sport-related concussion in children and adolescents mark ... · clinical report—sport-related...

DOI: 10.1542/peds.2010-2005; originally published online August 30, 2010; 2010;126;597Pediatrics

Mark E. Halstead, Kevin D. Walter and The Council on Sports Medicine and FitnessSport-Related Concussion in Children and Adolescents

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Clinical Report—Sport-Related Concussion inChildren and Adolescents

abstractSport-related concussion is a “hot topic” in the media and in medicine.It is a common injury that is likely underreported by pediatric andadolescent athletes. Football has the highest incidence of concussion,but girls have higher concussion rates than boys do in similar sports.A clear understanding of the definition, signs, and symptoms of con-cussion is necessary to recognize it and rule out more severe intracra-nial injury. Concussion can cause symptoms that interfere with school,social and family relationships, and participation in sports. Recogni-tion and education are paramount, because although proper equip-ment, sport technique, and adherence to rules of the sport may de-crease the incidence or severity of concussions, nothing has beenshown to prevent them. Appropriate management is essential for re-ducing the risk of long-term symptoms and complications. Cognitiveand physical rest is the mainstay of management after diagnosis, andneuropsychological testing is a helpful tool in the management of con-cussion. Return to sport should be accomplished by using a progres-sive exercise programwhile evaluating for any return of signs or symp-toms. This report serves as a basis for understanding the diagnosisand management of concussion in children and adolescent athletes.Pediatrics 2010;126:597–615

INTRODUCTIONSince 1999, an extensive amount of research and media coverage hasbeen dedicated to sport-related concussions. Young athletes pose aunique challenge, because their brains are still developing and may bemore susceptible to the effects of a concussion. Even 10 years ago, ayoung athlete with a “ding” or low-grade concussion would have beenallowed to return to sports as soon as 15 minutes after his or hersymptoms had cleared. Since then, more extensive research has pro-vided medical professionals with a better understanding of the symp-tomatic course and risk of potential long-term complications fromconcussions. As a result, management has evolved. Unfortunately, manyparents, coaches, and young athletes still seem to believe that youth is aperiod of indestructibility. Concussion education in youth and high schoolsports communities is complicated by the misconception that a concus-sionmaybe “toughedout” anddoesnot require aphysician visit. Researchand carefully documented experience show otherwise, although to thepeoplewho believe thosemisconceptions, itmay seemas though the land-scape of managing concussion has changed overnight.

Some organizations, such as the American College of Sports Medicineand National Athletic Trainers Association, have addressed sport-

Mark E. Halstead, MD, Kevin D. Walter, MD, and THECOUNCIL ON SPORTS MEDICINE AND FITNESS

KEY WORDSconcussion, sports, head injury, mild traumatic brain injury,return to play, athletes, second-impact syndrome,postconcussion syndrome

ABBREVIATIONSCIS—concussion in sportLOC—loss of consciousnessSAC—Standardized Assessment of ConcussionBESS—Balance Error Scoring SystemSCAT2—Sport Concussion Assessment Tool 2CT—computed tomography

The guidance in this report does not indicate an exclusivecourse of treatment or serve as a standard of medical care.Variations, taking into account individual circumstances, may beappropriate.

This document is copyrighted and is property of the AmericanAcademy of Pediatrics and its Board of Directors. All authorshave filed conflict of interest statements with the AmericanAcademy of Pediatrics. Any conflicts have been resolved througha process approved by the Board of Directors. The AmericanAcademy of Pediatrics has neither solicited nor accepted anycommercial involvement in the development of the content ofthis publication.

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PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2010 by the American Academy of Pediatrics

FROM THE AMERICAN ACADEMY OF PEDIATRICS

Guidance for the Clinician inRendering Pediatric Care

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related concussions in position state-ments.1,2 Three international symposiaon concussion in sport (CIS) have beenheld since 2001, although none fo-cused exclusively on the pediatric ath-lete.3–5 Although the Canadian Paediat-ric Society published guidelines on themanagement of the pediatric concus-sion, new research has been con-ducted since that statement.6 This re-port outlines the current state ofknowledge on pediatric and adoles-cent sport-related concussions.

DEFINITION

A clear definition of concussion re-quires consensus among researchers,clinicians, and patients, each of whomrequire a different construct for un-derstanding the injury. Some advocateusing the term “concussion,” and oth-ers advocate using the term “mildtraumatic brain injury” (mTBI). A re-cent study highlighted a general misin-terpretation that an injury describedas a concussion is less severe than onedescribed as mild traumatic brain in-jury, which may result in a prematurereturn to school and activity.7 In thisclinical report, we will refer to the in-jury as concussion.

The first of 3 international symposia onCIS was held in Vienna, Austria, in2001.3 From that meeting came a newconsensus definition for a sport-related concussion, with minor revi-sions occurring in the 2 subsequentsymposia held in Prague, Czech Repub-lic, in 20044 and Zurich, Switzerland, in2008.5 The Zurich statement definedconcussion as “a complex pathophysi-ological process affecting the brain, in-duced by traumatic biomechanicalforces”5 and includes 5major features:

1. Concussion may be caused either by adirectblow to thehead, face, orneckorelsewhere on the body with an “impul-sive” force transmitted to the head.

2. Concussion typically results in therapid onset of short-lived impair-

ment of neurologic function that re-solves spontaneously.

3. Concussion may result in neuro-pathological changes, but the acuteclinical symptoms largely reflect afunctional disturbance rather thana structural injury.

4. Concussion results in a graded setof clinical symptoms that may ormay not involve loss of conscious-ness (LOC). Resolution of the clini-cal and cognitive symptoms typi-cally follows a sequential course;however, it is important to note thatin a small percentage of cases,postconcussive symptoms may beprolonged.

5. No abnormality on standard struc-tural neuroimaging studies is seenin concussion.

Biokinetics and Pathophysiology

The biokinetics that induce a concus-sion consist primarily of acceleration-deceleration and rotational forces.8,9 Ithas been proposed that greater forceis required to produce an injury to thepediatric brain than to the adultbrain.10 Adults typically develop moreintracranial injury in association withskull fractures than do children.11

These findings may be related to thedeveloping brain and skull, but it is un-clear whether this model applies tosport-related concussion.

