The 4th International Conference on Concussion in Sport Held in Zurich, November 2012
Br J Sports Med. 2013;47(5):250-258.
Section 1: Sport Concussion and its Management
The Zurich 2012 document examines the sport concussion and management issues raised in the previous Vienna 2001, Prague 2004 and Zurich 2008 documents and applies the consensus questions from section 3 to these areas.
Definition of Concussion
A panel discussion regarding the definition of concussion and its separation from mild traumatic brain injury (mTBI) was held. There was acknowledgement by the Concussion in Sport Group (CISG) that although the terms mTBI and concussion are often used interchangeably in the sporting context and particularly in the US literature, others use the term to refer to different injury constructs. Concussion is the historical term representing low-velocity injuries that cause brain 'shaking' resulting in clinical symptoms and that are not necessarily related to a pathological injury. Concussion is a subset of TBI and will be the term used in this document. It was also noted that the term commotio cerebri is often used in European and other countries. Minor revisions were made to the definition of concussion, which is defined as follows:
Recovery of Concussion
The majority (80–90%) of concussions resolve in a short (7–10 day) period, although the recovery time frame may be longer in children and adolescents.
Symptoms and Signs of Acute Concussion
The diagnosis of acute concussion usually involves the assessment of a range of domains including clinical symptoms, physical signs, cognitive impairment, neurobehavioural features and sleep disturbance. Furthermore, a detailed concussion history is an important part of the evaluation both in the injured athlete and when conducting a preparticipation examination. The detailed clinical assessment of concussion is outlined in the SCAT3 and Child SCAT3 forms, which are given in the appendix to this document.
The suspected diagnosis of concussion can include one or more of the following clinical domains:
If any one or more of these components are present, a concussion should be suspected and the appropriate management strategy instituted.
On-field or Sideline Evaluation of Acute Concussion
When a player shows ANY features of a concussion:
Sufficient time for assessment and adequate facilities should be provided for the appropriate medical assessment both on and off the field for all injured athletes. In some sports, this may require rule change to allow an appropriate off-field medical assessment to occur without affecting the flow of the game or unduly penalising the injured player's team. The final determination regarding concussion diagnosis and/or fitness to play is a medical decision based on clinical judgement.
Sideline evaluation of cognitive function is an essential component in the assessment of this injury. Brief neuropsychological test batteries that assess attention and memory function have been shown to be practical and effective. Such tests include the SCAT3, which incorporates the Maddocks' questions[4 5]and the Standardized Assessment of Concussion (SAC).[6–8] It is worth noting that standard orientation questions (eg, time, place and person) have been shown to be unreliable in the sporting situation when compared with memory assessment.[5 9] It is recognised, however, that abbreviated testing paradigms are designed for rapid concussion screening on the sidelines and are not meant to replace comprehensive neuropsychological testing which should ideally be performed by trained neuropsychologists who are sensitive to subtle deficits that may exist beyond the acute episode; nor should they be used as a stand-alone tool for the ongoing management of sports concussions.
It should also be recognised that the appearance of symptoms or cognitive deficit might be delayed several hours following a concussive episode and that concussion should be seen as an evolving injury in the acute stage.
Evaluation in the Emergency Room or Office by Medical Personnel
An athlete with concussion may be evaluated in the emergency room or doctor's office as a point of first contact following injury or may have been referred from another care provider. In addition to the points outlined above, the key features of this examination should encompass:
In large part, these points above are included in the SCAT3 assessment.
A range of additional investigations may be utilised to assist in the diagnosis and/or exclusion of injury. Conventional structural neuroimaging is typically normal in concussive injury. Given that caveat, the following suggestions are made: Brain CT (or where available an MR brain scan) contributes little to concussion evaluation but should be employed whenever suspicion of an intracerebral or structural lesion (eg, skull fracture) exists. Examples of such situations may include prolonged disturbance of the conscious state, focal neurological deficit or worsening symptoms.
Other imaging modalities such as fMRI demonstrate activation patterns that correlate with symptom severity and recovery in concussion.[10–14] Although not part of routine assessment at the present time, they nevertheless provide additional insight to pathophysiological mechanisms. Alternative imaging technologies (eg, positron emission tomography, diffusion tensor imaging, magnetic resonance spectroscopy, functional connectivity), while demonstrating some compelling findings, are still at early stages of development and cannot be recommended other than in a research setting.
