Concussion

David T Bernhardt, MD; Chief Editor: Sherwin SW Ho, MD, et al.

Practice Essentials

Concussion, or mild traumatic brain injury (MTBI), is common among contact and collision
sports participants.[1, 2, 3, 4, 5, 6, 7] One definition of concussion is a condition in which there is a
traumatically induced alteration in mental status, with or without an associated loss of
consciousness (LOC).[1] A broader definition is a traumatically induced physiologic disruption in
brain function that is manifested by LOC, memory loss, alteration of mental state or personality,
or focal neurologic deficits.

Essential update: New concussion guidelines from the American Academy of

Neurology
In March 2013, the American Academy of Neurology (AAN) updated its 1997 guidelines on the
evaluation and management of sports concussion. A major change is the removal of return-toplay recommendations. The current recommendation for an athlete who has sustained a
concussion is immediate removal from play to minimize the risk for further injury. The athlete
should not be allowed to return to play until assessment by a health care professional. Young
athletes should be managed even more conservatively as it takes longer for their symptoms
and neurocognitive performance to improve after a concussion.
Highlights from the revised recommendations include the following[8, 9] :

There is no evidence that medication improves recovery after concussion.

The risk for concussion is greatest in football and rugby, followed by hockey and soccer.
The risk for concussion for young women and girls is greatest in soccer and basketball.
An athlete who has a history of 1 or more concussions is at greater risk for being
diagnosed with another concussion.
The first 10 days after a concussion appears to be the period of greatest risk for being
diagnosed with another concussion.
Evidence suggests that use of helmets may prevent concussion vs no helmet, but there
is no clear evidence that one type of football helmet can better protect against
concussion over another kind of helmet.
Licensed health professionals trained in treating concussion should look for ongoing
symptoms, history of concussions, and younger age in the athlete.
Risk factors linked to chronic neurobehavioral impairment in professional athletes
include prior concussion, longer exposure to the sport, and having the ApoE4 gene.
Symptom checklists, the Standardized Assessment of Concussion (SAC),
neuropsychological testing (paper-and-pencil and computerized), and the Balance Error
Scoring System may be helpful tools in diagnosing and managing concussions but should
not be used alone for making a diagnosis.
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Although an athlete should immediately be removed from play after a concussion, there
is insufficient evidence to support absolute rest after concussion.

Signs and symptoms

An athlete suffering from an MTBI may demonstrate the following:

Confusion: Athletes with an MTBI often appear acutely with a confused or blank
expression or blunted affect
Delayed responses and emotional changes: Delayed response to simple questioning may
be demonstrated, along with emotional lability; the emotional lability may become
more evident as the athlete attempts to cope with his or her confusion
Pain/dizziness: Many athletes report an associated headache and dizziness
Visual disturbances: Visual complaints may include seeing stars, blurry vision, or double
vision
Amnesia: Pretraumatic (retrograde) and posttraumatic (antegrade) amnesia may be
present; usually, the duration of retrograde amnesia is quite brief, while the duration of
posttraumatic amnesia is more variable (lasting seconds to minutes), depending upon
the injury
Signs of increased intracranial pressure: A history of persistent vomiting may suggest a
significant brain injury with associated elevated intracranial pressure; other signs of
increased intracranial pressure include worsening headache, increasing disorientation,
and a changing level of consciousness

Physical examination
The physical examination should include assessment of the following:

Appearance: The initial clinical examination should include a careful inspection of the
athlete's general appearance
Head and neck: Palpating the head and neck is important when looking for an
associated skull or cervical injury
Facial bones: Palpate the facial bones and the periorbital, mandibular, and maxillary
areas after any head trauma
Jaws: Open and close the mouth to help in the evaluation of possible
temporomandibular joint (TMJ) pain, malocclusion, or mandibular fracture
Nose: Inspect the nose for deformity and tenderness, which may indicate a possible
nasal fracture
Presence of discharge: Persistent rhinorrhea or otorrhea (clear) indicates a possible
associated skull fracture.
Vision: Perform a careful, detailed neurologic examination that includes evaluation of
the visual fields, extraocular movements, pupillary reflexes, and level of the eyes
Strength and sensation: Assess upper-extremity and lower-extremity strength and
sensation
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Coordination and balance: Concussed patients often have difficulty with the finger-nosefinger test and will use slow, purposeful movements to complete the task

Postconcussive syndrome
Postconcussive syndrome consists of prolonged symptoms that are related to the initial head
injury. Symptoms usually consist of the following:

Persistent, recurrent headaches

Dizziness
Memory impairment
Loss of libido
Ataxia
Sensitivity to light and noise
Concentration and attention problems
Depression
Anxiety

Diagnosis
Imaging
The following imaging studies can be used in the examination of head injury:

Computed tomography scanning: CT scanning continues to be the imaging study of

choice for evaluating acute head injury
Magnetic resonance imaging: MRI is the imaging study of choice for patients who have
prolonged symptoms (>7 days) or when a late change occurs in an individual's
neurologic signs or symptoms

Although positron emission tomography (PET) scanning and functional MRI (fMRI) may be used
in evaluating patients with concussion, their clinical application in most cases of MTBI is
uncertain.[10, 11, 12]
Neuropsychological testing
Detailed neuropsychologic testing is employed more often at the professional level and in
research in athletes with MTBI.

Management
Most patients with MTBI recover in 48-72 hours, even with detailed neuropsychological testing,
and are headache free within 2-4 weeks of the injury.
A clinical report by the American Academy of Pediatrics (AAP) on the diagnosis and
management of sports-related concussions in adolescents and children noted the following[13] :
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Cognitive and physical rest is the mainstay of management of patients with concussion
Ongoing neuropsychological testing is a helpful tool during management

Although several different guidelines regarding return to play have been established, the main
criteria for an athlete's return to play after a concussion include the following:

Complete clearing of all symptoms

Complete return of all memory and concentration
No symptoms after provocative testing: Provocative testing includes jogging, sprinting,
sit-ups, or pushups (ie, exercise that raises the athlete's blood pressure and heart rate)

Background
Concussion has many different meanings to patients, families, and physicians.[14, 15, 16, 1] One
definition of concussion is a condition in which there is a traumatically induced alteration in
mental status, with or without an associated loss of consciousness (LOC).[1] A broader definition
for concussion is a traumatically induced physiologic disruption in brain function that is
manifested by LOC, memory loss, alteration of mental state or personality, or focal neurologic
deficits.[1] Concussions usually result in relatively temporary impairment of neurologic
function.[16, 10, 17]
Concussion or mild traumatic brain injury (MTBI) is common among most contact and collision
sports participants.[1, 2, 3, 4, 5, 6, 7] For many physicians, even those who specialize in MTBI, this
area is confusing due to the paucity of scientific evidence to support much of the clinical
decision making that is faced in the office.[14, 15, 4, 11, 18] The inconsiderable amount of good
scientific research in the area of MTBI is due to problems with ambiguous definitions of
concussion, inconsistent criteria when selecting patients to study, variability of injury
mechanisms and locations, and differing means of measuring cognitive function.[19, 20] The
purpose of this article is to review the epidemiology and diagnosis (but not necessarily the
classification) of MTBI, as well as the role of imaging studies, issues regarding return to play,
and complications surrounding MTBI.

Epidemiology
Frequency
United States
The incidence of head injury varies with the sport and the age of the participants; many head
injuries are likely unreported due to their supposed mild nature; mild concussions may go
unnoticed by teammates, coaches, and even the athletes themselves.[1] An athlete's fear of
medical disqualification may also lead to underreporting. Studies of high school athletes show
the rate of concussions per 1000 exposures as follows: 0.59 for football (boys), 0.25 for
wrestling (boys), 0.18 for soccer (boys; 0.23 for girls), 0.09 for field hockey (girls), and 0.11 for
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basketball (boys; 0.16 for girls). The data from one study noted that concussions account for
nearly 15% of all sport-related injuries in high school athletes.[21]
Among National Collegiate Athletic Association (NCAA) soccer players, the rate of injury has
been reported as 0.4-0.6 per 1000 athlete exposures[6] ; 72% of these injuries were described as
mild and were almost always secondary to direct contact with an opponent. None of the
injuries in this group of Atlantic Coast Conference (ACC) soccer players was noted to be a direct
result of heading the ball. In contrast, boxing is the sport with the highest rate of head injuries
and has more deaths than any other organized athletic activity. At the professional level, many
of the boxing bouts end with a technical knockout (ie, brain injury).
Sports activities that place the athlete at high risk for a head injury include boxing, football, ice
hockey, wrestling, rugby, and soccer. Physicians and other allied health providers who are
responsible for the medical care of such contact or collision sports participants should be adept
at evaluating, treating, and making playability decisions related to the short- and long-term
consequences of an injury to the brain.