The pathophysiology of a concussion,as described from animal models,starts with a disruption of the neuro-nal membrane, which results in a po-tassium efflux to the extracellularspace with a subsequent release ofglutamate, an excitatory amino acid.12

Glutamate potentiates further potas-sium efflux, which results in the depo-larization and suppression of neuronalactivity. To restore ion balance, thesodium-potassium ion pumps in-crease activity, which results in exces-sive adenosine triphosphate consump-tion and glucose utilization.13 Lactate

accumulates and cerebral blood flowdecreases, which leads to a proposed“energy crisis.”13 A large amount of cal-cium also accumulates in cells, whichmay impair oxidative metabolism andallow for the initiation of biochemicalpathways that result in cell death.13 Af-ter the increase in glucose metabo-lism, there is a subsequent hypometa-bolic state that may persist for up to 4weeks after injury.14,15 Because thepathophysiology has only been estab-lished from animal models, it is stillunclear whether this can be applied tothe sport-related concussion.16

Grading Scales

There are more than 25 different pub-lished grading systems for concus-sions.17 They were developed throughexpert opinion and rely heavily on LOCand a few symptoms, such as confu-sion and amnesia, to determine theseverity of the concussion and subse-quent return to play. The 3 concussion-grading scales most commonly usedare the American Academy of Neurol-ogy,18 Colorado Medical Society,19 andCantu20,21 grading systems. In recentconsensus statements, the CIS grouprecommended abandoning the use ofgrading scales and endorsed usingseveral evaluation measures to indi-vidually guide return-to-play deci-sions.3–5 In the 2004 Prague statement,the CIS group subsequently introducedthe classification of concussions intosimple and complex groups.4 Thesegroups were subsequently abandonedin the 2008 Zurich statement, becausethe delineation was also arbitrary andnot found to be useful in managingconcussion.5 The current recommen-dation remains theabandonmentof pre-vious grading scales for a symptom-based approach for determination ofreturn to play.5

EPIDEMIOLOGY OF CONCUSSION

It is commonly reported that 300 000sport-related concussions occur each

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year, although it was estimated in arecent review that up to 3.8 millionrecreation- and sport-related concus-sions occur annually in the UnitedStates. The large variance is attribut-able to original estimates includingconcussions that only involved LOC.22,23

This highlights the difficulty with con-cussion epidemiology because of un-derreporting and the lack of wide-spread use of an injury surveillancesystem in youth sports.24,25 With in-creasing access to recreational andorganized (club and school) sports, aswell as better awareness and recogni-tion of the injury, the number of diag-nosed concussions will likely increase.Because of the large numbers of par-ticipants in youth and high schoolsports, concussions in the pediatricand adolescent age groups accountfor the majority of sports-relatedconcussions.

Concussions represent an estimated8.9% of all high school athletic inju-ries.26 Data are significantly lackingabout concussions in grade school andmiddle school athletes, which high-lights the need for more researchabout concussions in this younger agegroup.

Girls are reported to have a higherrate of concussion than boys in similarsports.26–30 The reason for this differ-ence is unknown, although some havetheorized that female athletes haveweaker neck muscles and a smallerhead mass than their male counter-parts.31,32 Alternatively, male athletesmay be more reluctant to report theirinjuries for fear of removal from com-petition, which may result in the inci-dence of concussion in boys beingunderestimated.24,33

The sport with highest risk of concus-sion in high school is football (Table1).26 In girls’ sports, the rate of concus-sion is highest in girls’ soccer andgirls’ basketball. Rugby, ice hockey,and lacrosse also account for higher

rates of concussions but are often clubsports, which limits their data inclu-sion in the larger high school sportsepidemiologic studies.34–37

SIGNS AND SYMPTOMS

The signs and symptoms of concussionfall into 4 categories: physical, cogni-tive, emotional, and sleep (Table 2).38

Headache is the most frequently re-ported symptom.39 LOC occurs in lessthan 10% of concussions but is an im-portant sign that may herald the needfor further imaging and interven-tion.40–42 Along with LOC, amnesia may

be an important indicator of more se-rious injury.40 The athlete should beevaluated for retrograde (before theevent) and anterograde (after theevent) amnesia by asking questionsabout details of events before and af-ter the injury. The symptoms of retro-grade amnesia may improve overtime.43 Often, the athlete hears peers,family, and coaches discuss eventssurrounding the injury and, subse-quently, may falsely report remember-ing more about the injury. Mental fog-giness may be a good predictor of aslower recovery from concussion inathletes.44

The signs and symptoms of concussionare similar to depression, anxiety, andattention-deficit disorders. In patientswith preexisting mental health disor-ders, concussion may exacerbatethose symptoms and make them moredifficult to control. It is important tomonitor this population carefully andconsider altering existing care plans.Patients with learning disabilities andcognitive delays will also exhibit simi-lar signs and symptoms, which can in-crease the challenge of managingtheir concussion.

Several factors may complicate therecognition of concussion for the ath-lete. Athletes may not recognize thatthey have concussion symptoms be-cause of poor understanding of a con-cussion and its associated symptomsor from cognitive impairment from theinjury itself. Symptoms may not ap-

TABLE 1 Concussion Rates in High SchoolSports

Sport Injury Rate, per 1000Athlete Exposures

Football 0.47–1.03a,b

Girls’ soccer 0.36a

Boys’ lacrosse 0.28–0.34c,d

Boys’ soccer 0.22a

Girls’ basketball 0.21a

Wrestling 0.18a

Girls’ lacrosse 0.10–0.21c,d

Softball 0.07a

Boys’ basketball 0.07a

Boys’ and girls’ volleyball 0.05a

Baseball 0.05a

a Data from Gessel LM, Fields SK, Collins CL, Dick RW, Com-stock RD. Concussions among United States high schooland collegiate athletes. J Athl Train. 2007;42(4):495–503.b Data from Guskiewicz KM, Weaver NL, Padua DA, GarrettWE. Epidemiology of concussion in collegiate and highschool football players. Am J Sports Med. 2000;28(5):643–650.c Data from Lincoln AE, Hinton RY, Almqueist JL. Head, face,and eye injuries in scholastic and collegiate lacrosse: a4-year prospective study. Am J Sports Med. 2007;35(2):207–215.d Data from Hinton RY, Lincoln AE, Almquist JL. Epidemiol-ogy of lacrosse injuries in high school-aged girls and boys:a 3-year prospective study. Am J Sports Med. 2005;33(9):1305–1314.