Published studies, using both sophisticated force plate technology, as well as those using less sophisticated clinical balance tests (eg, Balance Error Scoring System (BESS)), have identified acute postural stability deficits lasting approximately 72 h following sports-related concussion. It appears that postural stability testing provides a useful tool for objectively assessing the motor domain of neurological functioning, and should be considered as a reliable and valid addition to the assessment of athletes suffering from concussion, particularly where the symptoms or signs indicate a balance component.[15–21]
The significance of Apolipoprotein (Apo) E4, ApoE promoter gene, Tau polymerase and other genetic markers in the management of sports concussion risk or injury outcome is unclear at this time.[22 23]Evidence from human and animal studies in more severe traumatic brain injury demonstrates induction of a variety of genetic and cytokine factors such as: insulin-like growth factor 1 (IGF-1), IGF binding protein 2, Fibroblast growth factor, Cu-Zn superoxide dismutase, superoxide dismutase 1 (SOD-1), nerve growth factor, glial fibrillar acidic protein (GFAP) and S-100. How such factors are affected in sporting concussion is not known at this stage.[24–31] In addition, biochemical serum and cerebral spinal fluid biomarkers of brain injury (including S-100, neuron-specific enolase (NSE), myelin basic protein (MBP), GFAP, tau, etc) have been proposed as a means by which cellular damage may be detected if present.[32–38] There is currently insufficient evidence, however, to justify the routine use of these biomarkers clinically.
Different electrophysiological recording techniques (eg, evoked response potential (ERP), cortical magnetic stimulation and electroencephalography) have demonstrated reproducible abnormalities in the postconcussive state; however, not all studies reliably differentiated concussed athletes from controls.[39–45] The clinical significance of these changes remains to be established.
The application of neuropsychological (NP) testing in concussion has been shown to be of clinical value and contributes significant information in concussion evaluation.[46–51] Although cognitive recovery largely overlaps with the time course of symptom recovery in most cases, it has been demonstrated that cognitive recovery may occasionally precede or more commonly follow clinical symptom resolution, suggesting that the assessment of cognitive function should be an important component in the overall assessment of concussion and, in particular, any RTP protocol.[52 53] It must be emphasised, however, that NP assessment should not be the sole basis of management decisions. Rather, it should be seen as an aid to the clinical decision-making process in conjunction with a range of assessments of different clinical domains and investigational results.
It is recommended that all athletes should have a clinical neurological assessment (including assessment of their cognitive function) as part of their overall management. This will normally be performed by the treating physician often in conjunction with computerised neuropsychological screening tools.
Formal NP testing is not required for all athletes; however, when this is considered necessary, it should ideally be performed by a trained neuropsychologist. Although neuropsychologists are in the best position to interpret NP tests by virtue of their background and training, the ultimate RTP decision should remain a medical one in which a multidisciplinary approach, when possible, has been taken. In the absence of NP and other (eg, formal balance assessment) testing, a more conservative RTP approach may be appropriate.
NP testing may be used to assist RTP decisions and is typically performed when an athlete is clinically asymptomatic; however, NP assessment may add important information in the early stages following injury.[54 55] There may be particular situations where testing is performed early to assist in determining aspects of management, for example, return to school in a paediatric athlete. This will normally be best determined in consultation with a trained neuropsychologist.[56 57]
Baseline NP testing was considered by the panel and was not felt to be required as a mandatory aspect of every assessment; however, it may be helpful to add useful information to the overall interpretation of these tests. It also provides an additional educative opportunity for the physician to discuss the significance of this injury with the athlete. At present, there is insufficient evidence to recommend the widespread routine use of baseline neuropsychological testing.
The cornerstone of concussion management is physical and cognitive rest until the acute symptoms resolve and then a graded programme of exertion prior to medical clearance and RTP. The current published evidence evaluating the effect of rest following a sports-related concussion is sparse. An initial period of rest in the acute symptomatic period following injury (24–48 h) may be of benefit. Further research to evaluate the long-term outcome of rest, and the optimal amount and type of rest, is needed. In the absence of evidence-based recommendations, a sensible approach involves the gradual return to school and social activities (prior to contact sports) in a manner that does not result in a significant exacerbation of symptoms.
Low-level exercise for those who are slow to recover may be of benefit, although the optimal timing following injury for initiation of this treatment is currently unknown.
As described above, the majority of injuries will recover spontaneously over several days. In these situations, it is expected that an athlete will proceed progressively through a stepwise RTP strategy.
Graduated RTP Protocol
RTP protocol following a concussion follows a stepwise process as outlined in Table 1.
With this stepwise progression, the athlete should continue to proceed to the next level if asymptomatic at the current level. Generally, each step should take 24 h so that an athlete would take approximately 1 week to proceed through the full rehabilitation protocol once they are asymptomatic at rest and with provocative exercise. If any postconcussion symptoms occur while in the stepwise programme, then the patient should drop back to the previous asymptomatic level and try to progress again after a further 24 h period of rest has passed.
