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Return to athletic competition following concussion.

To establish guidelines for the examination of patients and the resumption of athletic activity after concussion, the injury is characterized as mild, moderate or severe (unconscious only transiently, for less than 5 minutes or for more than 5 minutes). The basic recommendation is that return to training and competition should be deferred until all associated symptoms such as headaches have completely resolved. The decision to return must take into account the nature of the sport, the athlete's level of participation and the cumulative effect of previous concussions. Some athletes will have to avoid any further participation in their sport.

Activities of Daily Living↗

[Short-latency brain-stem auditory evoked potentials in patients with a brain concussion].

The short-latent acoustic stem potentials were examined in 72 males aged 9 to 61 years (mean 32.3 +/- 10.2 years) with concussion of the brain in different early posttraumatic periods (0.5-15 days). The clinical picture of the victims was characterized by systemic cerebral and mild transient symptoms of involvement of stem regions of the brain. Two thirds of the patients were found to have decreased rates of conduction of electric pulses along the acoustic pathway of the brain stem. Moreover, a fourth of the victims had a retarded perception of acoustic stimuli, which implies that concussion of the brain led to the decreased function of the auditory nerve and all relay nuclei of the acoustic system of the brain. The normal pattern of short-latent acoustic stem evoked potentials was seen in 8.3%, their mild and moderate abnormal changes were observed in 40.3 and 51.4% of the patients. Prolongation of a latent period and interpeak intervals, the deformation and lack of waves were considered to be criteria for abnormal changes in short-latent acoustic stem evoked potentials.

Acoustic Stimulation↗

Concussions in sports: guidelines for return to competition.

Concussion is the most common head injury in sports. The injury ranges from a simple "ding" to prolonged loss of consciousness with amnesia. Proper grading of the severity of the injury is necessary to establish a protocol for deciding when to allow an athlete to return to his or her sport. This approach to concussions will minimize the risk of further, even fatal, complications.

Athletic Injuries↗

Clinical management of concussion.

Concussion is an injury that occurs frequently in the general community. Most cases are caused by sporting accidents, falls and assaults. This article reviews the presentation and management of this common problem. High velocity impacts as in motor vehicle accidents may result in concussion but are more likely to produce a serious brain injury.

Amnesia, Retrograde↗

[The significance of radiologically diagnosed brain concussion for the outcome after head injury].

The early and late outcome was evaluated in head injury patients who presented brain contusion(s) on the cranial CT scan and in patients hospitalized for concussion. There was a high degree of concurrence between mortality and CT findings. Late complaints were common among cases of concussion of the brain. However, the frequency of impaired memory and concentration, speech problems, paresis and epileptic seizures was increased in cases where the CT scan showed brain contusion. Adaptive and social functioning was most impaired in cases with multifocal contusions in both hemispheres.

Adolescent↗

[Current views on brain concussion].

Modern views on brain concussion are reviewed by the authors who present also the evolution of the views on this problem in the last five decades. Owing to devising of an experimental model of light craniocerebral injuries the presence of structural changes in the central nervous system developing after concussion has been demonstrated. Using the modern diagnostic imaging techniques (SPECT) in clinical practice persistent disturbances of regional cerebral blood flow were found following such head injuries. The mechanism, which could explain the development of cerebral perfusion changes, could produce also axonal disorders, breakdown of the blood-brain barrier, atrophy of hippocampal neurons which lesions had been noted previously in experiments. The results of SPECT investigations put in doubt the presence of a "pure" functional brain damage following slight craniocerebral injury and provide evidence for the existence will aim at correlating of electrophysiological phenomena, vascular changes and biochemical disturbances with lesions leading to disorders of behaviour observed in the so called postconcussion syndromes.

Atrophy↗

Concussions in athletics: guidelines for return to sport.

Physicians are required to make determinations that affect the health and well-being of their patients on a daily basis. None of these judgements may have as profound an impact as the decisions rendered for athletes who have suffered a concussion. Concussions occur with regularity in sports and vary in severity and appropriate management. Guidelines should be followed and used as a tool to allow safe return to competitive endeavors in the athletic arena. Following guidelines will decrease the likelihood of worsening the condition with potentially fatal consequences.

Athletic Injuries↗

Spinal cord concussion.

A reliable experimental model using decerebrate frogs has been developed by which a measured cutaneous stimulus to the right forelimb produces a single electrical response from the left sciatic nerve. Using this model, the minimal concussing force necessary to abolish the propagation of the nerve impulse down the spinal cord was established by trial and error. The mean recovery time was 31.2 seconds, with a standard deviation of 1.32 seconds. Recovery of function of the spinal cord, as measured this method, was complete following single and multiple concussions.

Animals↗

Spinal-cord concussion in frogs. A study of reflex changes.

A reliable experimental model of the spinal frog, employing the flexor withdrawal reflex to a noxious stimulus, has been used to study the response to single and repeated concussing blows over the spinal column. It is evident that caudally placed blows depress the reflex response, whereas more cephalad blows facilitate the response. The results of studies using repeated concussing blows support the concept that neuronal units may completely lose their function without suffering permanent structural damage.

