Current Concepts in Concussion: Initial Evaluation and Management

 

Mild traumatic brain injury, also known as concussion, is common in adults and youth and is a major health concern. Concussion is caused by direct or indirect external trauma to the head resulting in shear stress to brain tissue from rotational or angular forces. Concussion can affect a variety of clinical domains: physical, cognitive, and emotional or behavioral. Signs and symptoms are nonspecific; therefore, a temporal relationship between an appropriate mechanism of injury and symptom onset must be determined. Headache is the most common symptom. Initial evaluation involves eliminating concern for cervical spine injury and more serious traumatic brain injury before diagnosis is established. Tools to aid diagnosis and monitor recovery include symptom checklists, neuropsychological tests, postural stability tests, and sideline assessment tools. If concussion is suspected in an athlete, the athlete should not return to play until medically cleared. Brief cognitive and physical rest are key components of initial management. Initial management also involves patient education and reassurance and symptom management. Individuals recover from concussion differently; therefore, rigid guidelines have been abandoned in favor of an individualized approach. As symptoms resolve, patients may gradually return to activity as tolerated. Those with risk factors, such as more severe symptoms immediately after injury, may require longer recovery periods. There is limited research in the younger population; however, given concern for potential consequences of injury to the developing brain, a more conservative approach to management is warranted.

Mild traumatic brain injury, also known as concussion, accounts for 80% to 90% of traumatic brain injuries and is recognized as a major national health concern.17 Whereas 2.8 million traumatic brain injuries were reported in 2013,8 estimates suggest up to 3.8 million occur annually.4,7,9 Concussion diagnosis and management can be challenging, complicated by the lack of a universal definition.2,6,10 No single objective measure or combination of measures for diagnosis and no definitive evidence-based treatments exist. Return-to-activity and return-to-play decisions are limited by a shortage of prospective data.6 Physicians must rely on expert guidelines and available assessment tools with clinical judgment for diagnosis and treatment.2,5,6

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Athletes should not return to play until symptoms of concussion are completely resolved and they are cleared by a health care professional.

C

2, 46, 13, 33

Imaging should be used only to eliminate concerns of more significant injuries and not for evaluation of uncomplicated concussion.

C

2, 47, 10, 12, 13

Early patient education and reassurance are a cornerstone of concussion management.

C

5, 10, 12

Initial management of concussion includes brief cognitive and physical rest. The degree and duration of rest are not well defined, but most guidelines recommend at least 24 to 48 hours.

C

2, 5, 6, 12, 27, 28

No medications are available specifically for concussion. Treatment focuses on symptom management with the same medications used in patients without a concussion.

C

6, 7, 10, 12

An individualized approach to the gradual return to activity after concussion is favored over rigid guidelines, and most algorithms allow for patients to progress at various rates.

C

2, 5, 6, 10, 1213

After an initial brief rest period, individuals with concussion should be encouraged to gradually return to normal daily routines, such as school, work, and leisure activities, as tolerated.

C

6, 10, 12, 14, 3033

A more conservative approach, including waiting longer for return to activity/return to play and more frequent follow-up, is recommended for children and adolescents with concussions.

C

4, 5, 7, 13, 28

Children and adolescents should not return to play in sport until they have successfully tolerated returning to school.

C

5, 6

Protective gear should be worn to prevent overall head and dental injuries, but this has not been clearly shown to reduce the incidence of concussion in most sports.

C

47


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Athletes should not return to play until symptoms of concussion are completely resolved and they are cleared by a health care professional.

C

2, 46, 13, 33

Imaging should be used only to eliminate concerns of more significant injuries and not for evaluation of uncomplicated concussion.

C

2, 47, 10, 12, 13

Early patient e

The Authors

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KEITH A. SCORZA, MD, MBA, is the medical director of Robinson Heath Clinic, Womack Army Medical Center, Ft. Bragg, N.C....

WESLEY COLE, PhD, is a neuropsychologist and research director at the Intrepid Spirit, Womack Army Medical Center.

Address correspondence to Keith A. Scorza, MD, Womack Army Medical Center, 2817 Reilly Rd., Fort Bragg, NC 28310 (e-mail: kascorza@hotmail.com). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

show all references

1. Scholten J, Vasterling JJ, Grimes JB. Traumatic brain injury clinical practice guidelines and best practices from the VA state of the art conference. Brain Inj. 2017;31(9):1246–1251....

2. McCrea MA, Nelson LD, Guskiewicz K. Diagnosis and management of acute concussion. Phys Med Rehabil Clin N Am. 2017;28(2):271–286.

3. Dessy AM, Yuk FJ, Maniya AY, et al. Review of assessment scales for diagnosing and monitoring sports-related concussion. Cureus. 2017;9(12):e1922.

4. Giza CC, Kutcher JS, Ashwal S, et al. Summary of evidence-based guideline update: evaluation and management of concussion in sports: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2013;80(24):2250–2257.

5. Kerrigan JM, Giza CC. When in doubt, sit it out! Pediatric concussion—an update. Childs Nerv Syst. 2017;33(10):1669–1675.

6. McCrory P, Meeuwisse W, Dvořák 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.

7. Scorza KA, Raleigh MF, O'Connor FG. Current concepts in concussion: evaluation and management. Am Fam Physician. 2012;85(2):123–132.

8. Taylor CA, Bell JM, Breiding MJ, Xu L. Traumatic brain injury-related emergency department visits, hospitalizations, and deaths—United States, 2007 and 2013. MMWR Surveill Summ. 2017;66(9):1–16.

