CRMC: Concussions


Wyoming Orthopedics and Sports Medicine

4017 Rawlins St.
Cheyenne, WY 82001

(307) 635-2562

 

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The following information is courtesy Dr. Dan Kisicki, a primary care sports medicine physician at Cheyenne Family Medicine and Wyoming Orthopedics and Sports Medicine. Citing the CDC as a source.

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What exactly is a concussion?
Concussion is a type of traumatic brain injury, which leads to a transient, trauma-induced alteration in brain function. This means that the symptoms have a discrete start and stop time and they are associated with a discrete traumatic event.

Concussion is a complex process affecting the brain and basically changes the way the brain works. It may be caused by a direct blow to the head, face, neck or even elsewhere on the body; typically, the brain moves quickly back and forth after such an impact.

It is a “functional” not a “structural” brain injury; therefore, abnormalities specific to concussion are not seen on standard medical imaging. Concussion is often described as a “mild” traumatic brain injury, in that it is typically not life-threatening; regardless, it can still result in serious effects. It results in a graded set of clinical symptoms and may or may not involve loss of consciousness. Symptoms typically resolve spontaneously over time and follow a sequential course.

How common are concussions and who is at greater risk?
According to the Centers for Disease Control, in the US in 2007, there were 38 million children and adolescents in organized sports and 170 million adults in physical activity not related to work.

The American College of Sports Medicine estimates that there are approximately 1.6-3 million concussions per year in the US. This could represent approximately 9% of all high school athletic injuries.

Concussion can occur in any sport or activity, but it is more common in contact or collision sports, such as bicycling, football, soccer, basketball, and playground activities. It is commonly seen at a higher sporting level and in athletes with high-risk or dangerous styles of play. Children and teens are more likely to sustain traumatic brain injuries and often have a prolonged concussion recovery course; number of previous concussions, duration of symptoms (>10 days), severity of symptoms seem to play a role in risk; repeat concussions, especially ones occurring close together in time, factor in as well.

How does one recognize a potential concussion?

When suspecting a concussion, it is important to look for the following in an athlete: an injury that could lead to concussion AND a change in the athlete's behavior, thinking, or physical functioning.

One can suspect a concussion if at least 1 of the following is present:
•Clinical symptoms: headache, feeling “in a fog”, emotional liability
•Physical signs: loss of consciousness, amnesia
•Cognitive impairment: slowed reaction times
•Neurobehavioral features: irritability
•Sleep disturbance: insomnia
•Balance or motor coordination problems: stumbling, slow/labored movements
•Loss of memory: before or after the injury
•Blank or vacant look

NOTE: Loss of consciousness is not a mandatory aspect in concussion. In other words, the athlete does not have to be “knocked out” to sustain a concussion. In fact, some studies indicate that less than 10% of concussions involve LOC.

What are some of the possible symptoms reported in concussion?
•Headache
•“Pressure in head”
•Neck pain
•Nausea or vomiting
•Dizziness
•Blurred vision
•Balance problems
•Sensitivity to light
•Sensitivity to noise
•Feeling slowed down
•Feeling “in a fog”
•“Don’t feel right”
•Difficulty concentrating
•Difficulty remembering
•Fatigue or low energy
•Confusion
•Drowsiness
•Trouble falling asleep
•More emotional
•Irritability
•Sadness
•Nervous or anxious

What do you do if you suspect a concussion?

Ideally, a physician or other licensed health care professional should evaluate the athlete in question if possible. This is often not possible at the time of injury (most environments in which concussion occurs, such as youth sporting events, recreational games, playground activities and the like, do not have medical personnel in attendance).

If possible, it is important to consider more serious injuries as well and consider basic CPR approaches and spinal cord stabilization if necessary. If health care providers are not available, it is helpful to remove the athlete safely from practice or play and arrange for urgent referral/evaluation (PCP, sports medicine doctor, urgent care, or emergency room follow up depending on the injury).
IF A CONCUSSION IS SUSPECTED, THE BEST APPROACH IS TO PLAY IT SAFE AND REMOVE THE ATHLETE FROM PARTICIPATION: “WHEN IN DOUBT, SIT THEM OUT!”

