For the highly motivated athlete, and often from a parent’s point of view, the return to play after a mild traumatic brain injury (mTBI, or concussion) may affect future scholarship and professional prospects, but it also carries the risk of further injury and permanent disability. Recognition of sport-related mTBI has been described as the most challenging aspect of managing this particular injury.1 Research has shown that patients, athletes,2-7 and health care providers8-10 all lack knowledge regarding some aspect of mTBI, and appropriate education is crucial.
Management of the athlete with mTBI requires both acute and follow-up care, using assessment tools found to be sensitive to detect deficits in cognition, balance, and coordination.
CASE STUDY
An 18-year-old high school football player was tackled during a Saturday afternoon game; on the previous play, he had run 80 yards following an interception. The tackle caused both his ear pads and his chinstrap to break, but he did not lose consciousness. Within two minutes, he was evaluated on the sidelines by the team’s physician assistant and its certified athletic trainer, during which he became nauseated and vomited several times. The player also complained of a new-onset headache and some dizziness. Three weeks earlier, he had been diagnosed with an mTBI; he recovered fully and was medically cleared to play one week later.
On the sidelines immediately after the current injury, the athlete underwent a neurologic examination that yielded no focal neurologic findings. He was transported to the local emergency department (ED) because of the headache and vomiting. The ED provider made a diagnosis of “forehead contusion” and told the patient that he “did not have a brain injury since there was no loss of consciousness.” CT was not ordered, and the athlete was prescribed ibuprofen for his headache.
The following Monday, the athlete was reevaluated by the team PA and the PA’s supervising physician. The athlete reported some residual headache but said the dizziness, nausea, and vomiting had resolved shortly after the injury. His neurologic exam was unremarkable, and although no baseline data were available, results from the Automated Neuropsychological Assessment Metrics (ANAM)11 computerized test demonstrated deficits in reaction time, problem solving, and short-term memory, in comparison with age-matched individuals. CT with contrast performed at that time was negative for hematoma or intracranial swelling.
The athlete was diagnosed with a resolving mTBI and postconcussion syndrome. The consensus was that the vomiting was most likely not a result of the head injury but rather was triggered by the physical exertion of having sprinted 80 yards on the previous play. He was restricted from any exercise and all contact sports until he was asymptomatic, both at rest and during physical activity. The athlete and his mother were informed about the risks of second-impact syndrome.12,13 Follow-up ANAM testing was suggested, but the patient did not return to the office for the test.
mTBI IN THE YOUNGER PATIENT
This case is not an isolated occurrence. In the United States, annual estimates of sport-related traumatic brain injuries, predominantly concussions, range from 1.6 million to 3.8 million.14 According to recent data from injury surveillance systems, concussions sustained by high school athletes represent a greater proportion of sport-related injuries (8.9%) than do those among college athletes (5.8%). Female athletes sustain sport-related mTBI and associated injuries at a higher rate and proportion than do males participating in the same sports.15
Sustaining a sport-related mTBI at an early age is of particular concern: The brain is still developing, and younger patients have an enhanced potential for cumulative effects and prolonged cognitive deficits. Athletes with even one previous mTBI are at increased risk for future mTBI (adjusted risk ratio, 1.4, compared with athletes who have never sustained such an injury).16 Of even greater concern, high school athletes tend to experience delays in cognitive and symptomatic recovery following a concussive injury.17
A growing body of literature has demonstrated difficulties in recognizing and managing mTBIs at all levels of play and within various patient populations.1,18,19 One survey of mTBI evaluation in primary care settings revealed that only 33% of practitioners responsible for sideline coverage used a standard, objective protocol, and an additional 31% used no mTBI guidelines. Among the latter, 71% cited a lack of knowledge, and 16% said they found existing guidelines confusing.10
Another study revealed that hospital discharge instructions for children sustaining an athletic mTBI were inadequate in 69.7% of cases.9 Among these patients, 13% were instructed to return to activity too soon, and 87% were given no instructions at all. The need to better educate athletes, parents, coaches, and health care professionals about the potential seriousness of sport-related mTBI and safe return to the playing field is clear.1,20