual experiences the more likely they are to experience more intense and frequent headaches (3).

  • Dizziness

  • Balance Problems

  • Photophobia (sensitivity to light)

  • Blurred Vision

  • Attention and Concentration Difficulties

  • Temporary Loss of Consciousness

  • Mental Fatigue (fogginess)

Post Concussion Syndrome

While most who suffer from a concussion will find that their symptoms resolve within the days and weeks following the incident when given adequate rest, some will continue to suffer from concussion related symptoms for weeks and months following the incident of head trauma. The term used for people who experience these prolonged effects is “post concussion syndrome (PCS)”. Symptoms are similar to those mentioned above and also commonly include emotional symptoms, such as, depression and anxiety. Individuals who have suffered numerous concussions are more vulnerable to developing PCS.

  • Headache: Commonly referred to as Post Traumatic Headache (PTH) usually develops within 7 days following an incident of head trauma. While many cases of PTH resolve within 3 months, many people (estimated 47% to 95%) will develop a chronic (long term) case of post traumatic headache (4).

  • Cognitive Deficits (e.g. memory processing, concentration, reaction time) : A 2012 study published in the Brain Injury Journal found that the neurophysiological effects following a concussion persisted for a minimum of 6 months post concussion (5). This particular study looked at the neurophysiological effects following a concussion in 3 different age group populations: Children (9-12yrs), Adolescents (13-16yrs), and Adults ( > 16yrs). The most interesting finding, in my opinion, was that the adolescent age group were most sensitive to the cognitive effects following a concussion.

  • Depression: The emotional effects following concussion are well established in the research. One study found that concussed athletes demonstrate significantly higher levels of depression at 2, 7 and 14 days post injury compared to baseline (6). According to this study, college athletes have significantly higher rates of depression at 14 days post injury compared high school athletes.

Post Concussion Management for the Athlete - Short Term

Any athlete who has experienced a blow to the head should be assessed by a medical professional for concussion severity as soon as first aid and emergency care priorities (e.g. possible spinal cord injury) are completed. Standardized concussion assessments such as the SCAT5 (Sport Concussion Assessment Tool, 5th Edition) are an efficient and evidenced backed method of assessing an individual post head trauma. The SCAT5 is designed to be utilized by a medical professional. If a situation arises in which a medical professional is not immediately available, then the athlete should be referred to a medical facility for urgent assessment as soon as possible. If a medical professional is not present to administer the SCAT5 on-field assessment the CRT5 (Concussion Recognition Tool) can be used for initial assessment.

There are two components to the SCAT5, an initial “on-field” assessment and an “off-field” assessment that is performed later after any possible red-flags have been cleared. The initial assessment includes: ruling out of red flags, examining for signs of serious head trauma, and assessing the cervical spine for possible injury. The second part of the SCAT5 is performed later once serious head trauma and structural injury have been addressed or ruled out. It is designed to assess severity of post concussion symptoms, such as, cognition, balance, reaction time and decision making. Concussion signs and symptoms are evolving and any athlete who experiences a concussion should be retested within the days and weeks following the incident.

Any athlete who experiences a concussion should be removed from the playing field immediately and should not return to play for the day even if assessment results are normal. Any athlete who experiences a concussion should not return to play until test results are back to baseline (or “normal” if no baseline test was administered) and a medical professional clears the athlete for return to sport. As I mentioned earlier, the effects of concussion on the brain are cumulative. This is why it is vital to ensure that an athlete has returned to baseline before returning to sport where they will risk suffering another concussion.

CRT5: http://www.parachutecanada.org/downloads/resources/CRT5.pdf

SCAT5: https://bjsm.bmj.com/content/bjsports/early/2017/04/26/bjsports-2017-097506SCAT5.full.pdf

Post Concussion Management for the Athlete - Long Term

As mentioned earlier, post concussion syndrome is a term that refers to concussion symptoms that do not resolve within the initial weeks following a concussion. There are several different treatment methods worth seeking out if you or your child are experiencing any persisting post concussion symptoms.

Vision Symptoms - Including blurred vision, motion sensitivity, difficulty with eye movements, eye pain, dizziness, light sensitivity, peripheral vision problems.

  1. Oculomotor Training - Large range of techniques designed to help train specific aspects of the visual system

  2. Neuro-Optometric Rehab- Individualized training plan that utilizes prisms, lenses, filters and occlusion to help stimulate parts of the brain which are not functioning to their highest potential, due to interruptions caused by the brain injury

Vestibular Symptoms - balance and dizziness

  1. Vestibular Therapy - Exercises designed to train specific components of the vestibular system that may be impaired post concussion. Common Vestibular training exercises include gaze stabilization, habituation training, and balance training. Physical Therapists and some Doctors are trained in Vestibular rehabilitation.

Headaches

  1. Physical Therapy/Chiropractic - Treatment interventions such as dry needling, cervical spine manipulation, and other manual therapy techniques have proven helpful in treating post-concussion headaches

Behavioral Changes - Anxiety, depression, personality changes

  1. Cognitive Behavioral Therapy (CBT)- Administered by a licensed psychiatrist, CBT helps patients develop the ability to identify negative thought patterns that contribute to a patients individual difficulties, and teaches concrete skills that patients can use to help manage them.

Resources

  1. https://www.upmc.com/services/sports-medicine/services/concussion/facts-statistics

  2. http://www.protectthebrain.org/Brain-Injury-Research/What-is-a-Concussion-.aspx

  3. https://www.neurologyadvisor.com/topics/migraine-and-headache/treating-post-traumatic-headache-after-concussion/

  4. https://www.theraspecs.com/blog/post-concussion-headaches/

  5. Baillargeon A, Lassonde M, Leclerc S, Ellemberg D. Neuropsychological and neurophysiological assessment of sport concussion in children, adolescents and adults. Brain Inj. 2012;26(3):211-20.

  6. Depression and Neurocognitive Performance After Concussion Among Male and Female High School and Collegiate Athletes. Kontos, Anthony P. et al. Archives of Physical Medicine and Rehabilitation, Volume 93, Issue 10,1751-1756.

Lizzy Landreneau