Concussion Assessment on the Field and in the Clinic

By: Dr. Jill Murphy, DPT, LAT, CSCS

photo credit: Britnee Gibson

Last month we began our series on concussions with an overview of the definition, prevalence, and risk factors that contribute to concussions. This month we are focusing on the assessment of concussions at the time of the injury and days later in a clinical setting. But first, a quick review. In layman’s terms, a concussion is any impact to the brain from trauma that causes a symptom. Loss of consciousness is not necessary to diagnose a concussion.

Symptoms from concussion range from those impacting a person mentally, emotionally, and physically, as well as those derived from alterations in the visual and vestibular systems. The most common symptoms of concussion are headache, nausea and/or vomiting, dizziness, lightheadedness, fuzzy thinking/brain fog, dilated pupils, diminished balance, impaired memory, tinnitus (ringing in the ears), slurred speech, disorientation, confusion, loss of appetite, slowed cognition (thinking), double vision, light sensitivity, and changes in behavior (especially becoming more emotional than usual). Some other symptoms that occur less frequently but are  still very important to recognize are depressed mood, fatigue, sleeping more than usual, insomnia, dyscoordination, seizures, numbness, tingling, difficulty reading, difficulty focusing, and problems with concentration for test taking.

When a concussion occurs, it is imperative that the athlete honestly reports what happened to a coach and athletic trainer on the sideline. Athletes, coaches, and parents should be informed as to what a concussion might look and feel like, so they can quickly recognize any symptoms after a mild or major blow to the head or face. Remember that any injury to the head or face, and even simply whiplash, can cause a concussion because the brain sloshes back and forth in the skull, abutting sharp bony prominences that can cause damage to the brain, including a concussion. Awareness is the first step in diagnosing a concussion because so many of the symptoms are self-reported by the athlete. Parents should be alert when after a game an athlete may ask for ibuprofen or Tylenol to treat a headache. If this request is made, the athlete should be questioned further as to what symptoms are they feeling. If there was any blow to the head (or their head hit the ground), have your athlete reports their symptoms to their licensed athletic trainer at their high school or middle school at the next earliest convenience. If there is no athletic trainer available, you can report these symptoms to your child’s pediatrician or primary care doctor. It is okay to give athletes Tylenol to make them comfortable even if they have suffered a concussion. This will help make them more comfortable. Realize that this may also mask symptoms; do not allow your athlete to participate in any physical activity until they have been cleared to return to activity by a licensed medical provider qualified to diagnose and manage concussions.

Most concussions can be effectively evaluated by a licensed athletic trainer or sports medicine physician at the athletic event where and when the injury occurs. If no qualified medical professionals are available, no on field or on court evaluation can occur. In Wisconsin, the WIAA has granted referees and officials the power to end an athlete’s participation in the game or tournament if there is a high suspicion that a concussion has occurred. Should this happen, your athlete will need to be cleared by a sports medicine physician, primary doctor, or pediatrician before returning to play.

The sideline concussion evaluation will start with subjective data gathering to determine what symptoms are present. Next are the following cursory screenings with full exams to follow as necessary: vision, cervical spine,gait (walking ability), strength, sensation, balance, coordination, memory, orientation to time and place, and any other pertinent tests. Some schools and athletic trainers have the ability to perform a neurocognitive test on the sideline or in a classroom during or after the sporting event. These technology-based assessment tools are very effective at catching cognitive and processing changes from the athlete’s own baseline tests performed during pre-season that are not able to be assessed by a clinician in a clinical exam.

If a neurocognitive assessment is not available at the event, the athlete might visit a physician’s office to be given this test. Seek out a sports medicine or family physician who specializes in managing concussions to gain access to appropriate concussion management if this testing is not available at an athlete’s school. Before an athlete is allowed to return to play, this test will be repeated to ensure that an athlete’s cognitive, memory, and processing abilities have returned to baseline (or to a normative value for the athlete's age if a baseline test score is not available).

When parents envision a major concussion, a vision of an injured athlete lying motionless on a football field may come to mind. It may be surprising to parents and coaches that the majority of concussions are not observed from the sideline. Whether a direct hit with another athlete or hard hit on the ground or court, frequently a significant concussion can occur without anyone seeing it. When a major concussion occurs and athletes are not moving, athletic trainers, the team physician, and/or EMT’s will immediately come to the athlete’s aide on the field and provide appropriate medical evaluation and care. If no such medical professionals are available, and the athlete is not moving or unconscious, 911 should be called immediately while the athlete is monitored but not moved.

For these more serious on-field presentations, athletes will be assessed for a serious neck injury with instability, movement ability, and any changes in sensation once airway, breathing, and circulation have been established. Frequently, any immediate movement or sensory changes clear within seconds to minutes and if cleared to do so, the athlete is then assisted to the sideline for further evaluation. If there is a serious injury including any possibility of a serious neck injury such as a fracture or spinal cord contusion, the athlete will be spine-boarded on the field and transported to a hospital for further tests. If an athlete is transported to a hospital for concussion only, a brief concussion assessment and typically a CT scan is performed to rule out a brain bleed or swelling, although many times significant edema from a concussion may not appear until 24 hours after the injury. It is important to note that whether or not any symptoms appear on a CT scan does not determine the severity of the concussion. Typically the severity of the concussion can be generally determined at the initial assessment or within several days of the initial assessment. However, frequently the final determination of whether the concussion is mild, moderate, or severe will be made after the last remaining concussion symptom has cleared, as the classification is time-based. If the symptoms are clearing by the time the athlete arrives at the ER, doctors may feel it is not necessary to complete a CT scan. The athlete will be released back home with follow up handled by the team’s athletic trainer, a sports medicine physician who specializes in concussions, or with a neurologist who specializes in concussions.

How do you know if your athlete who has just suffered a concussion needs emergent medical care? Here are some red flag signs and symptoms:

  • Headache is worsening over time instead of getting better
  • Seizures or convulsions
  • Unresponsiveness or altered responsiveness
  • Worsening nausea leading to repetitive vomiting
  • Problems with vision or hearing that worsen over time
  • Pupil unevenness
  • Difficulty waking from sleep
  • Worsening symptoms for coordination, balance, numbness, tingling, or slurred speech
  • Confusion, agitation, unusual behavior that is worsening

If your athlete is suffering any of the above, worsening symptoms, a trip to the ER and/or a call to 911 is warranted.

If a concussion has been diagnosed, it is very important that a qualified medical professional with experience in treating concussions manages an athlete’s treatment plan. A treatment plan for concussion should include the following:

  • Activity modification: generally rest, followed by a slow build-up back into activity guided by a medical professional, determined by progress in clearing symptoms and no symptom return during or after new activity.
  • Academic participation plan: if the concussion has caused significant cognitive and processing issues including short term memory loss, a formal or informal plan is devised with the athlete’s school and/or teachers to modify participation in classes and/or development of an alternative test schedule, so the athlete has more time to complete assignments and tests if needed.
  • Treatment by a physical therapist or athletic trainer specially trained in post-concussion management to address any lingering symptoms such as neck pain, dizziness, nausea, and visual and vestibular processing issues from the original concussion.

Next month we will thoroughly address the recovery process from concussion, post-concussion syndrome, second impact syndrome, and address return to play considerations. If you or your athlete is suffering from lingering symptoms of a concussion, please contact MotionWorks Physical Therapy at 920-215-2050 to for further advice, guidance, and treatment options from our staff specially trained in concussion treatment.