Editing Concussion (section)

==Diagnosis==
{| class="wikitable" style="float: right; margin-left:15px; text-align:center"
|+ align="bottom" style="caption-side: bottom; text-align: center; font-style: normal; font-weight: normal; font-size: smaller;"| Red flags are warning signs that may indicate a more serious problem and require immediate emergency medical attention
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! Red flag symptoms (emergent assessment required)<ref name="Ontario Neurotrauma Foundation_2019">{{cite web |last1=Zemek |first1=R |last2=Reed |first2=N |date=2023 |title=Living Guideline for Pediatric Concussion Care |url=https://pedsconcussion.com|access-date=February 9, 2024}}</ref>
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|[[Seizure]] or [[convulsion]]s
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|Worsening [[headache]]
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|Difficulty waking up (or loss of consciousness)
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|[[Diplopia|Seeing double]]
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|Problems recognizing people or places or confusion
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|Repeated [[vomiting]]
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|Numbness, weakness in extremities, or slurred speech
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|Not usual self, aggressive, or agitated behaviour
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|Neck pain or tenderness in the neck
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|}
[[Image:Anizokoria.JPG|thumb|upright=1.3|[[Anisocoria|Unequal pupil size]] is not a sign of concussion and can be a sign of a more serious brain injury.]]
Head trauma recipients are initially assessed to exclude a more severe [[medical emergency|emergency]] such as an intracranial hemorrhage or other serious head or neck injuries. This includes the "ABCs" (airway, breathing, circulation) and stabilization of the [[cervical vertebrae|cervical spine]], which is assumed to be injured in any athlete who is found to be unconscious after head or neck injury. Indications that screening for more serious injury is needed include 'red flag symptoms' or 'concussion danger signs': worsening headaches, persisting vomiting, increasing disorientation or a deteriorating level of consciousness, seizures, and [[anisocoria|unequal pupil size]].<ref name="British Journal of Sports Medicine_2017" /><ref name="cdcfacts">{{cite web |publisher=Centers for Disease Control and Prevention |year=2006 |url=https://www.cdc.gov/ncipc/tbi/contents.htm |title=Facts About Concussion and Brain Injury |access-date=2008-01-13 |archive-date=2007-12-17 |archive-url=https://web.archive.org/web/20071217210849/http://www.cdc.gov/ncipc/tbi/contents.htm |url-status=live }}</ref><ref name="CookSchweer">{{cite journal | vauthors = Cook RS, Schweer L, Shebesta KF, Hartjes K, Falcone RA | title = Mild traumatic brain injury in children: just another bump on the head? | journal = Journal of Trauma Nursing | volume = 13 | issue = 2 | pages = 58–65 | year = 2006 | pmid = 16884134 | doi = 10.1097/00043860-200604000-00007 | s2cid = 43369337 | doi-access = free }}</ref><ref name="Kayteasdale">{{cite journal | vauthors = Kay A, Teasdale G | title = Head injury in the United Kingdom | journal = World Journal of Surgery | volume = 25 | issue = 9 | pages = 1210–1220 | date = September 2001 | pmid = 11571960 | doi = 10.1007/s00268-001-0084-6 | s2cid = 24959890 }}</ref> Those with such symptoms, or those who are at higher risk of a more serious brain injury, require an emergency medical assessment.<ref name="British Journal of Sports Medicine_2017" /> Brain imaging such as a [[CT scan]] or [[MRI]] may be suggested, but should be avoided unless there are progressive neurological symptoms, focal neurological findings, or concern of skull fracture on exam.<ref name="AMSSMfive">{{Citation |author1 = American Medical Society for Sports Medicine |author1-link = American Medical Society for Sports Medicine |date = 24 April 2014 |title = Five Things Physicians and Patients Should Question |publisher = American Medical Society for Sports Medicine |work = [[Choosing Wisely]]: an initiative of the [[ABIM Foundation]] |url = http://www.choosingwisely.org/doctor-patient-lists/american-medical-society-for-sports-medicine/ |access-date = 29 July 2014 |archive-date = 29 July 2014 |archive-url = https://web.archive.org/web/20140729224526/http://www.choosingwisely.org/doctor-patient-lists/american-medical-society-for-sports-medicine/ |url-status = live }}</ref>

