Recovery from Concussion in Young Athletes

From The Child's Doctor, Fall 2012

Brian T. Hang, MD

Attending Physician, Pediatric Emergency Medicine; Pediatric Sports Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago; Instructor in Pediatrics, Northwestern University Feinberg School of Medicine

Disclosure: Dr. Hang has no industry relationships to disclose and does not refer to products that are still investigational or not labeled for the use in discussion.

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In the past decade, there has been a media frenzy regarding concussions and concerns regarding long-term effects of recurrent injuries. More and more states are passing concussion legislation requiring high school athletes to be medically evaluated and cleared prior to being allowed back to sports participation. To help pediatricians accurately assess sport concussion recovery and make safe return to play recommendations, this article will review subjective and objective assessment tools and discuss the latest management guidelines for children recovering from concussion. 

A concussion, as defined by the American Academy of Neurology, is “a trauma-induced alteration in mental status that may or may not include loss of consciousness.”[1] A concussion can be caused by either a direct blow to the head, face, neck or elsewhere in the body with an “impulsive” force transmitted to the brain.[2] Using this broad definition, concussions can be caused by roller coaster rides and motor vehicle collisions. Though not completely understood, concussions are thought to be a metabolic rather than a structural injury. Ionic shifts and changes in cellular environment caused by biomechanical injury are hypothesized to create increased energy demands in brain cells. Concussive injuries also bring about neurovascular vasoconstriction and decreased cerebral blood flow leading to decreased energy supply to the brain.[3] 

Over 1 million high school and college athletes compete in contact sports each year. The CDC (Centers for Disease Control and Prevention) estimates that each year, over 170,000 sports- and recreation-related head injuries in children under 19 years of age are evaluated in emergency departments in the U.S.[4] When considering these numbers, it is important to realize that up to 50% of football players fail to report concussive symptoms due to players’ lack of knowledge regarding concussions or motivation to continue playing despite symptoms.[5,6] In a study of high school football teams in Minnesota, 69% and 81% of players reported returning to play the same day after sustaining an injury with loss of consciousness (LOC) and a concussion without LOC, respectively.[7] 

Often during the evaluation, the athlete or his/ her parents asks “When can I/he/she play again?” Previous work investigating recovery time from concussions found that NFL players typically recover within 3 days,[8,9] college athletes within 7 days,[10,11] and high school football players longer than 7 days.[9,11,12] The majority of high school athletes will require more than 7-10 days to recover from concussions. Approximately 10% of high school athletes still have concussive symptoms at 1 month after the injury. There is limited data on recovery from concussions in elementary and middle school children. 

Ascertaining full recovery from concussion is critical, since returning a young athlete back to a sport with a high risk of sustaining another concussive injury prior to that athlete’s recovery from a previous concussion can potentially lead to prolonged worsening symptoms or even death in some cases. Current studies are underway to determine more long-term consequences of recurrent head injuries. 

According to the consensus statement from the International Conference on Concussion in Sport, return to play recommendations should be tailored to the individual athlete’s symptoms and situation. Early and accurate assessment with proper outpatient guidance and recommendations may decrease symptomatology, recovery time, complications, and stress associated with the injury. 

Assessment tools 

Unfortunately, the identification of concussions relies on the subjective reporting of symptoms by athletes. Currently, there is not a true gold standard test to diagnose concussions, nor is there a tool to identify when an athlete is fully recovered. Ideally, clinicians would like to accurately identify the young athletes that will require longer periods to recover from concussions and restrict those athletes from returning to play too soon. The early identification of athletes at risk of prolonged recovery could assist with triage of future outpatient resources and facilitate an earlier safe return to play. 

Contrary to popular opinion, loss of consciousness is not predictive of prolonged recovery. However, the presence of on-field post injury retrograde amnesia (odds ratio, OR =10), anterograde amnesia (OR = 4.2), and disorientation >5 minutes (OR = 4.4) are associated with prolonged recovery.[13] A history of at least 1 prior concussion also increases the likelihood of prolonged symptoms. 

