Concussions: Diagnosing the prevalent, though often unrecognized, injury

Much more prevalent than previously thought, concussions are the most common sports injury. And that’s with as many as 2 million concussions going unidentified each year, said R. Robert Franks, DO, who spoke yesterday during a two-hour OMED session sponsored by the American Osteopathic Academy of Sports Medicine.

“Once a concussion has occurred, a player is four to six times more likely to sustain a second concussion,” Dr. Franks said. “This is a statistic that always gets parents’ attention.”

Due to increased awareness of the problem, laws are being introduced across the country that address concussion management in athletes, and 40 states now have some kind of concussion legislation. “It has become difficult to keep up with the legal, as well as the clinical, aspects of managing concussion,” said Dr. Franks, the director of the Pennsylvania-based Rothman Institute’s sports concussion program.

Dr. Franks noted that concussions are caused either by a direct blow to the head, face or neck or by an impact somewhere else on the body that transmits an “impulsive force” to the head. Athletes who participate in football, boxing, hockey, wrestling, gymnastics, lacrosse, soccer, basketball or cheerleading are particularly susceptible.

Concussions typically cause short-lived impairment of neurological function that resolves spontaneously. But in some athletes, particularly those who have had previous concussions or have multiple symptoms, concussions can cause longer-term or even permanent impairment.

Recognizing the signs

Diagnosing a concussion begins with closely observing the patient. “I like to watch the athlete walk into the exam room,” Dr. Franks said. “Is the patient able to walk a straight line? Is he or she having problems maneuvering in an unfamiliar environment?”

Dr. Franks noted that physicians should ask the following questions when evaluating athletes for possible concussions:

• Do you have a pressure headache, and does it get worse in school or with exertion?
• Do you get dizzy with movement?
• Do you get fatigued at a certain point in the day?
• Are you more sensitive to light or noise?
• Have you been more distracted lately?
• Have you had trouble falling or staying asleep?
• Have you been more moody or irritatble?
• Do you feel “foggy”?
• Have the symptoms affected your classes and your grades?

Early symptoms of concussion include headache, dizziness, confusion, tinnitus, nausea, vomiting and vision changes. Late symptoms include memory disturbances, poor concentration, sleep disturbances, irritability, personality changes and fatigue.

Those who have the greatest number of symptoms have the worst prognostic outcomes, Dr. Franks said. Adolescents and female patients are more vulnerable to long-term impairment from concussions.

“The symptom that I look for a lot is a vacant stare,” Dr. Franks said. “I also look for slurred speech and behavioral changes.”

Dr. Franks urged physicians to consult with anyone else who may have examined the patient, from emergency physicians to athletic trainers, and obtain any previous neurocognitive tests. He recommends that athletes suspected of having a concussion be given a neurocognitive test known as ImPACT (Immediate Post-concussion Assessment and Cognitive Testing), which assesses reaction time, impulse control, working memory, verbal memory and visual motor speed.

Concussed athletes often are easily distracted, react slowly to requests, and are unable to process information quickly. They may be slow to recall words and unable to remember what they’ve read.

Dr. Franks also recommended that athletes suspected of concussion undergo vestibular testing as part of the physical examination. “I look at both horizontal and vertical gaze,” he said. “I’ll put two fingers up in front of the patient and say, ‘I want you to take your eyes and look back and forth between my two fingers without moving your head. And I want you to look up and down between my two fingers using just your eyes.’ For someone who is nauseated and has a headache to begin with, this can be a challenge.” Vestibular testing provides a good indication of whether an athlete is ready to return to play.

Before returning to play, athletes need a recovery phase of complete rest, Dr. Franks stressed. Once their neurocognitive functioning returns to their baseline level and they’ve been asymptomatic for 24 hours, athletes can begin a stepwise program of activity, starting with light aerobic exercise, such as walking and swimming, and progressing to sport-specific training.

Building awareness

Much work still needs to be done in educating coaches and parents about concussion prevention and treatment, said Jeffrey R. Bytomski, DO, during his portion of the presentation. A 2007 study showed that 45% of youth coaches believed concussion did not warrant an athlete’s removal from contest or practice. Only 45% to 62% of the surveyed coaches were able to identify the proper protocols for managing concussions.

Using the right helmet is a key to preventing concussions in contact sports, he said. Besides being able to absorb energy, helmets need to be comfortable, lightweight and durable; promote good visibility; and remain in position on the head.

“Concussion remains a diagnosis dominated by the subjective information given by the athlete, while the clinician seeks objective data to support clinical decisions,” said Dr. Bytomski, the head team physician for Duke Sports Medical Center in Durham, N.C.

Audience member and family physician Eric S. Bohn, DO, of Reading, Pa., has been seeing more concussed athletes in his practice. While he already uses ImPACT software as a diagnostic tool, Dr. Bohn said that he drew much from the concussion presentations. “I learned more about the biomarkers for concussion, the best use of imaging technology and medication options,” he said.

cschierhorn@osteopathic.org