Diagnosis of concussion requires an assessment performed by a physician or nurse practitioner to rule out severe injuries to the brain and cervical spine, mental health conditions, or other medical conditions.<ref name="Marshall2023" /> Diagnosis is based on physical and neurological examination findings, duration of unconsciousness (usually less than 30 minutes) and post-traumatic amnesia (usually less than 24&nbsp;hours), and the Glasgow Coma Scale (people with mTBI have scores of 13 to 15).<ref name=BorgHolm04/> A CT scan or MRI is not required to diagnose concussion.<ref name="Marshall2023" /><ref name="www.cdc.gov_2020" /> [[Neuropsychological test]]s such as the SCAT5/child SCAT5 may be suggested measure cognitive function.<ref name="Mc2017" /><ref>{{cite journal | vauthors =  | title = Sport concussion assessment tool - 5th edition | journal = British Journal of Sports Medicine | volume = 51 | issue = 11 | pages = 851–858 | date = June 2017 | pmid = 28446451 | doi = 10.1136/bjsports-2017-097506SCAT5 | doi-access = free }}</ref><ref>{{cite journal | vauthors =  | title = Sport concussion assessment tool for children ages 5 to 12 years | journal = British Journal of Sports Medicine | volume = 51 | issue = 11 | pages = 862–869 | date = June 2017 | pmid = 28446448 | doi = 10.1136/bjsports-2017-097492childscat5 | url = https://bjsm.bmj.com/content/51/11/862 | access-date = 2020-08-12 | url-status = live | doi-access = free | archive-url = https://web.archive.org/web/20210225121414/https://bjsm.bmj.com/content/51/11/862 | archive-date = 2021-02-25 }}</ref> Such tests may be administered hours, days, or weeks after the injury, or at different times to demonstrate any trend.<ref name="moser">{{cite journal | vauthors = Moser RS, Iverson GL, Echemendia RJ, Lovell MR, Schatz P, Webbe FM, Ruff RM, Barth JT | display-authors = 6 | title = Neuropsychological evaluation in the diagnosis and management of sports-related concussion | journal = Archives of Clinical Neuropsychology | volume = 22 | issue = 8 | pages = 909–916 | date = November 2007 | pmid = 17988831 | doi = 10.1016/j.acn.2007.09.004 | doi-access = free }}</ref> Some athletes are also being tested pre-season (pre-season baseline testing) to provide a baseline for comparison in the event of an injury, though this may not reduce risk or affect return to play and baseline testing is not required or suggested for most children and adults.<ref name="pmid21228656">{{cite journal | vauthors = Randolph C | title = Baseline neuropsychological testing in managing sport-related concussion: does it modify risk? | journal = Current Sports Medicine Reports | volume = 10 | issue = 1 | pages = 21–26 | year = 2011 | pmid = 21228656 | doi = 10.1249/JSR.0b013e318207831d | s2cid = 42295204 | doi-access = free }}</ref><ref>{{cite web|last=Parachute|date=November 2018|title=Statement on Concussion Baseline Testing in Canada|url=https://parachute.ca/wp-content/uploads/2019/06/BaselineTestingStatement-Parachute.pdf|access-date=August 12, 2020|archive-date=July 17, 2020|archive-url=https://web.archive.org/web/20200717224549/https://parachute.ca/wp-content/uploads/2019/06/BaselineTestingStatement-Parachute.pdf|url-status=live}}</ref>

If the Glasgow coma scale is less than 15 at two hours or less than 14 at any time, a CT is recommended.<ref name=NEJM2007/> In addition, a CT scan is more likely to be performed if observation after discharge is not assured or [[Substance intoxication|intoxication]] is present, there is suspected increased risk for bleeding, age greater than 60,<ref name=NEJM2007/> or less than 16. Most concussions, without complication, cannot be detected with MRI or CT scans.<ref name="Poirier">{{cite journal|author=Poirier MP |year=2003 |title=Concussions: Assessment, management, and recommendations for return to activity |journal=Clinical Pediatric Emergency Medicine |volume=4 |issue=3 |pages=179–85 |doi=10.1016/S1522-8401(03)00061-2}}<!--abstract linked with url because doi doesn't take you right to it. no PMID found--></ref> However, changes have been reported on MRI and SPECT imaging in those with concussion and normal CT scans, and [[Post-concussion syndrome|persisting concussion symptoms]] may be associated with abnormalities visible on [[single photon emission computed tomography|SPECT]] and [[Positron emission tomography|PET scan]]s.<ref name=Iverson2005/>{{Update inline|date=August 2019|reason=}} Mild head injury may or may not produce abnormal [[Electroencephalography|EEG]] readings.<ref name="Binder86">{{cite journal | vauthors = Binder LM | title = Persisting symptoms after mild head injury: a review of the postconcussive syndrome | journal = Journal of Clinical and Experimental Neuropsychology | volume = 8 | issue = 4 | pages = 323–346 | date = August 1986 | pmid = 3091631 | doi = 10.1080/01688638608401325 }}</ref><ref name="pmid29213487">{{cite journal | vauthors = Ianof JN, Anghinah R | title = Traumatic brain injury: An EEG point of view | journal = Dementia & Neuropsychologia | volume = 11 | issue = 1 | pages = 3–5 | date = 2017 | pmid = 29213487 | pmc = 5619208 | doi = 10.1590/1980-57642016dn11-010002 }}</ref> A blood test known as the Brain Trauma Indicator was approved in the United States in 2018 and may be able to rule out the risk of intracranial bleeding and thus the need for a CT scan for adults.<ref>{{cite web|title=Press Announcements – FDA authorizes marketing of first blood test to aid in the evaluation of concussion in adults|url=https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm596531.htm|website=www.fda.gov|access-date=24 February 2018|archive-date=9 September 2018|archive-url=https://web.archive.org/web/20180909033418/https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm596531.htm|url-status=dead}}</ref>

