Not Just a Bump on the Head: Concussion Management for Youth Athletes in Primary Care
Aaron J. Provance, MD
Co-Director, Children's Hospital Colorado Sports Medicine Program
Assistant Professor, Department of Orthopedics, University of Colorado School of Medicine
Making decisions with a family about when a young athlete with a concussion can return to play has become increasingly challenging in primary care because of changes in concussion management guidelines and research in the past few years. Pediatric and adolescent concussions commonly cause anxiety for the treating physician because of the possibility of Second Impact Syndrome (SIS), a rare condition in which the brain can swell rapidly - and even becomes fatal - after a person suffers a second concussion, before symptoms from an earlier one have subsided. Another question can arise about when to refer a young patient to a concussion clinic/specialist when symptoms do not resolve within the typical 10 to 14-day recovery period.
New guidelines for concussion management have helped with initial treatment and return to play decisions. Yet with the recent abandonment of the older concussion grading scales, many providers are concerned that they are not providing the most up-to-date care for these patients when making return to play decisions.
Severity of concussion is now determined by the nature of the head injury, burden on the patient/athlete and the duration of the clinical post-concussive symptoms.1 The role of post-traumatic amnesia as a measure of concussion severity is unclear at this time. Most concussions do not involve loss of consciousness and there is a great variability in presentation and post-concussive symptoms.
The exam in the primary care office should include:
- a concussion history
- detailed neurological examination focusing on:
- mental status
- cognitive functioning
- gait and balance1
Post-concussive symptoms can include:
- headache
- loss of consciousness
- feeling like "in a fog"
- increased emotionality
- amnesia
- irritability
- slowed reaction times
- difficulty with concentration or memory
- fatigue
- blurred or double vision
- sleep disturbances
- sensitivity to light or noise
It is important to determine whether there has been improvement or deterioration in clinical status since the time of injury. The primary care provider must also determine if there is a need for an emergent CT scan.
If the young patient/athlete is stable clinically, then education on concussion and Second Impact Syndrome should be completed and the parents and athlete introduced to the Return-to-Play-Protocol. In 2004, the Return-to-Play-Protocol was published as part of the Consensus Statement on Concussion in Sport.2 Scientific evidence does not provide a guide for the exact number of days before individuals can return to sport. There is also no definite number of concussions sustained before one is retired from contact sports. These decisions are made on an individual basis and will differ from case to case.
Before beginning the protocol, the youth/athlete must be completely asymptomatic. The athlete can continue on to the next level of play if he/she has been asymptomatic for 24 hours at the current level. It should take around one week for a young athlete with a concussion to complete the Return-to-Play-Protocol. If any symptoms occur, then the athlete should drop back to the previous step and try to progress again after a 24-hour period of rest has passed without symptoms.2
Every athlete, regardless of age, must recover clinically and cognitively before consideration for return-to-play.3 It was acknowledged in the Zurich guidelines that there is evidence some adult athletes are able to return to play more quickly than youth, and some may even return-to-play the same day without a risk of recurrence or complications.1
Pediatric and adolescent athletes may have neurological deficits after a head injury that may not be evident on the sidelines and are more likely to have delayed onset of symptoms. These young athletes should never be allowed to return to a practice or game on the same day they suffer a concussion and should be treated more conservatively than adults with concussions.
The most current data shows different physiological responses and longer recovery with head injuries in the younger population. The increased risk of second impact syndrome in youth must be a constant reminder to be careful with this group of athletes and mandates more cautious return-to-play decisions.3
It is important that younger athletes have cognitive rest from both physical and mental activities until asymptomatic. Limitations should be placed on school performance, text messaging and even video game playing to avoid prolonging symptoms.1 The treating physician may need to extend the amount of time of rest or the length of the return to play protocol in children and adolescents. No athlete should ever be returned-to-play while still symptomatic, regardless of time between concussion and athletic event.
Referral to a concussion clinic or specialist should be considered when the post-concussive symptoms have lasted more than 14 days. MRI of the brain should also be considered in these cases to evaluate for any underlying malformations, intracranial cysts, or other structural anomalies that may be responsible for the delay in recovery of the athlete. Structural anomalies may put the athlete at increased risk when returning to contact sports. In these situations, referral to a neurosurgeon for decisions on return to specific sports may be indicated.
Neuropsychological testing remains a very controversial topic in concussion assessment and management. It should never be used solely as a tool for return-to-play decision making. A good history and clinical exam cannot be replaced by computerized neuropsychological testing. Each case should be considered on an individual basis. Sideline assessment using the SCAT or SAC tools have been used by some, but not most high schools. It is important for the primary care provider providing game coverage to be familiar with neuropsychological testing and sideline assessment tools.
The Zurich guidelines also emphasize that neuropsychological testing is best analyzed by neuropsychologists and not by sports medicine physicians or primary care providers.1
For more information
For more information on the Concussion Program at Children's Hospital Colorado, please call (720) 777-2806.
Dr. Provance's clinical areas of interest include pediatric concussions and pediatric musculoskeletal injuries. His current research involves analyzing barriers to ski helmet use in children, the role of MRI spectroscopy in sport concussion assessment, and patient/family education on concussions in the emergency department/urgent care setting.
References:
1.McCrory P, Meeuwisse W, Johnston K, Dvorak J, Aubry M, Molloy M, Cantu R. Consensus statement on Concussion in Sport 3rd International Conference on Concussion in Sport held in Zurich, November 2008. Clin J Sport Med. 2009 May;19(3):185-200.
2. McCrory P, Johnston K, Meeuwisse W, Aubry M, Cantu R, Dvorak J, Graf-Baumann T, Kelly J, Lovell M, Schamasch P. Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague 2004. Br J Sports Med. 2005 Apr;39(4):196-204.
3. Smith BW, Head Injuries-Book Chapter. Care of the Young Athlete. 2000:172-7.
