The purpose of this chapter is to outline aspects of

sport-related concussions most relevant in the manage-

ment of young athletes seen in practice. At the outset, it
is recognized that research-based data for the evaluation
and management of sport-related concussions in chil-
dren and adolescents are limited. Because no guideline
or protocol has been specically studied for its applica-
bility in children and adolescents, a more cautious
approach to management of concussions is recom-
mended in this age group.
DEFINITION
There is no universal consensus on the denition of
concussion.
14
In its practice parameter on concussion
management in sports, the American Academy of Neu-
rology denes concussion as a trauma-induced alter-
ation in mental status that may or may not be associated
with loss of consciousness.
5
Confusion, loss of memory,
and impaired information processing speed, which may
occur immediately or several minutes later, are consid-
ered to be the key features of concussion and seen in all
instances.
18
The Prague Conference (Second International
Conference on Concussion in Sports, 2004, Prague) in
its definition includes the following key elements
associated with concussion as a result of trauma in
sports
6
:
1. Concussion may be caused by a direct blow to
the head, face, neck, or elsewhere on the body
with impulsive force transmitted to the head.
2. Concussion typically results in the rapid onset
of short-lived impairment of neurologic func-
tion that resolves spontaneously.
3. Concussion may result in neuropathologic
changes, but the acute clinical symptoms largely
reect a functional disturbance rather than
structural injury.
4. Concussion may result in a graded set of clinical
syndromes that may or may not involve loss of
consciousness. Resolution of the clinical and
cognitive symptoms typically follows a sequen-
tial course.
5. Concussion is typically associated with grossly
normal structural neuroimaging studies.
The term postconcussion syndrome refers to the
persistence of symptoms and signs following the brain
injury. Postconcussion syndrome can last for weeks,
months, or years. Postconcussion syndrome indicates a
more severe injury and precludes athletes return to
high-risk sports.
EPIDEMIOLOGY
In addition to direct impact to the head or other part of
the body in contact/ collision sports, concussion can
also occur in noncontact sports as a result of sudden
acceleration, deceleration, or rotational forces imparted
to the brain.
69
Thus, absence of a history of direct
impact to the head or elsewhere on the body does not
rule out the possibility of a concussion.
In high school sports in the United States,
300,000 head injuries are reported every year, and 90%
of these are concussions.
13
Reported incidence of
concussions at high school level is 0.14 to 3.66 con-
cussions per 100 player seasons accounting from 3% to
5% of all sport-related injuries.
8
The highest number
of concussion has been reported in American football
(Table 11-1).
14
Concussions
Dilip R. Patel
CHAPTER 11
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Symptoms and signs of concussion are by deni-
tion transient and therefore many athletes may fail to
grasp the signicance of head trauma and subsequent
symptoms of concussion and not seek timely medical
attention. Some athletes may not report symptoms or
head injury for fear of being excluded from further sport
participation. Because of these reasons it is generally
accepted that the reported incidence of concussion is an
underestimate. Most athletes with concussion seen in a
pediatric practice are adolescents, and the following dis-
cussion is most applicable to the adolescent age group.
Pathogenesis
Animal and experimental models have shown that in
moderate to severe traumatic brain injuries a cascade of
complex metabolic and biochemical changes in the set-
ting of genetic overlay results in diffuse neuronal cell
injury and dysfunction.
29
Alterations in the intracellular
and extracellular potassium and calcium ions and exci-
tatory neurotransmitter glutamate have been described.
It has been proposed that concussive brain injury causes
a disturbance in the autoregulation of cerebral blood
ow resulting in a relative decrease in cerebral blood
ow, while at the same time there is an increased meta-
bolic demand by the neuronal cells.
29
The resultant mis-
match between the cellular metabolic demands and
cerebral blood ow is believed to be a key contributing
factor leading to cellular dysfunction and increased vul-
nerability to further injury. There are fundamental dif-
ferences between the developing brain of the child and
adolescent and the mature brain of the adult making
adult models of pathophysiology far less applicable to
children. In broad terms, these differences include con-
tinuing neurocognitive maturation, anatomical congu-
ration of the head and brain, structural properties of the
skull, biomechanics of head trauma, vulnerability of
neurons to injury, and neuronal recovery.
