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Brain Trust

Some of What You Think about Concussions is Wrong

Dolbec, Katherine, MD

Emergency Medicine News: May 2019 - Volume 41 - Issue 5 - p 9
doi: 10.1097/01.EEM.0000558180.93004.6f
Brain Trust

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The recent hype surrounding concussion may make you feel even more confused than your concussed patient when it comes to workup, diagnosis, and plan for mild traumatic brain injury. But fear not! Hot off the press is the American Medical Society for Sports Medicine's updated position statement on concussion.

Sport-related concussion has become a hot topic in medicine and the lay press over the past decade. It is a common injury in adults and kids, with up to 1.8 million sports-related concussions occurring annually in children under 18 in the United States. (Pediatrics. 2016;138[1]. pii: e20154635; http://bit.ly/2F65Af1.) Sports-related concussion has been associated with post-concussion syndrome, second impact syndrome, and chronic traumatic encephalopathy. Health care professionals are left scratching their heads as they try to decide whether to get a CT, how long to relegate their patients to confinement in a dark, stimulus-free room, and when to allow patients to return to school, work, and sports.

Concussion is a traumatically induced transient disturbance of brain function that involves a complex pathophysiological process.” (Br J Sports Med. 2019;53[4]:213; http://bit.ly/2EYCmhZ.) It is not completely understood, but involves a complex metabolic and biochemical disturbance in response to post-impact neuronal stretching. A clinical diagnosis of concussion is established in a patient with history and examination consistent with mild traumatic brain injury after ruling out intoxication, underlying medical conditions, and other injuries.

Clinical signs and symptoms are currently the only reliable way to diagnose concussion. Patients describe symptoms such as headache, dizziness, mood changes, fogginess, feeling “out of it,” visual changes, and neck pain. Objective findings of concussion include loss of consciousness, post-impact seizure, tonic posturing, gross motor instability, confusion, and amnesia. Findings such as prolonged loss of consciousness, severe or worsening headache, multiple episodes of vomiting, mental status deterioration, focal neurologic deficits, and concern for cervical spinal injury warrant additional workup for more severe closed head or cervical spinal injury. This generally involves the use of imaging. Biomarkers that may someday prove useful for ruling out structural brain damage exist, but they are not ready for prime time.

So you diagnosed your patient with a concussion. Now what? For starters, you can provide reassurance that concussion symptoms are generally self-limiting. The vast majority of older adolescents and adults will be back to baseline within two weeks. The recovery process for younger children is generally slower, but most recover within four weeks.

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A Big Change

Perhaps the biggest paradigm shift with the updated guidelines is a change in treatment recommendations for acute concussion. Mounting evidence shows that the previously held mainstay of treatment, complete brain and physical rest, is actually harmful. The new recommendation is to engage in symptom-limited rest for the first 24-48 hours, followed by a gradual increase in activity, making sure to avoid exertion that causes the return of symptoms. (Br J Sports Med. 2019;53[4]:213; http://bit.ly/2EYCmhZ.) Light aerobic exercise may actually accelerate recovery from a concussion.

Patients should be advised to return to work and school as soon as they are able to do so without experiencing symptom exacerbation. Return to sports should not begin until there is complete return to school or work, and should follow a supervised, graded plan with 24-hour symptom-free periods between each progressive step.

Patients should be counseled about the potential risks of driving after sustaining a concussion. Reaction time, concentration, memory, and visual perception are compromised during the acute concussive period and even for a period of time after symptom resolution and may make driving unsafe. Unfortunately, there is not yet good evidence or available guidelines about driving after concussion, so you will just need to use your best judgment and encourage your patient to do the same.

The risks of returning to sports too early include delayed recovery and increased risk of musculoskeletal injury. Another rare and controversial consequence of premature return to sports is second impact syndrome, the rapid development of diffuse cerebral edema, herniation, and death when a brain recovering from concussion sustains a subsequent traumatic blow. This risk should deter even the most zealous athlete from attempting to play too soon.

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Dr. Dolbecis an emergency physician at the University of Vermont Medical Center. She completed a fellowship in primary care sports medicine at Evergreen Sports Medicine Fellowship, also in Maine. She is a physician for the US Ski and Snowboard Team. Follow her on Twitter @DolbecKatie.

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