Concussion

A concussion is a 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.

Over the past decade, sports related concussion has received much attention in the media as well as in the research labs.  As the number of young people participating in sports grows, so will the number of sports-related injuries.  Many concussions go unreported every year for a variety of reasons. But the truth is that brief symptoms such as dizziness, memory loss, feeling in a fog and headache following a blow to the head is a concussion.

On Tuesday, April 23rd, 2013, COA physicians Dr. Marshall and Dr. Kroll were all present as Governor Nathan Deal signed a new concussion bill named the Return to Play Act. House Bill 284 creates new protocols for informing parents about the dangers of concussions and for identifying and treating players with head injuries. To read the bill in its entirety, click here

Causes and Symptoms

It has been estimated that 1.6 – 3.8 million concussions occur each year, many of which go unreported or unnoticed. It has been shown 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.

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.

 

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 liability Changes in sleep patterns
Behavior changes Impaired concentration
Poor balance Irritable, emotional, sad

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. 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 warrants referral to the Emergency Department.

  • Loss of consciousness 
  • Progressive memory loss
  • Severe or worsening headache, nausea or vomiting
  • Seizures

Diagnosis

Since a concussion is a functional injury to the brain versus structural, standard imaging such as CAT scanning and MRI are normal. They may be helpful in ruling out other causes of symptoms like skull fracture, bleeding in the brain and tumors.

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 neurospsychologists at the University of Pittsburgh and consists of a twenty to thirty 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.

The ImPACT test should be administered within seventy-two hours of a concussion to all athletes age twelve and above. The test can be re-administered every seven to ten days to document normalization of neurocognitive functioning until the athlete fully recovers and is cleared by his/her doctor. 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, (i.e.football, soccer, lacrosse, wrestling, gymnastics, ice hockey, and basketball), take a baseline test at the beginning of the seventh, ninth and eleventh grade. This will aid in determining when a concussed athlete’s cognitive function has returned to “normal.”

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.

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 a gradual return to physical activity
  3. Normalization of neurocognitive testing
  4. Written clearance by a medical professional trained in the management of concussions

The concussed brain is in the midst of a metabolic crisis, and the injured brain cells are trying to recover despite having a decreased blood supply. Therefore, any type of activity, mental or physical, may stress the brain and worsen symptoms and delay recovery. This concept is similar to continuing to run on a sprained ankle.

As long as the athlete has signs and/or symptoms of a concussion, he or she should be held out from school, avoid video games, texting, action-packed TV, computer work or prolonged reading. They should also not attend practice even just to “watch.”

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 until all symptoms subside. When asymptomatic, the physical stress will be ramped up, adding light, 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.

Prognosis

If an athlete suffers a second blow to the head before full recovery, 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 second injury before full recovery is post-concussive syndrome. Post-concussive syndrome is when an athlete suffers long-term (over six weeks) of symptoms. It is difficult to 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 three to four 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.