Sports-related concussion in the young athlete: Who plays? Who sits?

By Walter L. Calmbach, MD, MPH
Department of Family and Community Medicine, UT Health
Science Center at San Antonio

Mark Hutchens, MD
Texas Sports and Family Medicine, Austin

Background: Concussions are a common injury among athletes, with an estimated 300,000 sports-related concussions occurring annually in the U.S. However, as many as 50 percent of the concussions may go unreported. Recent studies have shown that young athletes are more susceptible to concussions than older athletes, and due to the ongoing neurocognitive development that occurs throughout adolescence, concussions can have severe acute and long-term complications in young athletes. These findings have serious implications because participation in high school athletics has increased for years, with more than half of all high school students, over 3.1 million girls and 4.2 million boys, participating in sports during the 2009-10 school year.

Higher risk for young athletes: Worryingly, children seem to be more vulnerable to the effects of brain injury than adults. After concussion, there are specific changes at the cellular level resulting in a “metabolic mismatch:” increased glucose utilization and reduced cerebral blood flow. Physicians must be aware of the athlete’s increased vulnerability to injury during the recovery period, which typically takes seven to 14 days.

Boys and Girls: It is important for primary care physicians to be aware that while overall, boys have a higher concussion rate than girls, for some sports (e.g., soccer and basketball) girls actually have a slightly higher concussion rate than boys.

Concussion–A functional disturbance: After a blow to the head or helmet, the athlete commonly experiences the rapid onset of usually short-lived neurological impairment. These include a range of clinical symptoms that may or may not involve loss of consciousness (see Table 1). The symptoms could be very subtle, such as lack of focused concentration or balance disturbance. Typically, these symptoms resolve spontaneously. It is important to recognize that these acute clinical symptoms reflect a functional disturbance rather than structural injury. Because of this, neuroimaging studies are typically normal.

Individualized Management: Recently, recommendations on treating athletes have undergone a major paradigm shift, with a new focus on individualizing management after sports-related concussion. In the past there was an overreliance on published guidelines, which were not uniform, lacked prospective validation, and over-emphasized loss of consciousness as a marker of severity. However, published guidelines remain useful as a starting point when evaluating athletes. Importantly, outdated guidelines once allowed for same-day return-to-play, but the new consensus is that there is no same-day return-to-play for an athlete with a concussion.

We now recognize the broad individual variation in presentation and recovery after concussion. Therefore, current recommendations focus on individualized management based on the athlete’s signs and symptoms, guided by routine use of standardized assessment tools. Some of these common assessment tools include the Standardized Assessment of Concussion, the Sport Concussion Assessment Tool 3rd Edition, the Balance Error Scoring System, and various computerized neurocognitive testing systems. The SAC is a simple paper-and-pencil scoring tool that assesses orientation, immediate recall, common neurological symptoms, concentration (both numbers and months), and delayed recall. The athlete receives a total score that guides diagnosis, management, and return-to-play decisions. You can find the SCAT3 form at bjsm.bmj.com/content/47/5/259.full.pdf.

Neurocognitive testing: Computerized neurocognitive testing systems measure concussion-related symptoms, verbal and visual memory, processing speed, and reaction time. They can objectively evaluate post-injury status, and track recovery for safe return-to-play, especially if baseline testing is present. Neurocognitive testing is useful as one component of the evaluation, but should not be used in isolation to manage athletes or make return-to-play decisions. It can be helpful in the overall management along with past medical history (e.g., history of previous concussion), presence of comorbid conditions (e.g., anxiety, depression, and learning disability), presence or persistence of post-concussion symptoms, and physical examination.

Physical and cognitive rest: Athletes with concussions benefit from a brief period of physical and cognitive rest immediately after the injury to allow symptoms to abate. The rest period varies for each individual. In the immediate post-injury period, athletes should avoid activities that exacerbate concussion symptoms. It is also essential the athlete avoid any contact or collision activities that increase the risk for a repeat head injury during this vulnerable acute post-injury period. After a brief period of physical and cognitive rest, during which symptoms usually decrease, athletes can gradually resume routine cognitive and physical tasks, while being careful to avoid activities that cause an increase or return of symptoms (see Tables 4 and 5).

Predictors of prolonged recovery: Several factors have been suggested as predictors of prolonged recovery after concussion, including younger age, female gender, history of multiple concussions, and learning disability. Other neurocognitive impairments, including slowed reaction time and impaired visual memory, have also been shown to be predictive of prolonged recovery. Finally, posttraumatic migraine has been associated with a more severe and protracted recovery after concussion.

University Interscholastic League: Due to changes to the Texas Education Commission mandated by the 82nd Texas Legislature, the University Interscholastic League now requires a concussion management team at each UIL-aligned school district. One key task of the concussion management team is to design a return-to-play protocol that describes in detail the steps athletes must follow before they are allowed to resume full athletic competition. The UIL also requires a concussion acknowledgement form to be signed by the student and parent or guardian, as well as a concussion management protocol return-to-play form to be signed by a school official and the parent or guardian. The UIL site also provides a link to concussion management recommendations published by the National Federation of State High School Associations, found at www.uiltexas.org/health/concussions.

Summary: Sports-related concussion is common, with more than 300,000 occurring each year in the U.S. Family physicians must be aware of the special circumstances of young athletes, who are at greater risk of injury, and tend to recover more slowly than adults. When possible, preseason baseline cognitive assessment is recommended, whether with the paper-and-pencil Standardized Assessment of Concussion or computerized neurocognitive testing systems. When managing an athlete with a sports-related concussion, the physician should follow a structured follow-up and return-to-play protocol. Finally, as primary care physicians we have a special responsibility to protect young athletes: “When in doubt, sit them out.”

Conclusion: Family physicians should take every concussion seriously. The concussed athlete has a decreased ability to process new information, and the degree of impairment is proportional to the severity of the injury. Moreover, symptoms worsen with repeated injury (the so-called cumulative concussion). Thus, no head injury is “minor;” all need prompt evaluation before returning to play.

Online resources

“Sport-Related Concussion in Children and Adolescents.” Mark E. Halstead, Kevin D. Walter and The Council on Sports Medicine and Fitness
http://pediatrics.aappublications.org/content/126/3/597.full

AAFP’s American Family Physician
www.aafp.org/afp/viewRelatedDocumentsByMesh.htm?meshId=D001924

FamilyDoctor.org
www.familydoctor.org/familydoctor/en/diseases-conditions/concussion.html

American Academy of Pediatrics HealthyChildren.org
www.healthychildren.org/English/health-issues/injuries-emergencies/sports-injuries/Pages/Concussions.aspx

American Academy of Neurology Concussion Management guidelines
www.neurology.org/content/80/24/2250.full

Centers for Disease Control and Prevention Heads-Up program
www.cdc.gov/headsup

Sport Concussion Assessment Tool, 3rd Edition
http://bjsm.bmj.com/content/47/5/259.full.pdf

University Interscholastic League
www.uiltexas.org/health/concussions

National Federation of State High School Associations Suggested Guidelines for Management of Concussion in Sports
www.uiltexas.org/files/health/2013_Suggested_Guidelines_for_Management_of_Concussion_in_Sports.pdf

Neurocognitive testing: Immediate Post-Concussion Assessment and Cognitive Testing
www.impacttest.com

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