Concussion may be under-diagnosed because of the lack of the highly noticeable signs and symptoms while athletes may minimize their injuries to remain in the competition.<ref name="BarthVarney99">{{cite book |vauthors=Barth JT, Varney NR, Ruchinskas RA, Francis JP |chapter=Mild head injury: The new frontier in sports medicine |veditors=Varney NR, Roberts RJ |title=The Evaluation and Treatment of Mild Traumatic Brain Injury |publisher=Lawrence Erlbaum Associates |location=Hillsdale, New Jersey |year=1999 |pages=85–86 |isbn=978-0-8058-2394-3 |chapter-url=https://books.google.com/books?id=i4Tpx6wHvJ4C&pg=PA21 }}{{Dead link|date=December 2023 |bot=InternetArchiveBot |fix-attempted=yes }}</ref> Direct impact to the head is not required for a concussion diagnosis, as other bodily impacts with a subsequent force transmission to the head are also causes.<ref>{{cite journal | vauthors = Scorza KA, Cole W | title = Current Concepts in Concussion: Initial Evaluation and Management | journal = American Family Physician | volume = 99 | issue = 7 | pages = 426–434 | date = April 2019 | pmid = 30932451 | url = https://www.aafp.org/afp/2019/0401/p426.html | access-date = 2020-12-07 | url-status = live | archive-url = https://web.archive.org/web/20210429024353/https://www.aafp.org/afp/2019/0401/p426.html | archive-date = 2021-04-29 }}</ref> A retrospective survey in 2005 suggested that more than 88% of concussions are unrecognized.<ref name="Delaney">{{cite journal | vauthors = Delaney JS, Abuzeyad F, Correa JA, Foxford R | title = Recognition and characteristics of concussions in the emergency department population | journal = The Journal of Emergency Medicine | volume = 29 | issue = 2 | pages = 189–197 | date = August 2005 | pmid = 16029831 | doi = 10.1016/j.jemermed.2005.01.020 }}</ref> Particularly, many younger athletes struggle with identifying their concussions, which often result in the non-disclosure of concussions and consequently under-representing the incidence of concussions in the context of sport.<ref name="Kerr_2014">{{cite journal | vauthors = Kerr ZY, Register-Mihalik JK, Marshall SW, Evenson KR, Mihalik JP, Guskiewicz KM | title = Disclosure and non-disclosure of concussion and concussion symptoms in athletes: review and application of the socio-ecological framework | journal = Brain Injury | volume = 28 | issue = 8 | pages = 1009–1021 | date = July 2014 | pmid = 24738743 | doi = 10.3109/02699052.2014.904049 | s2cid = 207448513 }}</ref>

Diagnosis can be complex because concussion shares symptoms with other conditions. For example, persisting concussion symptoms such as cognitive problems may be misattributed to brain injury when, in fact, due to [[post-traumatic stress disorder]] (PTSD).<ref name=Bryant08/>

There are no fluid biomarkers (i.e., blood or urine tests) that are validated for diagnosing concussion in children or adolescents.<ref>{{cite journal | vauthors = Mannix R, Levy R, Zemek R, Yeates KO, Arbogast K, Meehan WP, Leddy J, Master C, Mayer AR, Howell DR, Meier TB | display-authors = 6 | title = Fluid Biomarkers of Pediatric Mild Traumatic Brain Injury: A Systematic Review | journal = Journal of Neurotrauma | volume = 37 | issue = 19 | pages = 2029–2044 | date = October 2020 | pmid = 32303159 | doi = 10.1089/neu.2019.6956 | s2cid = 215809672 }}</ref>