TABLE 2 Signs and Symptoms of a Concussion

Physical Cognitive Emotional Sleep

Headache Feeling mentally “foggy” Irritability DrowsinessNausea Feeling slowed down Sadness Sleeping more than usualVomiting Difficulty concentrating More emotional Sleeping less than usualBalance problems Difficulty remembering Nervousness Difficulty falling asleepVisual problems Forgetful of recent informationFatigue Confused about recent eventsSensitivity to light Answers questions slowlySensitivity to noise Repeats questionsDazedStunned





pear until several hours after a con-cussive episode.4 In addition, youngathletes may not be forthcoming withtheir symptoms for fear of activityrestrictions.

A number of immediate motor phe-nomena, such as tonic posturing orconvulsive movements, may accom-pany a concussion.5 These immediateresponses are uncommon, are gener-ally benign, and require nothing morethan standard management of the un-derlying concussion.5,45 Although abrief seizure immediately after a con-cussive impact may not be problem-atic, any athlete who has a seizure af-ter concussion should be transportedemergently to amedical facility for fur-ther evaluation.

An athlete may be followed through hisor her recovery with the use of thepostconcussion symptom scale (Table3). Although there are several varia-tions, a 22-item symptom list is mostcommonly used. The scale is a 7-pointLikert scale graded from 0 (no symp-toms) to 6 (severe symptoms). An ath-lete may bemore likely to report symp-toms if given a graded scale than ifasked a “yes” or “no” question. Thesescales have validity but have not beenassessed adequately for reliability.46,47

Results of a recent analysis of varioussymptom scales suggest that a 13-itemchecklist may be more helpful, butfurther research is needed to validatethat recommendation.48 Symptomscales have not been adequately stud-ied in the grade school athlete.47 At anyage, it is important to make sure thepatient understands what each symp-tommeans and is able to complete thesymptom scale independent of paren-tal influence. Athletes with preinjurydepression, sleep disturbances, and/or attention-deficit/hyperactivity dis-order may not be expected to have atotal score of 0 on a symptom scalebefore considering return to play. Theevaluator must take a thorough his-

tory of the patient and account forthese problems when making deci-sions about return to play.

Physical exertion and cognitive exer-tion, such as doing schoolwork, read-ing, playing video games, using a com-puter, and watching television, mayworsen symptoms, although no link tolong-term outcomes has been de-scribed. Athletes can develop symp-toms during and after exertion, whichindicates incomplete recovery.

INITIAL ASSESSMENT

On the Field

As with all acute head and neck inju-ries, initial assessment of the “ABCs”(airway, breathing, and circulation)and stabilization of the cervical spineare of the utmost importance. Cervical

spine injury should be assumed in anyathlete who is found to be unconsciousafter head or neck trauma. Maintain-ing adequate cervical spine stabiliza-tion is critical until neurologic functionin all 4 limbs is evaluated and found tobe intact and the athlete has no re-ported neck pain or cervical spine ten-derness on palpation. If this evaluationcannot be accomplished or if a quali-fied medical professional is not avail-able on the field, transport to an emer-gency facility is warranted. An athletewho was not unconscious or whoquickly regained consciousness and isnot suspected of having a cervicalspine injury can be further evaluatedon the sidelines.

Initial sideline evaluation should in-clude an inquiry into the athlete’ssymptoms, a neurologic examination,and evaluation of the athlete’s cogni-tion by using one of several availablesideline assessment tools, such as theMaddocks questions,49 StandardizedAssessment of Concussion (SAC),50 Bal-ance Error Scoring System (BESS),51 orSport Concussion Assessment Tool 2(SCAT2).5 The SCAT2 (Appendix 1) wasreleased in the CIS Zurich statement asan enhanced version of the originalSCAT introduced in the CIS Viennastatement and includes the majority ofaccepted sideline assessments in acomprehensive evaluation.3,5

The Maddocks questions are a briefset of questions to evaluate orienta-tion as well as short- and long-termmemory related to the sport and cur-rent game.49 The questions are forsideline use only and are included inthe SCAT2.5 Examples of questions in-clude “What team did you play lastweek?” and “Did the team win the lastgame?”

The BESS is an assessment of posturalstability that is performed with thesubject in 3 positions, first on a firmsurface and then on a 10-cm-thickpiece of foam. The 3 positions include

TABLE 3 Postconcussion Symptom Scale (noSymptoms, 0; Moderate, 3; Severe, 6)

Headache 0 1 2 3 4 5 6Nausea 0 1 2 3 4 5 6Vomiting 0 1 2 3 4 5 6Balance problems 0 1 2 3 4 5 6Dizziness 0 1 2 3 4 5 6Fatigue 0 1 2 3 4 5 6Trouble falling to sleep 0 1 2 3 4 5 6Excessive sleep 0 1 2 3 4 5 6Loss of sleep 0 1 2 3 4 5 6Drowsiness 0 1 2 3 4 5 6Light sensitivity 0 1 2 3 4 5 6Noise sensitivity 0 1 2 3 4 5 6Irritability 0 1 2 3 4 5 6Sadness 0 1 2 3 4 5 6Nervousness 0 1 2 3 4 5 6More emotional 0 1 2 3 4 5 6Numbness 0 1 2 3 4 5 6Feeling “slow” 0 1 2 3 4 5 6Feeling “foggy” 0 1 2 3 4 5 6Difficulty concentrating 0 1 2 3 4 5 6Difficulty remembering 0 1 2 3 4 5 6Visual problems 0 1 2 3 4 5 6

Use of the postconcussion symptom scale: The athleteshould complete the form, on his or her own, by circling asubjective value for each symptom. This form can be usedwith each encounter to track progress toward symptomresolution. Many athletes may have some of these re-ported symptoms at a baseline, such as concentrationdifficulties in the patient with attention-deficit disorder orsadness in an athlete with underlying depression. Thismust be taken into consideration when interpreting thescore. Athletes do not need a total score of 0 to return toplay if they had symptoms before their concussion. Thisscale has not been validated to determine concussionseverity.



standing flat on both feet with handsplaced on the iliac crests, standing ona single leg on the nondominant foot,and standing flat on both feet with eyesclosed. Each assessment lasts 20 sec-onds. A score is obtained by totalingthe number of errors the athletemakes over the 6 tests.51 The BESSseems to have a practice effect andalso seems to be affected not only bythe environment in which the test isconducted but also by how soon afterexercise the test is given.52–55 There areconcerns of intra-rater and inter-raterreliability as well as determining themost reliable components of the indi-vidual tests.56,57 On the basis of thesestudies, it seems beneficial to test anathlete more than 15 minutes aftercessation of exercise and in a settingin which he or she will be doingfollow-up assessments, rather than onthe sideline.

