Recognizing Concussion Signs and Symptoms and How to Manage Them

According to a Consensus Statement from the International Conference on Concussions in Sports that took place in 2008, a concussion is a defined as, “a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces”¹. Traumatic brain injuries have contributed to a substantial number of deaths or permanent disability, with 2.5 millions traumatic brain injuries occurring as isolated injuries or along with other injuries in 201⁰². Moreover, the Centers for Disease Control published data in 2011 demonstrating that the estimated number of emergency department hospital visits for sports and recreation-related concussions from 2001 to 2009 in the United States had increased by 62% in persons 19 years or younger³. This significant increase in concussion incidence continues to rise exponentially and has generated substantial concern amongst the general population, especially coaches, athletes and their parents. Although concussion are often associated with sports, they may also occur in non-sports related settings such as motorcycle or car accidents, falls and fights.

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Etiology

A concussion may be caused by either a direct or indirect impact to the head. A direct impact to the head would be when an object comes into contact with the head directly (i.e. head to head contact in sports). An indirect impact to the head occurs when there is an impact elsewhere on the body and the forces are transmitted to the head. There are two types of forces that may cause a concussion: linear and rotational. A linear force will cause the brain to hit the inner walls of the skull, causing the brain to move in an anterior-posterior direction. When the brain accelerates forward and is stopped by the skull, this initial hit is called the “coup”. The force of the impact may then force the head back, causing the posterior part of the brain to hit against the inner wall of the skull. This second impact is called the “contra coup”. A rotational force can lead to two types of injuries: shearing/tearing of brain tissue and stretching of tissue. This typically occurs when the impact is to the side of the head, causing a swift rotation of the head and neck⁴.

Pathophysiology⁴

The signs and symptoms experienced post concussion are a result of what is referred to as a “neurotoxic cascade”. Upon impact, there is an increase in blood pressure and decrease in blood flow to the brain. The shearing of the brain tissues alters the activity of the neurons, causing a massive wave of depolarization and release of excitatory amino acids. The latter results in a hypermetabolic (increase in cellular activity) state of the brain, which in turns requires a substantial amount of oxygen, glucose and adenosine triphosphate (ATP) to maintain. However, due to decreased cerebral blood flow, glucose stores at the brain become depleted. This results in an inability to keep up with the energy demand. This hypermetabolic state has been shown to last approximately 6 hours and is proceeded by a state of hypometabolism (decrease in cellular activity). This transition is responsible for the symptoms experienced post concussion.

Concussion Diagnosis

There are no diagnostic tests or biomarkers that can be used to diagnose a concussion. The structural changes that occur with a concussion cannot be observed with an MRI and CT scans. Imaging is typically done to rule out consequences of more severe traumatic brain injuries such as intracranial hemorrhaging and fractures of the skull⁵.

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Potential Symptoms of a Concussion⁵

  • Headache
  • Pressure in the head
  • Fatigue
  • Nausea or vomiting
  • Balance problems
  • Sensitivity to light or noise
  • Feeling sluggish or in a fog
  • Concentration or memory difficulties
  • Confusion
  • Feeling more emotional, nervous or anxious
  • Not “feeling right” or “feeling down”

Medical Management

When an athlete recently suffers a potential concussion, the athlete is removed from play. The medical management begins with a sideline assessment, typically performed by a team physician, sports physiotherapist or athletic therapist on the field immediately post injury. The latter consists of asking the patient if they are experiencing any of the symptoms above. If the athlete answers yes to experiencing any of the above symptoms (even if it is one symptom), there is a chance that the athlete is concussed. To help develop a more sound clinical impression, it is often helpful to look for certain signs to further support the hypothesis, such as appearing dazed or confused, responding to questions slowly, being confused, forgetting instructions, unable to recall events and losing consciousness. This collection of information may be complicated by the fact that some symptoms may only appear several hours after the initial injury, coinciding with the transition from cerebral hypermetabolism to hypometabolism. Therefore, it is of utmost importance to educate the parents of the athlete with regards to signs of severely worsening symptoms (i.e. vomiting, severe headaches, inability to be awoken, fluid or blood leaking from the nose or ears, worsening memory difficulties, slurring of speech, numbness or weakness of arms or legs, etc.)⁶. If any of these severe symptoms are experienced, consult the nearest emergency department immediately. Moreover, balance testing and cognitive testing may be completed during the sideline assessment as well, given that any spine injuries or other severe injuries have been ruled out. This is typically done using the SCAT-3. However, it is important to note that the SCAT-3 is not very accurate if no baseline testing has been done (baseline testing is a battery of tests done before the season begins to provide information concerning the patient’s baseline status so that when an injury occurs, a test such as the SCAT-3 may show deviations from the patient’s normal performance).

As previously mentioned, imaging is typically done post injury to the head to rule out any intracranial hemorrhages and skull fractures. Afterward, the athlete is seen in a clinical setting, anywhere between 24 hours or later post concussion. The physician and/or physiotherapist will then perform a battery of tests including symptom assessment, balance testing, neuropsychological testing, etc. to further confirm the initial diagnosis of a concussion⁵.

