Concussion (Mild Traumatic Brain Injury) and the Team Physician: a Consensus Statement*

SPECIAL COMMUNICATIONS Team Physician Consensus Statement

Concussion (Mild Traumatic Brain Injury) and the Team Physician: A Consensus Statement*

DEFINITION SUMMARY

Concussion or mild traumatic brain injury (MTBI) is a pathophysiological This document provides an overview of select medical issues that are process affecting the brain induced by direct or indirect biomechanical important to team physicians who are responsible for athletes with con- forces. cussion. It is not intended as a standard of care, and should not be Common features include: interpreted as such. This document is only a guide, and as such, is of a general nature, consistent with the reasonable, objective practice of the • Rapid onset of usually short-lived neurological impairment, which healthcare professional. Individual treatment will turn on the specific facts typically resolves spontaneously. and circumstances presented to the physician. Adequate insurance should • Acute clinical symptoms that usually reflect a functional disturbance be in place to help protect the physician, the athlete, and the sponsoring rather than structural injury. organization. • A range of clinical symptoms that may or may not involve loss of This statement was developed by a collaboration of six major profes- consciousness (LOC). sional associations concerned about clinical sports medicine issues; they • Neuroimaging studies that are typically normal. have committed to forming an ongoing project-based alliance to bring together sports medicine organizations to best serve active people and athletes. The organizations are: American Academy of Family Physicians, GOAL American Academy of Orthopaedic Surgeons, American College of Sports Medicine, American Medical Society for Sports Medicine, American Or- The goal is to assist the team physician in providing optimal medical thopaedic Society for Sports Medicine, and the American Osteopathic care for the athlete with concussion. Academy of Sports Medicine. To accomplish this goal, the team physician should have knowledge of and be involved with: EXPERT PANEL • Epidemiology • Pathophysiology Stanley A. Herring, M.D., Chair, Seattle, Washington • Game-day evaluation and treatment John A. Bergfeld, M.D., Cleveland, Ohio • Post–game-day evaluation and treatment Arthur Boland, M.D., Boston, Massachusetts • Diagnostic imaging Lori A. Boyajian-O’Neill, D.O., Kansas City, Missouri • Management principles • Return-to-play Robert C. Cantu, M.D., Concord, Massachusetts • Complications of concussion Elliott Hershman, M.D., New York, New York • Prevention Peter Indelicato, M.D., Gainesville, Florida Rebecca Jaffe, M.D., Wilmington, Delaware W. Ben Kibler, M.D., Lexington, Kentucky *Editor’s Note: The Team Physician Consensus Statement was published Douglas B. McKeag, M.D., Indianapolis, Indiana in the November 2005 Medicine & Science in Sports & Exercise௡ without two final corrections. The corrected statement is published here in its Robert Pallay, M.D., Hillsborough, New Jersey entirety. Margot Putukian, M.D., Princeton, New Jersey