29
CLINICAL PRESENTATION
AND EVALUATION
History
Pediatricians may see an athlete with concussion on the
eld or more commonly in the ofce setting. On the
sideline, the athlete may present with a history of direct
blow to the head or other part of the body. The athlete
may give a history of collision with another player, a fall
to the ground, or being struck by an object such as a ball,
a puck, or a bat. Concussion can result from indirect
shearing or rotational forces imparted to the brain with-
out direct impact. Not uncommonly, a teammate may
notice that something is not right with the athlete and
communicate that to the trainer on the sideline. The
athletic trainer or the coach or less commonly a specta-
tor may see collision and observe that the player is con-
fused. Typically, the confused and disoriented athlete is
not able to execute proper moves or follow commands
as expected in the context of the play at the time.
The most common scenario for a pediatrician to
see an athlete with a concussion is in the ofce setting
when the athlete presents for a follow-up of head injury
and needs a medical clearance to return to sport. The
athlete may be symptomatic or asymptomatic. On the
other hand, some athletes may initially present with
symptoms or signs of concussion several days or weeks
after the head injury; many may not realize the signi-
cance of the initial symptoms and delay seeking medical
attention, or seek medical attention because of persist-
ence or worsening or onset of new symptoms. Parents
may rst seek pediatricians advice when they notice
deterioration of academic performance and changes in
behavior, mood, or personality in the athlete; this is crit-
ically important to recognize and a probing history of
antecedent head trauma must be ascertained.
During the annual sport preparticipation evalua-
tion (PPE), a past history of head injury should be ascer-
tained. Detailed history should include: when did the
most recent concussion occurred, what were the symp-
toms and signs, how long did it take for full recovery,
how many concussions have occurred in the past, inter-
val between concussions, and results of any neuropsy-
chologic testing or neuroimaging done.
1012
PPE visit is
also the time for prevention education.
A relevant review of systems should include any
known (preinjury) neurologic condition or learning
disability, attention deficit hyperactivity disorder,
depression, academic function before and since the
injury, use of drugs or performance enhancing supple-
ments, and use of therapeutic medications. Psychosocial
history should assess athletes interest in sports, and any
evidence of parental pressure to return to sport.
13
CHAPTER 11 Concussions 111
Table 11-1.
Sports with Relatively Higher Risk for Concussion*
American football
Ice hockey
Soccer
Wrestling
Basketball
Field hockey
Baseball
Softball
Volleyball
*Listed in decreasing order of risk.
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Symptoms and Signs
The athlete with concussion may manifest any one or
more of a number of symptoms or signs (Table 11-2);
some immediately after the injury to the brain, whereas
others may be delayed for days or weeks.
38,1417
Because
no one or a set of symptoms and signs is pathogno-
monic of concussion, and most are nonspecific in
nature, a contemporaneous relationship between the
time of initial injury to the brain and subsequent devel-
opment of symptoms and signs should be established
on the basis of history and examination.
In the evaluation of an athlete with symptoms
and signs of concussion the physician should consider
other conditions that can present with similar clinical
features. In the acute setting, heat-related illness,
effects of dehydration, hypoglycemia, and acute exer-
tional migraine can mimic concussion. Many of the
delayed symptoms of concussion are nonspecic, mak-
ing it necessary to carefully delineate the differential
diagnosis or concomitant conditions such as depression,
attention decit/hyperactivity disorder, sleep disorder,
cerebellar or brain stem lesions, or psychosomatic dis-
order. By denition a variable degree of mental status
impairment is seen in all cases of concussion.
Mental Status and Cognitive Function
Assessment of cognitive functions and neurologic
examination are essential components of evaluation of
athletes with concussion. An athlete with concussion
may continue to manifest physical and emotional symp-
toms even after resolution of cognitive decits. Cogni-
tive function can be affected by many factors other than
the effects of concussion, such as baseline (preinjury)
intellectual ability, learning disability, attention decit/
hyperactivity disorder, substance abuse, level of educa-
tion, cultural background, lack of sleep, fatigue, anxiety,
age, and developmental stage.
