By Robert Paras, M.D.
During the 2008-2009 football and hockey seasons, fans throughout the nation saw two athletes fall victim to head injuries- Willis McGahee of the Baltimore Ravens and Chicago Blackhawks defenseman Duncan Keith. McGahee had just caught a pass and turned to run when he was leveled by a brutal helmet to helmet hit from Pittsburgh Steelers safety Ryan Clark. He was carted off the field. Duncan Keith was knocked down to the ice as a result of an apparent high elbow to the side of the head by the Buffalo Sabres’ Drew Stafford. Keith managed to wobble to his feet and was helped off the ice. Both athletes were diagnosed with concussions.
Sports-related concussion or mild traumatic brain injury (MTBI) occurs at all levels of sports participation and at epidemic proportions. The Centers for Disease Control estimates that at least 1.6 to 3.8 million sports-related and recreation-related concussions occur each year. Up to 20 percent of high school and 10 percent of college athletes sustain concussions each year. In fact in young people ages 15 to 24, sports are second only to motor vehicle crashes as the leading cause of traumatic brain injury.
Participation in competitive sports, especially full contact sports, increases an individual’s risk for MTBI. High risk sports include football, ice hockey, wrestling, soccer, and lacrosse. Football and soccer are the leading causes of sport-related concussions in high school males and females respectively.
A concussion occurs as a result of a bump, blow, or jolt to the head or body which causes the brain to rapidly move within the skull causing a disturbance in brain function. MTBI is a metabolic injury- not a structural injury- of the brain. In other words, the violent shaking of the brain within the skull sets in motion a complex cascade of events that causes a temporary disruption of how the brain utilizes energy. The end result is ineffective functioning of the brain tissues. Since CT scans and MRIs only show structural or bleeding injuries of the brain they are not helpful in the diagnosis of concussions. This metabolic cascade does not appear to produce a permanent injury in the vast majority of cases. However, research suggests that repeated injury, particularly during the recovery period, may result in more severe and, in some rare cases, life threatening injury (second impact syndrome).
The recognition of a concussion is not always straightforward. More often than not there is no recallable significant trauma and associated loss of consciousness. The athlete may be unaware that he or she has suffered a concussive injury and may not immediately exhibit the usual signs of concussion. To complicate matters, research has shown that athletes at all levels may minimize or hide symptoms to prevent their removal from play. This increases their potential for more severe injury. In order to ensure the safety and to optimize the recovery of an athlete with a concussion, parents and coaches should familiarize themselves with the signs and symptoms of MTBI, understand the principles of treatment and timetable for recovery of an injured athlete, and adhere to return to play guidelines.
The signs and symptoms of concussion are quite varied and an athlete may exhibit one or many symptoms. Signs disorientation, balance problems, memory and concentration problems, and change in personality and inappropriate emotions. Symptoms may include headaches and nausea, ringing of the ears, feeling off balance or dizzy, visual difficulties, sensitivity to light and noise, and feeling “out of it” or “hazy”. It is important to highlight the fact that some of these symptoms may not appear immediately. Many athletes may not exhibit the majority of symptoms until two or three days following injury. Not all headaches following a head injury are medical emergencies. However, if an athlete has a severe or progressively worsening headache, especially when associated with vomiting or rapidly declining mental status, he or she should be transported immediately to a hospital emergency room.
It was previously thought that a concussion was severe only if the athlete sustained a loss of consciousness. This is not the case. Researchers have clearly shown that amnesia, especially retrograde amnesia- inability to recall events occurring during the period preceding the trauma- was most predictive of difficulties at three days post-injury, not loss of consciousness.
Other predictors of severity of injury include complaints of headaches, age of athlete, and history of prior concussions. Headaches are the most commonly reported symptom of MTBI and, when present, are associated with continued impairment. Younger athletes have been shown to recover much more slowly than older-aged athletes. On average it takes seven days for the high school athlete to recover from a concussion as compared to three days in their college-aged counterparts. Athletes with a history of three or more concussions are nine times more likely to have more severe symptoms with subsequent injury, three times more likely to sustain an additional injury, and usually recover more slowly.
