Return to play. Because a significant number of concussion-related injuries occur within the sporting arena, many providers seek guidelines on when to counsel athletes, parents, and coaches about returning to competition. Most experts concur that no athlete should return to play on the day that a concussive injury occurred. This minimizes the risk for complications resulting from a repeated head injury. Moreover, research indicates that athletes at the collegiate and high school level are more likely to have a delayed onset of symptoms and neuropsychological deficits following injury as a result of same-day return to play.4 The current recommendations use a stepwise process and graduated return-to-play protocol as defined in Table 2. Essentially, an athlete should progress to the next level if he or she remains asymptomatic within the current level. Therefore, it takes about 1 week to progress through the full rehabilitation protocol because each step should take approximately 24 hours. However, if any postconcussion symptoms occur during the graduated return-to-play program, the patient should “drop back” to the previous asymptomatic level and attempt progression again after a 24-hour period of rest. Patients who fail to recover or who exhibit persistent concussion-related symptoms should be referred to specialists with experience managing concussions in a multidisciplinary approach.
A more conservative return-to-play protocol has been proposed for children and adolescents that includes extended periods without symptoms and/or longer periods of graded exertion. This approach is recommended because of the different physiologic responses of children and adolescents to head trauma and the longer time needed for recovery.4 Participation in school-related extracurricular activities, including athletics, is not usually recommended until the patient has fully resumed school activities.16 Lastly, each return-to-play progression, regardless of the patient’s age, should be individualized, with the final clearance documented by a licensed healthcare provider knowledgeable in the evaluation and management of concussions.11
Pharmacologic therapy. The use of medications in treating concussion is tailored mainly to the management of symptoms. According to the most recent position statement on concussion in sport from the American Medical Society for Sports Medicine, no convincing evidence has been found of the effectiveness of any particular medication in treating the acute symptoms of concussion.11 Acetaminophen is currently recommended in the treatment of postconcussive headaches, with the addition of physical measures such as massage, the application of ice, and rest in a dim, quiet environment. Sleep disturbances should initially be managed with conservative measures, such as sleep hygiene, but medical and/or cognitive therapy or even referral to a sleep specialist should be considered for a patient with protracted symptoms. Stimulants are not currently recommended for treating cognitive symptoms, such as decreased attention. True vertigo and balance dysfunction may be mitigated by meclizine or diazepam, but these drugs should be used judiciously because they can affect cognitive function. There is currently insufficient evidence to determine the effectiveness of vestibular therapy in patients with vertiginous symptoms. Patients who have depressive symptoms should be screened and treatment with medication and/or cognitive therapy should be considered if the symptoms persist beyond 6 to 12 weeks.11
Second-impact syndrome is a rare but potentially fatal complication leading to diffuse cerebral swelling that can occur after a patient who is still symptomatic from an earlier concussion sustains a second head injury.17 The term postconcussion syndrome encompasses the symptom complex of headache, dizziness, neuropsychiatric symptoms, and cognitive impairment.18 These symptoms can develop in the first few days after a mild TBI but typically resolve within a few weeks to few months. Patients can also exhibit isolated symptoms as sequelae that include posttraumatic headaches and/or posttraumatic vertigo. The incidence of posttraumatic epilepsy is increased 2-fold after mild TBI, with 50% of cases occurring during the first year and 80% within the first 2 years.19 However, prophylactic treatment with anticonvulsants is not currently recommended because it has not been shown to be effective. Chronic traumatic encephalopathy (CTE) has been one of the most publicized potential long-term complications, with increasing reports of dementia occurring in National Football League players who have a history of multiple concussions. CTE is a neurodegenerative disease that is associated with repetitive brain trauma and pathologically characterized by the accumulation of an abnormal tau protein in specific areas of the brain. Patients should be aware of this potential long-term complication of cumulative head trauma, although most experts agree that larger-scale, epidemiologic studies are required to understand the causes and develop prevention strategies.11
Concussions remain a complex and common type of mild TBI evaluated by primary care providers. Diagnosis and management remain challenging because of insufficient scientific evidence to support much of the clinical decision making required for good patient care. It is essential that healthcare providers be able to recognize the symptoms and signs of a concussion, but it is equally important that athletes, coaches, officials, and parents be educated so that patients are properly evaluated. Healthcare providers trained in the evaluation and management of concussion are therefore important in establishing the diagnosis. Standardized diagnostic tools provide a helpful and uniform approach to assessing and following a patient with a concussion. However, further research is needed to determine their accuracy. The mainstay of treatment remains physical and cognitive rest. No athlete with a concussion should be allowed to return to play on the day of the injury or while he or she is symptomatic. Moreover, the decision to return to play should be a medical one, with clearance given by a licensed healthcare provider. A provider with any uncertainty regarding an athlete’s return to play should follow the mantra “when in doubt, sit them out.”
