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© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (2): ITC2-1.
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© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (2): ITC2-1.
in the clinic
Concussion
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (2): ITC2-1.
Who is at risk for a concussion?
 Youths aged 10–19 years (highest risk)
 Males more than females
 Participants in sports
 Concussions 13.2% of all reported H.S. sports injuries
 Highest rates occur in:
 Boys: Football, ice hockey, lacrosse
 Girls: soccer, lacrosse, basketball
 In sports with similar rules (basketball, soccer) rate of
concussions higher among girls than boys
 Other risk factors: falls, motor vehicle accidents
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (2): ITC2-1.
Are certain types of head trauma more
likely to result in concussion?
 Any event in which forces result in the brain moving
within the skull may result in concussion
 Direct trauma to head is not necessary
 Indirect forces transmitted to the head from an impact to
the body may cause a concussion
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (2): ITC2-1.
How can concussions be prevented?
Primary prevention
 Minimize exposure to forces that lead to brain injury
 Wear seat belts in motor vehicles
 Wear well-fitted protective equipment during sports
 Both measure prevent catastrophic brain injury
 Less effective for preventing concussion or mild TBI
 Change rules to decrease exposure to concussive forces
 Such as raising the body-checking age in youth ice hockey
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (2): ITC2-1.
Secondary prevention
 Eliminate unnecessary risk for repeated head trauma
 Full recovery from initial concussion is essential
 Second concussion may prolong signs and symptoms
 Possible increased risk for catastrophic death or disability
from second head injury after a recent head injury
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (2): ITC2-1.
CLINICAL BOTTOM LINE: Prevention…
 Primary concussion prevention
 Reduce exposure to concussive forces and injury
 Rule changes in sports
 Enactment of laws for safety reasons
 Secondary prevention
 Appropriate, knowledgeable clinical management is essential
 Full recovery from initial concussion is essential before
exposure to any risk for second head injury
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (2): ITC2-1.
What acute symptoms immediately following
head injury should prompt consideration of
concussion?
Early (minutes to hours later)
Late (days to weeks later)
 Headache
 Persistent low-grade headache
 Dizziness or vertigo
 Lightheadedness
 Lack of awareness of
surroundings
 Poor attention, concentration
 Nausea or vomiting
 Balance problems
 Visual disturbance
 Mental confusion
 Amnesia (retro-/anterograde)
 Perseveration
 Memory dysfunction
 Easy fatigability
 Irritability, frustration
 Intolerance of loud noises
 Anxiety or depressed mood
 Numbness or tingling
 Sleep disturbance
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (2): ITC2-1.
 If symptoms present but no history of head injury
 Participants in contact or collision sports: consider
concussion due to the many impacts sustained routinely
 Otherwise: consider other causes than concussion
 If symptoms are minimal or absent after a head injury
 Observe patient over subsequent hours and days
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (2): ITC2-1.
What evaluation should be performed
immediately following head injury?
 Assess for cervical or intracranial injury
 If cervical tenderness or limitation of cervical ROM:
immobilize + use spine board for emergency transport
 If patient is conscious, engage verbally while immobilized
 Evaluate various domains of brain function
 Neurocognitive; balance; eye tracking
 Refer patient to emergency department
 If loss of consciousness or traumatic convulsive activity
 If mental status deteriorates
 If focal neurologic signs develop
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (2): ITC2-1.
What imaging tests should be used in the
evaluation of possible concussion?
 CT imaging
 Consider on an individual basis: not universally indicated
 If there’s concern for intracranial hemorrhage based on
clinical signs and symptoms
 If neurologic status deteriorates
 Imaging methods under investigation
 Diffusion tensor imaging
 Functional MRI
 Magnetic resonance spectroscopy
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (2): ITC2-1.
When head injury occurs during sport, how
should the safety of returning to play be
made, and by whom?
 Remove injured athlete from play
 Athlete should never return to play on the same day a head
injury occurs
 Assess and monitor on the sideline if appropriate,
depending on severity and symptoms
 Refer to emergency dept if any deterioration in clinical
status causes concern
 Physician should oversee the safe return to play
 49 states require clearance from a licensed medical
professional with concussion experience to return to play
 Physician should have experience and training in
concussion management and return-to-play issues
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (2): ITC2-1.
What items are important in the history and
physical examination of a patient with
suspected concussion?
Elements of history
 Mechanism of injury
 Timing of the development of symptoms after injury
 Subsequent course of events (delayed-onset symptoms,
activities that exacerbate symptoms)
 Assessment of preinjury function and ability to tolerate
return to full function
 History of concussion and any comorbid conditions
 Anxiety, depression, ADHD, or preexisting migraine
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (2): ITC2-1.
Physical Examination: Tests
 Smooth pursuits: Examiner’s finger moves horizontally,
progressively increasing speed
 Saccades: Examiner’s fingers held at shoulder-width and
forehead and chin distance to test horizontally & vertically
 Gaze stability: Patient fixes gaze on examiner’s thumb while
nodding (vertical) and then shaking (horizontal) head
 Convergence insufficiency: Patient takes a pen with letters and
holds at arm’s length and brings towards their nose
 Balance: Tandem heel-toe gait forward and backward with eyes
opened and closed
 Signs of concussion deficits: Unable to perform or can only
perform a few repetitions before symptoms or signs are provoked

Such as headache, dizziness, eye fatigue, blurry vision

Physical signs, such as watering of eyes or swaying of body
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (2): ITC2-1.
What other tests should be performed?
 Concussion symptom scales
 Help delineate severity and extent of symptoms after injury
 Can be followed serially
 Computerized neurocognitive testing
 Now widely used in h.s. and college sports as well as pro
 Helps quantify cognitive effects of injury
 Accurate preinjury information contributes to a more
individualized assessment
 ? Test for serum biomarkers for acute concussion
 ? Test for alleles that may predispose to concussion
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (2): ITC2-1.