1,2,18,19
Cognitive assess-
ment techniques should be appropriate for the athletes
age, level of education, and developmental stage or
maturity.
A practical way to assess memory and orientation
on the sidelines is Maddocks questions (Table 11-3); not
able to answer or incorrect answer to any one of the
Maddocks questions indicates concussion.
20,21
The fol-
lowing areas of cognitive functioning and assessment
techniques are generally included in a brief mental sta-
tus examination of athletes with sport-related concus-
sion.
57,15,22,23
1. OrientationOrientation in person, place, and
time.
2. Attention

Digit span: Recite a series of two digits to the

athlete at a rate of about one per second. Ask
the athlete to repeat the numbers back to
112 Section 2: Medical Conditions and Sport Participation
Table 11-2.
Symptoms and Signs of Concussion
Mental status changes
Amnesia
Confusion
Disorientation
Easily distracted
Excessive drowsiness
Feeing dinged or stunned or foggy
Impaired level of consciousness
Inappropriate play behaviors
Poor concentration and attention
Seeing stars or ashing lights
Slow to answer questions or follow directions
Physical or somatic
Ataxia or loss of balance
Blurry vision
Decreased performance or playing ability
Dizziness
Double vision
Fatigue
Headache
Lightheadedness
Nausea, vomiting
Poor coordination
Ringing in the ears
Seizures
Slurred, incoherent speech
Vacant star/glassy eyed
Vertigo
Behavioral or psychosomatic
Emotional liability
Irritability
Low frustration tolerance
Personality changes
Nervousness, anxiety
Sadness, depressed mood
Table 11-3.
Maddocks Questions
Which ground are we at?
Which team are we playing today?
Who is your opponent at present?
Which quarter is it?
How far into the quarter is it?
Which side scored the last goal?
Which team did we play last week?
Did we win last week?
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you. If the athlete is able to correctly repeat
the two digits, recite a series of three num-
bers, then four, ve, and so on, as long as the
athlete is able to correctly repeat the digits
back to you. If the athlete makes an error, try
one more time with another series of the
same length. Stop after the athlete fails at the
second attempt. Similarly, have the athlete
repeat the digits backwards starting with a
series of two. Normally the athlete should be
able to repeat correctly at least ve digits for-
ward and four backwards.
Serial 7s: Ask the athlete to subtract 7 from
100 and keep subtracting. Typically, the ath-
lete should be able to complete a serial 7 in
1.5 minutes with fewer than four errors. If
the athlete nds it difcult to do serial 7s,
have him do serial 3s in a similar way.
Spelling backwards: Say a ve-letter word,
spell it, then ask the athlete to spell it back-
ward.
3. Memory
Give the athlete ve words and ask him or
her to repeat them back to you. The athlete
with intact registration and immediate recall
should be able to correctly repeat the ve
words back to you. Without informing the
athlete that he or she will be asked to recall
these words later, move on to another task of
assessment in the meantime. Five minutes
later ask the athlete to recall the ve words.
The athlete with intact delayed recall should
be able to recall the ve words.
Ask the athlete to recite the months of the
year in reverse order starting with a given
month or the current month (other than
December or January).
Ask the athlete to tell current score of the
game, which quarter it is and the name of the
opposing team (recent memory).
Ask the athlete to tell you the name of his or
her elementary school or place of birth
(remote memory).
The onset of posttraumatic amnesia, a
key feature of concussion, may be delayed for
more than 20 minutes following injury to
the brain.
2
Resolution of posttraumatic
amnesia is best indicated by the athletes
ability to recall fully the events from before
the injury to the brain to present (continu-
ous memory).
2,8,16
4. Higher cognitive functionsGeneral knowl-
edge and vocabulary are good indicators of
intellectual function. Assess calculation ability
by asking the athlete to perform a simple task:
how many nickels make a quarter? Or what is
the square root of 64? Abstract thinking can be
assessed by asking the athlete meaning of a
common proverb for example: rolling stone
gathers no moss; or by similarities test, for
example: how are a train and an airplane simi-
lar? Constructional abilities give a good indica-
tion of visual motor abilities. To test construc-
tional abilities ask the athlete to draw for
example a clock face with numbers and hands
and judge the quality of the drawing.