===Classification===
No single definition of concussion, minor head injury,<ref name="SatzZaucha">
{{cite journal | vauthors = Satz P, Zaucha K, McCleary C, Light R, Asarnow R, Becker D | title = Mild head injury in children and adolescents: a review of studies (1970-1995) | journal = Psychological Bulletin | volume = 122 | issue = 2 | pages = 107–131 | date = September 1997 | pmid = 9283296 | doi = 10.1037/0033-2909.122.2.107 }}</ref> or mild traumatic brain injury is universally accepted.<ref name="ComperBisschop">{{cite journal | vauthors = Comper P, Bisschop SM, Carnide N, Tricco A | title = A systematic review of treatments for mild traumatic brain injury | journal = Brain Injury | volume = 19 | issue = 11 | pages = 863–880 | date = October 2005 | pmid = 16296570 | doi = 10.1080/02699050400025042 | s2cid = 34912966 }}</ref> In 2001, the expert Concussion in Sport Group of the first International Symposium on Concussion in Sport<ref name="aubry"/> defined concussion as "a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces."<ref name="canturc06">{{cite journal | vauthors = Cantu RC, Aubry M, Dvorak J, Graf-Baumann T, Johnston K, Kelly J, Lovell M, McCrory P, Meeuwisse W, Schamasch P, Kevin M, Bruce SL, Ferrara MS, Kelly JP, McCrea M, Putukian M, McLeod TC | display-authors = 6 | title = Overview of concussion consensus statements since 2000 | journal = Neurosurgical Focus | volume = 21 | issue = 4 | pages = E3 | date = October 2006 | pmid = 17112193 | doi = 10.3171/foc.2006.21.4.4 | doi-access = free }}<!-- No PMID found --></ref> It was agreed that concussion typically involves temporary impairment of neurological function that heals by itself within time, and that [[neuroimaging]] normally shows no gross structural changes to the brain as the result of the condition.<ref name="AndersonT"/>

However, although no structural brain damage occurs according to the classic definition,<ref>
{{cite journal|author=Parkinson D |year=1999 |title=Concussion confusion |journal=Critical Reviews in Neurosurgery |volume=9 |issue=6 |pages=335–39 |issn=1433-0377 |doi=10.1007/s003290050153|s2cid=195203684 }}</ref> some researchers have included [[injury|injuries]] in which structural damage has occurred, and the [[National Institute for Health and Clinical Excellence]] definition includes physiological or physical disruption in the brain's [[chemical synapse|synapse]]s.<ref name="NICE">{{cite book |url=http://www.nice.org.uk/nicemedia/pdf/CG56guidance.pdf |publisher=National Institute for Health and Clinical Excellence |title=Head Injury: Triage, Assessment, Investigation and Early Management of Head Injury in Infants, Children and Adults |isbn=978-0-9549760-5-7 |date=2007 |access-date=2008-01-26 |archive-date=2013-02-22 |archive-url=https://web.archive.org/web/20130222032536/http://www.nice.org.uk/nicemedia/pdf/CG56guidance.pdf |url-status=live }}</ref> Also, by definition, concussion has historically involved a loss of consciousness. However, the definition has evolved over time to include a change in consciousness, such as amnesia,<ref name="RuffGrant">{{cite book |vauthors=Ruff RM, Grant I |chapter=Postconcussional disorder: Background to DSM-IV and future considerations |veditors=Varney NR, Roberts RJ |title=The Evaluation and Treatment of Mild Traumatic Brain Injury |publisher=Lawrence Erlbaum Associates |location=Hillsdale, New Jersey |year=1999 |page=320 |isbn=978-0-8058-2394-3 |chapter-url=https://books.google.com/books?id=i4Tpx6wHvJ4C&pg=PA21 }}{{Dead link|date=December 2023 |bot=InternetArchiveBot |fix-attempted=yes }}</ref> although controversy continues about whether the definition should include only those injuries in which [[unconsciousness|loss of consciousness]] occurs.<ref name="Pearce"/> This debate resurfaces in some of the best-known concussion grading scales, in which those episodes involving loss of consciousness are graded as being more severe than those without.<ref name="cobb">{{cite journal | vauthors = Cobb S, Battin B | title = Second-impact syndrome | journal = The Journal of School Nursing | volume = 20 | issue = 5 | pages = 262–267 | date = October 2004 | pmid = 15469376 | doi = 10.1177/10598405040200050401 | s2cid = 38321305 }}<!--doi 10.1622/1059-8405(2004)20[262:SS]2.0.CO;2 apparently broken--></ref>

