Overview
Definition:
A concussion is a traumatic brain injury, induced by biomechanical forces, resulting in a transient disturbance of brain function
The "return to play" (RTP) protocol involves a stepwise, individualized approach to safely reintroduce athletes to physical activity and sports after a concussion, aiming to prevent prolonged symptoms, second impact syndrome, and further injury
This protocol emphasizes a gradual increase in physical and cognitive demands.
Epidemiology:
Concussions are common in pediatric and adolescent sports, with estimates varying widely depending on the sport and reporting methods
In the US, sports-related concussions are estimated to affect hundreds of thousands of young athletes annually
Football, ice hockey, soccer, and basketball are among the sports with the highest incidence
Pediatric and adolescent brains may be more vulnerable to the effects of concussion and may have longer recovery periods.
Clinical Significance:
Inadequate management of concussions and premature return to play can lead to prolonged post-concussion syndrome, cognitive deficits, emotional disturbances, and, in rare cases, catastrophic outcomes like second impact syndrome
A structured RTP protocol is crucial for protecting the health and safety of young athletes, ensuring full recovery before resuming demanding physical activity, and minimizing long-term risks.
Clinical Presentation
Symptoms:
Headache
Dizziness
Nausea or vomiting
Sensitivity to light or sound
Blurred or double vision
Feeling dazed or stunned
Confusion or memory problems
Feeling slowed down
Difficulty concentrating
Irritability, sadness, or nervousness
Sleep disturbances (more than usual or less than usual).
Signs:
Appears dazed or stunned
Forgets instructions
Is confused about game, score, or opponent
Moves clumsily
Answers questions slowly
Loses consciousness (even briefly)
Shows mood, behavior, or personality changes
Can't recall events prior to or after the hit or fall.
Diagnostic Criteria:
There is no definitive diagnostic test for concussion
diagnosis is primarily clinical
It is based on a history of a suspected or confirmed blow to the head or body causing impulsive force transmitted to the head, and the presence of one or more of the following: amnesia, momentary loss of consciousness, confusion, or disorientation
Symptoms appearing immediately or developing hours to days later are considered.
Diagnostic Approach
History Taking:
Mechanism of injury: direct blow, rotational forces, fall
Loss of consciousness (LOC) duration if any
Post-traumatic amnesia (PTA) details
Immediate symptoms reported by athlete and witnesses
Previous concussions or head injuries
History of migraines, ADHD, learning disabilities, or mood disorders
Use of psychoactive medications
Red flags: worsening headache, repeated vomiting, seizures, focal neurological deficits, loss of consciousness > 30 seconds, significant amnesia, neck pain indicating potential cervical injury.
Physical Examination:
Vital signs including blood pressure, heart rate, and oxygen saturation
Neurological examination: mental status (orientation, attention, memory), cranial nerves, motor strength, sensation, coordination, reflexes, gait
Assess for signs of cervical spine injury
Balance and coordination tests (e.g., tandem gait, Romberg test)
Ocular motor screening (e.g., smooth pursuit, saccades, convergence).
Investigations:
Typically, neuroimaging (CT scan or MRI) is NOT required for the diagnosis of a typical concussion if there are no red flags suggesting a more severe injury (e.g., skull fracture, intracranial hemorrhage)
Imaging is indicated for persistent or worsening symptoms, focal neurological deficits, suspected skull fracture, or significant impact
Neuropsychological testing (e.g., SCAT5, ImPACT) can be useful for baseline assessment and in guiding return to play decisions, especially for athletes with prolonged recovery, but is not diagnostic of concussion itself.
Differential Diagnosis:
Migraine
Vestibular dysfunction
Cervical spine injury
Intracranial hemorrhage (subdural hematoma, epidural hematoma)
Skull fracture
Post-traumatic seizure
Metabolic disturbances
Hypoglycemia
Hypoxia
Drug intoxication
Functional neurological disorder.
Management
Initial Management:
Immediate removal from play or activity
Medical evaluation by a qualified healthcare professional experienced in concussion management
Relative cognitive and physical rest: avoiding strenuous activity, limiting screen time, and reducing academic load initially
Education of the athlete and family on concussion symptoms and the recovery process.
Medical Management:
There is no specific medication to cure concussion
Treatment focuses on symptom management
Analgesics like acetaminophen can be used for headaches
Antiemetics may be prescribed for nausea
Management of mood or sleep disturbances may involve specific medications under specialist guidance
Avoidance of aspirin and NSAIDs in the acute phase if there is concern for bleeding
Careful consideration of any pre-existing medications.