5. Other areas of mental statusInsight, judg-
ment, affect, and mood are other areas of men-
tal status that should be assessed in athletes with
concussion.
Neurologic Examination
A complete neurologic examination is essential in the
evaluation of athletes with concussion with specific
attention to the following components: (1) Speech, (2)
visual acuity, visual elds, ocular fundi, pupillary reac-
tions, and extraocular movements, (3) muscle strength
and deep tendon reexes, and (4) tandem gait, nger-
nose test, pronator drift, and Romberg test. By deni-
tion, neurologic examination should be normal in ath-
letes with concussion, except the mental status
functions. Abnormal or focal ndings on neurologic
examination should prompt consideration of a focal
intracranial pathology and emergent evaluation and
management of the athlete.
Before the athlete is allowed to return to play, he
or she must be asymptomatic both at rest as well as on
exertion and the examination must be normal. The ath-
lete should be assessed for recurrence of any symptoms
or signs on physical exertion; simple exertion provoca-
tive measures (Table 11-4) can be integrated in the
examination.
2,5,6,8
Severity Grading of Concussions
Most concussion grading systems are based on the pres-
ence or absence of loss of consciousness, duration of loss
of consciousness, presence or absence of confusion, and
CHAPTER 11 Concussions 113
Table 11-4.
Exertion Provocative Measures
40-yard sprint
5 push-ups
5 sit-ups
5 jumping jacks
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presence or absence and duration of posttraumatic amne-
sia, none of which have been shown to reliably predict the
severity or prognosis for recovery.
16,8,24
The duration of
symptoms and signs following the initial brain injury has
been shown to predict the severity of concussion and
prognosis for recovery more reliably, hence the prevailing
view is to consider the severity grading of concussion ret-
rospectively after the clinical resolution of concus-
sion.
2,6,8,24
Although more than 20 grading schemes for
concussion have been published, the American Academy
of Neurology (Table 11-5) and Cantu (Table 11-6) grad-
ing systems are the most widely known.
2,5,24
The Prague Concussion in Sport Consensus State-
ment does not recommend use of conventional grading
scales in the management of concussions.
6
It is recog-
nized that the severity of concussion in an individual
athlete can only be ascertained retrospectively after full
clinical recovery has occurred. A simple concussion typ-
ically resolves within 7 to 10 days and requires no fur-
ther intervention, whereas a complex concussion is
characterized by failure of clinical resolution and asso-
ciated sequelae.
DIAGNOSTIC STUDIES
Neuroimaging
Neuroimaging is indicated in athletes with focal neuro-
logic signs, those with progressively worsening symp-
toms and signs, failure of clinical resolution of symptoms
(typically more than 2 weeks), severe acute headache,
and loss of consciousness greater than a few seconds.
24
Static imaging with magnetic resonance imaging (MRI)
or computerized tomography does not show any struc-
tural abnormalities of brain in concussion. Imaging
modalities such as positron emission tomography (PET),
functional MRI (fMRI), or single photon emission
tomography (SPECT) provide information on brain
metabolism and regional blood ow; however, their
application in clinical evaluation and management of
athletes with concussion is limited at best.
Neuropsychologic Testing
The important domains of cognitive function assessed by
neuropsychologic (NP) testing include: memory, speed of
information processing, visual spatial and visual motor
abilities, and various components of executive function
(including working memory, attention, planning, and
organization).
25,26
Memory and speed of information
processing (or reaction time) are the most important cog-
nitive functions impaired by concussion that are meas-
ured by NP testing. Conventional (or paper and pencil)
NP testing utilizes a battery of tests administered over one
or more sessions (several hours) and interpreted by
trained neuropsychologists. Conventional NP tests are
neither specically designed nor validated to assess ath-
letes with sport-related concussion, cannot be easily
adapted for mass application, and are relatively expensive.
During the adolescent years there is continued
neurological maturation associated with increased
acquisition of neurocognitive abilities as well as rapid
acquisition of new skills and knowledge.
1,14
A sensitive
indicator of resolution of concussion is a return to base-
line neuropsychological prole following concussion;
however because of continued neuomaturation during
adolescence, a return to baseline NP prole may not
necessarily indicate full recovery. This confounding
factor should be taken into account in interpreting NP
tests in adolescents.