Subjective tools 

The CDC developed a screening tool, Acute Concussion Evaluation (ACE), to identify patients suspected of having a concussion. ACE is a useful tool for the initial management of head injuries. Athletes with symptoms that persist beyond 7 days may require subspecialist referrals and further assessments. ACE cannot be used to assess recovery. ACE can be downloaded at http://www.cdc.gov/concussion/headsup/pdf/ACE-a.pdf. 

The Post-Concussion Symptom Scale (PCSS) is a symptom inventory where the athlete self-reports the severity of 22 commonly reported concussive symptoms on a scale of 0 to 6. The 22 items in the PCSS are used in ACE. Based on the normative data, for regular education high school boys and girls,[14,15] about 75% of the sample (N=588 and N=119 respectively) would have a raw score of 6 or less or 8 or less, respectively, and classified as having normal PCSS results. High school athletes with scores greater than these values would be considered symptomatic or concussed. The PCSS can be used to track recovery. 

Objective tools 

Computerized neuropsychological testing is used as an adjunctive tool by clinicians to make objective assessments and return to play recommendations for athletes following a concussion. As stated above, athletes can fail to disclose true severity of symptoms in subjective reporting tools such as ACE and PCSS. Computerized neuropsychological testing provides more objective performance-based assessments. 

Although there are a few other computerized neuropsychological test batteries available, ImPACT (Immediate Post Concussion Assessment and Cognitive Testing) appears to be the most widely studied and used in athletes. ImPACT is a validated computerized neuropsychological test inventory widely used by professional sports teams, colleges, and high schools to diagnose, follow, and manage concussions.[2,8,13-23] ImPACT (version 2.0) incorporates 6 test modules that measure different aspects of neurocognitive functioning: memory, reaction time, processing speed, and attention. Four domain scores (a numeric value or time) are generated: verbal memory, visual memory, visual motor processing speed, and reaction time. There are published age-normalized scores and percentile ranks for ages 11-18 years. A fifth score, impulse control, is used to control for the examinee’s performance, whether the athlete is putting forth the maximum effort or if he/she is confused about the instructions. It takes approximately 20-30 minutes for an athlete to complete. The PCSS is also a part of the ImPACT evaluation. The overall sensitivity and specificity of ImPACT in detecting concussions are 81.9% and 89.4%, respectively.[17] The reliability and validity of ImPACT has been evaluated in a number of studies.[14,17-23] The PCSS and ImPACT have only been validated down to age 11 years. 

Current limitations to the usage of computerized neuropsychological testing are the cost, availability, and interpretation of test results. The ideal method to utilize ImPACT is to have each athlete obtain a baseline score. In 2006, Lovell estimated that ImPACT was used by over 125 Division I-A and I-AA colleges, over 300 high schools across the country, and by the majority of teams in the National Football League and National Hockey League.[23] The Institute of Sports Medicine at Lurie Children’s has ImPACT testing available for patients. 

The Balance Error Scoring System (BESS) is a method of assessing the postural stability of athletes in the clinic setting and is commonly used by athletic trainers and sports medicine specialists in assessing concussed athletes. Athletes are required to maintain 3 stances (double leg, single leg, and tandem stance) for 20 seconds on 2 different surfaces (firm and foam). Athletes are observed and given a score based on how many errors they commit during the testing period. BESS can be downloaded at http://www.sportsconcussion.com/pdf/management/BESSProtocolNATA09.pdf. 

Management guidelines 

There have been numerous published concussion guidelines and much variability in the treatment and return to play recommendations given to athletes with sports-related concussion from physicians.[24-28] Many high school athletes refrain from reporting symptoms in order to be cleared to play sooner.[5-6] Until recently, there were not a great deal of agreed upon resources to help diagnose and follow concussions, making accurate return to play recommendations difficult. 

