Last month, we discussed the details of traumatic brain injuries and sports-related concussion (SRC). The topic is one of great import among physicians, and a regular conference is held in Berlin to examine the most current research and come to conclusions. The Berlin Consensus has given “11 R’s of SRC Management,” and here we explore each of them in greater depth.
Recognize
The first step of SRC management is to recognize the problem. Unfortunately, there is no perfect diagnostic test for immediate diagnosis of concussion in sporting environments. Most sports related concussions do not present frank neurological signs, and it can be difficult to recognize concussion immediately after an inciting event.
To recognize SRC, we must first clarify that it is often defined as the representation of immediate and transient symptoms of traumatic brain injury (TBI). Unfortunately, this definition can only take physicians so far. While on-hand physicians should consider the symptoms, they should recognize that sometimes they do not manifest immediately. One response to be cautious of is the bilateral fencer response, in which the athlete’s arms are held rigidly in the air after impact. This posture is an indication of traumatic brain injury and usually only lasts a few seconds.
More serious abnormal involuntary physical responses include Decorticate (Flexor Posture) and Decerebrate (Extensor Response). The former manifests as rigidly straight legs, clenched fists, and arms bent to hold the hands at the chest, and the latter sees the upper extremities and head extended and the back arched. The flexor posture following TBI has only a 37% survival rate, and the extensor response’s survival rate is a mere 10%.
Remove
An athlete who is suspected to have concussion must be removed from play and from the field, court, or track in order to benefit from further SRC management strategies. He or she should undergo medical assessment and monitoring for deterioration without delay. Preliminary first aid should be administered, and SCAT5—a standardized tool for evaluating concussions—performed.
SCAT5 is used as a screening evaluation in the diagnosis of sports-related concussion. It does have a limited role in tracking recovery, so it should not be used by itself to make or exclude the diagnosis of concussion.
Only trained professionals should move the athlete or remove the helmet or other equipment. The evaluation should be performed by a physician or other healthcare professional. After the injury, the player should not be left alone. Monitoring should be constant. If concussion is diagnosed, the athlete should not be allowed to return to play until the concussion has abated.
Re-Evaluate
In the ER or a doctor’s office, further evaluation should be performed. This should take into account medical history, the improvement or deterioration from the time of injury, a neuropsychological assessment, and a neurological examination, including cognitive fxn, mental status, vestibular function, sleep/wake disturbance, ocular function, gait and balance.
Rest
Rest is the most commonly prescribed intervention for SRC management, despite the lack of evidence that such a prescription is helpful. However, to avoid the risk of exacerbating the damage, patients should refrain from activity for at least 48 hours. Rest can ease discomfort during the recovery period by mitigating symptoms and minimizing the demands on the brain.
Rehabilitation
The rehabilitation stage of SRC management is often paired with rest, especially in the initial Berlin Consensus. Athletes should be aware that treatments vary by patient, but careful monitoring is a necessity.
Refer
A definition of persistent symptoms is required to describe the failure of normal recovery after an injury to the brain. These “persistent symptoms” encompass a wide array of non-specific post-traumatic symptoms that may be linked to other factors, and they fall beyond the “normal recovery time” for such injuries (>10-14 Days for adults and > 4 weeks for children).
Recovery
Though information exists online that cites a concussion recovery period of 10 days, know that that number is far too low. Most concussed athletes recover—clinically speaking—within the first month of injury. The exact window is highly dependent on the SRC management strategies employed during recovery. Athletes should work with their physicians to track recovery, taking advantage of diagnostic tools such as functional magnetic resonance imaging (fMRI), fluid biomarkers, and transcranial magnetic stimulation.
Return to Sport
The process for concussed athletes to return to sport should be graduated, following a stepwise rehabilitation strategy. Athletes should work with their physicians to follow a timetable that works with their symptoms and recovery speed. The first step recommended is to keep all activity to levels that does not exacerbate symptoms. After a reasonable time, athletes may return to light aerobic exercise and then sport-specific exercise. The fourth stage is non-contact training drills, and the fifth is full-contact practice. Once these stages have been completed incrementally, an athlete is likely to be cleared to return to sport.
Reconsider
The high incidence of sports-related concussions does not have to be a foregone conclusion. We can adjust the way we play, and schools especially can implement an SRC policy. All athletes, regardless of level of participation, should be addressed with the SRC management strategies outlined in the Berlin Consensus.
Residual Effects and Sequelae
Further research is required to fully understand the long-term effects of SRC. Though it has been suggested that repeated concussion or subconcussive impacts cause chronic traumatic encephalopathy (CTE), the true relationship between the two remains uncertain.
Risk Reduction
Prevention is the best medicine, the list of SRC management strategies would be incomplete without suggestions for SRC prevention. This includes effective protective equipment, such as helmets (especially common for skiing, snowboarding, and American football) and mouthguards (though the evidence for their effectiveness in preventing SRC is mixed). Preventions can also be behavioral, such as limiting the use of body checking or contact in general during practice.
Prevention begins with understanding the problem, so improving our education about concussions and SRC management plays a critical role in limiting the issue. Further research, especially about the effectiveness of SRC prevention interventions, is a must.