Computerized NP testing specically designed to
assess athletes with sport-related concussion, is now
114 Section 2: Medical Conditions and Sport Participation
Table 11-5.
American Academy of Neurology Concussion Severity
Grading System
Grade Criteria
1 Transient confusion
No loss of consciousness
Symptoms and mental status abnormalities resolve
in less than 15 min
2 Transient confusion
No loss of consciousness
Symptoms and mental status abnormalities last
more than 15 min
3 Any loss of consciousness
Table 11-6.
Cantu Concussion Severity Grading System
Grade Criteria
1 No loss of consciousness and posttraumatic
amnesia less than 30 min; and postconcussion
signs and symptoms less than 24 h
2 Loss of consciousness less than 1 min; or
posttraumatic amnesia equal to or less than 30
min and less than 24 h; or postconcussion signs
and symptoms equal to or more than 24 h and
less than 7 d
3 Loss of consciousness equal to or more than 1 min;
or posttraumatic amnesia equal to or more than
24 h; or postconcussion signs and symptoms
equal to or more than 7 d
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being utilized at high school, collegiate, and professional
levels to obtain baseline as well as postconcussion neu-
ropsyhological prole of athletes to monitor recov-
ery.
1,2,2529
Some of the advantages of computerized test-
ing include: simple to administer, less expensive, takes
only few minutes to administer, can be easily given to a
group of athletes (team), and easy to interpret. Examples
of currently available computerized NP tests are listed in
Table 11-7. For interested physicians detailed informa-
tion on each of the tests is available at their websites.
Notwithstanding the increased application of
computerized NP testing, their validity and reliability has
been a subject of much debate.
25
NP testing, either con-
ventional or computerized, must not be used in isolation
in the assessment or monitoring recovery of athletes with
concussion, and return to play decisions should not be
guided solely based on results of NP testing. With more
baseline data being accumulated, properly constructed
and administered computerized NP testing hold great
promise as a valuable tool to objectively assess and mon-
itor athletes with sport-related concussion. Formal NP
testing is useful to delineate specic impairments in ath-
letes who fail to recover as expected or deteriorate or
those who have had multiple concussions. NP testing can
be useful in guiding the management of academic dif-
culties in children and adolescents.
MANAGEMENT
On Field Management
Recognition, stabilization, and appropriate disposition
of athletes with severe head and neck injuries should be
the rst priority of the physician on the eld. From a
practical perspective it is difcult to assess severity of
injury in athletes with loss of consciousness of any dura-
tion, and therefore it is most prudent to immediately
initiate stabilization and transport of the unconscious
athlete to the emergency department. Fortunately severe
head and neck injuries are rare in youth sports.
Once the young athlete is recognized to have a
concussion he or she must be removed from the prac-
tice or game for the day.
2,4,8,14
The athlete should not be
left unattended on the sideline, and must be assessed
periodically for evolving symptoms and signs. Acute
symptoms typically resolve within few minutes in most
athletes and the athlete may be allowed to go home with
appropriate instructions and a follow-up should be
arranged for the next day in the ofce. The Prague state-
ment recommends that the athlete should watch for the
following symptoms and to seek immediate medical
attention if any occurs
6
:
headache that gets worse
feeling drowsy or difcult to be awakened
difculty recognizing people or places
repeated vomiting
increased confusion
increased irritability
seizures
weakness of arms or legs
unsteady gait
slurred speech
The athlete whose symptoms fail to resolve within
a few minutes, whose symptoms worsen, or who is noted
to have abnormal ndings on neurological examination
should be transferred to the emergency department for
further evaluation and management Box 11-1. With the
recognition of the fact that each athlete follows a variable
time course to recovery from acute cerebral concussion,
an individualized, stepwise plan for return to play is now
considered the most preferred practice rather than fol-
lowing the conventional return to play guidelines. The
more widely known Cantu and the AAN guidelines, base
return to play decisions on the severity grading of con-
cussions. In practice this approach is less useful because
severity of a concussion can be more reliably determined
retrospectively after clinical resolution of the concussion.