How is the severity of a concussion assessed?
 Concussion grading systems have been abandoned
 Data are lacking with which to predict prognosis
 Severity can only be assessed after recovery complete
 However, there are predictors of prolonged recovery
 Younger age and female
 History of multiple concussions
 Diagnosed learning disability
 Slowed reaction time and impaired visual memory
 Post-traumatic migraine
 Subacute (within 3 to 7 days) symptoms
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (2): ITC2-1.
CLINICAL BOTTOM LINE: Diagnosis…
 Concussion was once defined as constellation of subjective
symptoms after head injury
 Now specific areas affected in concussion have been identified
 Neurocognitive
 Vestibular
 Oculomotor
 Balance
 Use physical exam to assess & identify deficits in these areas
 Obtain a detailed and accurate history
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (2): ITC2-1.
Should patients with a concussion be
restricted from work, school or other
activities?
 Immediately after the injury
 Patients benefit from brief physical + cognitive rest
 Then resume activities gradually
 Modify cognitive activities as needed
 Return to normal physical activity as tolerated
 Pay close attention to symptom threshold
 Noncontact aerobic activity probably isn’t harmful
 Athletes can enter a formal return-to-play progression once
able to tolerate a full cognitive load
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (2): ITC2-1.
What behavioral interventions are helpful
in the management of concussion?
Return to school
 Cognitive rest—No school, homework, or electronic devices
 Relative rest—Reintroduce short periods of aforementioned
activities that don’t trigger severe symptom exacerbation
 Homework at home—Longer periods of cognitive activity
 Return to school—Partial-day school with accommodations
after tolerating 1-2 cumulative hours of homework at home
 Ramp up to full day—With accommodations for full work load,
limited make up work
 Full return to school—Full day, full work load, fully caught up
with makeup load
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (2): ITC2-1.
Return to play
 Physical rest—avoid activities that result in sustained
increased heart rate or breaking a sweat or severe symptom
exacerbation; additional sleep may be needed
 Light activity associated with everyday life avoiding triggering
severe symptoms—walking
 Light aerobic exercise—To increase heart rate without
triggering severe symptom exacerbation
 Sport-specific aerobic exercise—Noncontact skating,
dribbling, or running drills as tolerated
 Advance to complex noncontact sport-specific training drills
and add resistance training as tolerated
 After medical clearance, full contact practice
 Normal game play
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (2): ITC2-1.
Are there pharmacological measures known
help in treating patients with a concussion?
 Analgesics: may be helpful (acetaminophen, ibuprofen)
 But symptoms best managed with behavioral
interventions, such as rest and modification of activities
 Avoid daily use (prevent rebound headaches)
 Melatonin: if sleep is disordered
 Amantadine: for mental slowing or fogginess
 Amitriptyline or topiramate: for chronic daily headaches
outside of the acute phase of concussion
 Methylphenidate: persistent attention issues after TBI
 Referral for anxiety and depression medication may be
warranted in the chronic post-concussion phase
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (2): ITC2-1.
What are the complications of concussion?
 Complications vary and may include:
 Vestibular deficits
 Oculomotor and visual convergence deficits
 Anxiety and depression
 Chronic headaches
 Attention or concentration issues
 Slowed processing speed or memory issues
 Postconcussion syndrome
 Term reserved for prolonged and persistent symptoms
 May involve multiple domains of brain function
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (2): ITC2-1.
When should rehabilitation therapies be
considered?
 If vestibulo-ocular deficits persist beyond acute phase
 Directed therapy reduces symptoms, improves function
 Aerobic rehabilitation with exercise training is beneficial
 Formal binocular vision therapy may be indicated
 If unable to resume preinjury level of cognitive function
 Cognitive or speech therapy may be indicated
 Modification of school activities may be sufficient to
rehabilitate cognitive deficits
 Refer for cognitive or speech therapy if more significant
accommodations are needed
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (2): ITC2-1.
When should a specialist be consulted for
the treatment of a concussion?
 Concerns about the timing of return to a contact or
collision sport
 Concerns about a prolonged recovery from concussion
 Rehabilitation may be required
 Hx multiple concussions or preexisting neurologic issues
 Such as migraines, anxiety, or depression
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (2): ITC2-1.
CLINICAL BOTTOM LINE: Treatment…
 Management for patients with a typical recovery
 Brief period of early physical and cognitive rest after injury
 Then gradual reentry into physical and cognitive activities
 Modify activities to minimize symptom exacerbation
 Refer to specialist with experience managing concussion if:
 Patient has preexisting comorbid conditions / risk factors
 Symptoms are prolonged
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (2): ITC2-1.
What factors predict the prognosis of
patients with concussion?
 Poorer prognosis + prolonged recovery more likely with:
 Greater number of symptoms
 Greater severity of symptoms
 History of concussion
 Younger age
 Apolipoprotein e4 genotype (may be associated with more
significant neurologic deficits)
 Loss of consciousness and impact seizure (not consistently
correlated w/ poorer outcome)
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (2): ITC2-1.
 Symptoms associated with prolonged recovery:
 Amnesia
 Prolonged headache
 Fatigue or fogginess
 Cognitive problems
 Dizziness at the time of injury
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (2): ITC2-1.
CLINICAL BOTTOM LINE: Prognosis…
 Patients may recover with few, if any, long-term sequelae
 Risk factors predictive of a prolonged recovery:
 History of concussion
 Greater number and severity of symptoms
 Deficits that persist despite rehabilitation
 Discuss the future risk for concussion vs. the benefits of a
high-risk activity
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (2): ITC2-1.