Sports Related Concussion

• It has been estimated there are between 1.6 million to 3.8 million sport related concussions each year in North America. • The true number is not known as studies estimate more than 80% of individuals can not adequately identify a concussion. • It has been reported that each year almost 50% (47.2%) of high school football players suffer a concussion. – More than 1/3 of players may have multiple concussions in the same season. • The NCAA, through its Injury Surveillance System (ISS), showed a 7% annual increase in the number of concussions between 1988/1989 and the 2003/2004 seasons. • Not surprisingly the rate of concussions is much higher in high and medium contact sports (including hockey, football, and soccer).

SIGNS AND SYMPTOMS OF A CONCUSSION:

WHY IS IT SO IMPORTANT TO PROPERLY TREAT CONCUSSIONS?

INTRODUCTION:

Over the last few years Concussions have become a “hot topic” in both sporting and non-sporting communities. There are numerous educational resources now available and the amount of information can be somewhat daunting. This document is designed to provide a brief but accurate summary of the major issues relating to concussions.
It is important to state early that each concussion is unique and highly individualized. There is no accurate way to predict how any one concussion will heal. Common thinking now advocates that each concussion be dealt with on a case by case basis.

DEFINITION:

A Concussion is defined as:
“a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces”

COMMON THEMES WITH CONCUSSIONS:

1. Concussion may be caused either by a direct blow to the head or anywhere else on the body with an ‘‘impulsive’’ force transmitted to the head.
2. Concussions typically result in the rapid onset of short-lived impairment.
– Approximately 80-90% of athletes are symptom-free within 10 days.
3. A concussion is a “functional injury” of the brain affecting your ability to perform tasks, not a “structural” injury. This means you cannot “see” a concussion on CT scan or MRI.
4. A concussion causes a set of clinical symptoms with or without a loss of consciousness (LOC). Improvement typically follows a progressive course; however, it is impossible to predict how long symptoms may persist.

WHAT CAUSES THE SYMPTOMS OF A CONCUSSION?

It is a very complex process but essentially most of the symptoms are believed to be due to a combination of the following:
1) Changes in blood flow to the brain
2) Abnormalities in the ion concentrations in the brain (like sodium, potassium and calcium).
3) Temporary, localized, and microscopic swelling in the brain,
4) A mismatch in energy supply and demand within the brain.

EPIDEMIOLOGY: HOW BIG OF A PROBLEM ARE CONCUSSIONS?

n It has been estimated there are between 1.6 million to 3.8 million sport related concussions each year in North America.
n The true number is not known as studies estimate more than 80% of individuals can not adequately identify a concussion.
n It has been reported that each year almost 50% (47.2%) of high school football players suffer a concussion.

► More than 1/3 of players may have multiple concussions in the same season.

n The NCAA, through its Injury Surveillance System (ISS), showed a 7% annual increase in the number of concussions between 1988/1989 and the 2003/2004 seasons.
n Not surprisingly the rate of concussions is much higher in high and medium contact sports (including hockey, football, and soccer).

SIGNS AND SYMPTOMS OF A CONCUSSION:

n The classic symptoms of a concussion are headache, confusion, and amnesia often without a loss of consciousness (LOC).

► Approximately 80% of sports related concussions occur without a LOC.

• Symptoms can be subtle and may not appear until many hours after the impact.
Symptoms of concussions include:

• Headache (the most common complaint),
• Visual and hearing impairment,
• Lethargy (excessive tiredness),
• Insomnia (an inability to sleep),
• Amnesia (cant remember the event priors to the hit or after the hit),
• Memory impairment (can’t remember things on a day to day basis),
• Imbalance or Vertigo (the sense the word is spinning around you) or
• Lack of awareness of surroundings,
• Nausea and vomiting,
• Mood changes (increased irritability)
• Cognitive disturbances (feeling like you are in a “fog”),
• Sensitivity to light and noise,
Less common signs include:

• Vacant stare (befuddled facial expression),
• Delayed verbal expression (slow to answer questions or follow instructions),
• Inability to focus,
• Disorientation (walking in the wrong direction, unaware of time, date, place)
• Slurred or incoherent speech
• Gross observable in-coordination
• Emotionality out of proportion to circumstances (appearing distraught, crying for no apparent reason)
• Seizures

MANAGEMENT:

WHY IS IT SO IMPORTANT TO PROPERLY TREAT CONCUSSIONS?

The main reason to be cautious when returning to activity after a concussion is because multiple concussions can lead to significant long-term impairment.
► Approximately 225,000 new patients each year show long-term deficits from mild brain injuries (concussions). This is approximately equal to the number of patients diagnosed annually with breast cancer, multiple sclerosis, and traumatic spinal cord injury combined!
Another reason to be more conservative when dealing with a concussions and returning an athlete to play is something called Second Impact Syndrome. It is a very rare and controversial phenomenon that is believed to occur when someone receives another head injury while still symptomatic from a previous concussion. It is characterized by acute brain swelling and has a 70-80% mortality rate.

