The Facts About Concussions
The Quick View
- A concussion is a mild traumatic brain injury.
- A certified athletic trainer is one of the best healthcare providers to manage an athlete's concussion from beginning to end.
- The most common signs and symptoms are headaches, difficulty focusing, and personality changes.
- All concussion are head injuries. Not all head injuries are concussions.
- A conservative 360,000 to liberal 3.8million concussion occur each year.
The Recent Interest in Concussion
In the past few few years, concussion have come into the spotlight in the media. There are constantly new reports, blogs, commentary, and discussion. What caused the surge in media coverage? Concussion have been a part of sports since the beginning. Why all of a sudden has this become a major issue? It's due to the perfect storm of tragic events. In 2009 the Zachary Lystedt law was passed in Washington state after a tragic head injury in a game in 2006. (check out the 6 minute video for more details). In 2002 Mike Webster, a retired Pittsburgh Steeler lineman, passed away. His autopsy showed significant brain damage. In 2005 the book League of Denial was published. This book was inspired by Mike Webster's debilitating brain damage and death. In response to all the criticism of concussions in football, Daniel Flynn wrote the book The War on Football. I have read both books and find them fascinating. I highly recommend reading both books (links can be found to both below).
With all these factors coming together around the same time, it is no wonder why concussions have come to the forefront of all football talk. Concussion are not limited to only the sport of football. They can occur in any sport. The top 5 sports, based on the NCAA Injury Surveillance System, are men's and women's soccer, men's and women's ice hockey, and football.
Below are the facts about concussion including mechanism of injury, signs and symptoms, current practice, and more.
What is a Concussion?
A concussion is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces (McCrory et al. 2013). Basically this means a person who sustained a hit, not necessarily to the head, starts to exhibit the signs and symptoms of a concussion because the neurons in the brain of misfiring as a result of the blow.
Further Definition Paraphrased from McCrory et al. 2013
- A concussion can be caused by a direct hit to the head, face, neck, or elsewhere on the body with a force transmitted to the head.
- Typically, a concussion results in the rapid onset of short-lived impairment of neurologic function that resolve spontaneously. In some cases symptoms may take minutes or hours to develop.
- Concussions may result in neuropathologic changes. Acute clinical symptoms reflect a functional disturbance rather than a structural injury. Because of this, a concussion will not show on any standard neuroimaging.
- Concussion result in a graded set of clinical symptoms that may or may not include loss of consciousness. Resolution of symptoms normally follows a sequential track. In some cases symptoms may be prolonged.
Concussion Signs & Symptoms
Some common signs and symptoms of a concussion include:
- Ringing in the Ears
- Sensitivity to light and/or sound
- Anterograde amnesia
- Retrograde amnesia
- Pressure in the head
- Loss of consciousness
- Trouble balancing
- Blurry vision
- Difficulty concentrating
- Feeling in a fog
- More emotional
- Nervous or Anxious
The SCAT3 in a brief neuropsychological assessment that includes the Maddock Questions and Standard Assessment of Concussion (SAC). Click here for a downloadable copy from the International Rugby Board.
The SCAT3 is a brief neuropsychological test batteries that assess the attention and memory functions. The SCAT3 has been shown to be practical and effective. The SCAT 3 incorporates the Maddocks questions and the Standard Assessment of Concussion (SAC).
Evaluation of a Concussion
A concussion evaluation can be performed on-field/sidelines, in the emergency room, or in a medical office.
Sideline Concussion Evaluation
On the sidelines that athlete should be examined by a physician or other licensed health care provider like a certified athletic trainer. In this first step special attention should be given to rule out a cervical spine injury. The health care provider must determine the status of the athlete in a timely manner. If one is not present then the athlete should be removed from participation and an urgent referral to a physician should be arranged. Once any first aid issues are tended to, the health care provider should administer a SCAT3 (Standard Concussion Assessment Tool 3rd Revision). The athlete should not be left alone for the first few hours after the initial injury. Serial monitoring is essential for determining if the athlete is deteriorating. An athlete diagnosed with a concussion should not be allowed to return to play on the same day.
SCAT3 Paper Based
Office or ER Concussion Evaluation
An athlete being evaluated by a doctor might be the first time the athlete is being assessed or may be referred there from another health care provider. In this setting the medical assessment should include a detailed medical history, detailed neurological exam, assessment of gait, balance, cognitive function, and mental status. The health care provider may seek additional information from coaches, parents, teammates, and eyewitnesses. The final step in this examination should determine the need for neuroimaging to rule out more severe brain injuries. Most of the items discussed above are included in the SCAT3.
The 4th International Conference on Concussion in Sport, "unanimously agreed that no RTP [return-to-play] on the day of the concussive injury should occur." The data shows that high school and collegiate athletes are more likely to have a delayed onset of symptoms.
There is no magic cure for a concussion. The only thing that will heal a concussion is time and rest.
Modifying Factors in Concussion Management
There are four major factors that can influence the management of a concussion. The items below are not listed in any particular order.
Some research shows that gender plays a role as a risk factor for this injury and/or can influence the severity of the injury. There is not enough research yet for the council to come to a unanimous decision but, it did agree it could be a potential factor.
Loss of Consciousness
The duration of loss of consciousness is a predictor of outcome. It has been determined that loss of consciousness for more than one minute should be considered a factor to modify concussion management.
Motor and Convulsive Phenomena
Immediate posturing may occur and even convulsions in some concussion cases. These are generally considered benign in concussion duration and severity.