Surgical Management:
Surgical management is generally not indicated for concussion itself but is reserved for complications like acute epidural or subdural hematomas requiring evacuation, or for managing severe intracranial hemorrhages
These are neurosurgical emergencies.
Supportive Care:
Symptomatic management is key
Adequate hydration and nutrition
Encouraging gradual return to normal sleep patterns
Gradual reintegration into school and social activities as tolerated
Cognitive rest is crucial in the initial phase, followed by a gradual increase in cognitive load.
Graded Protocol Return To Learn Play
Return To Learn:
Stage 1: Symptom-limited activity
Rest
Stage 2: Light aerobic exercise
Stage 3: Sport-specific exercise
Stage 4: Non-contact training drills
Stage 5: Full contact practice
Stage 6: Return to competition
Each stage should last at least 24 hours
If symptoms return at any stage, the athlete returns to the previous symptom-free stage.
Return To Play:
Progression should be individualized and supervised by a healthcare professional
Step 1: Light aerobic activity (e.g., walking, stationary bike)
Step 2: Sport-specific exercise (e.g., jogging, skating)
Step 3: Drills without collisions (e.g., passing, drills)
Step 4: Full contact practice (supervised)
Step 5: Return to full game play
If any symptoms appear during a stage, the athlete should stop and return to the previous asymptomatic stage.
Age Considerations:
Adolescent brains are still developing and may be more susceptible to the effects of concussion
Recovery may be slower in younger athletes
RTP decisions for pediatric athletes must involve parents/guardians and focus on long-term neurological health over immediate return to sport.
Monitoring During Progression:
Athletes should be monitored closely for any symptom recurrence during each stage
If symptoms reappear, the athlete must revert to the previous stage and remain there for at least 24 hours before attempting to progress again
Any new neurological symptoms or significant worsening of existing symptoms should prompt immediate cessation of activity and re-evaluation by a healthcare professional.
Complications
Early Complications:
Post-concussion syndrome (PCS) with persistent headaches, dizziness, and cognitive issues
Increased risk of cervical spine injury
Acute intracranial hemorrhage (rare but life-threatening)
Seizures.
Late Complications:
Chronic Traumatic Encephalopathy (CTE) - a degenerative brain disease associated with repeated head trauma
still under active research
Persistent cognitive deficits
Mood and behavioral changes (depression, anxiety)
Sleep disorders
Increased risk of neurodegenerative diseases later in life.
Prevention Strategies:
Adherence to strict RTP protocols
Proper technique in sports to minimize head impacts
Use of appropriate protective equipment (though no equipment can prevent concussion)
Education of athletes, coaches, parents, and officials about concussion recognition and management
Prompt medical evaluation and management of suspected concussions
Avoiding return to play while symptomatic.
Prognosis
Factors Affecting Prognosis:
Severity of initial injury
Number of previous concussions
Presence of pre-existing neurological or psychological conditions
Age of the athlete
Adherence to RTP protocols
Timeliness and quality of medical management.
Outcomes:
Most pediatric athletes with a single, uncomplicated concussion recover fully within 1-4 weeks
However, a significant proportion may experience prolonged symptoms or require a more extended recovery period
Early and appropriate management improves outcomes and reduces the risk of long-term sequelae
Athletes with multiple concussions or complex presentations may have poorer prognoses.
Follow Up:
Follow-up with a healthcare professional experienced in concussion management is crucial throughout the recovery process, especially for athletes with prolonged symptoms or those who have had multiple concussions
Regular reassessment of symptoms, cognitive function, and physical capacity is necessary
A graduated return to school and sport is essential
Long-term monitoring may be considered for athletes with a history of multiple concussions.
Key Points
Exam Focus:
Recognition of concussion symptoms and signs
Red flags requiring urgent imaging/evaluation
The stepwise approach to Return to Play (RTP)
Importance of relative cognitive and physical rest
individualized RTP progression
Role of neuropsychological testing.
Clinical Pearls:
Always suspect concussion in any athlete with a head injury, even without LOC
"When in doubt, sit them out." Educate parents and athletes on the risks of early return to play
The brain needs time to heal
pushing too hard too soon is detrimental
RTP is a medical decision, not an athlete or coach decision.
Common Mistakes:
Confusing concussion with structural brain injury (e.g., hemorrhage)
Relying solely on symptom resolution without considering cognitive and physical exertion
Premature return to play
Inadequate initial rest
Dismissing subtle symptoms
Not involving parents/guardians in decision-making.