Also, loss of consciousness used as one of the criteria to
grade concussion severity has not been shown to be a
reliable indicator of severity of concussion. It is now gen-
erally agreed that, although most athletes recover over a
CHAPTER 11 Concussions 115
Table 11-7.
Computerized Neuropsychological Tests
Test Contact/Web Site
Automated National Rehabilitation Hospital
Neuropsychological Assistive Technology and
Assessment Metrics Neuroscience Center,
(ANAM) Washington, DC
http://thirlstanewest.com/
CCN/ANAM.php
(1) CogSport CogState Ltd, 51 Leicester Street,
(2) Concussion Sentinel Carlton South, Victoria 3053,
(Specically designed for Australia www.cogsport.com
American athletes)
(1) Concussion Resolution HeadMinder, Inc, 15 Maiden Lane,
Index (CRI) Suite 205, New York, NY 10038,
(2) eSAC for sideline testing USA www.headminder.com
(1) Immediate Post ImPACT Applications, Inc,
Concussion Assessment P.O. Box 23288, Hilton Head
and Cognitive Testing Island, SC 29925, USA
(ImPACT 2.0) www.impacttest.com
(2) Sideline ImPACT for
sideline testing
Immediate Postconcussion ImPACT Applications, Inc, P.O.Box 23288, Hilton
Head Island, SC
Assessment and Cognitive Testing (ImPACT 2.0) Sideline ImPACT for sideline
testing www.impacttest.com
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period from 2 to 3 weeks to 1 to 3 months, each athlete
follows a variable trajectory to recovery following a con-
cussion, making any xed period of time out before
return to play a less valid approach.
13,8
Follow-up and Subsequent
Management
The athlete must be seen in the ofce the next day and
further management should be guided by the Prague
consensus statement, which recommends the following
stepwise approach of management
6
:
1. No activity, complete rest, once asymptomatic,
proceed to (step 2).
2. Light aerobic exercise such as walking, station-
ary cycling, and no resistance training.
3. Sport-specic exercise (e.g., skating in hockey,
running in soccer), progressive addition of
resistance training at step 3 and 4.
4. Noncontact training drills.
5. Full-contact training after medical clearance.
6. Return to sport.
With the stepwise progression, the athlete should
continue to proceed to the next level if asymptomatic at
the current level. If postconcussion symptoms reoccur
the athlete should fall back to the previous asympto-
matic step and try to progress after 24 hours.
Increasing evidence suggests that concussion-rat-
ing scales based on athlete self-report of multiple symp-
toms are a reliable and practical way of detecting and
monitoring concussion during recovery phase.
2,6,17,29,30
The Concussion Symptom Inventory (Table 11-8) is one
such scale shown to be sensitive and specic for track-
ing subjective symptoms following sport-related con-
cussion, and is recommended for use during the postin-
jury monitoring.
17
A baseline Concussion Symptom
Inventory prole (preseason) can be valuable to com-
pare later with postinjury prole of the same athlete at
various time intervals.
Children and adolescents should return to
increasing level of schoolwork gradually.
4
They need
cognitive rest until full cognitive recovery.
4,6,14
The
school should be informed of the athletes need for spe-
cial accommodations during the recovery phase. Most
student athletes recover fully from concussion within a
few days or weeks, a few may need to utilize Section 504
plan, and even fewer may need implementation of the
individualized education plan.
Return to play decisions should be individualized
and ultimately are made based on the clinical judgment
of the physician.
1,2,4,6,8,12
Athlete with Multiple Concussions
The adverse effects of repeated concussions on the brain
are cumulative and relatively greater as the interval
between two successive concussions gets shorter.
3036
Likelihood of long-term and permanent impairment in
cognitive functioning is increased significantly with
each repeated concussion. The effects of neurotrauma
are even greater for the developing brain.
1,4,17
An athlete
can sustain multiple concussions during the same day,
during the same season, or over his or her career. There
are no scientically validated criteria for return to play
for athletes who have sustained more than one concus-
sion.
32,33,34
116 Section 2: Medical Conditions and Sport Participation
Table 11-8.
