Should I still use a grading system to help manage my patients who have or are suspected of having a concussion?

Extensive research on concussions has provided medical professionals with a much better understanding of the symptomatic course and risk of potential long-term complications. Clinicians involved in the assessment and management of sport-related concussions began to notice that patients who lost consciousness for brief periods of time often recovered more quickly than those who did not lose consciousness at all. This led to the realization that diagnosing those who did not lose consciousness with a lower grade of concussion was inaccurate.

As a result of this understanding, and other realizations, grading systems have been replaced with more individualized concussion management.

Learn more about signs and symptoms of a concussion

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Is a blow to the head the only way a patient can sustain a concussion?

No, a concussion may be caused by a direct blow to the head, face, neck, or a blow elsewhere on the body with an 'impulsive' force transmitted to the head.

Learn more about etiology of a concussion

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Does the force of impact have to be of a particular magnitude to cause a concussion?

No, concussions occur from blows to different parts of the body of varying magnitude. A relatively minor impact may result in a concussion while a high-magnitude hit may not. There is therefore no way to know for certain whether a particular blow will lead to a concussion.

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What neuroimaging should I order for my patients who have been diagnosed with a concussion?

Conventional structural neuroimaging is normal in concussive injury and so in most cases unnecessary. The following suggestions were made by the panel in Zurich:

Brain CT scans (or where available, brain MRI) contribute little to concussion evaluation but should be employed whenever suspicion of an intracerebral structural lesion exists. Examples of such situations may include a prolonged disturbance of the conscious state, a focal neurological deficit or worsening symptoms.

Learn more about assessment of a concussion

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When examining a patient with a suspected concussion, what should my initial exam include?

The key features of this exam should include:

  1. A medical assessment encompassing
    • a comprehensive history
    • detailed neurological examination including a thorough assessment of mental status, cognitive functioning and gait and balance
  2. A determination of the clinical status of the patient including whether there has been improvement or deterioration since the time of injury. This may involve seeking additional information from parents, coaches, teammates and eyewitnesses to the injury.
  3. A determination of the need for emergent neuroimaging in order to exclude a more severe brain injury involving a structural abnormality.

Most of the elements of an assessment are included in the SCAT3 (Sport Concussion Assessment Tool)

Learn more about assessment of a concussion

Use the online Auto SCAT3

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When should I refer my patient to a concussion specialist?

Concussion specialists are a valuable resource for concussion management. Though you can refer any patient to a concussion specialist to assist you in their care, you should consider referring your patient to a physician or health professional specializing in concussion (neuropsychologists, neurologists, and sport medicine specialists) in the following situations:

  • Any indication or suspicion of neurologic deterioration
  • Patients whose symptoms remain steady or worsen after 3 to 5 days
  • Young children exhibiting the following symptoms for an extended period of time:
    • Excessive crying
    • Persistent headache
    • Poor attention
    • Change in sleep patterns
    • Change in nursing or eating habits
    • Becoming upset easily or increased temper tantrums
    • Sad or lethargic mood
    • Lack of interest in favourite toys
  • If you need help to determine return to play, work or school

For children and adolescents, it is more important to consider the use of trained paediatric neuropsychologists to interpret assessment data, particularly in children with learning disorders and/or ADHD who need more sophisticated assessment strategies.

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Why was the Zurich Consensus organized?

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Can I use a SCAT3 for my patients with non-sport-related concussions?

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Are the number of concussions increasing?

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What is the best approach to investigation and management of persistent (>10 days) postconcussive symptoms?

Persistent symptoms (>10 days) are generally reported in 10-15% of concussions. This may be higher in certain sports (eg, elite ice hockey) and populations (eg, children). In general, symptoms are not specific to concussion and it is important to consider and manage co-existent pathologies.

Investigations may include formal neuropsychological testing and conventional neuroimaging to exclude structural pathology. Currently, there is insufficient evidence to recommend routine clinical use of advanced neuroimaging techniques or other investigative strategies.

Cases of concussion in sport where clinical recovery falls outside the expected window (ie, 10 days) should be managed in a multidisciplinary manner by healthcare providers with experience in sports-related concussion. Important components of management after the initial period of physical and cognitive rest include associated therapies such as cognitive, vestibular, physical and psychological therapy, consideration of assessment of other causes of prolonged symptoms and consideration of commencement of a graded exercise programme at a level that does not exacerbate symptoms.

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