Concussions

Barely a week passes without mention of new statistics on concussion.  Most recently, concussion related to youth sports injuries has received front page billing.  Historically the widely accepted incidence of sports related concussion in the United States was 300,000 each year.  Estimates have recently been updated to reflect 1.6-3.8 million concussions in the United States on an annual basis.  The disparity between the old and new estimates is clearly striking and what becomes apparent is the frequently underreported and/or undiagnosed scenario of this serious condition. 

Concussion is a brain injury and the result of not recognizing that a person has sustained a concussion can be devastating.  Other important aspects of concussion include:

	Concussions can occur without loss of consciousness – in fact most of them do
	Concussions can not be seen on an MRI
	Concussions can occur in any sport
	Recognition and proper management  of concussions when they first occur can help prevent further injury (permanent brain damage) or DEATH
	High school athletes are more vulnerable to concussions than older athletes and may take longer to recover
	High school athletes are three times more likely to experience a second concussion if concussed once during a season
	More than 5% of high school athletes are concussed each year from collision and contact sports.
	Concussions are also frequent in motor vehicle accidents and in work related injuries

Under the leadership of Dr. Dean Karahalios, CINN neurosurgeon, CINN is developing a concussion program to provide athletes and others access to technology and professional resources focused on the identification and treatment of concussions.  CINN’s two clinical psychologists, Von Shade-Zeldow, Ph.D. and Dino Kostas, Ph.D. are also directors of the program.  Through these clinical psychologists at CINN, education and coping mechanisms can be introduced to concussion sufferers to assist in their rehabilitation.  Please call 1-800-446-1234 if you would like to speak with Von Shade-Zeldow, Ph.D., Director of the Concussion Program at CINN.

In December 2007 an article appeared in the Journal of Athletic Training that detailed the incidence of concussion in various youth sports.  The graph provides these statistics. 

Based upon data presented on the Illinois High School Association website, there are just over 200,000 high school athletes in Illinois participating in the above listed sports.  At this level of participation and looking at all of these sports together, concussion is estimated to occur 45 times during each contest or practice session statewide.   As would be expected, football is plagued with the highest incidence of concussion and over 200 concussions are suspected among Illinois high school players each year.   Perhaps less understood, female soccer and basketball carry relatively high incidence rates, and it is estimated that there are over 100 concussions in female soccer and basketball in Illinois each season.

Clearly these statistics are alarming and education can significantly reduce both the incidence and repercussions of concussion.  CINN physicians are routinely involved in providing education sessions for sports camps and coach clinics.  A complementary coach’s clipboard sticker is also available outlining the symptoms, management recommendations and return to play guidelines.  Requests should be submitted through the CINN website (www.cinn.org). 

Adequate and effective communications with parents and players is one of the key strategies to prevention.  Some key thoughts for players to keep in mind:

	“Every bump, blow or jolt to the head is a potential concussion.”
	“Signs and symptoms of concussions can appear right away or days or weeks after injury.  Know and look for any signs of a concussion, even if you think the injury was minor.”
	“Tell coaching staff, you parents, or a health care professional if you receive a bump, blow or jolt to the head or have signs or symptoms of a concussion.”
	“Tell your coach if you received a concussion in another sport.”
	“You can get a concussion during drills, practices and games.”
	Do not play through symptoms of a concussion.  Your risk of having a second concussion and serious injury increases during this time.”

Educational opportunities are available both before during and after a season.  Coaches should take a leadership role in concussion prevention tactics – as is the case with all injury prevention programs.  During pre-season, prevention tactics can include:

	Ensure players are in good condition to participate
	Establish an action plan for concussions that occur
	Explain your concerns and expectations about concussions and safe play to athletes, parents and officials
	Ask if players have had one or more concussions during previous season
	Remind athletes to tell coaching staff if they suspect that a teammate has a concussion
	Determine if pre-season baseline testing of brain function is feasible.  This baseline testing may be performed using software called ImPACT Concussion Management Software.  ImPACT is used by many professional, collegiate and high school sport programs throughout the country.  In addition, it is also used physician offices and clinics specializing in the diagnosis and management of concussion.  It is a sophisticated research-based software tool developed to help sports-medicine clinicians evaluate recovery following concussion. ImPACT evaluates and documents multiple aspects of neurocognitive functioning including memory, brain processing speed, reaction time, and post-concussive symptoms.  If baseline testing is performed using the ImPACT software, post-injury tests are also performed to determine the severity of the concussion and the back to play or work timetable.