Concussion Symptom Inventory*
Symptom Absent Present
Headache 0 1
Nausea 0 1
Balance problems/dizziness 0 1
Fatigue 0 1
Drowsiness 0 1
Feeling like in a fog 0 1
Difculty concentrating 0 1
Difculty remembering 0 1
Sensitivity to light 0 1
Sensitivity to noise 0 1
Blurred vision 0 1
Feeling slowed down 0 1
Total
*Randolph C, Barr WB, McCrea M, et al: Concussion symptom inventory (CSI): an
empirically derived scale for monitoring resolution of symptoms following
sport-related concussion. www. smf.org/articles/hic/concussion_symptom_
inventory, 2006. Accessed 2006.
Box 11-1 When to Refer to Specialist
Acute*
Severe head and neck trauma
Focal neurologic signs
Acute severe posttraumatic headache
Severe persistent vomiting
Prolonged loss of consciousness
Posttraumatic seizures
Deteriorating mental status
Chronic

Multiple concussions
Persistent postconcussion symptoms
Symptoms of depression
Changes in personality
Changes in behavior
Deteriorating academic functioning
*Appropriate specialists include neurologist, neurosurgeon, and ortho-
pedic surgeon.
Specialists include sports medicine physician, psychologist, or child
and adolescent psychiatrist.
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There is no agreement as to how many concus-
sions are too many to disqualify the athlete from further
participation in high-risk sports; however some have
suggested 3 concussions as the magic number.
2,3,32
For
the young athlete a more conservative approach is rec-
ommended. The young athlete and his or her parents
must be educated about the signicance of repeated
concussions on the developing brain and a serious con-
sideration must be given not to return the athlete with
multiple concussions to high-risk sports.
OUTCOME
Most young athletes recover fully from concussion. In
fact 30% of high school and collegiate athletes return to
play the same day, and 70% after 4 days.
2
Based on NP
testing data, correlation between NP testing and clinical
ndings indicate that most athletes with simple (mild)
concussion recover cognitive function within 7 to 10
days, and those with complex (severe) concussion show
recovery over a period of 1 to 3 months.
6,26
Athletes who
have recovered in terms of their neurocognitive decits
may still have persistent emotional symptoms.
Children and adolescents have a relatively more
prolonged recovery course compared with adults, are
signicantly more likely to have another concussion,
and the effects of repeated concussion are cumula-
tive.
4,14,3346
Children and adolescents can have lifelong
implications as a result of concussion in terms of poor
academic achievement, emotional symptoms, and psy-
chosocial difculties.
A syndrome of rapidly progressive brain edema,
brain stem herniation, and high mortality within min-
utes of a second concussion in an athlete who still has
persistent symptoms (or has not clinically fully recov-
ered) from a previous concussion has been described in
adolescent male athletes.
47
Although some recent
reports have raised doubts on the occurrence or signi-
cance of second impact syndrome, the issue has neither
been fully elucidated nor resolved.
1,2,4,14,47
It seems pru-
dent at present that no athlete should return to play
until fully asymptomatic and has normal examination
at rest and on provocative exertion.
PREVENTION
Increased awareness among athletes, parents, coaches,
and public at large, of various aspects of sport-related
concussion is the most essential element of prevention
strategy.
1,4,6,48,49
On an individual level the pediatrician
should incorporate education about sport-related con-
cussion in the anticipatory guidance during well visits as
well as during the evaluation and management of ath-
CHAPTER 11 Concussions 117
letes who present with concussion. Key aspects of such
education include: recognition of features of concus-
sion, importance of seeking timely medical attention,
not to return to sports before recovery is complete,
potential acute and known long-term consequences of
concussion.
Enforcement of rules of the game play important
role in prevention of head and neck injuries. Use of hel-
mets in American football has reduced the likelihood of
severe skull injury; however, helmet use has not been
shown to be effective in prevention of brain concus-
sion.
6,8,50
Appropriate use of mouth guards has been
shown to reduce the incidence of orofacial injuries; their
efcacy in prevention of concussion has not been estab-
lished
51,52
Strong neck muscles may allow the athlete to
tense these muscles and maintain the head and neck in a
xed position just prior to impact and help dissipate the
forces, theoretically reducing the impact on the brain.
However in real world, there is little time to anticipate the
impact and x the head and neck before the actual impact.
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