Concussion

Key principles

• concussion is a transient disturbance of brain function associated with a mild traumatic brain injury;

• patients should gradually resume normal activity after a brief period of relative rest;

• strict rest is not an effective strategy for recovery;

• light physical activity that does not exacerbate symptoms facilitates recovery;

• providing clear consistent guidance around return to school and return to sport is a key component of management.

Introduction

Concussion is a traumatically induced, transient disturbance of brain function which includes one or more of somatic, cognitive, or emotional symptoms, behavioural change, sleep disturbance, and/or transient physical signs.

Although the term concussion is often used interchangeably with mild traumatic brain injury, it more specifically describes a pattern of symptoms and signs that a person may experience following a mild traumatic brain injury.

The vast majority of concussions are mild, and typically cause transient, self-limiting symptoms.

Pathophysiology

The current international consensus is that concussion occurs as a result of functional disturbance rather than from macrostructural damage such as bruising, bleeding or swelling.

A concussion can result from both direct and indirect injury to the head. Clinicians often consider a direct, traumatic blow to the head as a significant cause of a concussion. However, indirect traumatic forces elsewhere in the body can lead to an acute acceleration/deceleration injury to the brain, which can also lead to concussion symptoms.

Diagnostic criteria

There is no single pathognomonic finding or a minimum number of symptoms for diagnosing a concussion.

Diagnosis of a concussion remains an exclusively clinical diagnosis based on history and exam findings.

Symptoms of concussion do not always develop immediately after an injury. The development of symptoms within hours to days after a precipitating injury may still indicate a concussion.

In general, concussion symptoms can be divided into the three main categories of physical, cognitive and behavioural/emotional. However, no features alone, or in combination, are specific for concussion.

Management

Imaging

Imaging (e.g. CT Head) is not required to make a diagnosis of concussion. Imaging is only required if the patient has unexplained focal neurology, symptoms suggestive of raised intracranial pressure, or fulfil the other criteria for obtaining a CT head (e.g. concern of intracranial bleeding) as outlined in the Starship Head Injury guideline. 

Graduated return to normal activity advice

Evidence suggests that patients with concussion can safely and gradually resume normal activity as early as 24 hours post-injury.

Strict rest until symptoms resolve is NOT an effective strategy for recovery from concussion. Light physical activity that does not exacerbate symptoms during the 48 hours after injury has been demonstrated to facilitate recovery.

Transient symptoms refer to a temporal onset of symptoms related to activity that typically resolve or improve in less than 24 hours. The onset of transient symptoms during a gradual return to activity is common and safe so long as these do not impair functional abilities beyond a short time frame and no new or further injury is caused. Exacerbation of symptoms lasting greater than 24 hours indicate that tolerance thresholds have been exceeded, and activity should be adjusted accordingly. Where progress is not seen, or is very slow, a reassessment by a healthcare professional is indicated.

1. Initial Relative Rest
   Physical Rest is recommended for a period not exceeding 48 hours, followed by gradually increasing, low to moderate physical activity that is at a level that does not result in a significant exacerbation of symptoms.
   
   Cognitive Rest is recommended for a period not exceeding 48 hours, followed by gradually increasing, low to moderate cognitive activity that is at a level that does not result in a significant exacerbation of symptoms. Reduced screen use in the first 48 hours following a concussion is also recommended.

2. Return to School
   The patient should return to school as soon as they are able to tolerate engaging in cognitive activities without a significant increase in their symptoms.
   
   To facilitate a patient’s return to school some temporary academic accommodations (e.g. return to the physical school environment part-time, modifications to class schedule, changes to the classroom environment and workload) may be required.
   

   Complete absence from school for more than one week is generally not recommended

   Refer to the Graduated Return to Education and Sport Protocol below.

3. Return to physical activity and sport
   Early introduction (after 24 hours) of gradually increasing, low to moderate physical activity is recommended provided it is at a level that does not result in a significant exacerbation of symptoms.
   
   Activities with a risk of contact, fall or collisions that may increase the risk of sustaining another head injury should be avoided during the recovery period.
   
   Patients who play sport should commence a modified, non-contact exercise program and must subsequently be asymptomatic before full contact training or game day play can resume. Return to contact sport should NOT occur until return to school has been successfully achieved.
   
   Starship has taken a pragmatic approach and made the considered opinion to align with the guidance of ACC and the majority of New Zealand professional sporting institutions (see links below) regarding the minimum stand down period between injury and return to sport. As such, return to full contact practice (Stage 5) should not occur before 14 days post the index injury and return to sports competition/game play (Stage 6) should not occur before 21 days post the index injury.
   
