Concussion Diagnosis

Concussion Signs and Symptoms

Concussion signs and symptoms generally fall into four categories: physical symptoms, cognitive symptoms, emotional symptoms, and sleep symptoms, and may include:

Physical	Cognitive	Emotional	Sleep
• Headache • Nausea • Vomiting • Balance Problems • Dizziness • Visual Problems • Fatigue • Sensitivity to light • Sensitivity to noise • Numbness/Tingling • Dazed or Stunned	• Feeling mentally "foggy" • Feeling slowed down • Difficulty concentrating • Difficulty remembering • Forgetful of recent information or conversations • Confused about recent events • Answers questions slowly • Repeats questions	• Irritability • Sadness • More emotional • Nervousness	• Drowsiness • Sleeping less than usual • Sleeping more than usual • Trouble falling asleep

Diagnosis

Diagnosing MTBIs can be challenging as symptoms of MTBI are common to those of other medical conditions (such as post-traumatic stress disorder [PTSD], depression, and headache syndromes), and the onset and/or recognition of symptoms may occur days or weeks after the initial injury.^14,18 A systematic assessment of the injury and its manifestations is essential to proper management and reduced morbidity. The Acute Concussion Evaluation (ACE) form included in this tool kit was developed to provide physicians with an evidence-based protocol to conduct an initial evaluation and diagnosis of patients (both children and adults) with known or suspected MTBI. The research evidence documenting the importance of these components in the evaluation of an MTBI is provided in the reference list. The ACE can also be used serially to track symptom recovery over time. It provides a systematic protocol for assessing the key components for diagnosing an MTBI and serves as the basis for management and referral recommendations provided by the ACE Care Plan (two versions). These tools were developed to provide physicians with a more individualized assessment of MTBI and to help guide the management and recovery, as well as the referral of patients with such injuries.

The ACE contains three major components that require evaluation:

• Characteristics of the injury;
• Types and severity of the symptoms; and
• Risk factors that can lead to a protracted period of recovery.

The ACE should be administered to patients for whom concussion is clearly indicated (e.g., loss of consciousness or change in mental status, confusion or amnesia) and to those for whom concussion should be suspected (e.g., other traumatic injuries are observed or reported; forcible blow to the head with functional changes). For example, concussions are often not recognized among children with orthopedic injuries. Physicians should consider screening for possible concussion among patients with various other types of injuries such as:

• High-speed activities (motor vehicle crashes, bicycle riding, skateboarding)
• Sports and recreation activities
• Falls (including those among older adults), especially from a significant distance (e.g., off a ladder, from a tree)
• Suspected child maltreatment (e.g., shaking, hitting, throwing)
• Exposure to blasts (includes military personnel returning from war zones)
• Injuries to the external parts of the head and/or scalp (e.g., lacerations)

The following summarizes the information contained on the ACE and outlines steps for diagnosing a patient with a known or suspected MTBI. Detailed instructions about how to use the ACE are provided on the back page of the form.

Figure 2. ACE Management Plan

A. Injury Characteristics

1. Injury Description. Ask the patient (and/or parent, if child) about how the injury occurred, type of force, and location on the head or body where the force (blow) was received. Different biomechanics of injury may result in varied symptom patterns. For example, an injury that occurs to the posterior aspect of the head may result in visual changes, balance problems, and fatigue. The force to the head may be indirect, such as with an individual being struck in the body resulting in the head accelerating forward and then backward
2. Cause. The cause of the injury may also help to estimate the force of the hit or blow the patient sustained. The greater the force associated with the injury, the more likely the patient will present with more severe symptoms. Conversely, significant symptoms associated with a relatively light force might indicate an increased vulnerability to MTBI (especially among patients with a history of multiple MTBIs or preexisting history of migraine) or the presence of other physical or psychological factors contributing to symptom exacerbation.
3. Amnesia (Retrograde). Determine whether amnesia (memory loss) has occurred for events before the injury and attempt to determine the length of time of memory dysfunction. Research indicates that even seconds of amnesia may predict more serious injury.¹⁹
4. Loss of Consciousness (LOC). Inquire whether LOC occurred or was observed and the length of time the patient lost consciousness. (Note: Research indicates that up to 90% of concussions do not involve LOC.)^19,20
5. Early Signs Observed by Others. Ask those who know the patient (parent, spouse, friend, etc) about specific signs of the MTBI that they may have observed. These signs are typically observed early after the injury. Record their presence or absence with a checkmark.
6. Seizures. Inquire whether seizures were observed (although this is uncommon).

B. Symptom Check List

Record the presence and severity of physical, cognitive, emotional, and sleep symptoms and the early signs since the injury.