Animals↗

Neuropsychological Outcome, Post Concussion Symptoms, and Forensic Considerations in Mild Closed Head Trauma.

Controversy regarding the long-term outcome of mild head trauma (MHT) is discussed. Variable results are related to potential methodological problems such as failure to consider issues of sensitivity, specificity, base-rates of symptoms in non-injured populations, and failure to match control to MHT subjects on demographic and motivational factors. Meta-analytic data from well-conducted studies show good long-term neuropsychological recovery for most persons who have sustained MHT. Symptom base-rate data show poor specificity for several so-called "post-concussion" symptoms, which occur frequently in non-brain damaged populations. Persistence of "post-concussive" complaints is considered as a function of somatization, which is potentially amenable to effective cognitive behavioral treatment. Forensic aspects of MHT are discussed, with particular reference to appropriate methods of clinical and scientific inference, and evaluation for malingering.

Journal Article↗

A study of persistent post-concussion symptoms in mild head trauma using positron emission tomography.

BACKGROUND: Complaints of persistent cognitive deficits following mild head trauma are often uncorroborated by structural brain imaging and neuropsychological examination. OBJECTIVE: To investigate, using positron emission tomography (PET), the in vivo changes in regional cerebral uptake of 2-[(18)F]fluoro-2-deoxy-D-glucose (FDG) and regional cerebral blood flow (rCBF) in patients with persistent symptoms following mild head trauma. METHODS: Five patients with mild head trauma and five age and education matched healthy controls were imaged using FDG-PET to measure differences in resting regional cerebral glucose metabolism. Oxygen-15 labelled water (H(2)(15)O)-PET was also used to measure group differences in rCBF changes during a spatial working memory task. In addition, neuropsychological testing and self report of dysexecutive function and post-concussion symptoms were acquired to characterise the sample. RESULTS: There was no difference between patients and controls in normalised regional cerebral FDG uptake in the resting state in frontal and temporal regions selected a priori. However, during the spatial working memory task, patients had a smaller increase in rCBF than controls in the right prefrontal cortex. CONCLUSIONS: Persistent post-concussive symptoms may not be associated with resting state hypometabolism. A cognitive challenge may be necessary to detect cerebral changes associated with mild head trauma.

Adult↗

Physiological effects of controlled concussive brain trauma.

Utilizing a fluid percussion device, we measured the physiological effects of brain trauma in cats exposed to controlled levels of injury. Concussive brain injury at 3-4 atm of intensity led to profound elevations of the mean systemic arterial blood pressure from 128 +/- 26 to 229 +/- 33 mmHg, left ventricular end-diastolic pressure from 4 +/- 2 to 24 +/- 15 mmHg, and pulmonary wedge pressures (PWP) from 5 +/- 3 to 27 +/- 17 mmHg and a relatively moderate increase in intracranial pressure (ICP) from 6 +/- 3 to 38 +/- 31 mmHg (all P < 0.001). Pulmonary edema was evidenced by a significant increase in lung tissue wet-to-dry weight ratios to 3.74 +/- 0.81 as compared with a control group of 2.29 +/- 0.23 (P < 0.001). There was poor correlation between wet-to-dry weight ratios and PWP. Approximately 60% of all spontaneously breathing animals become permanently apneic within 6 min after injury, while the remaining 40% developed transient apnea. Arterial O2 or CO2 pressure alterations, in contrast to pretreatment with phentolamine did not affect the hemodynamic or edemogenic response to trauma. Phentolamine did not block the apneic response or increase in ICP. Comparative studies using intravenous levarterenol without trauma produced responses similar to trauma. Concussive brain injury of 3-4 atm results in pulmonary edema, apnea, sympathetically mediated peripheral vasoconstriction and left ventricular failure effect.

Animals↗

[Clinical observation of dental pulp and root changes of juvenile anterior permanent teeth after concussion and luxation].

OBJECTIVE: To observe the incidence of pulp necrosis and root resorption of the juvenile anterior permanent teeth with concussion and luxation injuries and analyze the relationship between the type of injury and form of root resorption. METHODS: 157 teeth of 79 patients were chosen from 201 patients with concussion and luxation treated with functional-bite-plate at the Department of Pedodontics, School of Stomatology, Beijing Medical University from 1984 to 1996. RESULTS: High occurrence of pulp necrosis and root resorption were found in teeth with intrusion, and pulp necrosis occurred most within 3 months after the injury, while root resorption occurred during 3 weeks to 2 years. At the same time, surface resorption occurred mainly in the teeth with intrusion, extrusion and lateral luxation, and replacement resorption occurred only in intrusive teeth, however inflammatory resorption occurred in extrusive teeth whose pulp was infected. CONCLUSION: Intrusion is the most severe type of tooth trauma.

Adolescent↗

Repeat Administration Elicits a Practice Effect With the Balance Error Scoring System but Not With the Standardized Assessment of Concussion in High School Athletes.