THE FIRST STEP IN MANAGING A CONCUSSION: AN ON FIELD ASSESSMENT

Guidelines and Procedures for Coaches, Trainers, and Parents: Remember the 3 R’s!

►RECOGNIZE, REMOVE and REFER◄

1. Recognize A Concussion
All coaches and trainers should be familiar with the signs and symptoms of concussions.
Athletes should be checked upon after being part of a big collision of any sort.
2. Remove the Player From the Game
If a player is suspected of suffering a concussion, the athlete should be removed from the game. This is the safest thing to do.
3. Refer the Athlete to be evaluated
First by the athletic trainer and then by a physician trained in treating concussions.
The team trainer should be well educated in using a concussion screening tool.
The most widely used screening tool is the SCAT 2 (Sport Concussion Assessment Tool)
The SCAT 2 is available online at http://www.cces.ca/files/pdfs/SCAT2[1].pdf
RED FLAGS after a head injury:
Signs and Symptoms of a serious head injury requiring emergent referral to a hospital include:

• Inability to awaken the patient
• Severe or worsening headaches
• Severe somnolence or confusion
• Restlessness, unsteadiness, or seizures
• Persistent difficulties with vision
• Vomiting, fever, or stiff neck
• Urinary or bowel incontinence
• Weakness or numbness involving any part of the body
• Decrease in or irregularity of respirations
• Any irregularity in pulse
• Unequal, dilated, or un-reactive pupils
NOTE: Any athlete who is unconscious should be treated as if they have a head and neck injury, potentially a cervical spine injury.

► For More on Management if there is a persistent loss of consciousness:

Goulet, K.B. and Meehan, WP III. “Immediate Care for the Unconscious Athlete”: http://www.sportsconcussions.org/On-Field-care.html

RETURNING AN ATHLETE TO SPORT AFTER A CONCUSSION: THE PROTOCOL

The Most Basic Guidelines:
An athlete should NEVER return to sport:
1. While still having symptoms from a concussion.
2. The same day as having a concussion even if the symptoms have resolved.
3. Until cleared by a physician experienced in the management of sport-related concussion.

WHAT MAY HAPPEN IF YOU RETURN TO SPORTS TOO SOON AFTER A CONCUSSION?

1) An athlete is more likely to get a second concussion if they are still symptomatic from a previous concussion. They are also more likely to suffer a concussion if they had a concussion within the last 10 days.
2) A second concussion is likely to be more severe than the first.
It is in your best interest just to wait it out!

THE NEXT STEPS IN TREATING A CONCUSSION:

Recent thinking emphasizes PHYSICAL and COGNITIVE rest
COGNITIVE (Thinking) REST
Cognitive activities are those activities which require you to think harder than usual.
1. It is important to significantly limit/eliminate all non essential cognitive stresses. Initial steps you can take to limit the work your brain does are:
a) No text messaging
b) No Facebook or other social media
c) No video games
d) Limit pleasure reading at least initially
e) Limit movie theaters or any television that requires thought. Even watching sporting events
on TV or in person requires a lot of work by your brain and should be avoided.
Just think, the less you have to use your brain the quicker you will get better!
Cognitive Activity Scale
Stage Cognitive Level Examples
0 Complete cognitive rest No reading, homework, text messaging, video games, online activity (including Facebook etc), or similar activities. The most stimulating activities at this level would be listening to music (classical music preferred) or watching non stimulating television or quiet movies.
1 Minimal cognitive activity No reading, homework, crossword puzzles or similar activities. Less than 5 text messages per day, less than 20 minutes per day combined of online activity and video games.
2 Moderate cognitive activity Reading less than 10 pages per day, less than 20 text messages per day, and doing less than 1 hour combined of homework, online activity and video games per day.
3 Significant cognitive activity Reading less, doing less homework, working less online, test messaging less and doing less crossword or other similar activities than you would normally do, but more than listed in level 3.
4 Full cognitive activity You have not limited cognitive activity at all.
Modified from the Children’s Hospital Boston and Harvard Medical School

PHYSICAL REST:

Just like thinking too much can delay your recovery so can being too physically active. Initially after suffering a concussion you should limit all nonessential physical activity. Once an athlete isn’t having any more symptoms, they can begin the “Return to Sport Protocol”
Athletes can progress through the different stages only if they do not develop any new symptoms. The rate at which they can progress through these stages should be monitored by a physician.
Athletic Activity Scale
Stage Activity Level Examples
1 Rest No athletic activity except walking.
2 Light aerobic activity Walking or light stationary bike riding. Subjective intensity such that you barely break a sweat and are able to carry on a conversation. Objective level 70% of max heart rate (220- your age in years is your max heart rate). No resistance training.
3 Sport specific activity Sport specific or full aerobic activity such as running, ice skating, swimming, throwing, dribbling the ball or cycling.
4 Non-contact training drills Non-contact training drills such as passing, shooting and/or resistance training such as push ups, sit ups or weightlifting.
5 Full practice, including contact Full contact practice, including contact.
6 Game play You are able to pay without restriction.
*** Before being reintroduced to activities that are at risk for head injury athletes must have written documentation clearing them by a physician trained in dealing with concussions.