The SAC has been shown to have little tono practice effect.52,53 Baseline assess-ments with an SAC test can be helpful ininterpreting postinjury results. Any de-crease from the baseline score on anSAC was found to be 95% sensitive and76% specific for a concussion.58 The SAChas not been validated for use in thegrade school athlete.

The newer SCAT2 incorporates boththe BESS and the SAC; however, the fullSCAT2 evaluation has not been re-searched since its release with the Zu-rich concussion statement. Becausethe SCAT2 has not yet been studied, theZurich statement authors recom-mended relying on the SAC score untilprospective studies are conducted onthe SCAT2.5

If a concussion is identified, the athleteshould be removed from the remain-der of the practice or game(s) on thatday.5 The athlete should continue to bemonitored for several hours after theinjury to evaluate for any deteriorationof his or her condition. Referral to theemergency department is warranted

if an athlete experiences repeatedvomiting, severe or progressivelyworsening headache, seizure activity,unsteady gait or slurred speech, weak-ness or numbness in the extremities,unusual behavior, signs of a basilarskull fracture, or alteredmental statusresulting in a Glasgow Coma Score ofless than 15.

In the Office/EmergencyDepartment

When the athlete is evaluated initiallyin the office or emergency departmentafter a concussion, a thorough history,including signs and symptoms as wellas details of any previous head inju-ries; head and neck examination; neu-rologic examination, including gait andbalance assessment (such as theBESS, Romberg test, and tandem gait);and assessment of cognitive function,including relevant portions of the SACor SCAT2, should be performed. Al-though the use of terms such as a“ding” or “getting your bell rung” hasbeen discouraged because they mayminimize the severity of the injury, ath-letes may be more inclined to give apositive history if those terms areused.59 The athlete should also bemon-itored for any deterioration of his orher condition. If there is concern for astructural brain abnormality, neuro-imaging should be considered. Ath-letes and their parents or caregiversshould be instructed which signs andsymptoms to follow when at home andgiven clear guidelines on what wouldnecessitate a return to the emergencydepartment or pediatrician’s office.60

Even if an athlete’s symptoms clear onthe same day of the concussion andthe assessment in the office or emer-gency department is normal, the ath-lete should not be allowed to return toplay that same day. There is still de-bate about whether periodically wak-ing the athlete during the night is nec-essary, because there may be morebenefit from uninterrupted sleep than

frequent awakenings, which may exac-erbate symptoms.

NEUROIMAGING

Conventional neuroimaging is typicallynormal in a concussive injury. Routineimaging using computed tomography(CT) or MRI contributes little to concus-sion evaluation and management.5 Al-though rare, a concussive blow can beassociated with a cervical spine injury,skull fracture, or any of the 4 types ofintracranial hemorrhage (subdural, epi-dural, intracerebral, or subarachnoid).61

Neuroimaging should be consideredwhenever suspicion of an intracranialstructural injury exists. Signs andsymptoms that increase the index ofsuspicion for more serious injury in-clude severe headache; seizures; focalneurologic findings on examination;repeated emesis; significant drowsi-ness or difficulty awakening; slurredspeech; poor orientation to person,place, or time; neck pain; and signifi-cant irritability.38 Any patient withworsening symptoms should also un-dergo neuroimaging. Patients with LOCfor more than 30 seconds may have ahigher risk of intracranial injury, soneuroimaging should be consideredfor them.60 Normal neuroimaging re-sults in the acute phase of injury maynot rule out a chronic subdural hema-toma or subsequent neurobehavioraldysfunction.61

CT is the test of choice to evaluate forintracranial hemorrhage during thefirst 24 to 48 hours after injury.62,63 It isalso a superior imaging modality fordetection of skull fractures.64 CT isfaster, more cost-effective, and easierto perform than MRI. Although numer-ous criteria have been developed toguide neuroimaging decisions afterhead trauma, none are sensitive andspecific enough to diagnose all intra-cranial pathology.65–69

A 2010 Canadian study evaluated clini-cal criteria to determine who may be





at high risk of a structural brain in-jury identified on CT scan after ahead injury.70 Approximately 22% ofthe head injuries in this study weresport-related. Patients with a GlasgowComa Scale score of less than 15 at 2hours after injury, suspected open ordepressed skull fracture, history ofworsening headache, and irritabilityon examination were found to be athighest risk for a structural brain in-jury identified on a CT scan that neededneurosurgical intervention. One of thecriteria for inclusion in this study was awitnessed LOC. Because LOC is noted inless than 10% of sport-related concus-sions, these criteria may not be applica-ble to all sport-related concussions.

MRI provides the ability to detect cere-bral contusion, petechial hemorrhage,and white matter injury at a level supe-rior to CT.65 AnMRImay bemore appro-priate if imaging is needed for an ath-lete 48 hours or longer after an injuryand is best coordinated through theprimary care or specialist physicianevaluating the athlete. Newly emergingMRI modalities, such as gradient echoand perfusion and diffusion tensor im-aging, are better than conventionalMRI at detecting white matter alter-ation, especially in the pediatric popu-lation.71,72 However, there is a paucityof research at this time that limits theclinical usefulness of these newer MRImodalities.