9. O'Brien MJ, Howell DR, Pepin MJ, Meehan WP III. Sport-related concussions: symptom recurrence after return to exercise. Orthop J Sports Med. 2017;5(10):2325967117732516.

10. Marshall S, Bayley M, McCullagh S, et al.; mTBI Expert Consensus Group. Updated clinical practice guidelines for concussion/mild traumatic brain injury and persistent symptoms. Brain Inj. 2015;29(6):688–700.

11. McCrory P, Feddermann-Demont N, Dvořák J, et al. What is the definition of sports-related concussion: a systematic review. Br J Sports Med. 2017;51(11):877–887.

12. Stillman A, Alexander M, Mannix R, Madigan N, Pascual-Leone A, Meehan WP. Concussion: evaluation and management. Cleve Clin J Med. 2017;84(8):623–630.

13. Halstead ME, Walter KD, Moffatt K; Council on Sports Medicine and Fitness. Sport-related concussion in children and adolescents. Pediatrics. 2018;142(6):e20183074.

14. Lumba-Brown A, Yeates KO, Sarmiento K, et al. Centers for Disease Control and Prevention Guideline on the diagnosis and management of mild traumatic brain injury among children. JAMA Pediatr. 2018;172(11):e182853.

15. Centers for Disease Control and Prevention. HEADS UP to health care providers. Updated February 16, 2015. https://www.cdc.gov/headsup/providers/index.html. Accessed March 1, 2018.

16. Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT head rule for patients with minor head injury. Lancet. 2001;357(9266):1391–1396.

17. Haydel MJ, Preston CA, Mills TJ, Luber S, Blaudeau E, DeBlieux PM. Indications for computed tomography in patients with minor head injury. N Engl J Med. 2000;343(2):100–105.

18. Bouida W, Marghli S, Souissi S, et al. Prediction value of the Canadian CT head rule and the New Orleans criteria for positive head CT scan and acute neurosurgical procedures in minor head trauma: a multi-center external validation study. Ann Emerg Med. 2013;61(5):521–527.

19. Papa L, Stiell IG, Clement CM, et al. Performance of the Canadian CT Head Rule and the New Orleans Criteria for predicting any traumatic intracranial injury on computed tomography in a United States Level I trauma center. Acad Emerg Med. 2012;19(1):2–10.

20. Stiell IG, Clement CM, Rowe BH, et al. Comparison of the Canadian CT Head Rule and the New Orleans Criteria in patients with minor head injury. JAMA. 2005;294(12):1511–1518.

21. Żyluk A. Indications for CT scanning in minor head injuries: a review. Neurol Neurochir Pol. 2015;49(1):52–57.

22. Kuppermann N, Holmes JF, Dayan PS, et al.; Pediatric Emergency Care Applied Research Network (PECARN). Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study [published correction appears in Lancet. 2014; 383(9914):308]. Lancet. 2009;374(9696):1160–1170.

23. Easter JS, Bakes K, Dhaliwal J, Miller M, Caruso E, Haukoos JS. Comparison of PECARN, CATCH, and CHALICE rules for children with minor head injury: a prospective cohort study. Ann Emerg Med. 2014;64(2):145–152, 152.e1–152.e5.

24. U.S. Food and Drug Administration. Evaluation of automatic Class III designation for Banyan Brain Trauma Indicator: decision memorandum. https://www.accessdata.fda.gov/cdrh_docs/reviews/DEN170045.pdf. Assessed June 20, 2018.

25. U.S. Food and Drug Administration. De Novo classification request for BrainScope Ahead 100, Models CV-100 and M-100. https://www.accessdata.fda.gov/cdrh_docs/reviews/DEN140025.pdf. Assessed June 20, 2018.

26. U.S. Food and Drug Administration. De Novo classification request for InfraScan, Inc.'s Infrascanner Model 1000. https://www.accessdata.fda.gov/cdrh_docs/reviews/K080377.pdf. Assessed June 20, 2018.

27. Leddy JJ, Hinds AL, Miecznikowski J, et al. Safety and prognostic utility of provocative exercise testing in acutely concussed adolescents: a randomized trial. Clin J Sport Med. 2018;28(1):13–20.

28. McAbee GN. Pediatric concussion, cognitive rest and position statements, practice parameters, and clinical practice guidelines. J Child Neurol. 2015;30(10):1378–1380.

29. Broglio SP, McCrea M, McAllister T, et al.; CARE Consortium Investigators. A national study on the effects of concussion in collegiate athletes and US military service academy members: the NCAA-DoD concussion assessment, research and education (CARE) consortium structure and methods. Sports Med. 2017;47(7):1437–1451.

30. Moser RS, Glatts C, Schatz P. Efficacy of immediate and delayed cognitive and physical rest for treatment of sports-related concussion. J Pediatr. 2012;161(5):922–926.

31. Sawyer Q, Vesci B, McLeod TC. Physical activity and intermittent post-concussion symptoms after a period of symptom-limited physical and cognitive rest. J Athl Train. 2016;51(9):739–742.

32. Thomas DG, Apps JN, Hoffmann RG, McCrea M, Hammeke T. Benefits of strict rest after acute concussion: a randomized controlled trial. Pediatrics. 2015;135(2):213–223.

33. Centers for Disease Control and Prevention. Sports concussion policies and laws. Updated February 16, 2015. https://www.cdc.gov/headsup/policy/index.html. Accessed March 1, 2018.

34. Kushner DS. Concussion in sports: minimizing the risk for complications. Am Fam Physician. 2001;64(6):1007–1014.

35. Harmon KG. Assessment and management of concussion in sports. Am Fam Physician. 1999;60(3):887–892.

 

 

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