Copyright © 2005 by the American College of Sports Medicine (ACSM), American Academy of Family Physicians (AAFP), American Academy of INTRODUCTION Orthopaedic Surgeons (AAOS), American Medical Society for Sports Medicine (AMSSM), American Orthopaedic Society for Sports Medicine It is essential the team physician understand: (AOSSSM), and the American Osteopathic Academy of Sports Medicine (AOASM). • The recognition and evaluation of the athlete with 0195-9131/05/3711-2012/0 concussion. MEDICINE & SCIENCE IN SPORTS & EXERCISE® • Management and treatment of the athlete with concus- DOI: 10.1249/01.mss.0000186726.18341.70 sion be individualized. 2012 • The factors involved in making return-to-play (RTP) TABLE 1. Selected acute signs and symptoms suggestive of concussion. decisions after injury should be based on clinical judg- Cognitive Somatic Affective ment. Confusion Headache Emotional lability • A game-day medical plan specific to concussion inju- Posttraumatic amnesia (PTA) Fatigue Irritability Retrograde amnesia (RGA) Disequilibrium, dizziness ries be developed. Loss of consciousness (LOC) Nausea/vomiting • The need for documentation. Disorientation Visual disturbances • Feeling “in a fog,” “zoned out” (photophobia, blurry/double There is a paucity of well-designed studies of concus- Vacant stare vision) sion and its natural history. Inability to focus Phonophobia Delayed verbal and motor responses It is desirable the team physician: Slurred/incoherent speech Excessive drowsiness • Coordinate a systematic approach for the treatment of the athlete with concussion. On-Field • Identify risk factors and implement appropriate treat- ment. • Evaluate the injured athlete on-the-field in a systematic • Understand the potential sequelae of concussive inju- fashion: ries. • Assess for adequate airway, breathing, and circulation • Understand prevention strategies. (ABC’s) • Followed by focused neurological assessment empha- sizing mental status, neurological deficit, and cervical EPIDEMIOLOGY spine status • • Concussions occur commonly in helmeted and non- Determine initial disposition (emergency transport vs helmeted sports, and account for a significant number sideline evaluation) of time loss injuries. Sideline • Published reports indicate concussion injuries occur at a rate of: • Obtain a more detailed history and perform a more de- • 0.14–3.66 injuries per 100 player seasons at the tailed physical examination. high school level, accounting for 3–5% of injuries in • all sports Assess for cognitive, somatic, and affective signs and • 0.5–3.0 injuries per 1,000 athlete exposures at the symptoms of acute concussion (see Table 1), with collegiate level. particular attention to retrograde amnesia (RGA), post- • Self-report data suggests significantly higher incidence traumatic amnesia (PTA), and more than brief LOC of concussion. (minutes, not seconds), because of their prognostic • Because of under recognition and/or under reporting, significance. • Not leave the player unsupervised. the incidence of concussion and its sequelae is un- • known. Perform serial neurological assessments • Determine disposition for symptomatic and nonsymp- tomatic players, including postinjury follow-up (options PATHOPHYSIOLOGY include return-to-play, home with observation, or trans- port to hospital). • Metabolic changes that occur in the animal model, and • Provide postevent instructions to the athlete and others thought to occur in humans include: (e.g., regarding alcohol, medications, physical exertion • Alterations in intracellular/extracellular glutamate, and medical follow-up). potassium and calcium • A relative decrease in cerebral blood flow in the It is desirable the team physician: setting of an increased requirement for glucose (i.e., increased glycolysis). This mismatch in the meta- On-Field bolic supply and demand may potentially result in • Have a plan to protect access to the injured player cell dysfunction and increase the vulnerability of the • Have emergency medical personnel on-site cell to a second insult. • Have medical supplies on-site for rescue, immobiliza- tion and transportation [See “Sideline Preparedness for GAME-DAY EVALUATION AND TREATMENT the Team Physician: A Consensus Statement”; (1)] It is essential the team physician: Sideline • Implement the game-day medical plan specific to con- • Delineate the mechanism of injury. cussion. • Perform a more detailed assessment of cognitive func- • Understand the indications for cervical spine immobi- tion (e.g., memory, calculations, attention span, con- lization and emergency transport. centration, speed of information processing).

TEAM PHYSICIAN CONSENSUS STATEMENT Medicine & Science in Sports & Exerciseா 2013 • Coordinate the care and follow-up of the athlete with predicting severity and outcome. RTP guidelines concussion. which address these issues are more useful. • Discuss status of athlete with parents, caregivers, cer- • Duration of symptoms is a major factor in determining tified athletic trainers and coaching staff within dis- severity, therefore severity of injury should not be closure regulations. determined until all signs and symptoms have cleared. • The treatment of and the RTP decision for the athlete POST–GAME-DAY EVALUATION AND with concussion must be individualized. TREATMENT It is desirable the team physician: It is essential the team physician: • Coordinate a team for concussion management (e.g., physicians, certified athletic trainers, neuropsycholo- • Obtain a comprehensive history of the current concus- gists, emergency response personnel). sion, and any previous concussion. • Discuss status of athlete with parents, caregivers, cer- • Perform a physical examination, including a detailed tified athletic trainers and coaching staff within dis- neurological/cognitive evaluation. closure regulations. • Determine the need for further evaluation and consul- tation. RETURN-TO-PLAY (RTP) DECISION • Determine return-to-play status. The RTP decision should be individualized, and not based It is desirable the team physician: on a rigid timeline. The team physician is ultimately respon- • Coordinate the care and follow-up of the athlete. sible for the RTP decision. [See “The Team Physician and • Understand the indications and limitations of neuro- Return-To-Play Issues: A Consensus Statement”; (2).] psychological testing. It is essential the team physician understand: • Postinjury neuropsychological test data are more useful if compared to the athlete’s preinjury base- Same-Day RTP line. • • It is unclear what type and content of test data are There is agreement that athletes with significant, per- most valuable. sistent or worsening signs and symptoms (e.g., abnor- • It is only one component of the evaluation process. mal neurological examination, ongoing RGA or PTA, • Educate the athlete and others about concussion. prolonged LOC) should not RTP. • • Discuss status of athlete with parents, caregivers, cer- For other athletes with concussion, significant contro- tified athletic trainers and coaching staff within dis- versy exists for a same-day RTP decision and no closure regulations. conclusive evidence-based data are available. Areas of controversy include: • Returning an athlete with any symptoms to play. DIAGNOSTIC IMAGING • Returning an athlete with fully resolved symptoms It is essential the team physician understand: to play. • Certain symptoms, even if resolved, are contraindi- • The limited value of plain skull radiographs. cations to same-day RTP (e.g., any LOC, PTA, and • Indications of advanced imaging, such as CT or mag- RGA). netic resonance imaging (MRI), to assess associated • The duration and severity of symptoms are the de- injuries including intracranial bleed, cerebral edema, termining factors of RTP. diffuse axonal injury, and/or skull fracture. • It is the safest course of action to hold an athlete out. • Indications for the use of cervical imaging when cer- vical spine injury is suspected. Post–Game-Day RTP It is desirable the team physician: • Determine the athlete is asymptomatic at rest before • Review the results of the imaging studies and/or an- resuming any exertional activity. cillary tests such as facial bone radiographs. • Amnesia may be permanent. • Utilize progressive aerobic and resistance exercise MANAGEMENT PRINCIPLES challenge tests before full RTP. • Consider factors which may affect RTP, including: It is essential the team physician understand: • Severity of the current injury • Brief LOC (seconds, not minutes) is associated with • Previous concussions (number, severity, proximity) specific early deficits, but does not predict the severity • Significant injury in response to a minor blow of injury; therefore classification systems or RTP • Age (developing brain may react differently to guidelines based solely on brief LOC are not accurate. trauma than mature brain) • RGA, PTA, as well as the number and duration of • Sport additional signs and symptoms, are more accurate in • Learning disabilities

