By: Michael D. Mitchell, MD and Daniel A. Johnson, PT
Over the last several years, much has been written about the problem of concussions in sport. In years past, having your “bell rung”, was not thought of as having much significance and just thought to be part of the game. Now we know, that thinking was not true and we must do all that we can to identify concussions and treat them appropriately to prevent problems in the future.
A concussion is a brain injury. Concussions are usually caused by a blow to the head. Although concussions are brain injuries, there is actually no structural damage to the brain. CT Scans and MRI’s are usually normal in concussions. Concussions result in transient metabolic changes in the brain. An athlete does not have to lose consciousness to have a concussion. Symptoms of a concussion may include all or any of the following: headaches, visual disturbance, dizziness, loss of balance, confusion, memory loss, ringing in the ears, difficulty concentrating, nausea, feeling foggy or groggy, light and/or noise sensitivity. If an athlete suffers a concussion in an event, that athlete should not be allowed to return to play that day and should be referred for appropriate medical management of the concussion. The National Football League recently changed its policy on concussions to include this recommendation.
A recent panel on concussions held in Zurich in 2008, stated that the majority of concussions (80-90%) resolve in a short time frame (7-10 days), although recovery may be longer in children and adolescents.
Treatment of concussions should begin with a thorough assessment of the injury by a medical professional who is knowledgeable in the management of concussions. Once the diagnosis of concussion has been made, a plan of treatment can be initiated. The primary method of treating a concussion is rest. An athlete must rest completely until all symptoms related to the concussion have resolved. This should also include mental rest as well as physical rest. Even activities such as playing video games or studying can cause symptoms in some individuals, and should be curtailed until symptoms have cleared. Once all symptoms have gone and the athlete is back to normal, a graduated return to play protocol may be initiated. This type of protocol utilizes a time frame of graduated physical exercise over a period of days to a week. An example would be initiating simple activity such as light jogging, 24 hours after all symptoms have cleared. If symptoms recur, the athlete must return to complete rest. If symptoms do not recur, day two would involve activities such as sprinting and weightlifting. If symptoms recur, once again the athlete must stop and resume resting. If no symptoms, day three would include returning to non-contact sports specific drills. If the athlete completes that gradual progression without a recurrence of any symptoms, he or she may then return to full activity the next day. If symptoms return at any point, the athlete must once again rest.
The application of neuropsychological testing in concussion has shown to be of clinical value and continues to contribute significant information in the management of concussion. A commonly used process involves preseason computerized neuropsychological testing of athletes involved in high-risk sports. This establishes a baseline for each individual athlete. An athlete is not cleared to resume full activity until the results of repeat testing have returned to baseline. There are also now normative values established for each age group which also can be used in determining when it is safe to return to play.
A player returning to practice or competition while still having any symptoms of concussion, is susceptible to a condition called “second impact syndrome” which can be fatal. Cases, although rare, have been documented of athletes returning to play while still symptomatic, and incurring a slight blow to the head resulting in massive brain swelling and death.
It’s very important that coaches and parents teach young athletes about the symptoms of concussion and encourage them to always report them. Concussions are not just “part of the game” and something that you can “shake off”. Aside from the catastrophic events that although rare, can occur, once an individual has had a concussion, they are more likely to suffer future concussions than someone who has not had one. Treating the first concussion appropriately is the best way to prevent problems down the road.
Dr Mitchell is Medical Director of the WCA Hospital Sports Medicine Center.
Dan Johnson is a physical therapist and Director of Rehabilitation Services at WCA Hospital.
