Sports Related Concussion

A 17 year old football player is evaluated by you after sustaining a head injury during the game. He denied loss of consciousness or previous history of head injury. InItial evaluation, including mental status and balance testing, was normal as was repeat evaluation at halftime. After the game, you note that the athlete has increased headache and blunted affect. With of the following is correct regarding this injury?

• The findings are typical for a concussed athlete

• The athlete should be immediately transported for more extensive evaluation

• The athlete should go home to rest and be re-evaluated the next day

• The athlete can resume normal activities that evening

Answer explanation

Gerard C, Busl KM. Treatment of acute subdural hematoma. Curr Treat Options Neurol. 2014 Jan;16(1):275. doi: 10.1007/s11940-013-0275-0. PMID: 24363148.

Nagahiro S, Mizobuchi Y. Current topics in sports-related head injuries: a review. Neurol Med Chir (Tokyo). 2014;54(11):878-86. doi: 10.2176/nmc.ra.2014-0224. Epub 2014 Oct 31. PMID: 25367588; PMCID: PMC4533345.

Which of the following is most accurate regarding post-traumatic headache resulting from mild traumatic brain injury?

• Pre-existing conditions, such as migraine and depressive disorders, have no influence on post-traumatic headache or management

• Patients rarely overuse abortive medications and have little-to-no risk of developing overuse or rebound headache

• Abortive medications include tricyclic antidepressants and anti-epileptics, while preventative medications include non-steroidal anti-inflammatory drugs and triptans

• Patients with persistent post-traumatic headache may benefit from multimodal treatments, including physical rehabilitation and pain-focused, cognitive behavioral therapies

Answer explanation

Langdon R, Taraman S. Posttraumatic Headache. Pediatr Ann. 2018 Feb 1;47(2):e61-e68. doi: 10.3928/19382359-20180131-01. PMID: 29446796.

Evans RW. The postconcussion syndrome and the sequelae of mild head injury. Neurol Clin. 1992 Nov;10(4):815-47. PMID: 1435659.

What is the correct order of steps in the return to play protocol?

• Light aerobic exercise, non-contact drills, sports-specific exercise, full contact practice, full return to sport

• Light aerobic exercise, sport-specific exercise, non-contact drills, full contact practice, full return to sport

• Non-contact drills, light aerobic exercise, sport-specific exercise, full contact practice, full return to sport

• Sport-specific exercise, light aerobic exercise, non-contact drills, full contact, full return to sport

Answer explanation

May KH, Marshall DL, Burns TG, Popoli DM, Polikandriotis JA. Pediatric sports specific return to play guidelines following concussion. Int J Sports Phys Ther. 2014 Apr;9(2):242-55. PMID: 24790785; PMCID: PMC4004129.

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control

What is the first step when evaluating a player on the field for a suspected concussion

• Take their sporting equipment (helmet, pads, etc.) off

• Perform a complete neurological assessment

• Assess their body for an obvious fracture

• Assess airway, breathing, circulation

Answer explanation

McCrory P, Meeuwisse W, Dvořák J, Aubry M, Bailes J, Broglio S, Cantu RC, Cassidy D, Echemendia RJ, Castellani RJ, Davis GA, Ellenbogen R, Emery C, Engebretsen L, Feddermann-Demont N, Giza CC, Guskiewicz KM, Herring S, Iverson GL, Johnston KM, Kissick J, Kutcher J, Leddy JJ, Maddocks D, Makdissi M, Manley GT, McCrea M, Meehan WP, Nagahiro S, Patricios J, Putukian M, Schneider KJ, Sills A, Tator CH, Turner M, Vos PE. Consensus statement on concussion in sport-the 5^th international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med. 2017 Jun;51(11):838-847. doi: 10.1136/bjsports-2017-097699. Epub 2017 Apr 26. PMID: 28446457.

All of the following have some amount of evidence to indicate it as a risk factor for "prolonged" concussion symptoms EXCEPT:

• A previous history of migraines

• A previous history of multiple concussions

• Obesity

• High initial symptom load

Answer explanation

Scopaz KA, Hatzenbuehler JR. Risk modifiers for concussion and prolonged recovery. Sports Health. 2013 Nov;5(6):537-41. doi: 10.1177/1941738112473059. PMID: 24427429; PMCID: PMC3806172.

Ponsford J, Nguyen S, Downing M, Bosch M, McKenzie JE, Turner S, Chau M, Mortimer D, Gruen RL, Knott J, Green S. Factors associated with persistent post-concussion symptoms following mild traumatic brain injury in adults. J Rehabil Med. 2019 Jan 1;51(1):32-39. doi: 10.2340/16501977-2492. PMID: 30426138.

Which of the following statements regarding concussion is true?

• In order to be diagnosed with a concussion, the athlete's head must directly strike another object

• It is important to wake someone up every hour to check on them if they have sustained a concussion

• All screens and digital media should be avoided after a concussion

• Physical activity should not be allowed for at least 5-7 days after a concussion

• Symptoms of a concussion may start days after the initial injury