Concussion Treatment

During the first 24–48 hours post concussion, the patient should not take any medication, as this can mask any worsening symptoms and potentially increase bleeding in the brain. Moreover, the person should not be allowed to sleep within the first 3 hours post concussion even if they complain of being tired, as it is crucial to continue monitoring their symptoms. Do check up on the patient every 2 hours. If there is a concern regarding their breathing or sleeping, you may wake them up. As previously mentioned, if any symptoms begin to worsen, take the patient to the emergency department. It is recommended to schedule a more complete evaluation with a physician and/or physiotherapist trained in concussion management within 2 days of the injury⁷.

To begin, physical and cognitive rest is recommended for 7 days⁵, although guidelines are not consistent across all medical information resources. The patient should not return to sports or engage in any physical activity/exercise initially, as this may increase their symptoms and potentially delay recovery. In addition, if the patient engages in sports prior to being ready to do so, there is an increased risk of re-injury, which can be more serious that the initial injury and would also delay recovery⁵. Afterward, a gradual reintegration into a school setting may begin, with certain accommodations that may be provided to symptomatic athletes, such as reduced course load, sunglasses to counteract the sensitivity to light, a designated quiet area to counteract the sensitivity to noise, etc. Once the athlete is asymptomatic with school-related activities (cognitive activity), then they may begin a return to play protocol, which is a series of steps that the patient must follow before they can fully return to their sport⁵.

Furthermore, an athlete with a concussion may also present with other impairments such as increased muscular tension around the neck and shoulder area and cervical hypomobility or dysfunction, among others. The latter impairments can both contribute to increased headaches and can be treated by a physiotherapist.

Common False Beliefs Regarding Concussions

1. My son or daughter did not lose consciousness. They do not have a concussion.

I cannot possibly tell you how many times I have heard this statement either from a coach or athlete. Loss of consciousness is not a requirement for the diagnosis of a concussion. Approximately 90% of patients who suffer a concussion do not lose consciousness⁶.

2. My son or daughter only has a headache. They do not have a concussion.

Even if the athlete presents with one of the many concussion symptoms, it must be suspected as a potential concussion until it can be ruled out, especially if the headache occurred after a direct or indirect hit to the head. The number of symptoms an athlete is experiencing does not coincide with the severity of the concussion.

3. My son or daughter is no longer experiencing any symptoms. They can return to playing their sport.

NO! The athlete must follow the return to learn protocol before they can attempt the return to play protocol to decrease the risk of re-injury, which can be potentially fatal. They need to be stimulated mentally by increasing cognitive activity (returning to school) before they can begin any form of exercise or physical activity. Only then, can they begin the return to play protocol and I must emphasize that THERE ARE NO SKIPPING STEPS.

If you have any questions or concerns regarding concussions and how to manage them, please consult your doctor. If you have any questions or concerns regarding the content of this blog post, you may contact me directly infophysiotherapy10@gmail.com.

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DISCLAIMER: This blog is not meant for diagnostic or treatment purposes. It should not substitute for professional diagnosis and treatment. This blog was not created to provide physiotherapy consultations, nor was it created to obtain new clients. I am adamant on patient education and it is an absolute privilege to share my knowledge. The content of this blog is a resource for information only. This blog was created to inform the general population about different musculoskeletal, neurological and cardiorespiratory conditions in a variety of patient populations. For any further questions or concerns regarding concussions and how to manage them, please consult your doctor.

References

1. McCrory, P., Meeuwisse, W., Johnston, K., Dvorak, J., Aubry, M., Molloy M., & Cantu, R. (2009). Consensus statement on concussion in sport–the 3rd International Conference on concussion in sport, held in Zurich, November 2008. Clin J Sport Med, 19(3):185–200.

2. National Hospital Discharge Survey (NHDS). (2010). National Hospital Ambulatory Medical Care Survey (NHAMCS), 2010; National Vital Statistics System (NVSS). All data sources are maintained by the CDC National Center for Health Statistics.

3. Gilchrist, J., Thomas, K. E., Xu L., McGuire, L. C., & Coronado, V. G., (2011). Nonfatal sports and recreation related traumatic brain injuries among children and adolescents treated in emergency departments in the United States, 2001–2009. MMWR Morb Mortal Wkly Rep, 60(39):1337–42.

4. NYsportsconcussion.com. (2010). What is a concussion? NYsportsconcussion.com. Retrieved from: http://www.nysportsconcussion.com/concussion.php

5. Committee on Sports-Related Concussions in Youth; Board on Children, Youth, and Families; Institute of Medicine; National Research Council. (2014). Sports-Related Concussions in Youth: Improving the Science, Changing the Culture. Graham, R., Rivara, F. P., Ford, M. A., & Spicer, C. M. (Ed.). Washington, DC: National Academic Press (US). Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK185340/

6. Complete Concussion Management. (n. d.). What is Post-Concussion Syndrome? Complete Concussion Management. Retrieved from: https://completeconcussions.com/for-parents-athletes/what-is-post-concussion-syndrome/

7. Complete Concussion Management. (n. d.). What Do I Do if I Have a Concussion? Complete Concussion Management. Retrieved from: https://completeconcussions.com/for-parents-athletes/what-to-do/