   Refer to the Graduated Return to Education and Sport Protocol below.

4. Graduated Return to Education and Sport
   

   Graduated return to sport
   Stage	Day
   One	1-2		Relative rest for 24-48 hours (i.e. light activities that do not worsen symptoms)
   Two		Minimum of 24 hours between stages before progressing	Gradually introduce daily activities
   Three		Symptoms should be progressively improving	Increase tolerance for mental and exercise activities
   Four		If symptoms worsen, drop back a stage	Return to school/study and sport training - part time return to school - start training activities without risk of head impact
   Five	Earliest Day 14		Return to normal study and sport-specific training - completion of Stages 1-4 AND - fully returned to school AND - symptom free - AND > Day 14 post injury: integration into full sport-specific training can occur
   Six	Earliest Day 21		Return to sports competition - completion of Stage 5 AND - symptom free during sports training - AND > Day 21 post-injury - AND the player has received medical clearance from a qualified medical professional (from a general practice or primary care team)

   Day 0 = Day of the injury/concussion.

5. Screen time
   Use of screens should be consistent with the recommendation for gradually increasing cognitive activity based on symptoms and with the general recommendations around screen use in children

   1. aged 2–5 years
      limiting screen use to one hour per day
      avoid exposure to devices or screens for one hour before bed
      devices should be removed from bedrooms before bedtime

   2. over 5 years
      avoid exposure to devices or screens for one hour before bed

Devices should be removed from bedrooms before bedtime.

Analgesia

Concussion symptoms should be expected to resolve without the need for significant pharmacological intervention. If analgesia is required, prescribe simple non-opioid analgesia for short-term relief. Patients who are using greater than 15 days a month of analgesia should be medically reviewed.

Sleep disturbance

Sleep disturbance is common in patients who have sustained a concussion. Behavioural and environmental changes are recommended first-line interventions.

If sleep disturbances persist despite maintaining good sleep hygiene and a trial of cognitive behavioural therapies, consider a short-term trial of melatonin (unless contraindications).

Screening tests

Currently the sensitivity and specificity of concussion checklists or risk prediction scores to diagnose the likelihood of persistent concussive symptoms in paediatrics are modest and so are not currently recommended for use in the Children’s Emergency Department at Starship.

Patients who are admitted to Starship Hospital should be screened by a Paediatric Occupational Therapist as per the Starship - Concussion - Inpatient assessment and management guideline.

Requirement for Admission

If parenteral fluids, or high levels of analgesic/anti-emetic are required, then the patient should remain in hospital until these are readily controlled.

Referral to ACC Concussion Clinic

The majority of patients assessed in the emergency department should not be referred to ACC Concussion Services as their symptoms would be expected to resolve within 7 to 14 days.

All patients diagnosed with a concussion in the emergency department should be advised to see their GP or local urgent care for review at 7 to 14 days.

Consider referral to ACC Concussion Services if patients present to the emergency department with persisting symptoms of concussion and they meet the referral eligibility criteria below.

Patients diagnosed with a repeat concussion within 12 weeks of an index injury, or those who have had multiple discrete concussions are at increased risk of persistent concussive symptoms and so should be referred to ACC Concussion Services.

Persistent Concussive Symptoms

A range of factors have been identified that may affect the severity and duration of persisting concussive symptoms.

Repetitive head trauma and greater severity of symptoms at initial presentation have been associated with symptoms persisting for more than one month, although the vast majority of these patients recover by three months.

Post-concussion syndrome was the term previously used for persisting concussion symptoms. However, it has been determined that this term is non-specific and clinically unhelpful. As such the diagnosis of post-concussion syndrome has been removed from the latest versions of the Diagnostic and Statistical Manual of Mental Disorder (DSM-5) and the International Classification of Diseases (ICD-11).

Persistent concussive symptoms is the term now used for symptoms that persist for more than three months.

Sport Specific Guidelines 

The highest number of sport-related concussions occur in team-based sports (e.g., rugby, football, basketball) and from cycling and equestrian activities. 

1. Netball New Zealand Community Concussion Guidelines  

2. New Zealand Rugby Community Concussion Management 

3. New Zealand Cricket Concussion Policy 

4. New Zealand Football Head Injury & Concussion Policy 

5. Sport Concussion in New Zealand: National Guidelines 

6. Cycling New Zealand Concussion Awareness Policy 

Ministry of Education Guidelines  

Supporting learners with acquired brain injury