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Clinical Crossroads |

Diagnosis and Management of Sports-Related Concussion:  A 15-Year-Old Athlete With a Concussion

Ross Zafonte, DO, Discussant
JAMA. 2011;306(1):79-86. doi:10.1001/jama.2011.819.
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Concussion in youth athletes is a growing problem worldwide. During the past decade, significant progress has been made in standardization of the assessment of young athletes, and a growing appreciation of metabolic vulnerability, activity, and cognitive challenges has led to guidelines and suggestions for rest from the field as well as cognitive rest from school. Outcome data have begun to establish groups linked to symptom class, genetics, and sex who are at risk of worse outcomes from concussions. Decisions regarding return to activity are now based on at-rest symptoms, graded increases in activity, and neuropsychological testing. Using the case of Ms X, a 15-year-old otherwise healthy high school student who fell while skiing, evaluation, prognosis, and management of concussion are discussed.

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The Student-Athlete With Concussion: More Than Just Return to Play
Posted on July 3, 2011
Christina L. Master, MD
The Children's Hospital of Philadelphia and The Hospital of the University of Pennsylvania,
Conflict of Interest: None Declared
It is appropriate to conduct a primary assessment of the ABCDEs in the field. Any cervical tenderness or neurologic deficit warrants further evaluation in the emergency department.
The subsequent evaluation of an athlete sustaining a direct blow to the head or indirect blow to the body resulting in transmitted impulsive forces to the head should include a complete neurological examination with particular attention to cognition, balance and visual tracking. The athlete should not return to play that day and should be monitored for any neurological changes as concussion symptoms frequently evolve after injury. A specific assessment tool such as the SCAT2 1 for balance and cognition and the King-Devick test2 for visual tracking may be useful.
Return-to-play is often the primary concern of student-athletes and their families. Physicians must emphasize that the return-to-play issue is on the long-horizon, while the return-to-school issue is the more pressing short-horizon concern. Cognitive rest sounds simple, but in reality, concrete examples are essential: any interactive cognitive activity such as reading, texting, video games, computer use or school work constitutes a metabolic strain that can slow the symptomatic resolution of concussion. Specific instructions in the form of a concussion care plan must include cognitive brain-rest until symptom-free, followed by the step-wise re- introduction of cognitive activities at home and then school as long as symptoms are not induced. This must include academic accommodations for an incremental return to a full academic workload. Only after a full return to academic activity can the athlete initiate a return to athletic activities as outlined in the Zurich Consensus Guidelines.1
Student-athletes who have concussive symptoms lasting 6-8 weeks benefit from cardiac exertion as part of their rehabilitation regimen. While physical rest is important during the acute recovery from concussive injury, physical activity plays an important role in the rehabilitation of post-concussive syndrome. 3,4 Patients who have chronic headache symptomatology benefit from referral to neurology for headache syndrome management.
Previous concussion is a known risk factor for subsequent concussion; three concussions have been well-documented to be associated with a threefold increased risk of future re-injury in the student-athlete.5 There also appear to be detectable balance and neuropsychological deficits after even one or two concussions.6,7,8 Physicians caring for student- athletes suffering from concussion must take into consideration the length of recovery and return to baseline when counseling about return to sport. Each decision is an individual one, taking into account the opportunity- cost for each student-athlete in terms of time lost from sports and academics balanced with the benefit of sports participation.
For Ms. X, we recommend that she wear a helmet while downhill skiing which is a high-velocity sport. In addition, many are utilizing baseline computerized neuropsychological testing as a part of the assessment of the athlete recovering from concussion. More data are needed to make universal recommendations, but as with other emerging medical advances, there are many early adopters. We would recommend testing Ms. X during recovery in an attempt to determine her baseline for future use.9
1. McCrory PR, Meeuwisse W, Johnston K, Dvorak J, Aubry M, Molloy M et al. Consensus statement on concussion in sport. 3rd International Conference on Concussion in Sport. Clin J Sport Med 2009; 19-185-200.
2. Galetta KM; Barrett J; Allen M; Madda F; Delicata D; Tennant AT; Branas CC; Maguire MG; et al. The King-Devick Test as a Determinant of Head Trauma and Concussion in Boxers and MMA Fighters. Neurology February 2011;76(17):1456-62.
3. Leddy JJ, Kozlowski K, Donnelly JP, Pendergast DR, Epstein LH, Willer B. A preliminary study of subsymptom threshold exercise training for refractory post-concussion syndrome. Clin K Sport Med 2010; 20(1):21-7.
4. Gagnon I, Galli C, Friedman D, Grilli L, Iverson GL. Active rehabilitation for children who are slow to recover frollowing sport- related concussion. Brain Inj 2009; 23(12):956-64.
5. Reddy CC, Collins MW. Sports concussion: management and predictors of outcome. Curr Sports Med rep 2009; 8(1):10-5.
6. Collins MW, Lovell MR, Iverson GL, Cantu RC, Maroon JC, Field M. Cumulative effects of concussion in high school athletes. Neurosurgery 2002; 51:1175-81.
7. Guskiewicz KM, McCrea M, Marshall SW, Cantu RC, Randolph C, Barr W, et al. Cumulative effects associated with recurrent concussion in collegiate football players. The NCAA Concussion Study. JAMA 2003; 290:2549-55.
8. Guskiewicz K, Weaver N, Padua D, Garett W. Epidemiology of concussion in collegiate and high school football players. Am J Sports Med 2000:28:643-50.
9. Halsted ME, Walter KD. Council on Sports Medicine and Fitness. American Academy of Pediatrics. Clinical report: Sport-related concussion in children and adolescents. Pediatrics 2010; Sept; 126(3):597-615.
Conflict of Interest: None declared
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