Do People With a Concusson Have a Greater Chance of Getting Them Again
Sports Health. 2013 Nov; 5(half-dozen): 537–541.
Take chances Modifiers for Concussion and Prolonged Recovery
Kristen A. Scopaz
†Maine Medical Center Sports Medicine, Portland, Maine
John R. Hatzenbuehler
†Maine Medical Center Sports Medicine, Portland, Maine
Abstract
Context:
Currently, no consensus exists for grading the severity of concussions. Identification of risk factors that may bear upon concussion take chances and the likelihood of prolonged recovery tin can be of value to providers who manage concussion.
Evidence Acquisition:
Relevant studies were identified through MEDLINE (1996-2011) using the keywords concussion, postconcussive syndrome, and run a risk or chance cistron. Targeted searches for specific risk factors were conducted with additional keywords, such equally gender and migraine. Manual review of reference lists was also performed to identify pertinent literature.
Results:
For risk factors of concussion, history of prior concussion and female sex take the nearly supporting evidence. Sports with consistently high run a risk for sustaining a concussion include football, men's ice hockey, and women'due south soccer. Younger athletes appear to exist more susceptible to concussion, but information are limited and inconsistent. Protective equipment does not definitively alter concussion risk, though information technology protects confronting other injuries. Symptoms such as long headaches, migraines, amnesia, and multiple symptoms announced to be associated with prolonged recovery. Younger age may also increment the risk of prolonged concussion.
Conclusion:
High-quality evidence for risk modifiers in concussion remains thin. Prior concussion, collision sports, female person sex, and women's soccer are the strongest known gamble factors. Prove for nearly other factors is inconclusive.
Keywords: concussion, postconcussive syndrome, take a chance factors, gamble modifiers
A recent US epidemiologic study showed that concussions constituted 8.nine% of high school athletic injuries and 5.8% of collegiate able-bodied injuries, with an incidence of 0.23 per chiliad and 0.43 per 1000 athlete exposures, respectively.19 With this high incidence and potential for significant morbidity, it is essential to understand the complexities of concussion diagnosis and management.
Historical grading scales using clinical signs and symptoms, such as loss of consciousness, take failed to consistently predict severity level and length of recovery.35,43 Therefore, consensus guidelines currently recommend an individual approach to concussion management.37 Identifying take a chance factors for concussion risk and prolonged recovery, if they exist, would be of significant value.
Risk of Concussion
History of Concussion
Multiple prospective studies accept identified a history of prior concussion as a risk factor for subsequent concussion.21-23,45 In high schoolhouse athletes, a greater-than-twofold increment in concussion charge per unit was seen with history of concussion, even when adjusting for sport contact level, grade, and torso mass index.45 This association was strongest for football.45 Nonprofessional rugby has like findings.23 A dose-response relationship was seen in collegiate football game, including a 3-times-college risk of repeat concussion with a history of three or more concussions.21
Sports
Comparison of absolute risk amongst different studies is difficult owing to varied methods for computing incidence; however, several findings are evident. For individual sports, boxing has the highest incidence compared with martial arts.28 Collision team sports (football, water ice hockey, rugby) have the highest rates of concussion in men at multiple levels of competition.ten,xix,23,28,33,45 For women, soccer consistently has the highest take chances.x,nineteen,33 Wrestling, men's soccer, basketball, and lacrosse also put scholastic athletes at risk for concussion.10,19 In about sports, the rate of concussion is significantly college in games than do.ten,nineteen,22,45
Positions
Weak prove suggests that football linebackers, defensive backs, and offensive linemenxix,21,22; soccer goalkeepersxiii,19; defensive field players12; and rugby midfield backs27 sustain more concussions than other positions.
Age
The human relationship of age to overall hazard of concussion is unclear. A cross-sectional population survey in 12- to 24-year-olds found that younger age was associated with increased reporting of concussions; however, concussions and internal injuries were grouped.20 A prospective cohort of football players demonstrated that high school athletes had a college charge per unit of concussion than collegiate athletes.22 In contrast, a prospective cohort of athletes in various sports revealed a college overall rate of concussion for collegiate than loftier school sports; withal, concussions did account for a greater proportion of total injuries in most high school sports.xix In full general, weak testify suggests that a younger age is associated with an increased take chances of concussion.
Sexual activity
Female sex confers an increased take chances of concussion.14,xix,33 While overall rates of concussion at the high school and collegiate levels are college in male athletes, when sports are examined where the men's and women's games are similar (including soccer and basketball), female person athletes take a higher risk of concussion.nineteen,33 A prospective study in high school students differed in that boys' soccer had a college concussion charge per unit than girls'; all the same, the confidence intervals were big and overlapping.45 A recent critical literature review of sport concussion by sex analyzed prospective surveillance studies in sports with similar rules and equipment (soccer, basketball, ice hockey). Nine of ten studies had college injury rates for women, including those examining ice hockey, where the men's merely non women's game allows body checking; 4 studies reached statistical significance.14
Migraines
The overlap of symptoms betwixt migraine and concussion suggests a human relationship, but there are picayune quality data to support this.thirty,twoscore A Canadian cantankerous-sectional survey found that migraine was associated with an increased risk of sport-related concussion.20 Multiple unanswered questions remain regarding their association.30
Genetics
Picayune evidence exists for the role of family history and genetics as chance factors for concussion. Apolipoprotein E is involved in nervous tissue healing, and polymorphisms of the APOE gene have been implicated in Alzheimer illness,44 chronic traumatic encephalopathy,26 and worse outcome afterward traumatic brain injury.eighteen,48 Retrospective studies of college athletes suggest a possible clan betwixt minor alleles of the APOE promoter and risk of concussion with mixed results for minor alleles for the APOE cistron.49,50 A prospective written report showed that the minor APOE E4 allele was not significantly related to concussion.29
Equipment
Football game helmets reduce the acceleration of the caput from collisions and decrease severe head injuries,7,38 merely the rate and severity of concussion are not affected by different helmets.xi Similarly, ice hockey helmets subtract severe head injuries but not concussion rate.xi Headgear in rugby shows mixed results without conclusive evidence for a protective issue on concussion.eleven Two recent prospective studies showed a positive upshot on regular headgear use and a decreased rate of concussion; however, the studies were not designed to notice a protective result, and depression usage of headgear may have biased results.23,27 A minor retrospective study suggests that headgear in soccer may decrease concussion risk, but significant weaknesses, including just 19% wearing headgear, hamper conclusions.xi Mouthguards in multiple sports and confront shields in ice hockey decrease dental and orofacial injuries but have no issue on concussion risk.2,11,36,47
Risk of Prolonged Concussion
A bulk of concussed athletes accept symptom resolution within a calendar week.21 A subset, however, suffers prolonged symptoms lasting weeks to months.4,16 Current research on potential take a chance factors for prolonged recovery is promising but heterogeneous.43,51 At that place is disagreement in defining prolonged concussion, ranging from recovery greater than 7 days to symptoms at 3 months.