Shaun Lynch, PA-C, MS, MMSc, is a physician assistant and an assistant professor in PA studies at Elon University in North Carolina.
- Injury prevention & control: traumatic brain injury & concussion. Centers for Disease Control and Prevention website. http://www.cdc.gov/TraumaticBrainInjury/index.html. Updated February 9, 2016.
- Marin JR, Weaver MD, Yealy DM, Mannix RC. Trends in visits for traumatic brain injury to emergency departments in the United States. JAMA. 2014;311(18):1917-1919.
- Langlois JA, Rutland-Brown W, Wald MM. The epidemiology and impact of traumatic brain injury: a brief overview. J Head Trauma Rehabil. 2006;21(5):375-378.
- McCrory P, Meeuwisse W, Aubry M, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Clin J Sport Med. 2013;23(2):89-117.
- Duhaime AC, Beckwith JG, Maerlender AC, et al. Spectrum of acute clinical characteristics of diagnosed concussions in college athletes wearing instrumented helmets: clinical article. J Neurosurg. 2012;117:1092-1099.
- Kelly JP, Rosenberg JH. Diagnosis and management of concussion in sports. Neurology. 1997;48(3):575-580.
- Cantu RC. Posttraumatic retrograde and anterograde amnesia: pathophysiology and implications in grading and safe return to play. J Athl Train. 2001;36(3):244-248.
- Lee ST, Lui TN. Early seizures after mild closed head injury. J Neurosurg. 1992;76(3):435-439.
- Practice parameter: the management of concussion in sports (summary statement). Report of the Quality Standards Subcommittee. Neurology. 1997;48(3):581-585.
- Giza CC, Kutcher JS, Ashwal S, et al. Summary of evidence-based guideline update: evaluation and management of concussion in sports: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2013;80(24):2250-2257.
- Harmon KG, Drezner JA, Gammons M, et al. American Medical Society for Sports Medicine position statement: concussion in sport. Br J Sports Med. 2013;47:15-26.
- Hughes DG, Jackson A, Mason DL, Berry E, Hollis S, Yates DW. Abnormalities on magnetic resonance imaging seen acutely following mild traumatic brain injury: correlation with neuropsychological tests and delayed recovery. Neuroradiology. 2004;46(7):550-558.
- Lawler KA, Terregino CA. Guidelines for evaluation and education of adult patients with mild traumatic brain injuries in an acute care hospital setting. J Head Trauma Rehabil. 1996;11:18-28.
- Evans RW. Concussion and mild traumatic brain injury. UpToDate. http://www.uptodate.com/contents/concussion-and-mild-traumatic-brain-injury. Updated April 29, 2015.
- Concussion recognition, diagnosis, and acute management. In: Graham R, Rivara FP, Ford MA, Mason Spicer C, eds. Sports-Related Concussions in Youth: Improving the Science, Changing the Culture. Washington, DC: National Academies Press; 2014:99-180.
- Halstead ME, McAvoy K, Devore CD, et al. Returning to learning following a concussion. Pediatrics. 2013;132:948-957.
- Wetjen NM, Pichelmann MA, Atkinson JL. Second impact syndrome: concussion and second injury brain complications. J Am Coll Surg. 2010;211(4):553-557.
- Bazarian JJ, Wong T, Harris M, Leahey N, Mookerjee S, Dombovy M. Epidemiology and predictors of post-concussive syndrome after minor head injury in an emergency population. Brain Inj. 1999;13(3):173-189.
- Annegers JF, Grabow JD, Groover RV, Laws ER Jr, Elveback LR, Kurland LT. Seizures after head trauma: a population study. Neurology. 1980;30(7 Pt 1):683-689.
All electronic documents accessed August 4, 2016.