OBJECTIVE: To assess whether repeated administration of the Standardized Assessment of Concussion (SAC) and Balance Error Scoring System (BESS) demonstrates a practice effect in high school athletes. DESIGN AND SETTING: Subjects were assigned to either a control or practice group. Subjects in the control group were assessed twice, 30 days apart. Subjects in the practice group were assessed on 5 occasions. Four assessments were performed within a 7-day period and 1 more assessment 30 days after the initial test. SUBJECTS: Thirty-two uninjured high school athletes participated in this investigation. Sixteen were randomly assigned to a control group and 16 to a practice group. MEASUREMENTS: We measured performance on the SAC and on 6 test conditions of the BESS. RESULTS: We found a significant time-by-group interaction on BESS performance on the day-30 test session. A significant practice effect of the BESS was found during the course of repeated administrations in the practice group. After repeated testing, the number of BESS errors decreased with each test session, and error scores on day 5 (10.94 +/- 2.17) and day 7 (9.44 +/- 3.32) were significantly lower than the baseline score (12.88 +/- 3.34). We did not find group differences or a practice effect on the SAC (baseline score = 26.16). CONCLUSIONS: Our results revealed no practice effect with the SAC and a slight practice effect with repeated administrations of the BESS, especially with the single-leg stance on foam. Clinicians must acknowledge the potential for practice effects when readministering these concussion assessments to track recovery of an athlete or as a guide in return-to-play decision making.

Journal Article↗

Spinal cord concussion in pediatric athletes.

Children with a narrowed canal secondary to spinal stenosis or congenital malformation may be predisposed to spinal cord concussion when the canal is further narrowed in hyperflexion or hyperextension. Review of the medical records of the Winnipeg and Ottawa Children's Hospitals disclosed 12 children who had been treated for transient sensory or motor loss after a spinal injury. Measurements of the spinal canal were compared with standard normal measurements, and the spinal canal width was expressed as a percentage of the vertebral width (the Torg ratio). This study shows that narrowing of the spinal canal is an inconsistent predisposing factor to spinal cord concussion in children. A poor correlation between the Torg ratio and comparison with a series of normal control canal widths was noted.

Adolescent↗

Recovery of postural control after cerebral concussion: new insights using approximate entropy.

CONTEXT: The return-to-play decision after sport-related cerebral concussion depends in part on knowing when an athlete has fully recovered postural control after injury. OBJECTIVE: To describe the postconcussion recovery of postural control using approximate entropy (ApEn), a regularity statistic from nonlinear dynamics. DESIGN: Retrospective case series analysis. SETTING: Sports medicine research laboratory. PATIENTS OR OTHER PARTICIPANTS: Collegiate athletes from whom center-of-pressure and symptom data were collected at preseason, less than 48 hours after injury, and 48 to 96 hours after injury. MAIN OUTCOME MEASURE(S): Approximate entropy values reflecting the amount of randomness contained in center-of-pressure oscillations were calculated for anterior-posterior (AP) and medial-lateral (ML) time series. Equilibrium scores reflecting the amplitude of center-of-pressure AP oscillations were used to indicate postural stability. The number and severity of symptoms were described. RESULTS: Compared with the healthy preseason state, ApEn values for the AP and ML time series generally declined immediately after injury in both steady and unsteady injured athletes. At 48 to 96 hours after injury, ApEn values for the ML time series remained significantly depressed (mean difference compared with preseason = -0.268, standard error = 0.072), even among athletes whose initial postural instability had resolved. We found few significant relationships between changes in ApEn values and changes in symptoms before and after injury. CONCLUSIONS: The effects of cerebral concussion on postural control appear to persist for longer than 3 to 4 days, even among athletes with no signs of unsteadiness. Our results may reflect changes in neurophysiologic or mechanical constraints on postural control. Approximate entropy provides a theoretically distinct, valuable measurement alternative that may prove useful for reducing uncertainty in the return-to-play decision.

Journal Article↗

Histological changes in the internal retinal layers produced by concussive injuries to the globe. An experimental study.

The level of lesions within the human retina causing transient post-concussive retinal opacification (Berlin's oedema) remains unclear, as histological examination of this tissue is rarely possible before the ophthalmoscopic changes resolve. Studies in vivo of retinae in man and experimental animals previously subjected to blunt, nonperforating mechanical injuries suggest that the development of intracellular oedema may be the principal reason why the retina becomes opaque. The retinae of experimental animals (pigs), whose eyes had been subjected to concussive injuries, were examined histologically after the removal and fixation of the globes, at periods ranging from a few minutes to 7 days after trauma. Disturbances were noted in the inner retinal layers immediately after trauma, which included transient swelling of the mitochondria in the nerve fibres lasting for only a few hours, and marked intracellular oedema of the glial elements which took 2 to 3 days to resolve.

Animals↗

Endothelial loss in corneal concussion injury.

A patient who suffered a concussion injury to the cornea from blunt trauma was followed up by means of endothelial photography for seven months. The endothelial cell loss resulting from this injury was almost 50%. Concussion injury to the cornea can cause significant endothelial damage instead of a transient dysfunction.

Adolescent↗