Properly reviewing sports-related concussions.
Concussions are largely thought to be a result of functional, rather than structural disruption, which can result in a wide variety of signs and symptoms that may include a loss of consciousness and which cannot be explained by other etiologies (toxicology, other trauma, comorbidities, etc).
According to the 2016 Berlin consensus statement, sports-and-recreation-related concussions (SRRC) are “a traumatic brain injury induced by biomechanical forces”  that may be caused by direct or indirect forces, typically resulting in transient impairment of neurological function that resolves spontaneously.
SRRC may be considered a mild form of traumatic brain injury (mTBI) and these terms are frequently used interchangeably. However, there is a lack of consensus on validated diagnostic criteria . The current definition of SRRC based on the 2016 Berlin consensus statement is a “traumatic brain injury induced by biomechanical forces, which may be caused by a direct blow to the head, face, neck or body; typically resulting in the rapid onset of short-lived impairment of neurological function, with a functional rather than structural disturbance without any abnormality seen on standard neuroimaging studies, and which may or may not include loss of consciousness” .
SRRC can occur in any sport or recreational activity and result in significant morbidity and mortality. They are increasingly common in the United States, accounting for 5-9% of all sports-related injuries . The incidence of SRRC is not well delineated and likely understated in the literature. In one widely cited 2006 study, it was estimated that as many as 3.8 million cases of sports-related and recreation-related traumatic brain injuries (TBI) occur each year and as many as 50% of concussions may go unreported [3, 4].
In 2013, there were 2.8 million TBI-related Emergency Department (ED) visits, including 282,000 hospitalizations and nearly 50,000 deaths . It is estimated that as many as 1.9 million SRRC occur annually in children under 18 years or younger . In 2012, 329,000 children were treated in the ED for SRRC. That number has increased from 2001 to 2012 [6, 7]. At least 75% of all TBIs reported in the United States are classified as minor or mild concussions, which together encompass the spectrum of mild TBI (mTBI) .
Concussions can occur in any sport or recreational activity, but most occur in organized sports including football, wrestling, soccer and women’s basketball . The most common mechanism is player-to-player contact. With hockey players, 88% of concussions involve contact with an opponent .
Risk factors include younger age, past medical history of a learning disorder, ADD, migraines or mood disorder, certain positions and a history of previous concussion. As the incidence of concussions increase, it’s important that emergency physicians understand how to identify, evaluate and manage SRRC.
EMERGENCY DEPARTMENT DIAGNOSIS OF SRRC
SRRC are frequently misdiagnosed in the Emergency Department. In one pediatric study, of 443 children who met the Zurich criteria for SRRC (the criteria used in 2012 prior to the updated Berlin consensus statement made in 2016), only 200 were diagnosed with concussion by the EM physician .
Early concussion diagnosis has important prognostic implications. In military recruits, properly diagnosing a concussion early was associated with fewer neurocognitive symptoms when compared to recruits who went undiagnosed . The strongest and most consistent predictor of a patient’s recovery from SRRC is the severity of a person’s symptoms, typically measured with a sideline concussion assessment tool (i.e. Sport Concussion Assessment Tool or SCAT) in the first day or days after the initial insult .
Proper diagnosis of SRRC can also help avoid a rare condition termed “Second Impact Syndrome” where another head injury occurs during the post concussive period. It can result in autonomic dysfunction, cerebral edema, herniation and even death .
It is important to clarify the history of the patient’s presentation including mechanism of injury, duration of symptoms, removal from play, return to play and subsequent activity.
The most commonly reported symptoms in patients with SRRC are headache (92%) and dizziness (69%), but athletes may report a wide spectrum of others including physical (nausea, vomiting, balance), cognitive (difficulty with concentration or memory), emotional (irritable, sad, nervous) and sleep related symptoms (drowsiness, difficulty falling asleep) [12, 14].
Men are more likely to have amnesia and disorientation while women are likely to have headache, excess drowsiness, nausea and vomiting . Many of the symptoms in SRRC are nonspecific and may be attributed to other illnesses, so it is important to distinguish whether the symptoms were present prior to injury.
Loss of consciousness occurs only in 1.7% of initial concussions but in 6.8% of recurrent concussions . Seizures are an uncommon complication of SRRC and patients suffering a SRRC are not at increased risk of developing a seizure disorder . Special attention should be given to younger athletes due to challenges in reporting symptoms such as balance, vision, fatigue, emotional changes, irritability, memory and concentration .