Signs and Symptoms
Loss of consciousness had been a traditional marker of severity for concussions based on its association to outcome in moderate to astringent traumatic brain injury.25 Some evidence suggests a relationship,1 but overall data do non support a potent relationship.21,35,37,43 The low prevalence of loss of consciousness in sports concussions makes information technology less useful every bit a predictive gene,19,22,45 and it is no longer a major marker of severity.
Other signs and symptoms take been explored as markers of severity. Posttraumatic amnesia, both retrograde and anterograde, has been associated with more and longer elapsing of concussion symptoms.43 In professional person football, risk factors for return to play greater than 7 days included retrograde amnesia, general cognitive problems, fatigue, and a greater number of symptoms at initial presentation.42 A recent prospective cohort of Australian football game players showed that the post-obit factors were related to a longer time to return to play (as a continuous variable): prolonged headache (greater than lx hours), fatigue, "fogginess," or greater than three symptoms at initial presentation.35 A prospective descriptive report found several factors significantly related to prolonged return to play (greater than vii days), including headache lasting longer than 3 hours, trouble concentrating longer than 3 hours, retrograde amnesia, loss of consciousness, and a trend for anterograde amnesia.1 Confusion, retentivity problems, and greater number of symptoms are also associated with slower resolution of symptoms.15,34 Greater deficits in visual retentiveness and processing speed on computerized neuropsychologic testing scores have been associated with longer recovery (greater than 10 days).31 Sensitivity is improved by combining neurocognitive test scores with symptom scores.32
History of Prior Concussion
A statistically significant association between multiple prior concussions and longer recovery (greater than vii days) was demonstrated in a prospective accomplice of collegiate football players.21 However, there was no difference in protracted recovery (greater than 14 days32 or as a continuous variable35) in a comparing of those with and without prior concussion in 2 prospective cohorts.32,35
Attention Arrears/Hyperactivity Disorder and Learning Disability
Many concussion studies exclude those with attention deficit/hyperactivity disorder and learning disability. Studies that include these subjects have not found an association betwixt either and time to return to play.1,32
Mood Disorders
Feet and depression accept been shown to occur afterward traumatic brain injury, but they accept non been specifically studied as premorbid conditions that may bear on the hazard of concussion and/or prolonged symptoms.thirty Premorbid mood disorders may affect baseline cognitive functioning and confound postconcussion symptoms.24
Migraine and Migraine-like Symptoms
A small cohort report did not show that premorbid headaches or migraines predict protracted recovery after concussion.32 Posttraumatic migraine symptoms in concussed athletes have been associated with greater deficits on neurocognitive testing and overall higher symptom scores compared with those with nonmigraine symptoms.39 A case-control study in high schoolhouse football players showed a statistically significant association between migraine symptoms and longer fourth dimension to recovery.31
Age
Several studies advise a relationship between younger age and slower recovery from concussion.37,43 The developing brain has prolonged and widespread cognitive swelling and increased sensitivity to glutamate in response to head injury.6 Concussed high school athletes take longer to recover neurocognitive deficits compared with collegiate9,17,46 and professional athletes.41 A prospective descriptive written report of concussion management did not testify an clan with historic period less than 18 years and prolonged render to play (greater than 7 days).1
Sex
Women showed more cognitive role deficits and more symptoms than men after concussion.five,nine Given that multiple early symptoms are associated with a longer return to play,15,34,35 female sex may stand for an underlying risk factor. Among young elite soccer players, a higher percentage of female athletes reported belatedly sequelae from concussion.three
Decision
Prior concussion21,23,45 and female sex14,19,33,45 have pocket-size evidence for increased risk of concussion. Football, men's ice hockey, rugby, and women's soccer have consistently shown high risk for concussive injury.x,19,23,28,33,45 Younger athletes may experience higher rates of concussion.nineteen,xx,22 Protective equipment, such as helmets, headgear, and mouthguards, has not been shown to definitively alter concussion risk; they may protect against other caput and facial injuries.11 Multiple symptoms, postconcussion memory dysfunction, longer duration of headache, and migraine symptoms are suggestive of an increased risk for prolonged concussion symptoms.1,eight,fifteen,31,34,35,39,42,43 Younger historic period may predispose to longer recovery from concussion.17,41,43,46 Evidence for almost other factors is express or inconclusive. Overall, more research is needed to clarify the function of risk modifiers in concussion.
Footnotes
The authors study no potential conflicts of interest in the development and publication of this manuscript.
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