Concussions are a common problem for the pediatrician with 1.6 to 3.8 million occurring per year in the United States.1 Although falls, motor vehicle accidents, and assaults are the most common etiology, 1 in 5 is a sports-related concussion (SRC). The percentage of SRC is even higher in adolescents. The pediatrician needs to be able to discuss this topic with parents and caregivers, identify common symptoms, and know when a child can return to play when an SRC is suspected.
Concussion is synonymous with mild traumatic brain injury (MTBI) and can be defined as: “a complex pathophysiologic process affecting the brain, induced by traumatic biomechanical forces secondary to direct or indirect forces to the head. MTBI is caused by a blow or jolt to the head that disrupts the function of the brain. This disturbance of brain function is typically associated with normal structural neuroimaging findings (ie, computed tomography [CT] scan, magnetic resonance imaging [MRI]).”1
A number of different features may be used in further defining the nature of an SRC:2
· May be caused by a direct blow to the head or elsewhere (eg, neck or face) with forces transmitted to the head.
· Has typically rapid onset of and short duration of neurologic impairment with spontaneous resolution of symptoms. However, in some cases, signs and symptoms may evolve over a longer period (minutes to hours).
· May result in neuropathologic changes, but the acute injury reflects a functional disturbance as opposed to a structural injury.
· Range of clinical signs and symptoms may not involve a loss of consciousness. Resolution of symptoms typically follows a sequential course, but prolonged symptoms occur in some.
· Only 10% of concussions involve a loss of consciousness.
Pathophysiology and symptoms
The disturbance in brain function from a concussion is more related to brain metabolism than to a structural injury or damage. Neuronal dysfunction involves a number of different processes and a complex cascade of metabolic and physiologic events3 that may result in a constellation of symptoms (Table 1).
Diagnosis and assessment
Scenario 1: A 15-year-old lacrosse player comes off the field after a helmet-to-helmet contact complaining of headache, ringing in his ears, dizziness, and nausea. What should be done next?
Although an SRC can be difficult to diagnose in real time, the adolescent clearly had a helmet-to-helmet contact and now has symptoms. Further, the majority of SRCs do not involve a loss of consciousness. In any suspected case of concussion, the athlete should be removed from the activity and assessed by a physician or other licensed healthcare provider.2
Diagnosing suspected SRC involves the assessment of clinical symptoms, physical signs, cognitive impairment, neurobehavioral symptoms, and sleep/wake disturbances (Table 1). An SRC diagnosis should be suspected when there are abnormalities in 1 or more of these domains.2
Sideline assessments consisting of neuropsychologic test batteries and memory function are both effective and practical. The Sport Concussion Assessment Tool–5th Edition (SCAT5)4 is one such test and is the most well-established and rigorously tested assessment for SRC. The SCAT5 should be administered by an appropriately trained health professional, whereas coaches and other nonlicensed personnel should use the Concussion Recognition Tool 5th Edition (CRT5).5 There is no evidenced-based recommendation for any particular tool or protocol and best practice dictates a tool such as the SCAT with possible addition of video review if available.6
However, the SCAT5 should not continue to be used as an assessment tool when more than 3 to 5 days have lapsed since the injury.2 The SCAT5 can be used in children aged older than 12 years and adults. There is also a version for children aged younger than 12 years.7
The SCAT5 employs an on-field rapid assessment for suspected SRC. It is important for the pediatrician to understand that the tool does not provide definitive diagnosis of a head injury. The immediate sideline assessment consists of 5 steps (Table 2):4
STEP 1: RED FLAGS
In Step 1, the pediatrician or health professional is looking for red flag signs that should lead to immediate removal and evaluation. The symptoms include:4
· Neck pain (consider cervical-spine injury)
· Double vision
· Numbness or weakness in an extremity (consider cervical-spine or spinal-cord injury)
· Severe or worsening headache (consider intracranial bleed)
· Loss of consciousness or deteriorating level of consciousness (consider intracranial bleed)
· Vomiting (consider increased intracranial pressure)
· Restless, agitated, or combative (consider increased intracranial pressure or bleeding)
1. Centers for Disease Control and Prevention. Heads Up: Facts for Physicians About Mild Traumatic Brain Injury (MTBI). Available at: http://www.concussiontreatment.com/images/CDC_Facts_for_Physicians_booklet.pdf. Accessed July 2, 2018.
2. McCrory P, Meeuwisse W, Dvorák 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. 2017;51(11):838-847.
3. Giza CC, Hovda DA. The neurometabolic cascade of concussion. J Athl Train. 2001;36(3):228-235.
4. Echemendia RJ, Meeuwisse W, McCrory P, et al. The Sport Concussion Assessment Tool 5th Edition (SCAT5): background and rationale. Br J Sports Med. 2017;51(11):848-850.
5. Echemendia RJ, Meeuwisse W, McCrory P, et al. The Concussion Recognition Tool 5th Edition (CRT5): background and rationale. Br J Sports Med. 2017;51(11):870-871.
6. Patricios J, Fuller GW, Ellenbogen R, et al. What are the critical elements of sideline screening that can be used to establish the diagnosis of concussion? A systematic review. Br J Sports Med. 2017;51(11):888-894.
7. Davis GA, Purcell L, Schneider KJ, et al. The Child Sport Concussion Assessment Tool 5th Edition (Child SCAT5): background and rationale. Br J Sports Med. 2017;51(11):859-861.
8. Maddocks DL, Dicker GD, Saling MM. The assessment of orientation following concussion in athletes. Clin J Sport Med. 1995;5(1):32-35.
9. Creighton DW, Shrier I, Shultz R, Meeuwisse WH, Matheson GO. Return-to-play in sport: a decision-based model. Clin J Sport Med. 2010;20(5):379-385.
10. McLendon LA, Kralik SF, Grayson PA, Golomb MR. The controversial second impact syndrome: a review of the literature. Pediatr Neurol. 2016;62:9-17.
11. Thomas M, Haas TS, Doerer JJ, et al. Epidemiology of sudden death in young, competitive athletes due to blunt trauma. Pediatrics. 2011;128(1):e1-e8.
12. Halstead ME, McAvoy K, Devore CD, et al; Council on Sports Medicine and Fitness; Council on School Health. Returning to learning following a concussion. Pediatrics. 2013;132(5):948-957.
13. Howell D, Osternig L, Van Donkelaar P, Mayr U, Chou LS. Effects of concussion on attention and executive function in adolescents. Med Sci Sports Exerc. 2013;45(6):1030-1037.
14. Sady MD, Vaughan CG, Gioia GA. School and the concussed youth: recommendations for concussion education and management. Phys Med Rehabil Clin N Am. 2011;22(4):701-719.
15. May KH, Marshall DL, Burns TG, Popoli DM, Polikandriotis JA. Pediatric sports specific return to play guidelines following concussion. Int J Sports Phys Ther. 2014;9(2):242-255.