1. Signs and Symptoms. Use the ACE to record symptoms reported by the patient (and/or parent, if child) in each of the four symptom areas (physical, cognitive, emotional, and sleep). Determine if each symptom is present. If not present, circle "0" for No. If symptom is present (within the past 24 hours), circle "1" for Yes. Since symptoms can be present prior to the injury (e.g., inattention, headaches), it is important to assess any changes from usual symptom presentation.^19,21 Sum the total number of symptoms for each of the four symptom areas and for the Total Symptom Score. Any Total Symptom Score greater than "0" indicates a positive symptom profile. (Note: any presentation of lingering and/or persistent symptoms associated with MTBI indicates incomplete recovery and prudent management is indicated, especially pertaining to activities such as work, school, and sports.)
2. Exertion. Inquire whether any symptoms worsen with exertion, that is, with physical activity (e.g., running, climbing stairs, bike riding) and/or cognitive activity (e.g., academic studies, multi-tasking at work, reading or other tasks requiring focused concentration). Physicians should be aware that symptoms will typically worsen or re-emerge with exertion, indicating incomplete recovery, which may also be protracted with over-exertion.
3. Overall "Difference" Rating. Obtain an overall rating from the patient (and/or parent, if child) regarding their overall perceived change from their pre-injury self. This rating is helpful in summarizing the overall impact of the symptoms. Use the 7 point scale with "0" reflecting no change from normal, to "6" reflecting a major

C. Signs of Deteriorating Neurological Function

It is important to assess whether the patient with an MTBI exhibits any signs or reports any symptoms that would indicate deteriorating neurological functioning. Patients should be carefully observed over the first 24-48 hours for the serious signs listed below.²² If any of these signs are reported, they should be referred to an emergency department for an

• Headaches that worsen
• Seizures
• Focal neurologic signs
• Looks very drowsy or can't be awakened
• Repeated vomiting
• Slurred speech
• Can't recognize people or places
• Increasing confusion or irritability
• Weakness or numbness in arms or legs
• Neck pain
• Unusual behavior change
• Significant irritability
• Any loss of consciousness greater than 30 seconds or longer. (Brief loss of consciousness (under 30 seconds) should be taken seriously and the patient should be carefully monitored.)

D. Identify Risk Factors that may Complicate the Recovery Process

Each of the factors below have been identified through empirical research to be associated with a longer period of recovery from an MTBI. Identifying any of these factors is helpful for understanding the nature and extent of the patient's injury and for monitoring their recovery.

1. Concussion (or MTBI) History. Assess the number and date(s) of prior concussions and the duration of symptoms for each injury. The effects of multiple MTBIs may be cumulative, especially if there is minimal duration of time between injuries and less biomechanical force results in subsequent MTBI (which may indicate incomplete recovery from the initial trauma).^10,21-26
2. Headache History. Assess prior personal and/or family history of diagnosis and treatment for headaches. Headaches (migraines in particular) can result in protracted recovery from MTBI.^27-29
3. Developmental History. Assess for a history of learning disabilities, Attention-Deficit/Hyperactivity Disorder or other developmental disorders. Recovery may take longer in patients with these conditions.30
4. Psychiatric History. Assess for history of depression/mood disorder, anxiety, and/or sleep disorder.^31-33

E. Establishing the Diagnosis.

Following the above assessment, the diagnosis of concussion or MTBI using the following

1. 850.0 (Concussion, with no loss of consciousness) - Positive injury description with evidence of a direct or indirect forcible blow to the head, plus evidence of active symptoms and/or signs of any type and number related to the trauma; no evidence of LOC, skull fracture, internal bleed (i.e., intracranial injury).
2. 850.1 (Concussion, with brief loss of consciousness < 1 hour) - Positive injury description with evidence of a direct or indirect forcible blow to the head, plus evidence of active symptoms and/or signs of any type and number related to the trauma; positive evidence of LOC; no skull fracture, internal bleed.
3. 850.9 (Concussion, unspecified) - Positive injury description with evidence of a direct or indirect forcible blow to the head, plus evidence of active symptoms and/or signs of any type and number related to the trauma; unclear or unknown injury details and unclear evidence of LOC; no skull fracture, internal bleed.

If there is evidence of prolonged LOC (>1 hour), skull fracture, and/or intracranial injury, the diagnosis of 854 should be considered (consult the ICD-9-CM manual for detailed codes). Use of ICD-9-CM 959.01 Head injury, unspecified is not recommended for concussion/MTBI, as it excludes the above concussion diagnoses and is non-specific.

Next: Clinical Management