Concussion management has evolved over time. Current guidelines are summarized in this video and summary below.
https://players.brightcove.net/2696240571001/VyQDdgBTl_default/index.html?videoId=6329789349112
RECOGNIZE: symptoms of concussion
A concussion is a traumatic brain injury caused by a direct blow to the head, neck or body resulting in a force transmitted to the brain. This initiates a neurotransmitter and metabolic cascade, with possible axonal injury, blood flow change and inflammation affecting the brain. Loss of consciousness is rare - 90% of the time there is not
loss of conciousness..
Symptoms and signs may be immediate or evolve over minutes or hours. Symptoms usually resolve within days, but may be prolonged.
Concussions are diagnosed based on history and exam. Currently there are no imaging studies recommended for diagnostic purposes.
REDUCE: prevention of concussion
A focus on prevention to decrease the numbers of injury is recommended. This can include sport policy-makers to identify and use prevention strategies. These may include rule changes, personal protective equipment (helmet and mouth guard use), neuromuscular training of athletes and training of coaching staff to recognize symptoms and risks.
REMOVE: sideline evaluation
The recognition of a sports-related concussion is the first step to starting managment. Removal of a player from play should be done if there is suspicion of a possible concussion to avoid further potential injury.
Signs that warrant immediate removal
from the field include actual or suspected loss of consciousness, seizure, tonic posturing, incoordination, poor balance, headache, confusion, behavioral changes and amnesia. Players showing these signs should not return
to a match or training that day.
RE-EVALUATE: the office assessment
Clinical re-assessment is recommended to track and manage symptoms until recovery. Clearance can only be given after a history and exam show recovery.
Symptoms and signs of a concussion may evolve over minutes, hours or days. Whether a concussion is suspected or confirmed, the player should be re-evaluated at multiple times over days by a professional trained in concussion management.
The athlete’s history of concussions, how each concussion was managed and recovery time should be discussed and taken into consideration. Medical and psychological diagnoses that may affect symptoms and recovery include history of headaches, anxiety, and depression.
REST and exercise
Strict bedrest is not recommended. Relative rest IS recommended. Relative rest allows typical daily activities but limited screen time, for 2 days following injury. Light-intensity physical activity, such as walking that does not more than mildly trigger symptoms is allowed.
After 24-48 hours, physical activities that do not have a risk of contact, collision, or fall, such as stationary cycling, is allowed. After two days, aerobic exercise intensity can increase as tolerated as long as it does not lead to a mild increase in symptoms beyond an hour. If symptoms are more than mild or persist beyond an hour, reduce exercise intensity.
Aerobic exercise that is done days 2-10 after concussion that does not trigger moderate or severe symptoms or symptoms that last over an hour has been shown to improve recovery rates.
Sleep problems in the 10 days following concussion is associated with an increased risk of persisting symptoms and should be discussed with an experienced healthcare provider.
REFER
Referral to clinicians with specialized knowledge and skills (sports medicine physicians, athletic trainers, physical therapists, occupational therapists, neurolgists, neurosurgeons, ophthalmologists, psychologists, or psychiatrists) should be considered for the targeted treatment of persisting symptoms. This may include migraine and headache, cognitive and psychological difficulties, balance disturbances, visual changes, and others that are outside the scope of practice of the healthcare provider.
REHABILITATION
If dizziness, neck pain and/or headaches persist for more than 10 days, physical therapy for vestibular rehabilitation is recommended.
If symptoms persist beyond 4 weeks, specialty care specific to the symptoms is recommended.
RECOVERY
Assessment of clinical recovery should be done with clinical history and exam. Continued monitoring by the athlete, family, and coaches should continue to watch for return of symptoms or new injury.
Future research
Advanced neuroimaging, fluid-based biomarkers, genetic testing and other technologies are being assessed by researches to further improve concussion diagnosis, prognosis, and recovery. This research is required to validate their use in clinical practice to assess recovery and aid in the clinical management before these can be used in the typical management of concussions.
