As fall sports gear up to full speed, enough cannot be said about concussions: What they are; how to recognize one; what to do when an athlete has one; and how to prevent them.

What is a concussion?

Concussions in athletes at all levels – from professional to high school – have been all over the news every year. Not surprisingly, concussions are a relatively common occurrence in sports. An estimated 1.6 to 3.8 million sports and recreation-related concussions occur in the United States each year.

High school athletes suffer thousands of concussions every year. Most often concussions occur during football, ice hockey and soccer. Among high school athletes, concussions are most often caused by contact with an opponent, a teammate, the ground or a piece of equipment or object in the playing area. In organized high school sports, concussions occur more often in contact sports, with football accounting for more than 60 percent of concussions. For males, the leading cause of high school sports concussion is football; for females, the leading cause of high school sports concussion is soccer.

Among children and youth, ages 5-18 years, the five leading sports or recreational activities which account for concussions include bicycling, football, basketball, playground activities and soccer.

Concussions do not always involve being “knocked out” or a loss of consciousness. A concussion occurs whenever an athlete’s mental status changes as a result of trauma (usually a blow to the head). A child who shows signs of mental confusion or is “dinged” by a blow to the head has, by definition, suffered a concussion. A concussion, also known as a mild traumatic brain injury (MTBI), is caused by a bump, blow or jolt to either the head or the body that causes the brain to move rapidly inside the skull. A concussion changes how the brain normally functions.

Concussions can have serious and long-term health effects; therefore, even a seemingly mild “ding” or a bump on the head can be serious.

Signs and symptoms of concussion include headache, nausea, fatigue, confusion or memory problems, sleep disturbances and/or mood changes. Symptoms are typically noticed right after the injury, but some might not be recognized until days or weeks later.

What happens after a sports-related concussion?

Sports-related concussions often result in mental and physical symptoms, such as inability to concentrate, forgetfulness, headache, fatigue and dizziness. For many athletes, the symptoms disappear after about 10 days. They typically hardly ever last more than several months. In some cases though, concussions lead to persistent complaints of physical, mental, emotional and behavioral symptoms, sometimes referred to as post-concussion syndrome. We do not know whether persistent post-concussive symptoms result from primarily medical or psychological causes. In rare cases, when repeated concussions occur over a brief interval, athletes may suffer from second impact syndrome, a pathological response of the brain that can be life-threatening if not treated promptly. Parents should seek careful evaluation and management of any sports-related concussion.

How should a sports-related concussion be evaluated?

Concussions are typically managed according to their severity. Immediately after a concussion, medical evaluation is needed to determine a child’s vital signs and level of consciousness and to rule out any other injuries, such as those to the spine. Recent guidelines indicate that a hospital emergency department should evaluate any child who loses consciousness as a result of trauma during a sporting event.

In cases of less severe concussion, athletes are typically evaluated on site rather than in hospital emergency departments. There are a variety of approaches to the “sideline” assessment of concussion.

Guidelines are also available to assist in deciding when a child is ready to return to play after a concussion. Presently most recommendations strongly advise against return to play on the day of injury. High school athletes’ recovery times for a sports concussion are longer than college athletes’ recovery times.

High school athletes who sustain a concussion are three times more likely to sustain a second concussion. Lack of proper diagnosis and management of concussion may result in serious long-term consequences, or risk of coma or death.

Because of the potential long-term consequences of sports concussion, it is important that athletes, coaches and parents know as much as possible about how to recognize a concussion when it occurs.

Symptoms are not always obvious. Although it is commonly assumed that concussions cause loss of consciousness, many people with concussions have not been “knocked out.”

Concussion causes a variety of symptoms. These may appear right away, or may be delayed for several days after the injury. Some symptoms are physical, such as drowsiness. Others are cognitive, like memory loss. In many cases, people with concussions are more emotional than usual.

The most common symptoms of concussion include:

  • Drowsiness
  • Headache
  • Loss of consciousness
  • Memory loss
  • Irritability
  • Confusion
  • Balance problems, dizziness
  • Difficulty speaking and communicating
  • Depression
  • Nausea and vomiting
  • Changes in sleep patterns

Can neuropsychological assessment help?