4. SIMPLE STEPS TO TAKE AT HOME TO SPEED RECOVERY

(Prior To Seeing a Doctor):
1) Complete Cognitive and Physical Rest (as described above).
2) Stay well hydrated: Drinking a diluted sports drink or plain water.
3) Eat Frequent and Healthy Snacks: To keep the brain well fuelled.
4) Optimize Healthy Sleep: Accomplish this by going to be early, removing any television/phones from the bedroom, and avoiding caffeinated/sugary drinks before bed etc.

RECOVERY — WHAT TO EXPECT:

• Recovery is dependent on a number of factors but adults are generally recovered by Day 7 and the majority of children and adolescents (80-90%) are fully recovered within 10-14 days.
– This still leaves a significant amount of athletes (10-20%) who have prolonged concussive symptoms.
• It is not uncommon for children to have symptoms for weeks or months especially if they obtained a second concussion while still symptomatic from the first.
• It is impossible to accurately predict exactly how long it will take to recover. Symptoms may persist for months despite a seemingly “mild” injury.
• There are additional therapies that can be implemented for more severe cases. These treatments should only be implemented by those doctors with significant training in their usage.
Factors That Influence Recovery Time:
1) Age: Concussion is one of the extremely rare conditions where adults actually heal faster than children.
2) Gender: Studies show females generally take longer to recover and have more symptoms than males.
3) History of Prior Concussions: The more concussions you have had the longer it will take you to get better (as a general rule).
4) Pre-existing Medical Conditions: For example children with a history of migraines or learning disabilities are believed to take longer to recover.

LONG TERM EFFECT OF CONCUSSIONS:

There is currently no hard and fast rule about how many concussions are too many. After each concussion the child and parent should sit down and discuss the pros and cons of returning to play and decide what changes (if any) should be made.
The long term effects of multiple concussions are well recognized. The list includes, but is not limited to:

1) Alzheimer’s Type Disease
2) Chronic Traumatic Encephalopathy
3) Learning disabilities
4) Decreased attention
5) Parkinson’s Type Disease
6) Dementia
7) Second impact syndrome
8) More severe concussions in the future
9) Personality change
11) Depression
12) Substance abuse
12) Persistence of any acute symptom

GREAT RESOURCES AND FURTHER READING

The Centers For Disease Control and Prevention: The “Heads Up”Program http://www.cdc.gov/concussion/
ThinkFirst-SportSmart Concussion Education and Awareness Program http://www.thinkfirst.org/home.asp
Consensus statement on concussion in sport – The 3rd International Conference on concussion in sport, held in Zurich, November 2008
P. McCrory, W. Meeuwisse, K. Johnston, J. Dvorak, M. Aubry, M. Molloy, R. Cantu
Available at http://sportconcussions.com/html/Zurich%20Statement.pdf
For More information on the accumulative effects of concussions visit the Sports Legacy Institute: at www.sportslegacy.org
©Kristian Goulet

About the Author:

Dr Kristian Goulet is originally from Ottawa and played Junior Hockey in the area. He was recruited to play hockey at the collegiate level and did his undergraduate degree in Biology (Honours) at Queens University in Kingston, Ontario. His Medical School Training was in Ireland and this is where he first started his work with concussions, examining the prevalence in Irish Rugby players. He completed his Paediatric Residency training at the University of New Mexico. During this time he began giving concussion presentations at the local, State and National levels.

He then went on to do a Sports Medicine Fellowship at Harvard University. During this time he again was very active in the field of concussions giving multiple presentations at the local, regional, and national level. He has trained under some of the great leaders in the concussion field at the Concussion Clinic at the Children’s Hospital Boston; a center nationally recognized for innovative concussion treatments. Dr Goulet has also designed a concussion education program and is the Clinical Supervisor for the Concussion Education Program for the Sports Legacy Institute. He is also a Credentialed IMPACT Consultant (CIC) meaning he is trained to interpret all IMPACT neuropsychological testing for concussions.

Dr Goulet has recently returned to Ottawa and will be opening his clinic July 25th 2011. He will be seeing all paediatric patients with a special focus on Concussions and Pediatric Sports Injuries at the Active Care Clinic at 1108 Klondike Road. Kanata Ontario. For more information please call the clinic at 613 254 9777 or visit the website at: www.activecareclinics.ca.