Approximately 9% of patients will report a history of prior concussion and these patients are likely to have more symptoms and a longer time to resolution.
The initial physical exam performed should include ABCs, cervical spine exam, neurological exam and evaluation for other signs of trauma before focusing on a concussion evaluation regardless of how much time has passed since the initial insult.
When evaluating for SRRC, there are no best or pathognomonic physical exam findings and a concussion is diagnosed based on a thorough history and physical exam. Proper examination should include evaluation of subjective symptoms, neurocognitive evaluation and balance testing. Sideline and office examination tools have been developed for the emergency department including the Sport Concussion Assessment Tool 5 (SCAT5), Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) and NFL Sideline Concussion Assessment Tool. These assessment tools standardize and quantify both the subjective and objective symptoms, allowing the physician to trend them overtime as the athlete recovers and to guide return-to-play.
We tend to utilize the SCAT5 exam due to its evaluation of both signs and symptoms, ease of application and reproducibility during follow up. The SCAT5 is composed of an on-field component and an office component. Ideally, each athlete will have a “baseline” exam available to compare at the time of injury. The on-field assessment may be performed by an athletic trainer, coach or physician and evaluates for red flags, observable signs of injury, memory questions, GCS and cervical spine exam. If there are any abnormalities in the on-field assessment, the athlete is removed from play for further evaluation. In the presence of red flags, consideration is made to transfer to the hospital.
The office (or emergency department) component of the SCAT5 exam includes an evaluation of 22 symptoms individually scored from 0 to 6 that form the symptom severity score, which can be trended for recovery.
Cognitive testing includes orientation, immediate memory (recalling five objects back to the examiner), concentration (repeating digits in reverse order back to the examiner) and months in reverse order. Neurological screening evaluates the ability to read and follow instructions, passive neck range of motion, extraocular motion, finger-to-nose and gait. Finally, the BESS (balance error scoring system) exam provides an easy way to objectively assess balance by testing double-leg, single-leg and tandem stance for 20 seconds each and counting the number of errors (loss of balance, touching wall, etc). In totality, the symptom severity score is the most objective way to assess and quantify a patient’s concussion symptoms and trend them towards recovery. The BESS testing is likely the best physical exam test to evaluate for concussion.
Concussions don’t involve intracranial bleeding, skull fracture or other abnormalities that may be seen on neuroimaging. For this reason, neuroimaging including CT and MRI are not used for decision making in cases of suspected SRRC, unless the physician is suspicious of an intracranial injury. Loss of consciousness and amnesia are common in individuals with SRRC and may not require neuroimaging in an otherwise well appearing patient . MRI is the imaging study of choice in patients with prolonged symptoms of concussion, but is generally unnecessary for acute evaluation in the emergency department.
Various biomarkers have been studied including glial fibrillary acidic protein (GFAP), S-100ß and ubiquitin carboxyl-terminal hydrolase L1 (UCH-L1), total tau, and others [22, 23]. The lack of external validity and high risk of bias in some of the studies currently limits their use in the management or diagnosis of concussion [22, 23]. Note that in Europe, S-100ß is currently being investigated for use as a biomarker for excluding intracranial hemorrhage and other intracranial insults after mild head trauma .
EMERGENCY DEPARTMENT TREATMENT OF SRRC
The primary management of patient with suspected SRRC in the emergency department is removal from all high-risk activity and rest until they can be re-evaluated by their physician. Typically 24 to 48 hours is required before the patient can begin gradually increasing any activity to a sub-symptom exacerbation threshold. Patients and family members should generally be advised to avoid excessive or prolonged physical, visual, auditory of cognitive stimulation during the first few days following initial injury, especially if these activities are provoking or exacerbating symptoms.
Headaches are managed with NSAIDS and acetaminophen. In one double blinded, prospective randomized trial of children with headaches caused by SRRC, administration of 10 ml/kg of 3% hypertonic saline administered intravenously significantly improved self-reported symptoms of headache at time of administration and at 2 to 3 days after treatment . For the Emergency Medicine Physician, the most important management after ruling out any life-threatening injuries is stressing close follow up with the patient’s physician while avoiding activity.