2014 Official Journal of the American College of Sports Medicine http://www.acsm-msse.org • Understand contraindications for return to sport (e.g., symptomatic from prior brain injury abnormal neurological examination, signs or symp- • Prior brain injury can be earlier in same event toms with exertion, significant abnormalities on cog- • Vascular engorgement leads to massive increase in nitive testing or imaging studies). intracranial pressure and brain herniation • Controversy exists for postgame RTP decisions. • Usually with severe brain damage or death • May occur with associated small subdural hemotoma It is desirable the team physician: • Except for boxing, all cases in literature in adolescents (Ͻ20 yr old) Post–Game-Day RTP It is desirable the team physician: • Coordinate a team to implement progressive aerobic • and resistance exercise challenge tests before full RTP. Coordinate assessment and treatment of complications • • Recognize challenging cognitive effort may exacer- Discuss status of athlete with parents, caregivers, cer- bate symptoms of concussion and retard recovery. tified athletic trainers and coaching staff within dis- • Discuss status of athlete with parents, caregivers, closure regulations. teachers, certified athletic trainers and coaching staff within disclosure regulations. PREVENTION • Consider neuropsychological testing. Concussions cannot be completely prevented. It is essential the team physician understand: COMPLICATIONS OF CONCUSSION • Helmet use decreases the incidence of skull fracture It is essential the team physician: and major head trauma, but does not prevent, and may actually increase, the incidence of concussion. • Understand cumulative concussions may increase risk • Improper use of the head and improper fit of helmet or for subsequent concussions. protective equipment may increase the risk of concus- • Determine when the athlete may RTP. sion. It is also essential the team physician understand other • There are rules to limit concussion (e.g., spearing, complications may occur, including: head-to-head contact, leading with the head). • Convulsive motor phenomena It is desirable the team physician: • Tonic posturing or convulsive movements within • During the preparticipation evaluation, obtain a con- seconds of the concussion cussion history. • Dramatic, but usually benign • Discuss the enforcement of rules to limit concussion • Require no management beyond on-field ABCs with coaching staff and officials before practice and • No anticonvulsant therapy required competition. • Posttraumatic seizures • Discuss with players and coaches techniques which • Seizure occurs days to months after concussion may increase the risk of concussion. • Does require seizure management and precautions • Support the use of mouth guards to decrease the risk of • Usually requires anticonvulsant therapy dental and facial injury, although the protection they • Postconcussion syndrome provide to concussion risk is unclear. • Persistent postconcussion symptoms lasting months • Educate athletes, parents, and coaches on the impor- • Indicator of concussion severity tance of reporting symptoms of concussion to limit • Precludes RTP while present complications. • Second impact syndrome • Educate athletes, parents, and coaches regarding the • Occurs within minutes of concussion in athlete still escalation of violence in sports.

REFERENCES

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TEAM PHYSICIAN CONSENSUS STATEMENT Medicine & Science in Sports & Exerciseா 2015 SELECTED READINGS

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