There have been 3 International Conference on Concussion in Sport (Vienna 2001, Prague 2004, and Zurich 2008)[2,29-30] consensus statements that stated no previously published concussion management guidelines were adequate for managing every concussion. They emphasized the incorporation of post-injury neuropsychological testing in making return to play management guidelines and that conventional neuroimaging studies (CT, MRI, EEG) should be employed when a structural lesion is suspected. A large multicenter study by Kupperman et al in 2009 provided guidelines on when head CTs are needed in children under 18 years of age.[31] 

The first International Conference on Concussion in Sport in Vienna[2] introduced a 6-step graduated return to play protocol for athletes sustaining concussions (Table 1). In this protocol, step 1 requires an athlete to have complete rest and no activity. Once the athlete has been asymptomatic at rest for at least 24 hours, he or she can start rehabilitation. If at any point the athlete has recurrence of post-concussive symptoms during these steps, he or she should drop back a step to activities that did not trigger symptoms. Step 2 allows for light aerobic exercise, such as stationary bicycling or walking. Step 3 includes sport-specific exercise and light resistance training such as skating in hockey or running in soccer. Non-contact drills (jumping, cutting, turning) can be added in step 4. Full-contact training after medical clearance occurs in step 5. Full clearance for game play is the final step 6. Steps 2-6 have a mnemonic – BRAIN (Bicycling, Running, Agility, “In red,” No restriction) – that can help young athletes and their parents to keep track of each step. Athletes should remain asymptomatic for at least 24 hours before trying to proceed to the next level. Progression through each step should take a minimum of 1 day and may be longer depending on individual circumstances. 

The panel in Prague[29] also hypothesized a potential difference in the pathophysiology and natural course of concussions, including recovery time, in young children. A new concept of “cognitive rest” was proposed suggesting that concussed children limit their exertion with both physical and cognitive activities (ie, scholastic work and video games) while symptomatic. Helpful information on returning to school after a concussion is available at: http://www.cdc.gov/concussion/pdf/TBI_Returning_to_School-a.pdf.

At the current time, the graduated return to play guidelines described in the Vienna conference are applicable to children (5-18 years of age) though future research is needed in this area, particularly regarding the time of asymptomatic rest and the length of the graduated return to play guidelines. More studies are needed to evaluate the recovery patterns and effects of sports-related concussion in younger athletes. Our institution has recently received a grant to investigate and potentially validate assessment tools for concussed school-aged athletes (between ages of 6 to 13 years). 

Medications 

Presently, there is no evidence-based studies demonstrating the efficacy of acetaminophen, nonsteroidal anti-inflammatory drugs  (NSAIDs), or any other medication in treating or improving the recovery time for the concussed athlete. 

Summary 

1. Concussions are common in sports and still under-reported by young athletes. 

2. Subjective assessment tools are available to identify and follow concussed athletes, but these are dependent on the honest reporting of symptom severity by athletes. 

3. Objective assessment tools may assist a clinician’s decision on when a patient is ready to safely return to play. 

4. There is no evidence to support the routine use of medications to treat concussed athletes. 

5. The majority of high school athletes will require more than 7-10 days to recover from concussion and time is the best treatment for concussions. 

6. The graduated return to play protocol can be applied to young athletes when they are asymptomatic at rest. 

7. The ideal assessment of concussed athletes requires frequent reevaluations. 

References 

[1.] Practice parameter: the management of concussion in sports (summary statement). Report of the Quality Standards Subcommittee. Neurology 1997;48(3):581-585. 

[2.] Aubry M, Cantu R, Dvorak J, et al. Summary and agreement statement of the First International Conference on Concussion in Sport, Vienna 2001. Recommendations for the improvement of safety and health of athletes who may suffer concussive injuries. Br J Sports Med 2002;36:6-10. 

[3.] Giza CC, Hovda DA. The neurometabolic cascade of concussion. J of Athl Training 2001;36(3):228-235. 

[4.] Gilchrist J, Thomas KE, Xu L, McGuire LC, Coronado VG. Nonfatal sports and recreation related traumatic brain injuries among children and adolescents treated in emergency departments in the United States, 2001-2009. MMWR 2011;60(39):1337-1342. 

[5.] Kaut KP, DePompei R, Kerr J, Congeni J. Reports of head injury and symptom knowledge among college athletes: implications for assessment and educational intervention. Clin J Sport Med 2003;13(4):213-221. 

[6.] 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;14(1):13-17. 

[7.] Gerberich SG, Priest JD, Boen JR, Straub CP, Maxwell RE. Concussion incidences and severity in secondary school varsity football players. Am J Public Health 1983;73(12):1370-1375. 