It is a parent’s responsibility to seek out excellent youth sports programs for their children.  High quality youth sports programs are hallmarked by good coaches.  Good coaches teach good technique which prevents the whole gamut of potential injuries.

Re-enforcement of the injury prevention messages conveyed preseason should take place throughout the season – both at practices and during contests.  Key messaging for coaches and team staff on prevention during the season includes:

	Insist that safety comes first
	Teach safe playing techniques; players should follow rules of play 0% tolerance for unsportsmanlike conduct; strict officiating of game Ensure proper equipment; appropriate fit for equipment (helmet should move with head – and not wiggle around in the case of football/baseball)
	Teach athletes that it’s not smart to play injured
	It is NOT a badge of  honor to play injured Discourage pressuring injured athletes to play Don’t let athletes persuade you that they’re “just fine” after they have sustained ANY bump, blow or jolt to the head.

The following symptoms are RED FLAGS – if any of these are present after a bump, hit or jolt to the head it is an emergency and the athlete should be sent to the nearest emergency room.

	Headaches that worsen
	Seizures
	Focal neurologic signs
	Looks very drowsy/can’t be awakened
	Repeated vomiting
	Slurred speech
	Can’t recognize people/places
	Increasing confusion/irritability
	Weakness/numbness in arms/legs
	Neck pain
	Unusual behavior change
	Significant irritability
	Any loss of consciousness > 30 seconds

The signs of concussion can be obvious or very subtle.  As previously indicated, concussion can not be seen on an x-ray, MRI or any other imaging study of the brain.  Signs and symptoms indicating a concussion that might be observed by the coaching staff or on-field medical staff can include:

	Appears dazed/confused
	Is confused about assignment
	Forgets plays
	Is unsure of game, score, opponent
	Clumsy
	Answers questions  slowly
	Loses consciousness
	Shows behavior/personality changes
	Can’t recall events prior or subsequent to hit or fall

On the other hand, the injured athlete may report the following symptoms which are also suggestive of a concussion:

	Headache or “pressure” in head
	Nausea
	Balance problems or dizziness
	Double of fuzzy vision
	Sensitivity to light
	Sensitivity to noise
	Feeling sluggish or slowed down
	Feeling foggy or groggy
	Does not “feel right”

In order to assess the presence (or absence) of the aforementioned symptoms, the following on-field mental status evaluation may be helpful.  The coach or trainer should ask the following types of questions to assess orientation, memory, concentration, etc.

	Orientation
	What quarter/half are we in? What field is this? What city is this? Who is the opposing team? Who scored last? What team did we play last?
	Amnesia
	Ask the athlete to repeat the following words:  Girl, Dog, Green Do you remember the hit? What happened in the play prior to the hit? What happened in the quarter prior to the hit? What was the score prior to the hit?
	Concentration
	Ask the athlete to:
	repeat the days of the week backward starting with today repeat the months of the year backward starting with December repeat these numbers backward 63 (36), 419 (914), 6294 (4926) repeat the three words from earlier (Girl, Dog, Green)

If any deficits are detected during the mental status exam or if any of the aforementioned symptoms are identified, you should assume the athlete has been concussed and the following action plan should be followed:

	Remove the athlete from play
	Ensure the athlete is evaluated by the appropriate medical professional; do not try to judge the severity of injury yourself
	Inform the athlete’s parents/guardians about the known or possible concussion
	Allow athlete to return to play only with permission from an appropriate medical professional

Multiple concussions/second impact syndrome/post-concussion syndrome is very serious and should be prevented.  This serious condition is characterized by CHRONIC:

	Irritability
	Memory lapses
	Headache
	Fatigue
	Poor concentration

Keys to preventing second impact syndrome include:

	Keep athletes with known or suspected concussions from play
	All athletes with suspected concussion should be evaluated by the appropriate medical personnel
	Return to play upon permission of appropriate medical personnel
	Return to play should occur gradually after appropriate period of rest; concussion symptoms will typically worsen/re-emerge with exertion indicating incomplete recovery
	Provoking symptoms with exertion is recommended before resuming collision sport (5 push-ups; 5 sit-ups; 5 knee-bends, etc.)

During postseason, the following steps can be taken to refine the team’s concussion prevention program.  They include:

	Work with coaching staff to review injuries that occurred during the season
	Discuss any need for improvements in action plan
	Discuss any need for improvement for better sideline preparations.

For a video of Dr. Karahalios and Dr. Wolin discussing injuries in football and soccer, including concussion, please click here.

If you have any questions you would like to ask CINN regarding concussion, please email us at info@cinn.org or info@neuro-ortho.org.