While ED visits for concussions are increasing, hospitalization rates have decreased by 2.5% and mortality rates have decreased by 5% . Patients with sports related concussions should follow up with a physician with experience managing concussions. Patients should be instructed to avoid all physical or high-risk activity including participating in sports, physical education or any other recreational activity until they are re-evaluated by their physician as an outpatient.
Most athletes recover and are asymptomatic within 10-14 days of injury, although this may take up to four weeks in children [14, 28]. Subsequent management of the patient involves close monitoring of symptoms to resolution. As the symptoms resolve, the athlete can begin a stepwise return to play protocol prior to return to sport.
Students should progress through a graded return to academic and other activities of daily living before returning to sporting or recreational activities. Patients with premature return to sport or activity are at increased risk of prolonged concussion symptoms. The current standard definition for persistent post-concussive symptoms following a SRRC is failure of symptoms to resolve within two weeks in adults and four weeks in children . In cases of repeated concussions, there is increased risk of prolonged symptoms or cognitive deteriorations.
Patients with persistent post-concussive symptoms or repeat concussions may require specialized physical therapy, cervical, vestibular or ocular therapy, cognitive behavioral therapy and potentially a discontinuation of the offending sport.
Sports-and-recreation-related concussions are increasingly seen in the emergency department and emergency physicians should be prepared to identify and manage these patients. Up to half of all patients presenting with symptoms of a concussion may be misdiagnosed in the Emergency Department.
It is important to carefully review the history and mechanism of injury and to evaluate for other injuries. Most patients with SRRC present with headaches in addition to a wide variety of symptoms and physical exam should emphasize cognitive and balance evaluation.
Physicians should consider using one of the validated concussion tools and more research is needed to evaluate their use in the emergency department.
Most concussions can be safely discharged home with close follow up with a physician trained in managing concussions.
 McCrory, Paul, 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): bjsports-2017.
 Gessel LM, Fields SK, Collins CL, Dick RW, Comstock RD. Concussions among United States high school and collegiate athletes. J Athl Train. 2007 Oct-Dec;42(4):495-503.
 Langlois JA, Rutland-Brown W., et al. The epidemiology and impact of traumatic brain injury: a brief overview. J Head Trauma Rehabil. 2006;21:375–378.
 McCrea M, Hammeke T, Olsen G, Leo P, Guskiewicz K. Unreported concussion in high school football players: implications for prevention. Clin J Sport Med. 2004 Jan;14(1):13-7. PubMed PMID: 14712161.
 Taylor CA, Bell JM, et al. Traumatic Brain Injury–Related Emergency Department Visits, Hospitalizations, and Deaths — United States, 2007 and 2013. MMWR Surveill Summ 2017;66(No. SS-9):1–16.
 Coronado VG, Haileyesus T, et al. Trends in sports- and recreation-related traumatic brain injuries treated in US emergency departments: The National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP) 2001-2012. J Head Trauma Rehabil 2015; 30 (3): 185–197.
 Centers for Disease Control and Prevention. Nonfatal traumatic brain injuries related to sports and recreation activities among persons aged ≤19 years–United States, 2001-2009. MMWR Morb Mortal Wkly Rep. 2011;60(39):1337–1342 pmid:21976115
 National Center for Injury Prevention and Control. Report to Congress on mild traumatic brain injury in the United States: steps to prevent a serious public health problem. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/traumaticbraininjury/pdf /mtbireport-a.pdf. Published 2003
 Boutis K, Weerdenburg K, Koo E, Schneeweiss S, Zemek R. The diagnosis of concussion in a pediatric emergency department. J Pediatr. 2015 May;166(5):1214-1220.e1. doi: 10.1016/j.jpeds.2015.02.013. PubMed PMID: 25919731.
 O’Connor, K., et al. “History of diagnosed and undiagnosed concussions at baseline had differential impact on neurocognitive performance and symptom scores.” Journal of the Neurological Sciences 381 (2017): 758.
 Bey T, Ostick B. Second impact syndrome. West J Emerg Med. 2009;10(1):6-10.
 Harmon, Kimberly G., et al. “American Medical Society for Sports Medicine position statement: concussion in sport.” Br J Sports Med 47.1 (2013): 15-26.