Mental health issues have been reported in all forms of traumatic brain injuries, including concussions. It is recommended that the treating physician consider these issues when working with a concussed patient.
More Concussion Modifiers
Number, Duration (>10 Days), Severity
Prolonged loss of consciousness (>1 min), amnesia
Frequency, Timing, Recency
Repeated concussions with progressively less impact force
Comorbidities and premorbidities
Migrane, depression, or other mental disorders
Psychoactive drugs, anticoagulants
Dangerous style of play
High risk activity, contact and collision sports
While there is no guaranteed way to protect an athlete or person from a concussion, there are five distinct precautions that can be taken to reduce the incidence rate.
There is no such thing as a concussion proof helmet (some helmets are better than others but none are concussion proof) or a magic pill that will protect your brains against a concussion. These are just snakeoil and playing on your fears to take your money.
Injury Prevention: Protective Equipment
No study has shown that mouth guards and helmets reduce the incidence of concussions. The mouth guard does help to protect against dental injuries. The helmet helps to prevent other forms of head injuries, like fractures, when hitting another place or a hard surface.
Injury Prevention: Rule Changes
Considering rule changes to a particular sport can reduce the incidence rate of concussions. In soccer research shows about 50% of the concussions are a results of upper limb contact with the head. A rule change that took place already was the elimination of head down contact or "spearing" in football. Rule changes should also allow for effective off the field medical treatment without compromising the athlete's welfare or unfairly penalizing the team. Most importantly referees need to enforce these rule changes.
Injury Prevention: Risk Compensation
With the introduction of new protective equipment behavior should be monitored. An article in the British Journal of Sports Medicine shows that when protective equipment was introduced risk taking behaviour increased resulting in more injuries than before the equipment was introduced.
Injury Prevention: Aggression Versus Violence in Sport
Competitive aggression in sports make them fun to watch and participate in. This behaviour should not be discouraged. What should be discouraged is unnecessary violence specifically violence that increases concussion risk.
Injury Prevention: Knowledge Transfer
Little can be done to treat or reduce the effects of concussive injuries after the event. Education of athletes, parents, coaches, referees, and the general public is a necessity of concussion prevention. They must be educated on concussion detection, symptom presentation, and the concept of a safe return to play. The CDC has many great resources for concussion education.
Below are some resources that can help with concussion identification and safe return to play. First is an example of a graduated return-to-play protocol. This is based on the recommendation of McCrory et al. You can visit this article for more detail about returning to sports after a concussion.
The second is based on a handout that I give to every athlete with a head injury. These are precautions to reduce the risk of increasing concussion symptoms.
Graduated Return-to-Play Protocol
Functional Exercise at Each Stage of Rehabilitation
Objective(s) of Each Stage
1. No Activity
Symptom-limited physical and cognitive rest
2. Light Aerobic Activity
Walking, swimming, or stationary cycling, keeping the intensity <70% of maximum permitted heart rate; no resistance trainng
Increase heart rate
3. Sport Specific Exercise
Skating drills in ice hockey, running drills in soccer; no head-impact activities
4. Noncontact Training Drills
Progression to more complex training drills, eg, passing drills in football and ice hockey; may start progressive resistance training
Exercise, coordination, and cognitive load
5. Full-contact Practice
After medical clearance, participation in normal training activities
Restore confidence and assessment of functional skills by coaching staff
Return to Play
Normal game play
Head Injury Precautions
This is a copy I hand out to all of my head injury athletes. Whether or not I have assessed them as having a concussion, I hand them one of these form to give to their parent(s).
During the first 24 hours:
- Diet – drink only clear liquids for the first 8-12 hours and eat reduced amounts of foods thereafter for the remainder of the first 24 hours.
- Pain Medication – DO NOT take any pain medication unless specifically directed and prescribed by a physician.
- Activity – activity should be limited for the first 24 hours; this would involve no school, videogames, extracurricular physical activities or work when applicable.
- Driving – The sports medicine staff, based on national guidelines and position statements, strongly recommends that the athlete NOT drive for the first 24 hours.
- Observations – several times during the first 24 hours:
- Check to see that the pupils are equal. Both pupils may be large or small, but the right should be the same size as the left.
- Check the athlete to be sure that he/she is easily roused; that is, responds to shaking or being spoken to, and when awakened, reacts normally.
- It is unnecessary to wake the athlete during the night unless otherwise instructed.
- Check for and be aware of any significant changes. (See 6 below)
- Conditions may change significantly within the next 24 hours. Immediately obtain emergency care for any of the following signs or symptoms:
- Persistent or projectile vomiting
- Unequal pupil size (see 5.1 above)
- Difficulty in being roused
- Clear or bloody drainage from the ear or nose
- Continuing or worsening headache
- Slurred speech
- Inability to recognize people or places – increasing confusion
- Weakness or numbness in the arms or legs
- Unusual behavior change – increasing irritability
- Loss of consciousness
- Improvement – the best indication that an athlete who has suffered a significant head injury is progressing satisfactorily is that he/she is alert and behaving normally.
Mccrory, P., Herring, S. A., Putukian, M., Schneider, K., Tator, C. H., Guskiewicz, K. M., et al. (2013). Consensus Statement on Concussion in Sport: The 4th International Conference on Concussion in Sport, Zurich, November 2012. Journal of Athletic Training, 48(4), 554-575.
You can read the full article through the British Journal of Sports Medicine. It is free through this site.
League of Denial
The War on Football
© 2014 Trainer Joe