Functional imaging can be used tomeasure metabolic and hemodynamicchanges in the brain.71 Functional MRIis noninvasive and shows patterns thatcorrelate with symptoms during con-cussion, such as more widespreadbrain activation while symptomaticcompared with preinjury levels.73

Other functional imaging modalitiessuch as positron emission tomogra-phy (PET), magnetic resonance spec-troscopy (MRS), and single-photonemission CT (SPECT) offer promise butare still in the early stages of develop-

ment.74 Functional neuroimaging willlikely provide amore accurate picture ofthe injury andmay help predict recoverybetter than structural neuroimaging,but further researchandwider availabil-ity of this imagingmodality is needed be-fore it can be recommended.74,75

NEUROPSYCHOLOGICAL TESTING

Neuropsychological testing has be-come more commonplace in the evalu-ation of the athlete with concussion asa means to provide an objective mea-sure of brain function. Neuropsycho-logical testing is one of several tools inthe assessment of an athlete with con-cussion but does not independently de-termine if an athlete has experienced aconcussion or when he or she maysafely return to play.3–5 Currently, test-ing is performed by using one of sev-eral computerized neuropsychologicaltests including ANAM (Automated Neu-ropsychological Assessment Metrics),CogState, HeadMinder, and ImPACT(see Table 4) or through pencil-and-paper testing administered by a neu-ropsychologist. ANAM was initially de-veloped for use in the military,whereas the other tests were devel-oped specifically for sport-relatedconcussion.

Each of the computerized tests haspublished data on test-retest reliabil-ity, and all have demonstrated deficitsin concussed athletes compared withtheir baseline assessments.76–84 Onecritique of the computerized tests is that

the vast majority of studies have beenconductedby the developers of the tests,which raises some concern for bias, be-cause some independent study resultshave suggested slightly less reliable re-sults.85,86 A few of these computerizedtests have beenwidely adopted at all lev-els of sport participation.

More rigorous pencil-and-paper test-ing conducted formally by a neuropsy-chologist is also an option, althoughtest-retest reliability has been ques-tioned.87 Given the large number of ath-letes with concussion and relativescarcity of neuropsychologists, acces-sibility to these providers may often bechallenging andmay not be covered byinsurance carriers.88 Although the clin-ical neuropsychologist is often themost experienced person to interpretneuropsychological tests, nonneuro-psychologists may be trained to inter-pret them as well, which is an impor-tant advantage of the commerciallyavailable computerized tests.89

If computerized or pencil-and-paperneuropsychological testing is avail-able, ideally a baseline or preinjurytest should be obtained. Baseline test-ing is best performed before the startof the athlete’s season. Testing shouldbe performed in a quiet environment,free of noise or distractions, while theathlete is well rested rather than im-mediately after exercise. Many teamsand schools will administer tests incomputer laboratories proctored by a

TABLE 4 Internet Resources

Computerized neuropsychological testsUS Army Medical Department, Automated Neuropsychological Assessment Metrics (ANAM): www.armymedicine.army.mil/prr/anam.htmlCogState: www.cogstate.com/go/sportHeadminder: www.headminder.comImPACT: www.impacttest.comInformation on head injuryCenters for Disease Control and Prevention Heads Up Toolkit for High School Sports: www.cdc.gov/concussion/HeadsUp/high_school.htmlCenters for Disease Control and Prevention Heads Up Toolkit for Schools: www.cdc.gov/concussion/HeadsUp/schools.htmlCenters for Disease Control and Prevention Heads Up Toolkit for Physicians: www.cdc.gov/concussion/HeadsUp/physicians_tool_kit.html


www.cogstate.com/go/sport

www.headminder.com

www.impacttest.com


person with experience with the test,which allows for baseline testing oflarge groups of athletes over a shortperiod of time.

There are no evidence-based guide-lines or validated protocols aboutwhen to administer the computerizedneuropsychological test after a con-cussion. Some administer the testwhile an athlete is symptomatic to pro-vide objective data to the family andathlete regarding the injury and againwhen asymptomatic to help guidereturn to sport. Others administerthe test only after an athlete has be-come asymptomatic to documentthat the athlete’s cognitive functionhas returned to baseline. A symptom-atic athlete should not be returned toplay even with normal neuropsycho-logical testing. If no baseline test isavailable for the athlete, his or her re-sults can often be compared with age-established norms for the test. Inter-pretation of the tests should beperformed by a neuropsychologist orphysician who is experienced withthese tests. Further research needs tobe conducted to determine the opti-mum time and protocol for adminis-tering the computerized neuropsycho-logical tests.

The optimum time frame for repeatingbaseline neuropsychological testing, ifconducted, is still not well established,especially for the developing brain. Astudy that evaluated high school ath-letes with pencil-and-paper testingfound stabilization of baseline scoresbetween the 9th and 10th grades.90 An-other study of college athletes foundstable scores over a 2-year period on acomputerized test.91 One must alsoconsider that there is a lack of pub-lished baseline data in athletesyounger than 12 years. There is cur-rently no established, validated comput-erized neuropsychological test for thegrade school athlete, although at thetime of this clinical report, a computer-

ized test for use in athletes younger than12 years is being developed.

If an athlete is suffering from postcon-cussive symptoms over several monthsor has hadmultiple concussions, formalassessment by a neuropsychologistmaybe beneficial, specifically to identify ar-eas for which the athlete may need aca-demic accommodations.

MANAGEMENT

The goal of managing a young athletewith concussion is to hasten recoveryby ensuring that the athlete is aware ofand avoids activities and situationsthat may slow recovery. It is importantto stress to patients and their parentsto allow adequate time for full physicaland cognitive recovery. Treating youngathletes with a concussion is uniquelychallenging, because their brains arestill developing. Unfortunately, the lackof published data on the preadoles-cent athlete hinders evidence-baseddecision-making in thisagegroup.92 Also,there is a lack of consensus among phy-sicians and certified athletic trainers asto how to evaluate and treat an athletewith concussion, despite widely avail-able published guidelines.88,93,94

Medication Use

At the present time, there is currentlyno evidence-based research regardingthe use of any medication in the treat-ment of the concussed pediatric ath-lete.95 There is no evidence demon-strating the efficacy of the commonuse of nonsteroidal anti-inflammatorydrugs (NSAIDs) or acetaminophen inalleviating the symptoms or shorten-ing the course of an athlete’s concus-sion. In 1 animal study, chronic admin-istration of ibuprofen was found toworsen cognitive outcome after a trau-matic brain injury.96 It is commonlyrecommended that NSAIDs or aspirinbe avoided immediately after a sus-pected head injury for fear of potenti-ating the risk of intracranial bleeding.