Because it is difficult to determine when a concussion has fully healed, baseline neurocognitive evaluation is an important tool for assessing whether it is safe for an athlete to return to play. Before the sports season starts, each athlete takes a computerized test that measures brain functions, such as memory and reaction time. If an athlete later has a concussion, post-injury tests can be compared to the baseline evaluation to measure the severity of the concussion and help doctors monitor healing.

In addition, pre-season evaluations can help identify athletes who have had previous, unrecognized concussions and who are at risk for repeat concussions. For example, past injuries to the face or neck may have been accompanied by an unrecognized concussion.

Neuropsychological assessment is widely regarded as the most sensitive way of detecting disturbances in brain function associated with concussion. The National Football League and the National Hockey League have both instituted systematic programs of neuropsychological testing, as have many colleges.

Athletes are administered brief tests of attention, memory and speed of information processing before the season. Athletes who sustain concussions are tested again, typically within 48 hours of the injury and at regular intervals afterward. Recovery to baseline levels of performance is typically required before athletes are allowed to return to play. Similar cooperative programs can be instituted for organized athletic programs at the high school level. In the absence of programmatic testing, athletes who complain of persistent post-concussive symptoms should be considered for a more comprehensive neuropsychologic evaluation.

 What can be done to prevent or treat concussions?

Changes in the rules for athletic competition have reduced the number of sports-related concussions. After the National Collegiate Athletic Association made the use of the head when tackling illegal in 1976, the annual number of head and neck injuries in football declined by about 50 percent. The required use of helmets in many contact sports and advances in helmet design also has resulted in fewer head injuries. Improved conditioning of young athletes, especially strengthening of neck muscles, may also help to prevent concussions. The key to healing from a concussion is complete rest. This includes not just physical rest, but mental rest, as well. Reading, computer work, video games and television should be limited until all symptoms have resolved. This typically takes 7 to 10 days, although some people have symptoms for weeks or months after the injury.

Once you are free of symptoms, you can gradually return to physical and mental activity. It is important to slowly return to daily activities because being symptom-free does not mean the brain injury has fully healed. Your doctor may recommend a step-by-step program: first add an activity, then monitor your symptoms. If your symptoms do not return, you can continue increasing the challenges. This slow, steady approach typically reduces the time spent away from school, work, and athletics because it provides enough time for the injury to heal. Diving back into activities as soon as your symptoms have resolved can bring them back on and require a return to complete rest.

If a child sustains a concussion, parents should seek appropriate medical care. They should request a description of symptoms indicative of worsening brain injury and of common post-concussive symptoms, as well as guidelines for return to play and for medical follow-up. For athletes who experience persistent difficulties after a concussion, such as headaches, difficulty concentrating, irritability, sleep disturbances, or dropping grades, an effective treatment plan will often combine education, cognitive rehabilitation, psychological support and, in some cases, medication.

Getting back into the game too soon puts you at risk for another concussion. If you suffer a repeat concussion before your first concussion has healed, it may take much longer for your symptoms to resolve and you may have long-term problems, such as learning difficulties or chronic headaches. Although it rarely happens, repeat concussion can cause permanent brain damage and even death.

In 2010, the American Academy of Pediatrics recommended that young athletes with concussions be evaluated and cleared by a doctor before returning to sports. The American Academy of Neurology issued a similar statement and stressed that doctors who clear athletes for return to sports should be trained in managing and assessing sports concussions.

Although injury prevention begins with proper equipment, there is no such thing as a concussion-proof helmet or mouthguard. Young athletes must be trained in safe sports technique and to follow the rules of the game. In addition, rule changes should be considered in sports where force is delivered head first. This not only promotes fair play, but also protects both participants.

In order to get back into the game, most athletes will downplay their symptoms. Understanding the long lasting consequences of repeat concussion is an important part of prevention. Several medical and sports organizations have recently developed concussion awareness programs for athletes, coaches and parents. These educational programs play a critical role in helping to recognize concussions and prevent repeat injury.

By Dr. Michael Gross

Dr. Michael Gross, the founder and director of Active Orthopedic and Sports Medicine, is the section chief of sports medicine and the orthopedic director of the Center for Sports Medicine at Hackensack University Medical Center, as well as medical director of Active Center for Health and Wellness.

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