November 2013

Medical Section: Concussions in Sports

Author: John P. Batson, MD, FACSM

Concussions are defined as traumatic brain injuries. These injuries are very common in sports such as football, soccer, cheerleading hockey and lacrosse. In recent months, these sports related injuries have been a hot topic. The NFL recently settled a lawsuit, awarding past players $765 million for brain injuries they received while playing football. Former players have been found to have higher rates of problems such as dementia, depression, Alzheimer’s and other brain or psychological disorders after repetitive concussions. Also, we are seeing fines and penalties much more often for inappropriate tackles that intentionally injure another player. All this attention drawn to concussions in professional sports has had a trickle-down effect with more awareness in college and high school sports.

Concussions can occur as a result of a direct blow to the head or trauma to the body with the force transmitted to the head. The symptoms of a concussion often begin within the first few minutes after the injury. Of note, loss of consciousness (blacking out) does not occur with most concussions. The symptoms of a concussion usually resolve over a period of a few hours, but sometimes can persist for days or weeks.

Common signs and symptoms of concussion include headache, amnesia, dizziness and balance difficulty, feeling foggy or in a daze, visual problems (seeing stars, blurry, sensitive to light), ringing in the ears or sensitivity to loud noise, nausea or vomiting, loss of consciousness (blacking out), difficulty with concentration, and irritability.

Concussion evaluation
If an athlete sustains a concussion, it is very important that he or she is evaluated as soon as possible by a medical doctor skilled in concussion management or certified athletic trainer. We are fortunate in the Lowcountry to have well-qualified athletic trainers associated with the high schools. If the sports medicine team is not readily available to evaluate the injury, it is best to take the athlete to the emergency department.

A medical doctor or athletic trainer can perform an appropriate examination to determine if the athlete has a concussion and if any further evaluation is necessary. Neck injuries can occur along with concussions and should be ruled out prior to moving the injured athlete. It is important to remember concussions are physiologic problems, not structural (visible) problems. Therefore, tests such as cat scans (CT) or MRI do not have a role in concussion evaluation. CT scans in particular utilize a great deal of radiation. These tests should be performed only when it is necessary to ensure no other injury is present (i.e. bleed in the brain or fracture), not simply because a head injury has occurred.

Concussion management
Rest and observation are the mainstays of concussion management. It is important to watch the athlete for any worrisome signs (severe headache, excessive drowsiness, persistent vomiting, seizure activity) after the injury has occurred. Symptoms should gradually improve, not worsen over time. Tylenol can be given to help with mild headaches. It is not necessary to wake the athlete through the night after a concussion. Rather, simply check in periodically to make sure he or she is resting without problems. The athlete should not drive until cleared by a physician or athletic trainer. A relatively new concept is “cognitive or brain rest.” Student athletes may need a time off from school, additional time to take tests or other academic accommodations after a concussion while the brain is healing. Computer, iPad and smart phone use is discouraged.

Another new concept in sports concussion management involves brain testing called neuropsychological testing. These computerized tests evaluate brain tasks such as memory and reaction time. Athletes can take these tests before the start of the sports season to have a baseline measurement of their brain skills. If the athlete then has a concussion, this test can be repeated and results compared to the pre-injury level. Along with a proper medical exam these tests can help evaluate concussions and clear athletes to return to sports as their symptoms improve.

Long-term effects of concussions
Though most athletes recover without persistent problems, some long-term complications can result from concussions. These include persistent headaches, attention or concentration difficulties, and personality changes. Some individuals, due to genetic variance, may be more sensitive to subsequent head injuries and sustain repeated concussions. Younger athletes should be treated with extra caution due to the developing brain. Cognitive (brain function) difficulties can be present if severe head injuries occur or if repetitive minor injuries occur. Rarely devastating brain swelling can occur after concussions. This so called “second impact syndrome” is thought to be due to injuries which occur while a brain is not yet healed from a previous injury. This is one reason why it is so important athletes do not participate while symptoms are still present.

Returning to sports after a concussion
If an athlete sustains a concussion, he or she should not be allowed to go back in the game that same day, no matter how important the game. After the athlete’s symptoms have resolved, the team physician and/or athletic trainer will clear the athlete to begin a return to sport protocol. A typical return to sport protocol is as follows:
1. Athlete must have no symptoms at rest.
2. Light aerobic activity (stationary bike)
3. Sport-specific physical activity
4. Non-contact drills (start light resistance training)
5. Full contact after medical clearance
6. Return to competition

Progression from each phase occurs over 24 hours. If symptoms return, the athlete must not advance to the next phase.

Concussion prevention
Unfortunately there is no fail-safe concussion prevention strategy. As long as kids (and adults) continue to participate in contact and collision sports, we will continue to see athletes with concussions. While mouth guards and helmets do reduce oral, dental, facial and head injuries, they have not been shown to consistently lower concussion incidence in sports. Some would argue the opposite—with fancy helmets and face guards athletes feel invincible and may be more prone to concussions. Proper fitting equipment, tackling technique and other commonsense safe guards in sports are important, and time will tell if new tackling rules will have an impact on concussions. Our best strategy for now is likely continued efforts with education regarding concussions for athletes, parents and coaches. This will best ensure proper recognition and management when these injuries occur.

It is important to keep in mind, in particular with youth sports, that concussions are brain injuries and should be treated with caution. While we still have a lot to learn about concussions, the field of sports medicine has made great strides in recent years. In the past, when I was covering high school football games, it was not uncommon to have players, coaches or parents argue that “Johnny just got his bell rung; he is okay to get back in the game.” Nowadays, it is not uncommon for players and coaches to approach the sports medicine team and say, “You need to check out Johnny; I think he hit his head and has a concussion.” This awareness and attention drawn to sports related concussions has been one of the greatest advancements in sports medicine I have seen in my 10+ years serving as a team physician for various sports and teams.

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