Because no studies have documentedany harm from use of NSAIDs after asport-related concussion, this re-mains more of a theoretic risk.

Medication may be considered forthose athletes with more prolongedsymptoms such as difficulty concen-trating, headache, sleep disturbances,and depression. Continued medicationuse to control concussion symptomsindicates incomplete recovery. Beforeconsidering a return to play, any med-ications used to reduce symptomsmust be stopped and the athlete mustremain symptom-free off medication.5

Cognitive Rest

Many athletes will report increasedsymptoms with cognitive activities af-ter a concussion, which makes intui-tive sense because the concussion is afunctional rather than structural in-jury of the brain. Athletes with concus-sion often have difficulty attendingschool and focusing on schoolwork,taking tests, and trying to keep up withassignments, especially in math, sci-ence, and foreign-language classes.Reading, even for leisure, commonlyworsens symptoms.

To prevent exacerbation of the ath-lete’s symptoms and allow for contin-ued recovery, “cognitive rest” is rec-ommended. This rest may include atemporary leave of absence fromschool, shortening of the athlete’sschool day, reduction of workloadsin school, and allowance of more timefor the athlete to complete assign-ments or take tests. Taking standard-ized tests while recovering from a con-cussion should be discouraged, becauselower-than-expected test scores mayoccur.5,97 Test scores obtained whilethe athlete is recovering from con-cussion are likely not representativeof true ability. Communication withschool nurses, administrators, andteachers to be sure they understandthese recommendations is imperative.





After reintegration into school, a stu-dent should be allowed adequate timeto make up assignments, and the over-all volume of make-up work should bereduced. Because students physicallylookwell, it is not uncommon for teach-ers and other school officials to under-estimate the difficulties that a studentis experiencing and may downplay theneed for cognitive rest. Education ofteachers, counselors, and school ad-ministrators regarding the cognitiveeffects that a concussion may have ona student is important.

Other activities that require concen-tration and attention, including playingvideo games, using a computer, andviewing television, should also be dis-couraged, because they may exacer-bate symptoms. If phonophobia is asignificant symptom, exposure to loudmusic or the use of portable elec-tronic music devices with head-phones should be avoided. Sunglassesmay be considered for athletes withsignificant photophobia.98 Athletes of-ten have slowed reaction times after aconcussion and may need to avoiddriving temporarily.

Physical Rest

After a concussion, all athletes shouldbe withheld from physical exertion un-til they are asymptomatic at rest. Withthe proposed energy crisis in thebrain,13 increased energy demand inthe brain from physical activity may ex-acerbate symptoms and has the poten-tial to prolong recovery.99 An athlete inthe acute phase of a concussionshould be restricted from physical ac-tivity. However, results of preliminarystudies that evaluated patients withpostconcussion syndrome have shownpotential benefit from subsymptomthreshold exercise training, which in-volves short durations of light cardio-vascular activity without inducingsymptoms.100,101 Further researchneeds to be conducted before making

formal recommendations regardingthis treatment.

Broad restrictions of physical activityshould be recommended, includingnot only the sport or activity that re-sulted in the concussion but also anyweight training, cardiovascular train-ing, physical education classes, andeven sexual activity.102 Leisure activi-ties such as bike-riding, street hockey,and skateboarding should also be re-stricted, because they may impose arisk of additional head injury or symp-tom exacerbation. Assessment of men-tal health is also important, because aconcussion may result in depression,in part from the injury itself but alsofrom the prolonged time away fromsports, difficulties in school, and sleepdisturbances.

Recent Legislation

In May 2009, the state of Washingtonwas first to pass a law regardingconcussion management in young ath-letes. Also known as the Zackery Lyst-edt law, named after the then–13-year-old who sustained a serious headinjury while playing football, this lawrequires school boards, in conjunctionwith the state interscholastic activityassociation, to develop educationalmaterials and guidelines for athletes,coaches, and parents. The law also re-quires that parents and athletes signan informed-consent form acknowl-edging the dangers of concussions be-fore participation in sports. Finally, anathlete must be removed from anygame if suspected of having a concus-sion and may not return until evalu-ated and given clearance to return toplay from a licensed health care pro-fessional.103 Many other states havesubsequently either passed or areconsidering similar legislation.

RETURN TO PLAY

Determining when an athlete returnsto play after a concussion should fol-

low an individualized course, becauseeach athlete will recover at a differentpace. Under no circumstances shouldpediatric or adolescent athletes withconcussion return to play the sameday of their concussion. The phrase,“When in doubt, sit them out!” is para-mount in the management of a pediat-ric or adolescent concussion.3 No ath-lete should return to play while stillsymptomatic at rest or with exertion.Although the vast majority of athleteswith concussion will become asymp-tomatic within a week of their concus-sion, numerous studies have demon-strated a longer recovery of fullcognitive function in younger athletescompared with college-aged or profes-sional athletes104–108—often 7 to 10days or longer.109 Because of thislonger cognitive recovery period, al-though they are asymptomatic, thereshould be a more conservative ap-proach to deciding when pediatric andadolescent athletes can return to play.

Concussion Rehabilitation

Initially proposed in 2000 by the Cana-dian Academy of Sport Medicine andendorsed by the CIS group in Vienna, agraded return-to-play protocol after aconcussion is recommended.3,110 Thismay also be referred to as “concussionrehabilitation.” Once asymptomatic atrest, the athlete progresses in a step-wise fashion (Table 5) through the pro-tocol as long as he or she remainsasymptomatic. This progress may bemonitored by the parent or an athletictrainer if proper instructions are givenon how to proceed. Each step shouldtake at least 24 hours, and it will takean athlete a minimum of 5 days toprogress through the protocol to re-sume full game participation, providedsymptoms do not return. A return ofsymptoms indicates inadequate recov-ery from the concussion. If symptomsreturn while on the protocol, once theathlete is asymptomatic again for 24hours, the previous step may be at-



tempted again. Any athlete who contin-ues to have a return of symptoms withexertion should be reevaluated by hisor her health care provider. An athletewho has recovered from prolongedpostconcussion syndrome or with ahistory of multiple concussions mayneed a longer period of time toprogress through each step.

