No topic has garnered more attention over the last several years than concussions. The media is constantly showing violent hits in the NFL, NHL and other sports and the results of the hits are being shown more and more. Recent involvement by the NFL Players Association as well as many others, have sparked medical research and education into concussions and the long term effects they may cause. This movement has sparked many changes in the way concussions are handled and will greatly benefit an athlete’s health not only today, but in the future.
So, what exactly is a concussion? “A concussion is a traumatic injury to the brain that alters mental status or causes other symptoms.” (www.stopsportsinjuries.org) Concussions can be caused by a direct blow to the head or an indirect blow to the body that can violently shake the head. When a concussion occurs, the brain typically is accelerated quickly and can make contact with the inside of the skull causing a bruise or can be twisted or stretched causing a dysfunction of normal brain activity. Many concussions are often overlooked because athletes think “they just got their bell rung” or “didn’t get knocked out” or “just have a headache.” Though athletes, coaches and parents have been educated better in recent years, there is still a lot to learn regarding signs, symptoms and how to manage a concussion.
In 2012 there were an estimated 300,000 concussions reported in high school sports as noted in Marar M, McIlvain NM, Fields SK, Comstock RD article, Epidemiology of Concussions Among United States High School Athletes in 20 Sports published in the American Journal of Sports Medicine. Many research articles in recent years have noted that football, boys hockey and girls soccer have the highest incidence of sports related concussions and that schools with a certified Athletic Trainer seem to have more as well. Athletic Trainers are educated in picking out the subtle signs of concussions that may go unrecognized by the athlete, coach or parent and may be the reason for the increase in incidence.
So, how do you know if your athlete has a concussion? First you need to look for signs and symptoms of a concussion. The following is a list of the most common symptoms. These are not the only symptoms, but the more common ones.
- Appearing dazed or confused
- Balance difficulties
- Visual problems, such as blurriness or double vision
- Short or long term memory difficulties such as don’t remember the play that just occurred, the score of the game or what they had for breakfast
- Just not feeling right
- Sensitivity to light or noise
- Difficulty concentrating
If any of these signs or other symptoms occur following a collision, a concussion should be assumed and the athlete should be held out of participation and referred to a qualified sports physician who frequently deals with sports related concussions for proper diagnosis and management. It is always best to err on the side of caution as the athlete is at a higher risk of a second concussion that may occur before the first one has healed. This is additional injury is called second impact syndrome which can potentially be fatal.
Once your athlete is a diagnosed by a physician as having a concussion, what are the next steps? “Often physical and cognitive rest (yes, this may mean missing school) is prescribed for the first few boring days with no computers, television, cell phones, texting, music, reading or other stressors on the healing brain,” stated by Dr. Chris Koutures, a 2008 USA Olympic Team Physician. Immediately after receiving a concussion, the brain needs time to heal and anything that might increase a symptom or cause a new symptom needs to be avoided.
The goal of the initial rest period is to have the brain begin to heal and the symptoms to subside. Many times the symptoms will cease in the first few hours or days, but every concussion is different and how they will heal is hard to predict. It is key throughout the recovery to stay in close contact with your physician as well as other sports medicine professionals such as athletic trainers, physical therapists and strength coaches who will be involved in the athlete’s return.
Once the initial concussion symptoms have lessened, often your physician will have the athlete begin with cognitive activity such as reading, watching TV and going to school. These cognitive activities may or may not cause the symptoms to return and need to be relayed to your physician prior to advancing to physical activity. The athlete may notice they can only handle cognitive activity for a certain amount of time before feeling symptoms. At this point, they may need to limit the time of activity. This time may be increased as the athlete heals.
Once the athlete is symptom-free at rest and with cognitive activity, it may be time to return to phased-in physical activity. This stage in the process must be cleared by a physician. “Returning an athlete to participation should follow a progression that begins once the athlete is completely symptom-free. All signs and symptoms should be evaluated using a graded symptom scale or checklist when performing follow-up assessments and should be evaluated both at rest and after exertional maneuvers,” as stated in the National Athletic Trainers’ Association Position Statement: Management of Sport-Related Concussion. Many times the progression will begin with light aerobic activity such as jogging or riding a stationary bike. As the athlete is able to handle the workload without symptoms, the time duration and intensity may be increased. A next step may include agility drills as well as balance exercises with a progression to more intense jumping and sprinting drills. As the rehab process moves on, the athlete may get involved with sport specific exercises such as dribbling a basketball, playing catch, hitting a baseball or ice skating. If there are no symptoms during or following activity, many Physicians will allow the athlete to return to a non-contact practice and progress to a contact practice.
Once the athlete has handled all of the progressions without any issues, it is time for the physician to decide whether or not the athlete is ready to fully return. Often times a specific testing such as a SCAT test will be utilized to further evaluate the injury. The test scores will be compared to the athlete’s baseline test if they were tested prior to the injury or to normative data. This information will assist the Physician in making his or her decision regarding safe return to play.
This process may seem longer than it really is, but is imperative for a safe return. As Dr. Chris Koutures states, “Incomplete healing of a first head injury makes the athlete more prone to second, often more severe head injury with death as an uncommon but possible outcome. Some athletes may be diagnosed with post-concussive syndrome symptoms that last for weeks to months and not only affect sport participation, but also school and personal relationships.” In the wake of the recent NFL settlement regarding concussions and ongoing legal battles in other professional sports, everyone needs to be more educated in the signs, symptoms and management of concussions to secure a more safe and positive outcome.
If any problems during the return-to-play progression occur, it is best to have the athlete stop the activity and report back to their sports physician for further evaluation and instructions. Remember, not addressing all important details about the injury can lead to more problems down the road.
Chris Phillips is an Athletic Trainer with over 20 years of experience in professional hockey, football and soccer. Chris is currently the owner of Compete Sports Performance and Rehab in Orange County, California.