Dan Charek, PhD
Concussion Specialist, Sports Medicine
Sports Medicine Hotline
What is a concussion?
A concussion is a traumatic brain injury (TBI) resulting in short-term impairment of neurologic or brain function caused by a direct blow to the head, face or neck, or an indirect blow to another part of the body that transmits an acceleration or deceleration force to the brain. One does not have to lose consciousness to have a concussion. In fact, only 10% of concussions involve loss of consciousness.
How common are concussions?
It has been estimated that 1.6-3.8 million concussions occur each year, many of which go unreported or unnoticed. The sport with the highest risk of concussion is football, followed by girl’s soccer, boy’s soccer, and girl’s basketball. As lacrosse grows in popularity, this sport may account for a significant number of concussions, especially in the boy’s game. Other sports with a higher risk of concussion are gymnastics, cheerleading, hockey and wrestling.
What are the signs and symptoms of a concussion?
Signs (reported by observer) & Symptoms (reported by patient)
-Appears dazed or confused -Headache
-Vacant stare -Nausea/vomiting
-Disoriented -Dizzy -Feeling foggy, “out of it”
-Clumsy -Double or blurry vision
-Slow answering questions -Sensitive to light and noise
-Emotional lability -Changes in sleep patterns
-Behavior changes -Impaired concentration
-Poor balance -Irritable, emotional, sad
What should I do if an athlete suffers a concussion?
Any athlete that shows signs or symptoms of a concussion should be held out from further participation until evaluated and cleared by a medical professional trained in the management of concussions. They should not return to play in the same contest or the same day. They need to receive immediate attention and monitored closely for deterioration in their condition. A sideline assessment card can be a helpful guide for the initial evaluation of an athlete suspected of suffering from a concussion.
Any of the following conditions after a concussion warrants urgent referral to the Emergency Department.
-Loss of consciousness
-Progressive memory loss
-Severe or worsening headache, nausea or vomiting
-Seizures or focal neurologic signs
Will a CAT scan or MRI show that an athlete has a concussion?
Since a concussion is a functional injury to the brain and not structural, standard imaging such as CAT scanning and MRI are normal. In other words, a normal CAT scan does not mean your child did not suffer a concussion. CAT scan and MRI may be helpful in ruling out other causes of their symptoms like skull fracture, bleeding in the brain, and tumors.
When can athletes with a concussion return to play?
There is no set time frame that determines when a concussed athlete can return to the playing field. All concussive injuries must be treated individually just as no two brains are alike, no two concussions are alike
An athlete can return to sports when the following conditions are met:
1. Resolution of all symptoms after complete rest (physical and cognitive).
2. Remain symptom-free after a gradual return to a normal school day and a gradual return to full physical activity.
3. Normalization of neurocognitive testing.
4. Written clearance by a medical professional trained in the management of concussions.
What is neurocognitive testing?
ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) is the first, most widely used and the most scientifically validated computerized concussion evaluation system. It was developed in the early 1990’s by a group a neuropsychologists from The University of Pittsburgh Department of Neurosciences and consists of a 30-40 minute computer-based test that measures multiple aspects of cognitive functioning such as attention span, working memory, sustained and selective attention time, non-verbal problem solving, reaction time and response variability.
How is the ImPACT test used?
The ImPACT test should be administered within 72 hours of a concussion to all athletes age 12 and above. The test can be re-administered every 7-10 days to document improvement and eventual normalization of neurocognitive functioning.When the athlete has fully recovered, he or she must be cleared by his/her doctor before returning to play. It must be noted that the ImPACT test is only one tool to help determine when the athlete recovers and is not intended to be used as the sole determinant for return to play. Since each symptom, response, and recovery pattern due to concussion varies from individual to individual, it is important that all athletes participating in high-risk sports (football, soccer, lacrosse, wrestling, gymnastics, ice hockey, basketball, etc) take a baseline test at the beginning of 7th, 9th and 11th grade. This will aid in determining when a concussed athlete’s cognitive function has returned to “normal.”
Can the ImPACT test be used if the athlete does not have a baseline test?
Yes, the ImPACT test can still provide useful information in concussion management even if a baseline test is not available. During the development of the test, a large amount of normative data was collected for various age groups. These “normal” scores can be used in comparison to the concussed athlete’s scores.
Can an athlete with a concussion go to school or come to practice and just observe?
The concussed brain is in the midst of a metabolic crisis, consisting of a supply-and-demand mismatch and between the injured brain cells’ demand for oxygen and glucose to heal and the decreased blood supply to them as a result of the brain trauma. Therefore, any type of mental activity that requires concentration, remembering, thinking or reasoning will continue to stress the brain, worsen symptoms and delay recovery. As long as the athlete has signs or symptoms of a concussion, he or she should be held out from school, avoid video games, texting, action-packed TV, computer work or any reading and studying.For the same reason, they should also not attend practice even just to “watch.” Being at practice to watch or even just going to a game to “support his or her teammates and cheer them on” also puts increased demand on the concussed brain, worsens symptoms and delays recovery.
This rest will enable to brain to recover quicker and expedite the athlete’s safe return to school and athletics. When the symptoms subside, they can return to school in a partial-day format and eventually return to observe practice. Mental and physical work can be slowly increased as long as symptoms such as headache, dizziness, feeling slowed down, etc do not return. When asymptomatic, the physical stress will be ramped up, adding light, then moderate, then full contact. When all symptoms remain absent with a full return to the school day, resumption of unrestricted activities, and ImPACT scores return to baseline or are normal, his or her doctor will determine clearance to return to competition.
What can happen if an athlete returns too quickly, or is not completely recovered before returning to play?
If an athlete suffers a 2nd blow to the head before he/she has fully recovered, the consequence can be permanent brain damage or death. This Second Impact Syndrome (SIS) results in a massive rush of blood into the brain causing irreversible brain swelling, seizures, coma and death in one half of the people. Over 90% of survivors of SIS have permanent brain damage.
Another consequence of a repeated injury before full recovery is post-concussive syndrome.Post-concussive syndrome is when an athlete suffers long-term (over 6 weeks) of symptoms. It is difficult who predict who will get post concussive syndrome, but kids with previous concussion, ADHD, migraines, or any other neurological condition may be at a higher risk.
It has also been shown that kids who suffer one concussion have a 3-4 times higher risk of suffering a second concussion. The second concussion may occur with a lesser impact, and the symptoms will generally last longer than the first concussion.
Do boys’ response to concussion differ from girls?
It has been shown the there are gender differences between boys’ and girls’ response to concussions. On average, girls take a few days longer to recover than boys. It should also be noted that younger athletes usually take longer to recover than older athletes.
In summary, when an athlete suffers a concussion, a “Concussion Management Team” will form with the athlete at the center. “Team members” will each have their own individual roles in management of the athlete and ensuring their safe return to school and athletics.
The parents and family members will be responsible for home issues such as rest, avoidance of stressful situations and academic help.
School personnel such as teachers, counselors and administrators must work with the student to avoid the placing academic pressure on them during recovery. They can implement academic modification in the school environment such as giving pre-printed class notes, shortened home work assignments, untimed tests, etc.
Sports Medicine Hotline
Dan Charek, PhD
Concussion Specialist, Sports Medicine