PREVENTION

Although preventing all concussions isunlikely, many attempts have beenmade to reduce the risk of concussionfor athletes. These attempts includemodifications to protective gear, rulechanges, trying to identify athletes atrisk, and continuing to educate every-one involved with youth and highschool sports about the dangers ofconcussions.

Mouth Guards

The use of mouth guards for reducingthe risk of dental trauma is well estab-lished. The role of the mouth guard inpreventing concussions is more con-troversial. Although several studieshave evaluated various mouth guards,none have conclusively demonstratedthat mouth guards reduce the risk ofconcussion.111–116At this point in time,mouth guards are recommended to re-duce dental trauma, but further stud-ies are needed to evaluate their role inreducing the risk of concussions.

Helmets/Headgear

Helmets in sports have been shown inlaboratory studies to reduce impactforces to the head. However, reductionin concussion incidence has not beenconsistently seen, despite the use ofhelmets. One study evaluated newerfootball helmet technology in highschool athletes, which demonstrated a31% decrease in relative risk and 2.3%decrease in absolute risk for sustain-ing a concussion.117 Laboratory studiesof a newer helmet technology suggesta potential 10% decrease in risk of re-produced concussion hits.118 Contin-ued technologic advances should beapplauded, but further independentresearch and evaluation of these ad-vances is necessary before they can bereported to reduce concussion inci-dence. Helmets should be assessed tomeet the requirements of the NationalOperating Committee on Standards forAthletic Equipment for newly con-structed or reconditioned helmets andshould be appropriately fit for each in-dividual athlete.

Helmets have been demonstrated toreduce concussion incidence in skiingand snowboarding and are recom-mended for these sports.119–121 In astudy of concussed hockey playerswearing helmets with full face shieldscompared with half-face shield hel-mets, players wearing the full faceshield helmet returned to play sooner,

but there was no demonstrated de-crease in risk or incidence of concus-sion between the 2 groups.122

Results of soccer headgear studieshave revealed mild protection fromconcussion from players collidingheads but not from heading the ball.123

Headgear seems to protect againstsoft-tissue injuries, such as lacera-tions, contusions, and abrasions, andismore likely to beworn by female soc-cer players.123,124 Most studies havebeen found to have significant limita-tions in evaluating the potential for re-ducing concussions.125 Prospectivedata are not currently sufficient tosupport recommending universal useof headgear in soccer.126 Heading theball in soccer is felt to be safe, if per-formed properly.126 Avoiding headingdoes not prevent concussions.126

Genetic Testing

The presence of genetic markers (eg,apolipoprotein E4 gene, S-100 calcium-binding protein gene) and neuron-specific enolase have been evaluatedas possible predisposing risk factorsfor concussion. However, the few stud-ies conducted on younger athleteshave not demonstrated significant dif-ferences in head injury characteristicsor outcomes of athletes who possessthese genetic markers.127–129At thistime, genetic testing is not recom-mended for evaluating young athleteswith concussion.

Education

Education and recognition remain themost important components of im-proving the care of athletes with con-cussions. Education should target allthe key individuals involved, includingathletes, parents, coaches, school ad-ministrators, athletic directors, teach-ers, athletic trainers, physicians, andother health care providers. Previousstudies have demonstrated poorknowledge of concussion recognition

TABLE 5 Concussion Rehabilitation/Stepwise Return to Play

Rehabilitation Stage Functional Exercise

1. No activity Complete physical and cognitive rest2. Light aerobic activity Walking, swimming, stationary cycling at 70% maximum

heart rate; no resistance exercises3. Sport-specific exercise Specific sport-related drills but no head impact4. Noncontact training drills More complex drills, may start light resistance training5. Full-contact practice After medical clearance, participate in normal training6. Return to play Normal game play

Each stage in concussion rehabilitation should last no less than 24 hours with a minimum of 5 days required to consider afull return to competition. If symptoms recur during the rehabilitation program, the athlete should stop immediately. Onceasymptomatic after at least another 24 hours, the athlete should resume at the previous asymptomatic level and try toprogress again. Athletes should contact their health care provider if symptoms recur. Any athlete withmultiple concussionsor prolonged symptoms may require a longer concussion-rehabilitation program, which is ideally created by a physicianwho is experienced in concussion management.





and management by players, coaches,and even clinicians.130–133

In 2005, the Centers for Disease Con-trol and Prevention (CDC) published aseries of concussion toolkits, titled“Heads Up,” for coaches, practicing cli-nicians, teachers, and school counsel-ors. These toolkits are available freefrom the CDC via the Internet.134 A sur-vey of coaches showed high satisfac-tion with the CDC toolkit.135

COMPLICATIONS

Long-term Effects

The long-term effects of concussionsin athletes of all ages are cause forconsiderable concern. With a lack oflong-term prospective studies in highschool and younger athletes who sus-tained concussions, there are morequestions than conclusive answers. An18-year-old multisport athlete with ahistory of concussions from footballwas reported to have autopsy findingsof chronic traumatic encephalopathy,previously only reported in profes-sional football players and profes-sional boxers.136,137

Athletes with 3 or more concussionsare more likely to have had LOC,postevent amnesia, confusion, and 3 to4 abnormal on-field markers of con-cussion.138 Three months after a con-cussion, children 8 to 16 years of agehave been found to have persistentdeficits in processing complex visualstimuli.139 Athletes with 2 or more con-cussions who had not been concussedin the previous 6 months performedsimilarly on neuropsychological test-ing as did athletes without a history ofconcussions who were concussedwithin in the previous week.140 Com-pared with similar students without ahistory of concussion, athletes with 2or more concussions also demon-strate statistically significant lowergrade-point averages.140 More re-search is needed to investigate the

long-term effects of concussions at allages of childhood and adolescence.