Often athletes may sustain a mild concussion or “bell ringer”. Traditionally these athletes were allowed to return to play during the same practice or game once they were symptom free. However concussion experts are calling for a change in the way this group of athletes is handled. This is based on a study from the University of Pittsburgh Medical Center, which looked at a group of 13 to 17 year old football players who sustained a mild concussion (defined as less than 15 minutes of on field symptoms). Using neurocognitive testing they showed that it took at least four days for symptoms to resolve and seven days for full recovery of neurocognitive function. In another study, a similar group of athletes were examined 36 hours after a mild concussive injury. Declines in memory functioning and increases in symptom reporting were demonstrated. In light of these studies, high school athletes should not be allowed to reenter a game or return to a practice after sustaining a mild concussion no matter if their symptoms “resolve” quickly on the sideline.
To indicate the severity of a concussive injury, a “grade” is often assigned after the initial evaluation. These grading systems- of which more than eight exist- were developed from expert opinion or intuition during the late 1980’s to mid 90’s and not based on solid scientific evidence. This reflected the lack of consensus regarding the importance of specific signs and symptoms. The majority of these schemes overemphasizes the importance of loss of consciousness and minimizes other signs and symptoms when determining the severity of the concussion and time to return to play. For example, an athlete may present with complaints of headaches and dizziness -without a loss of consciousness- and still have a severe concussion. In contrast, according to some grading scales, an athlete with even the briefest loss of consciousness may be given a severe grade and withheld from participation for an unnecessarily long period when in fact the injury may be mild. Current management of MTBI does not rely on grading systems to judge the severity of the injury or to determine time off from sports participation.
Traditionally, the decision to return a concussed athlete to play relies on restricting participation in physical activity for a period of time based on the ‘grade’ of injury. For example an athlete with a grade 1 injury would typically be held out for one week. Upon reevaluation, the treating physician must determine if the athlete has resolved all of his or her symptoms. This relies on the honest, self-reporting of symptoms by the athlete. Unfortunately researchers have shown that athletes minimize, fail to recognize, or fail to report symptoms. This is the great pitfall in the customary management of concussions.
Recognizing the limitation of the sole-reliance on the self-report of the athlete in the management of concussion, the American Orthopedic Society for Sports Medicine called for an individualized data-driven approach to the concussed athlete. This has led to the development of ImPACT (Immediate Post concussion Assessment and Cognitive Testing), a computer-based neurocognitive test. This testing assesses brain function by measuring performance in verbal memory, visual memory, reaction time, and processing speed. The athlete is also required to complete an inventory of concussion symptoms and to rate the severity of each symptom at the time of their testing. These “test scores” are compared to the athlete’s baseline or pre-injury test results. One can demonstrate depression of these scores following a concussive injury. As the athlete recovers from the injury the test scores return to baseline reflecting the normalization of brain function. The athlete’s self-report of symptom resolution should be corroborated with results of his or her neurocognitive testing. Under no circumstances should an athlete be returned to play if he or she is symptomatic.
Dr. Robert D. Paras is board certified in Primary Care Sports Medicine. He specializes in the medical and orthopedic care of athletes and active people. Dr. Paras serves as the team physician for Aurora University, Oswego East High School, and Yorkville High School. He offers state of the art concussion evaluation and management with ImPACT testing at Castle Orthopaedics and Sports Medicine. Preinjury baseline testing is recommended for all athletes especially for those who participate in contact sports or for athletes with prior history of concussion. Baseline testing should also be considered for athletes who may find themselves at risk for a collision (i.e. baseball or softball catchers) or those with learning disabilities or other psychiatric disorders.
Castle Orthopaedics is proud to offer ImPACT testing for concussion symptoms for athletes of all ages.
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