Definitions of mild traumatic brain injury (mTBI) were inconsistent until the [[World Health Organization]]'s [[ICD-10|International Statistical Classification of Diseases and Related Health Problems]] (ICD-10) provided a consistent, authoritative definition across specialties in 1992.<ref name="Petchprapai07"/> Since then, various organizations such as the American Congress of Rehabilitation Medicine<ref name="Kushner98">{{cite journal | vauthors = Kushner D | title = Mild traumatic brain injury: toward understanding manifestations and treatment | journal = Archives of Internal Medicine | volume = 158 | issue = 15 | pages = 1617–1624 | year = 1998 | pmid = 9701095 | doi = 10.1001/archinte.158.15.1617 | doi-access = free }}</ref> and the [[American Psychiatric Association]] in its ''[[Diagnostic and Statistical Manual of Mental Disorders]]''<ref name="Petchprapai07"/> have defined mTBI using some combination of [[loss of consciousness]], [[post-traumatic amnesia]], and the [[Glasgow Coma Scale]].

Concussion falls under the classification of mild TBI,<ref name="LeeLK07">
{{cite journal | vauthors = Lee LK | title = Controversies in the sequelae of pediatric mild traumatic brain injury | journal = Pediatric Emergency Care | volume = 23 | issue = 8 | pages = 580–83; quiz 584–86 | date = August 2007 | pmid = 17726422 | doi = 10.1097/PEC.0b013e31813444ea | s2cid = 33766395 }}</ref> but it is not clear whether concussion is implied in mild brain injury or mild head injury.<ref name=LevinHS>{{cite book|vauthors=Benton AL, Levin HS, Eisenberg HM |title=Mild Head Injury |publisher=Oxford University Press |location=Oxford [Oxfordshire] |year=1989 |page=v |isbn=978-0-19-505301-2 }}</ref>{{update inline|date=December 2012}} "mTBI" and "concussion" are often treated as synonyms in medical literature<ref name="Kushner98"/> but other injuries such as [[intracranial hemorrhage]]s (e.g. [[intra-axial hematoma]], [[epidural hematoma]], and [[subdural hematoma]]) are not necessarily precluded in mTBI<ref name="AndersonT"/> or mild head injury,<ref name="vanderNaalt">{{cite journal | vauthors = van der Naalt J | title = Prediction of outcome in mild to moderate head injury: a review | journal = Journal of Clinical and Experimental Neuropsychology | volume = 23 | issue = 6 | pages = 837–851 | date = December 2001 | pmid = 11910548 | doi = 10.1076/jcen.23.6.837.1018 | s2cid = 146179592 }}</ref><ref name="Savitsky00">{{cite journal | vauthors = Savitsky EA, Votey SR | title = Current controversies in the management of minor pediatric head injuries | journal = The American Journal of Emergency Medicine | volume = 18 | issue = 1 | pages = 96–101 | date = January 2000 | pmid = 10674544 | doi = 10.1016/S0735-6757(00)90060-3 }}</ref> as they are in concussion.<ref name="ParikhKoch">{{cite journal | vauthors = Parikh S, Koch M, Narayan RK | title = Traumatic brain injury | journal = International Anesthesiology Clinics | volume = 45 | issue = 3 | pages = 119–135 | year = 2007 | pmid = 17622833 | doi = 10.1097/AIA.0b013e318078cfe7 | s2cid = 46012183 }}</ref> mTBI associated with abnormal neuroimaging may be considered "complicated mTBI".<ref name="Iverson2005"/> "Concussion" can be considered to imply a state in which brain function is temporarily impaired and "mTBI" to imply a [[pathophysiology|pathophysiological]] state, but in practice, few researchers and clinicians distinguish between the terms.<ref name="AndersonT"/> Descriptions of the condition, including the severity and the area of the brain affected, are now used more often than "concussion" in clinical neurology.<ref name="LarnerAJ">{{cite book|vauthors=Larner AJ, Barker RJ, Scolding N, Rowe D |title=The A–Z of Neurological Practice: a Guide to Clinical Neurology |publisher=Cambridge University Press |location=Cambridge|year=2005 |page=199 |isbn=978-0-521-62960-7 }}</ref>