Second-Impact Syndrome

Second-impact syndrome occurswhen an athlete who has sustained aninitial head injury sustains a secondhead injury before the symptoms asso-ciated with the first have fully cleared.Second-impact syndrome results in ce-rebral vascular congestion, which of-ten can progress to diffuse cerebralswelling and death.141

Although there is debate whether thecerebral swelling is attributable to 2separate hits or a single hit, there is noquestion that pediatric and adolescentathletes seem to be at the highest riskof this rare condition, because all re-ported cases are of athletes youngerthan 20 years.142 In addition, since 1945,more than 90% of the head injury–related fatalities from sports recordedby the National Center for CatastrophicSports Injury Research occurred inathletes in high school or younger.143

Catastrophic football head injuriesare 3 times more likely to occur inhigh school athletes than in collegeathletes.144

Postconcussion Syndrome

A clear definition for postconcussionsyndrome does not exist. The WorldHealth Organization (WHO) establisheda definition of the presence of 3 ormore of the following symptoms aftera head injury: headache; dizziness; fa-tigue; irritability; difficulty with con-centrating and performing mentaltasks; impairment of memory; insom-nia; and reduced tolerance to stress,emotional excitement, or alcohol.145

However, the WHO definition does notspecify a minimum duration of thesesymptoms to make the diagnosis.

Postconcussion syndrome is definedin the Diagnostic and Statistical Man-ual of Mental Disorders, Fourth Editionas 3 months’ duration of 3 or more

of the following symptoms: fatigue; dis-ordered sleep; headache; vertigo/dizziness; irritability or aggressive-ness; anxiety or depression; personal-ity changes; and/or apathy. Youngerpatients often demonstrate signifi-cant decline in school performance.Neuropsychological testing usuallydemonstrates difficulty in attentionor memory.146

A recently proposed definition ofpostconcussive syndrome is the pres-ence of cognitive, physical, or emo-tional symptoms of a concussion last-ing longer than expected, with athreshold of 1 to 6 weeks of persistentsymptoms after a concussion to makethe diagnosis.147

Retirement From Sports

As with determining return to play, de-termining when to retire an athletefrom 1 or multiple sports is often diffi-cult for all involved. No evidence-basedguidelines exist for the considerationof retiring an athlete from a sport.148 Ithas been proposed that any athletewho has sustained 3 concussions in anindividual season or has had postcon-cussive symptoms for more than 3months should be strongly consideredforaprolongedperiodof timeaway fromsports.149,150 If a clinician is not comfort-able making a determination about thelength of time to withhold the athletefrom sports or is contemplating perma-nent removal from sports, referral to aspecialist with expertise in sport-relatedconcussion is recommended.

CONCLUSIONS AND GUIDANCE FORCLINICIANS

1. Sport-related concussions arecommon in youth and high schoolsports. Limited data are availableon concussions in grade schoolathletes, and further research isneeded.

2. Concussion has many signs andsymptoms, some of which overlap



with othermedical conditions. LOCis uncommon, and if it lasts longerthan 30 seconds, it may indicatemore significant intracranial injury.

3. Results of structural neuroimag-ing, such as CT or MRI, generallyare normal with a concussion.

4. Neuropsychological testing can behelpful to provide objective datato athletes and their families aftera concussion. Neuropsychologicaltesting is 1 tool in the completemanagement of a sport-relatedconcussion and alone does notmake a diagnosis or determinewhen return to play is appropriate.

5. Athletes with concussion shouldrest, both physically and cogni-tively, until their symptoms haveresolved both at rest and with ex-ertion. Teachers and school ad-ministrators should work withstudents to modify workloads toavoid exacerbation of symptoms.

6. The signs and symptoms of a con-cussion typically resolve in 7 to 10days in the majority of cases.Some athletes, however, may takeweeks to months to recover.

7. Any pediatric or adolescent ath-lete who sustains a concussionshould be evaluated by a healthcare professional, ideally a physi-

cian with experience in concus-sion management, and receivemedical clearance before return-ing to play.

8. Pediatric and adolescent athletesshould never return to play whilesymptomatic at rest or with exer-tion. Athletes also should not bereturned to play on the same dayof the concussion, even if they be-come asymptomatic. The recoverycourse is longer for younger ath-letes than for college and profes-sional athletes, and a more conser-vative approach to return to play iswarranted.

9. The long-term effects of concus-sion are still relatively unknown,and further longitudinal researchis needed to offer further guid-ance to athletes of all ages.

10. Education about sport-relatedconcussion is integral to helpingimprove awareness, recognition,and management.

11. The safety and efficacy of medica-tions in the management of sport-related concussion has not beenestablished.

12. Retirement from contact or colli-sion sports may be necessary forthe athlete with a history of multi-ple concussions or with long

symptomatic courses after his orher concussion.

13. New evidence-based protocols forthe diagnosis and management ofconcussion should be incorpo-rated into pediatric training mod-ules and competencies.

LEAD AUTHORSMark E. Halstead, MDKevin D. Walter, MD

COUNCIL ON SPORTS MEDICINE ANDFITNESS EXECUTIVE COMMITTEE,2009–2010Teri M. McCambridge, MD, ChairpersonHolly J. Benjamin, MDJoel S. Brenner, MD, MPHCharles T. Cappetta, MDRebecca A. Demorest, MDAndrew J. M. Gregory, MDMark E. Halstead, MDChris G. Koutures, MDCynthia R. LaBella, MDStephanie S. Martin, MDAmanda K. Weiss-Kelly, MD

LIAISONSLisa K. Kluchurosky, MEd, ATC – NationalAthletic Trainers AssociationJohn F. Philpott, MD – Canadian PaediatricSocietyKevin D. Walter, MD – National Federation ofState High School Associations

CONSULTANTSMichael F. Bergeron, PhDGreg L. Landry, MDKelsey Logan, MD

STAFFAnjie Emanuel, [email protected]

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APPENDIX 1THE SCAT2.



APPENDIX 1Continued.





DOI: 10.1542/peds.2010-2005; originally published online August 30, 2010; 2010;126;597Pediatrics

Mark E. Halstead, Kevin D. Walter and The Council on Sports Medicine and FitnessSport-Related Concussion in Children and Adolescents

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