Same Day RTP
It was unanimously agreed that no RTP on the day of concussive injury should occur. There are data demonstrating that at the collegiate and high school levels, athletes allowed to RTP on the same day may demonstrate NP deficits postinjury that may not be evident on the sidelines and are more likely to have delayed onset of symptoms.[59–65]
'Difficult' or Persistently Symptomatic Concussion Patient
Persistent symptoms (>10 days) are generally reported in 10–15% of concussions. In general, symptoms are not specific to concussion and it is important to consider other pathologies. Cases of concussion in sport where clinical recovery falls outside the expected window (ie, 10 days) should be managed in a multidisciplinary manner by healthcare providers with experience in sports-related concussion.
Psychological Management and Mental Health Issues
Psychological approaches may have potential application in this injury, particularly with the modifiers listed below.[66 67] Physicians are also encouraged to evaluate the concussed athlete for affective symptoms such as depression and anxiety as these symptoms are common in all forms of traumatic brain injury.
Role of Pharmacological Therapy
Pharmacological therapy in sports concussion may be applied in two distinct situations. The first of these situations is the management of specific and/or prolonged symptoms (eg, sleep disturbance, anxiety, etc). The second situation is where drug therapy is used to modify the underlying pathophysiology of the condition with the aim of shortening the duration of the concussion symptoms. In broad terms, this approach to management should be only considered by clinicians experienced in concussion management.
An important consideration in RTP is that concussed athletes should not only be symptom-free, but also they should not be taking any pharmacological agents/medications that may mask or modify the symptoms of concussion. Where antidepressant therapy may be commenced during the management of a concussion, the decision to RTP while still on such medication must be considered carefully by the treating clinician.
Role of Preparticipation Concussion Evaluation
Recognising the importance of a concussion history, and appreciating the fact that many athletes will not recognise all the concussions they may have suffered in the past, a detailed concussion history is of value.[69–72] Such a history may pre-identify athletes who fit into a high-risk category and provides an opportunity for the healthcare provider to educate the athlete in regard to the significance of concussive injury. A structured concussion history should include specific questions as to previous symptoms of a concussion and length of recovery; not just the perceived number of past concussions. It is also worth noting that dependence on the recall of concussive injuries by teammates or coaches has been demonstrated to be unreliable. The clinical history should also include information about all previous head, face or cervical spine injuries as these may also have clinical relevance. It is worth emphasising that in the setting of maxillofacial and cervical spine injuries, coexistent concussive injuries may be missed unless specifically assessed. Questions pertaining to disproportionate impact versus symptom severity matching may alert the clinician to a progressively increasing vulnerability to injury. As part of the clinical history, it is advised that details regarding protective equipment employed at the time of injury be sought, both for recent and remote injuries.
There is an additional and often unrecognised benefit of the pre-participation physical examination insofar as the evaluation allows for an educative opportunity with the player concerned as well as consideration of modification of playing behaviour if required.
Modifying Factors in Concussion Management
A range of 'modifying' factors may influence the investigation and management of concussion and, in some cases, may predict the potential for prolonged or persistent symptoms. However, in some cases, the evidence for their efficacy is limited. These modifiers would be important to consider in a detailed concussion history and are outlined in Table 2.
Female Gender. The role of female gender as a possible modifier in the management of concussion was discussed at length by the panel. There was no unanimous agreement that the current published research evidence is conclusive enough for this to be included as a modifying factor, although it was accepted that gender may be a risk factor for injury and/or influence injury severity.[73–75]
Significance of LOC. In the overall management of moderate-to-severe traumatic brain injury, duration of LOC is an acknowledged predictor of outcome. Although published findings in concussion describe LOC associated with specific, early cognitive deficits, it has not been noted as a measure of injury severity.[77 78] Consensus discussion determined that prolonged (>1 min duration) LOC would be considered as a factor that may modify management.
Significance of Amnesia and Other Symptoms. There is renewed interest in the role of post-traumatic amnesia and its role as a surrogate measure of injury severity.[64 79 80] Published evidence suggests that the nature, burden and duration of the clinical postconcussive symptoms may be more important than the presence or duration of amnesia alone.[77 81 82] Further, it must be noted that retrograde amnesia varies with the time of measurement postinjury and hence is poorly reflective of injury severity.[83 84]
Motor and Convulsive Phenomena. A variety of immediate motor phenomena (eg, tonic posturing) or convulsive movements may accompany a concussion. Although dramatic, these clinical features are generally benign and require no specific management beyond the standard treatment of the underlying concussive injury.[85 86]
Depression. Mental health issues (such as depression) have been reported as a consequence of all levels of traumatic brain injury including sports-related concussion. Neuroimaging studies using fMRI suggest that a depressed mood following concussion may reflect an underlying pathophysiological abnormality consistent with a limbic-frontal model of depression.[34 87–97] Although such mental health issues may be multifactorial in nature, it is recommended that the treating physician consider these issues in the management of concussed patients.