[8.] Pellman EJ, Lovell MR, Viano DC, et al. Concussion in professional football: neuropsychological testing-part 6. Neurosurgery 2004;55:1290-1305. 

[9.] Pellman EJ, Lovell MR, Viano DC, et al. Concussion in professional football: recovery of NFL and high school athletes assessed by computerized neuropsychological testing-part 12. Neurosurgery 2006;58:263-274. 

[10.] McCrea M, Guskiewicz KM, Marshall SW, et al. Acute effects and recovery time following concussion in collegiate football players: the NCAA Concussion Study. JAMA 2003;290:2556-2563. 

[11.] Field M, Collins MW, Lovell MR, et al. Does age play a role in recovery from sports-related concussion? A comparison of high school and collegiate athletes. J Pediatr 2003;142:546-553. 

[12.] Collins MW, Lovell MR, Iverson GL, et al. Examining concussion rates and return to play in high school football players wearing newer helmet technology: a three year prospective cohort study. Neurosurgery 2006;58:275-286. 

[13.] Collins MW, Iverson GL, Lovell MR, et al. On-field predictors of neuropsychological and symptom deficit following sports-related concussion. Clin J Sport Med 2003;13:222-229. 

[14.] Janusz JA, Gioia GA, Gilstein K, et al. Construct validity of the ImPACT Post-Concussion scale in children. Br J Sports Med 2004;38:659. 

[15.] Lovell MR, Iverson GL, Collins MW, et al. Measurement of symptoms following sports-related concussion: reliability and normative data for the post-concussion scale. Appl Neuropsychol 2006;13:166-174. 

[16.] Peterson, SE, Stull MJ, Collins MW, Wang HE. Neurocognitive function of emergency department patients with mild traumatic brain injury. Ann Emerg Med 2009;53(6):796-803. 

[17.] Schatz P, Pardini JE, Lovell MR, Collins MW, Podell K. Sensitivity and specificity of the ImPACT Test Battery for concussion in athletes. Arch Clin Neuropsychol 2006;21;91-99. 

[18.] Iverson GL, Lovell MR, Collins MW. Interpreting change on ImPACT following sport concussion. Clin Neuropsychol 2003;17:460-467. 

[19.] Iverson GL, Lovell MR, Collins MW. Validity of ImPACT for measuring processing speed following sports-related concussion. J Clin Exp Neuropsychol 2005;27:683-689. 

[20.] Iverson GL, Lovell MR, Collins MW, et al. Tracking recovery from concussion using ImPACT: applying reliable change methodology. Arch Clin Neuropsychol 2002;17:770. 

[21.] Iverson GL, Franzen MD, Lovell MR, et al. Construct validity of ImPACT in athletes with concussions. Arch Clin Neuropsychol 2004;19:961-962. 

[22.] Tsushima WT, Oshiro R, Zimbra D. Neuropsychological test performance of Hawaii high school athletes: Hawaii ImPACT normative data. Hawaii Med J 2008;67:93-95. 

[23.] Lovell MR. The ImPACT Neuropsychological Test Battery. In: Echemendia RJ, ed. Sports Neuropsychology: Assessment and Management of Traumatic Brain Injury. New York: Guilford Press; 2006:193-215. 

[24.] Cantu RC. Guidelines for return to contact sports after a cerebral concussion. Phys Sports Med 1986;14:75-76,79,83. 

[25.] Cantu RC. Return to play guidelines after head injury. Clin Sports Med 1998;17(1):45-60. 

[26.] Colorado Medical Society School and Sports Medicine Committee. Guidelines for the management of concussion in sports. Colo Med 1990;87:4. 

[27.] Kelly JP, Rosenburg JH. Practice parameter: the management of concussion in sports. Neurology 1997;48:575-580. 

[28.] Collins MW, Lovell MR, McKeag DB. Current issues in managing sports-related concussion. JAMA 1999;282:2283-2285. 

[29.] McCrory P, Johnston K, Meeuwisse W, et al. Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague 2004. Br J Sports Med 2005;39(4):196-204. 

[30.] McCrory P, Meeuwisse W, Johnston K, et al. Consensus statement on concussion in sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008. Br J Sports Med 2009;43:i76-i84. 

[31.] Kupperman N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet 2009;374:1160-1170. 

 

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