Sport-Specific Biomechanics
The mechanisms of brain injury may differ among sports activities. Possible mechanisms of
injury include compressive forces, which may directly injure the brain at the point of contact
(coup); tensile forces produce injury at the point opposite the injury (contrecoup) because the
axons and nerves are stretched; finally, rotational forces may result in a shearing of axons.
Therefore, the direct force at the point of contact may not be solely responsible for the severity
of an injury if a high rotational component with a significant shear effect occurs.
All of the different mechanisms may result in biochemical changes related to perfusion, energy
demand, and utilization at the site of injury that are not well understood. At this time, it is
unclear whether any experimental animal model or human studies on more severe braininjured patients accurately reflect the pathophysiology of the typical mild traumatic alteration
in brain function.

History
Athletes with an MTBI often appear acutely with a confused or blank expression or blunted
affect. Delayed response to simple questioning may be demonstrated, along with emotional
lability. The emotional lability may become more evident as the athlete attempts to cope with
their confusion. Many athletes report an associated headache and dizziness. Visual complaints
may include seeing stars, blurry vision, or double vision.
Both pretraumatic (retrograde) amnesia and posttraumatic (antegrade) amnesia may be
present. Usually, the duration of retrograde amnesia is quite brief, with a more variable
duration of posttraumatic amnesia (seconds to minutes), depending upon the injury.
A history of persistent vomiting may suggest a significant brain injury with associated elevated
intracranial pressure. Other signs of increased intracranial pressure include worsening
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headache, increasing disorientation, and changing level of consciousness. Possible causes of

increasing intracranial pressure include subdural hematomas, epidural hematomas, or some
other type of intracranial hemorrhage.
It is important to document a previous history of concussions. Multiple concussions with
prolonged neurologic symptoms (eg, headache, hyperacusis, dizziness) suggest postconcussive
syndrome and should influence return-to-play decisions.[2, 3, 7, 22, 23, 24, 25]

Assessment tools
The Glasgow Coma Scale (GCS) is routinely used to assess head injuries in an emergency
department. This 15-point scale is used to assess eye (spontaneous opening = 4 to no response
= 1), motor (obeys commands = 6 to no response = 1), and verbal responses (oriented = 5 to no
response = 1) in an attempt to quantify the patient's level of consciousness. This tool is not
sensitive enough to evaluate more mild injuries and should not be used on the playing field to
judge playability.
McCrea et al developed a sideline evaluation to help the practitioner evaluate the more subtly
injured brain.[20, 26] A 30-point scale is used to assess an athlete's orientation, concentration,
immediate memory, and delayed recall. Preseason testing must be done if a practitioner is
hoping to use this tool as a supplement to the neurologic and mental status exam; if the
baseline status of an individual is not known, assessment for change after a head injury is
useless. McCrea's sideline evaluation uses recitation of the months of the year in reverse order
after a study by Young et al showed the lack of reliability of the "serial 7s" test (serial
subtraction by 7 from 100) in the baseline evaluation of mental status even in nonheadinjured athletes.[27]
Interestingly, the results from one study noted that administering preseason baseline
neurocognitive tests in a group versus individual setting resulted in significantly lower verbal
memory, visual memory, motor processing speed, and reaction time scores and a greater rate
of invalid baselines.[28]
Sport Concussion Assessment Tool (SCAT) is another standardized tool. SCAT combines multiple
assessments into a single instrument. This combined tool was produced as a part of the
Summary and Agreement Statement of the Second International Symposium on Concussion in
Sport.[29]

Classification
Many different classification schemes have been proposed over the last 2 decades. No one
classification system is necessarily better than another classification system. No scientific basis
for any of the classification systems exists.

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Cantu's guidelines,[7, 30] Ommaya and Gennarelli's guidelines,[31] the Colorado guidelines,[32] and
the 1997 American Academy of Neurology (AAN) guidelines[33] were proposed to aid in the
evaluation of a concussion. The free CDC Tool Kit on Concussion for High School Coaches is
available online in English and Spanish and uses the 1997 AAN guidelines to support a
classification scheme.[34] The authors prefer to characterize concussions as follows[34] :

A simple concussion injury progressively resolves after 7-10 days without complication.
The key to return to play is to hold the athlete from practice or competition until all
symptoms have resolved.
A complex concussion consists of persistent symptoms that may include those that
recur with exertion, specific sequelae such as seizure associated with the injury,
prolonged LOC (>1 min), or prolonged impairment of cognitive function.

