A 24 year old goalkeeper playing in the Champions League final in Ukraine is hit in the head by an opponent. Later he makes two errors costing his side two goals. His team lose 3-1. 5 days later he is diagnosed with having a concussion. There is later speculation about whether this concussion caused his errors.

Before we go on there has also been some interesting discussion on human factors including this article in The Times on focus and how too much can affect our performance.

What is concussion?

Concussion is usually used to describe a mild traumatic brain injury particularly the signs and symptoms an individual may experience after a mild traumatic brain injury. Mild TBI is described as a GCS of 13-15 following a head injury.

NHS UK list the following as symptoms of a concussion (1):

a headache that doesn't go away or isn't relieved with painkillers
dizziness
nausea or vomiting
feeling stunned, dazed or confused
memory loss – you may not remember what happened before or after the injury
clumsiness or trouble with balance
unusual behaviour – you may become irritated easily or have sudden mood swings
changes in your vision – such as blurred vision, double vision or "seeing stars"
being knocked out or struggling to stay awake

Most cases of concussion are mild (2) with contact sports having a relatively high incidence (3).

Concussion is believed to be caused by a functional rather than structural deficit following the brain hitting against the hard bony walls of the skull (4).

The diagnosis of concussion involves a full history and examination. Even so, over 80% of sufferers may not recognise their condition (5).

There are a number of diagnostic tools designed to help recognising concussion none are designed to rule out concussion and neither are superior to clinical examination and history taking (6).

It is important to remember the NICE CT Head criteria CG176. Check out our Adult Head Injury episode. Concussion should be diagnosed only if there is no suspicion of serious head injury or it has been ruled out with imaging.

Concussion advice

The Charity Headway recommend the following for anyone diagnosed with concussion:

Do make sure you stay within reach of a telephone and medical help
Do have plenty of rest and avoid stressful situations Do show this booklet to a friend or family member who can monitor your condition
Do take painkillers such as paracetamol for headache
Don’t stay at home alone for 48 hours after leaving hospital
Don’t drink alcohol until you feel better
Don’t take aspirin or sleeping tablets without consulting your doctor
Don’t return to work until you feel ready
Don’t play any contact sport for at least three weeks without consulting your doctor
Don’t drive until you feel you have recovered. If in doubt consult your doctor

Headway have an excellent booklet which you can find here

Post-concussion syndrome (PCS) is a symptom complex that includes headache, dizziness, neuropsychiatric symptoms, and cognitive impairment (7). It affects 30-80% of patients with mild TBI. Most cases resolve within 3 months. MRI Brain should be used in prolonged cases to rule out more sinister causes. Most clinicians will treat patients with PCS symptomatically (8).

Learning Points

Concussion is a functional deficit following mild traumatic brain injury which is common
There are many different symptoms of concussion which patients need to be advised about; diagnosis is through history and examination; no diagnostic score can be used to rule out concussion
Post-concussion syndrome is vague and usually resolves within 3 months

References

(1) https://www.nhs.uk/conditions/concussion/

(2) Vos PE, Battistin L, Birbamer G, Gerstenbrand F, Potapov A, Prevec T, Stepan ChA, Traubner P, Twijnstra A, Vecsei L, von Wild K, European Federation of Neurological Societies; EFNS guideline on mild traumatic brain injury: report of an EFNS task force; Eur J Neurol. 2002;9(3):207

(3) Guerriero RM, Proctor MR, Mannix R, Meehan WP 3rd; Epidemiology, trends, assessment and management of sport-related concussion in United States high schools; Curr Opin Pediatr. 2012 Dec;24(6):696-701

(4) McCrory P, Meeuwisse WH, Aubry M, Cantu B, Dvorák J, Echemendia RJ, Engebretsen L, Johnston K, Kutcher JS, Raftery M, Sills A, Benson BW, Davis GA, Ellenbogen RG, Guskiewicz K, Herring SA, Iverson GL, Jordan BD, Kissick J, McCrea M, McIntosh AS, Maddocks D, Makdissi M, Purcell L, Putukian M, Schneider K, Tator CH, Turner M; Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012; Br J Sports Med. 2013;47(5):250

(5) Delaney JS, Abuzeyad F, Correa JA, Foxford R; Recognition and characteristics of concussions in the emergency department population; J Emerg Med. 2005;29(2):189

(6) Giza CC, Kutcher JS, Ashwal S, Barth J, Getchius TS, Gioia GA, Gronseth GS, Guskiewicz K, Mandel S, Manley G, McKeag DB, Thurman DJ, Zafonte R; Summary of evidence-based guideline update: evaluation and management of concussion in sports: report of the Guideline Development Subcommittee of the American Academy of Neurology; Neurology. 2013;80(24):2250. Epub 2013 Mar 18

(7) Bazarian JJ, Wong T, Harris M, Leahey N, Mookerjee S, Dombovy M; Epidemiology and predictors of post-concussive syndrome after minor head injury in an emergency population; Brain Inj. 1999;13(3):173

(8) Evans RW, Evans RI, Sharp MJ; The physician survey on the post-concussion and whiplash syndromes; Headache. 1994;34(5):268