Sideline concussion assessment tools are used if available and appropriate staff is present. Do not leave the player alone after injury (have an adult sit with the athlete and monitor the progress or deterioration of symptoms). Serial monitoring for deterioration is important hours after the injury.

What is involved in the overall management of concussion?
The cornerstone of concussion management is PHYSICAL AND COGNITIVE REST; this means, in brief, “rest the body, rest the brain”. This is typically encouraged until acute symptoms resolve. While symptoms exist, those with suspected or confirmed concussion should avoid physical exertion, avoid tv/video games/computer use/texting/loud music/etc., and expect the need for additional time for schoolwork, tests and other cognitive activities.

It is important to remember that concussion is among the most complex injuries in Sports Medicine to diagnose, assess, and manage. It involves rapidly changing clinical signs and symptoms, with the majority of injuries occurring without LOC or focal neurologic signs and imaging does not assist in the diagnosis. There is no perfect diagnostic test or marker. Concussion requires rapid assessment during competition (time constraints typically present, the athlete is eager to return to play). Depending on the level of competition, we do not want to hold out an athlete without a concussion and impact the competition’s outcome; however, we do not want to improperly return a concussed athlete to play.

When can I return to play?
The biggest issue with return to play is ensuring complete healing before return to sport. This can be difficult. We typically rely on a multimodality assessment, focusing on a normal clinical exam, the patient’s self-report of no symptoms, a return to normal school or work performance (“RETURN TO LEARN PRIOR TO RETURN TO PLAY”), the ability to perform through a normal day, normal baseline balance testing and a return to baseline on neuropsychologic testing (if utilized).

Typically, most concussions resolve in about 7-10 days; children/adolescents often take longer. 85-90% of concussions resolve in <30 days. Some athletes are asymptomatic at rest; however, once they exert themselves, symptoms return. We don’t want to miss this type of patient and place them at increased risk of further harm, additional concussion, prolonged recovery or more serious issues.

Graduated Return to Play Protocol: (Again, prior to this, brain should be functioning normal at rest, attending a full day of school, normal workload without symptoms):
No activity (recovery)
Light aerobic activity, e.g. walking, swimming, stationary bike (increase HR)
Sport-specific activity, e.g. skating drills, running drills (add movement)
Non-contact training drills, e.g. more complex training drills, passing drills (exercise, coordination, cognitive load)
Full contact practice, following medical clearance (restore confidence, assess skills by coaching staff)
Return to play (normal game play)

How can I “prevent” concussions?
Unfortunately, there is no surefire prevention of concussions. The focus is more on risk reduction, recognition, and appropriate management. Parents, athletes, and coaches can ensure that athletic equipment and gear is up to safety standards; in addition, proper tackling, heading or other specialized techniques can be taught and practiced. Know the rules of the sport; practice good sportsmanship. Wear helmets to help reduce risk of severe brain injury or skull fracture (no helmet is designed to be “concussion-proof”). I encourage coaches, players and parents to educate themselves on concussion basics, including recognition and awareness (remember, most of these occur in the absence of healthcare professionals). Research is ongoing in this realm.

Where can I find good information on concussions? The CDC website is a great starting-point resource for athletes, parents, and coaches. I hope to get more involved in community-based parent/coach/student-athlete meetings and conferences here in Cheyenne to promote awareness and educate on the topic of concussion in the near future. I am also happy to work with athletes and their primary care providers in the evaluation and management of concussion in the clinic setting.

Take home messages:
•Concussion is a functional rather than structural brain injury
•No same day return to play
•Return to learn prior to return to play
•No stand-alone perfect tool for evaluation/management
•Treatment involves physical and cognitive rest
•Most resolve in 7-10 days; if prolonged issues arise, we usually involve experts, multidisciplinary approaches.
•“When in doubt, sit them out!”


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