 Hutchison MG, Comper P, Meeuwisse WH, Echemendia RJ. A systematic video analysis of National Hockey League (NHL) concussions, part I: who, when, where and what? Br J Sports Med. 2015 Apr;49(8):547-51.
 Wasserman EB, Kerr ZY, et al. Epidemiology of Sports-Related Concussions in National Collegiate Athletic Association Athletes From 2009-2010 to 2013-2014: Symptom Prevalence, Symptom Resolution Time, and Return-to-Play Time. Am J Sports Med. 2016 Jan;44(1):226-33.
 Currie DW, Comstock RD, Fields SK, Cantu RC. A Paired Comparison of Initial and Recurrent Concussions Sustained by US High School Athletes Within a Single Athletic Season. J Head Trauma Rehabil. 2017 Mar/Apr;32(2):90-97.
 Wennberg, Richard, et al. “Is concussion a risk factor for epilepsy?.” Canadian journal of neurological sciences 45.3 (2018): 275-282.
 Currie, Dustin W., et al. “A paired comparison of initial and recurrent concussions sustained by US high school athletes within a single athletic season.” Journal of head trauma rehabilitation 32.2 (2017): 90-97.
 Easter JS, Haukoos JS, Meehan WP, Novack V, Edlow JA. Will Neuroimaging Reveal a Severe Intracranial Injury in This Adult With Minor Head Trauma?: The Rational Clinical Examination Systematic Review. Jama. 2015;314(24):2672-81.
 Mastrangelo M, Midulla F. Minor Head Trauma in the Pediatric Emergency Department: Decision Making Nodes. Current pediatric reviews. 2017;13(2):92-9.
 Valovich McLeod TC. The Prediction of Intracranial Injury After Minor Head Trauma in the Pediatric Population. Journal of athletic training. 2005;40(2):123-5
 Amyot F, Arciniegas DB, Brazaitis MP, Curley KC, Diaz-Arrastia R, Gandjbakhche A, et al. A Review of the Effectiveness of Neuroimaging Modalities for the Detection of Traumatic Brain Injury. Journal of neurotrauma. 2015;32(22):1693-721.
 McCrea M, Meier T, Huber D, Ptito A, Bigler E, Debert CT, et al. Role of advanced neuroimaging, fluid biomarkers and genetic testing in the assessment of sport-related concussion: a systematic review. British journal of sports medicine. 2017;51(12):919-29.
 Lewis LM, Schloemann DT, Papa L, Fucetola RP, Bazarian J, Lindburg M, et al. Utility of Serum Biomarkers in the Diagnosis and Stratification of Mild Traumatic Brain Injury. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2017;24(6):710-20.
 David, A., et al. “Evaluation of S100B blood level as a biomarker to avoid computed tomography in patients with mild head trauma under antithrombotic medication.” Diagnostic and interventional imaging 98.7-8 (2017): 551-556.
 Lumba-Brown A, Harley J, Lucio S, Vaida F, Hilfiker M. Hypertonic saline as a therapy for pediatric concussive pain: a randomized controlled trial of symptom treatment in the emergency department. Pediatr Emerg Care. 2014 Mar;30(3):139-45.
 Bressan S, Marchetto L, Lyons TW, Monuteaux MC, Freedman SB, Da Dalt L, et al. A Systematic Review and Meta-Analysis of the Management and Outcomes of Isolated Skull Fractures in Children. Annals of emergency medicine. 2018;71(6):714-24.e2.
 Chauny JM, Marquis M, Bernard F, Williamson D, Albert M, Laroche M, et al. Risk of Delayed Intracranial Hemorrhage in Anticoagulated Patients with Mild Traumatic Brain Injury: Systematic Review and Meta-Analysis. The Journal of emergency medicine. 2016;51(5):519-28.
 McCreaM., Guskiewicz KM, et al. Acute effects and recovery time following concussion in collegiate football players: the NCAA Concussion Study. JAMA. 2003;290:2556–2563.
 Bryan, Mersine A., et al. “Sports-and recreation-related concussions in US youth.” Pediatrics 138.1 (2016): e20154635.
 Meehan, William P., Pierre d’Hemecourt, and R. Dawn Comstock. “High school concussions in the 2008-2009 academic year: mechanism, symptoms, and management.” The American journal of sports medicine 38.12 (2010): 2405-2409.