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Update on Concussion

The understanding of concussion and its more serious counterpart — traumatic brain injury —  continues to advance as diagnostic practices evolve. For example, loss of consciousness occurred in fewer than 10% of the cases reviewed,[1] whereas once it was thought to be a primary indicator. As more PAs and NPs are exposed to patients with potential head injuries, it’s important to have a solid understanding of current diagnostic techniques.​

Pathophysiology of a Concussion

Three components contribute to the presence of a concussion:[23]

  1. Violent force transmitted to the head, which can come from a direct blow or fall striking the head or from the neck or upper body
  2. Metabolic changes that result in:
      a. headache, light and sound sensitivity
      b. amnesia, slowed reaction time, or a cognitive deficit
      c. reduced energy level
  3. Loss of consciousness, although not required

Presentation of the Patient with a Concussion

The initial contact with the patient offers some valuable signs of the trauma. It’s important to have friends or family members present during the examination. Some of the symptoms will prevent the patient from being a good reporter of his or her own status.

Some key observations include:[4]

  1. Confusion. The patient may appear with a blank look or flat response to questions.
  2. Delayed responses. Patients may have difficulty remembering details of the event or finding the words to describe it.
  3. Pain or dizziness. The patient may complain of a headache or of dizziness when seated. Headaches are the most common complaint and most often occur in the forehead or top of the head.
  4. Visual anomalies.  Symptoms such as blurry or double vision and seeing “stars” or flashes of light are often reported by the patient.
  5. Amnesia. The concussion patient may report mild amnesia for a few minutes after the event with a subsequent return of memory. A patient who presents with continued amnesia may be showing signs of traumatic brain injury.
  6. Increased intracranial pressure. Persistent vomiting, worsening headache, and disorientation may be symptomatic.

Physical Examination

To quickly ascertain the status of a potential concussion patient, you may find it useful to create a physical or mental checklist to guide you through the examination. This will help you determine whether more aggressive diagnostic procedures are needed or if the patient should be referred to a neurological specialist.

Such a checklist should include:

  1. Appearance. Look for bruising, wounds, or signs of deformity on the head and neck.
  2. Head and neck. Palpation of the head and neck will disclose less obvious injuries to the skull and cervical spine.
  3. Facial structures. Palpate the bones around the eyes, jaw, and temple for fractures. Move the mandible and feel around the temporomandibular joint for fractures or dislocation.
  4. Nose. Look for deviation or fracture.
  5. Fluid discharge. Fluid discharge from the ears or eyes can indicate skull fractures.
  6. Vision. Examination of the patient’s vision should include:
    a. visual field presence and depth
    b. abnormal eye movement
    c. pupil responses
    ​d. coordination of eye movement
  7.  Strength assessment. Evaluate upper and lower extremity strength.
  8. Sensation. Examine sensation in upper and lower extremities.
  9. Coordination/Balance. The simple finger-nose-finger test can be a sign of acute head trauma. The Balance Error Scoring System (BESS) can assist in determining balance issues:[5]

  a. have the patient take three stances, first on a hard surface then on a foam pad, for 10 seconds each:

  • bipedal stance
  • unipedal stance
  • ​tandem stance

10. Cognitive Ability. The Standard Assessment of Concussion (SAC) test evaluates three areas of cognitive function:[6]

  • temporal orientation (eg, Ask “What year is it?”)
  • memory (eg, Have patient repeat specific words)
  • concentration (eg, Have patient repeat number strings backwards)

Diagnostic Testing
As yet there are no definitive diagnostic tests that indicate a concussion. When used, the two diagnostic tests employed include:

Computerized Tomography. Results most often appear normal in a concussion. CT can identify fractures, contusions, and intracranial hemorrhage when traumatic brain injury is suspected.

Magnetic resonance imaging. Results will also often appear normal in a standard MRI. A functional MRI may show increased cerebrovascular activity during the post-concussive period when symptoms are still present.

For these reasons, physical examination is relied upon heavily for the diagnosis of a concussion when no acute brain injury is suspected.

[bg_collapse view=”link” color=”#4a4949″ icon=”arrow” expand_text=”Reference” collapse_text=”Reference”]
Cullen M. Orthopedists should stay up-to-date on advances in concussion diagnosis, Orthopedics Today. December 2015.
2. Bassett A, McCullough P. Concussions (mild traumatic brain injury). Ortho Bullets.
3. American Association of Neurological Surgeons. Concussion.
4. Bernhardt DT. Concussion. Medscape. September 24, 2018. (Medscape)
5. Balance Error Scoring System. Physiopedia.
6. Standardized Assessment of Concussion. Family Practice Notebook.

Last updated on 9/25/19.

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