Some studies have suggested that LOC may not be a great predictor of short-term or long-term
neurologic functioning, which makes the guidelines more controversial.[35, 36]
Regardless of the classification scheme that is used, all concur with the ultimate
recommendation: Do not allow the concussed athlete to return to play until the patient is
completely asymptomatic. The athlete must be free of headache, dizziness, amnesia, blunted
affect, and delayed verbal or ocular responses, and all cognitive functioning must have returned
to normal.

Physical
Perform a thorough, organized assessment to better define the degree of injury when a player
is brought to the sidelines or emergency department for evaluation.
The initial evaluation should focus on airway, breathing, and circulation for any unconscious
patient. Assume all unconscious or mentally impaired patients have sustained an injury to their
cervical spine until proven otherwise.
For conscious patients, the remainder of the examination should be performed in a quiet place,
on the sidelines or in the locker room away from teammates and coaches, or in a private room
in an emergency department in order to get an accurate assessment of the cognitive status of
the injured athlete.
The initial clinical examination should include a careful inspection of the athlete's general
appearance.
Palpating the head and neck is important when looking for an associated skull or cervical injury.
Palpate the facial bones and the periorbital, mandibular, and maxillary areas after any head
trauma. (See also the Medscape Reference articles Sports-Related Facial Trauma, Maxillary and
Le Fort Fractures, and Management of Panfacial Fractures [in the Plastic Surgery section].)

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Open and close the mouth to help in the evaluation of possible temporomandibular joint (TMJ)
pain, malocclusion, or mandible fracture. (See also the Medscape Reference articles Initial
Evaluation and Management of Maxillofacial Injuries [in the Trauma section], Mandibular
Fracture Imaging [in the Radiology section], and Mandibular Body Fractures [in the
Otolaryngology and Facial Plastic Surgery section].)
Inspect the nose for deformity and tenderness, which may indicate a possible nasal fracture.
(See also the Medscape Reference articles Nasal and Septal Fractures [in the Otolaryngology
and Facial Plastic Surgery section], Nasal Fracture [in the Sports Medicine section], and Nasal
Fracture Surgery [in the Plastic Surgery section].)
Persistent rhinorrhea or otorrhea (clear) indicates a possible associated skull fracture. (See also
the Medscape Reference articles Imaging in Skull Fractures [in the Radiology section] and Skull
Fracture [in the Neurosurgery section].)
Perform a careful detailed neurologic examination to include examinations of the visual fields,
extraocular movements, pupillary reflexes, and level of the eyes.
Assess upper-extremity and lower-extremity strength and sensation.
Assess coordination and balance. Concussed patients often have difficulty with the finger-nosefinger test and will use slow, purposeful movements to complete the task.
Catena et al compared the immediate versus long-term effects of concussion on balance
control.[37] Individuals with concussion (n = 30) and matched controls (n = 30) performed a
single task of level walking, attention divided walking, and an obstacle-crossing task at 2
heights, with testing occurring 4 times postinjury.
The investigators demonstrated no significant difference between the 2 groups in the singletask level walking task. However, although concussed individuals walked slower within 48 hours
of the injury and had less motion of their center of mass in the sagittal plane with divided
attention during walking, there were no group differences by day 6 for the same task.[37]
In addition, there were no significant group differences in balance control during obstacle
crossing during the first 2 testing sessions, but by day 14, concussed individuals had less
mediolateral motion of their center of mass. Catena et al concluded that attention divided gait
is better at distinguishing gait adaptations immediately postconcussion, but obstacle crossing
can be used further along in the recovery process to detect new gait adaptations.[37]
Significant sway in Romberg testing may indicate persistent injury.
When examining an athlete on the sideline, perform repeat examinations every 15 minutes
until the symptoms have cleared. Repeat the examinations even if the athlete is allowed to
return to play.
The patient should not be allowed to return to competition if his/her symptoms or physical
examination findings do not return to normal after 15 minutes. For a few hours after the initial

Page 8 of 14

injury, close observation and monitoring of the athlete for worsening mental status or
neurologic status is warranted on the sideline or in the emergency department.

Causes
A previous concussion is a significant risk factor for sustaining a concussion.[2, 3, 7, 22, 23, 24, 25]
One study reported that the risk of sustaining a concussion was 4-5 times higher in patients
who had at least 1 concussion in the past. Another study reported that athletes with a history
of 3 or more previous concussions were 3-fold more likely to have a concussion than players
who had no history of concussion.[24]
Other risk factors for sustaining a concussion that have been suggested but not proven include
not wearing mouth guards, poor fitting helmets, and genetic predisposition.[38, 39] Research in all
of these areas continues.

Page 9 of 14

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