An Update on Current Practices in Concussion Management

September 2019

As school is getting ready to resume for children and teenagers across the country, so are several sports seasons. One of the most controversial topics over the past several years has been concussions in athletes and what to do about them. The recommendations have frequently changed as more research has become available to guide these decisions. Knowing what to do when a concussion has occurred can help prevent further injury and aid in recovery.

The first and most important thing to do when you or someone you know exhibits possible concussion symptoms is to remove the athlete from play. Concussion symptoms can take anywhere from seconds to days to emerge, so keeping an eye on a player who has taken a big hit is important. The most dangerous time for an athlete to receive a concussion is while they are already concussed. Most concussions resolve in 1-2 weeks, but receiving a second concussive hit while the brain is already injured can lead to further damage that takes months to heal and in rare cases cause a dangerous condition known as second impact syndrome.

Initial concussion symptoms can include concentration or memory problems, irritability, and migraine symptoms such as headache, light and noise sensitivity, nausea, blurry vision, and imbalance. A person suspected of a concussion should be evaluated by a medical professional, ideally a concussion specialist, within the first 24-48 hours after the injury if possible. CT scan of the head is no longer required as the overwhelming majority of cases produce a normal scan and thus exposes the person to unnecessary radiation. Concussed individuals should be allowed to sleep through the first night as long as there are no “red flags” within the first few hours.

Red flags for a head injury include prolonged loss of consciousness (over 30 seconds), repeated vomiting, slurred speech, weakness, numbness, vision loss and seizure that suggest something more serious than a concussion has occurred. In this case, an emergency room visit is required and head imaging should be performed.

For years, the standard treatment recommendation was “rest until you feel better, it will go away on its own” and not do any cognitive or physical activity until the symptoms are gone. This was known as “cocoon therapy.” This is no longer advised as it can actually lead to increased symptoms over time for several reasons. The most important thing to do is to avoid situations where another hit to the head can occur. A concussed individual should be allowed to avoid any mental or physical activities that worsen their symptoms for the first 2-3 days but it should be noted that regular daily activities do not further injure the brain, they merely cause the symptoms someone experiences to feel worse. It is now advised to begin returning to daily activities including school within the first week even if symptoms are still present. Speak with your physician about receiving a letter for academic accommodations and options for treating specific symptoms during the recovery. A return to school and light cardiovascular activity within the first week actually leads to quicker recovery in most cases.

Deciding when to return to sports after a concussion is also a common hurdle that athletes experience. Once symptoms have improved, an athlete will typically go through a return to play process involving 4-5 stages of a stepwise increase in physical activity until they are able to  complete a full practice without producing symptoms. A high school athletic trainer can typically assist an athlete in this process but in youth sports, this option is usually not available. Consulting with a sports neurologist experienced in creating individualized return process programs for athletes is the best option in those cases. A sports neurologist is also trained to help athletes identify and overcome issues that prevent athletes from progressing through the return process.

When symptoms last longer than a few weeks, a related but different condition known as post-concussion syndrome may develop. This is when the metabolic changes in the brain that occur during a concussion have healed but symptoms continue and some of the causes of those symptoms may not be directly related to the concussion itself. Many patients can require vestibular (balance) or vision therapy to correct physical changes that occurred as a result of the concussion. Some other possible contributing factors include neck muscle strains, anxiety, depression, ADHD, PTSD or other neurologic conditions. While a concussion requires rest early on as part of the healing process, post-concussion syndrome does not improve with rest and should be aggressively treated to control the symptoms. With properly targeted treatment such as physical therapy, medications, and cognitive therapy among others, patients suffering from post-concussion syndrome will typically experience a gradual improvement over time and many can return to their normal daily life.

If anyone you know suffers from concussion or post-concussion syndrome, consider recommending that they see a concussion specialist as early as possible for the best outcome.