Frequently Asked Questions about Sports Concussion
What is a concussion?
A concussion is a brain injury!!! In fact some refer to concussion as a mild traumatic brain injury. There is not one accepted definition of concussion in sports. Perhaps the best way to define concussion is a prolonged transient alteration in neuronal function caused by a blow to the athletes head, and/or body with transmission of force to the head, resulting in rotational and/or translational (i.e. angular and lateral) movement of the head resulting in neurological symptoms that resolve sequentially over time. The biggest misconception about concussion is that loss of consciousness is required. In fact the complete opposite is true with more than 90% of all concussions occurring without loss of consciousness. Unlike other sports related injuries you cannot just walk off a concussion.
What causes a Concussion?
A concussion is caused by a blow to the head or body where forces are transmitted to the head or neck, a direct blow to the head is not required to induce concussion. In order to sustain a concussion there must be rotation or angular acceleration (side to side movement) of the head or neck with enough force to cause the brain’s cerebral hemispheres to rotate around the upper part of the brainstem (the part of the brain that is involved in attention and arousal).
What happens to my brain when I sustain a Concussion or a traumatic injury?
During a concussion the brain experiences a cascade of complex and somewhat poorly understood electrical and biochemical changes followed by a period of recovery during which time the brain’s chemicals i.e. sodium, potassium and calcium, as well as its neurotransmitters return to their baseline levels. In most individuals this process takes approximately 10 to 14 days. In some individuals including young children, adolescents (high school aged) and individuals who have had a prior concussion, the symptoms can be prolonged. In lay terms one way to think of a concussion is use what happened to New Orleans in hurricane Katrina. The city experienced an initial blow from the hurricane. This caused a major disruption in the power grid and due to the initial blow the cities levy system failed resulting in water moving in and flooding the city (similar to the chemicals moving out of the brain) once the city was able to get past the initial blow and restore emergency power it was able to turn on the pumps and begin to pump out the water (this is very similar to what the brain does in an effort to restore electrical chemical balance). One can only imagine what would have happened to New Orleans if another storm would have hit before the city had time to fully recover.
How long does a concussion last?
Most concussions, especially if the athlete has no prior history of concussion, resolve in 10 to 14 days. However, some patients can have a more prolonged course which can last anywhere from a month to a year. It is essential that these patients be seen by a physician and preferably a neurologist with expertise and resources (see our concussion management program) to manage the various symptoms and needs of these athletes.
Are my chances of sustaining a concussion greater with certain sports?
Yes high impact sports such as football (which has the greatest number of concussions per year), ice hockey (which has the highest rate of concussion), lacrosse, and even soccer have the greatest risk of concussion. However, concussion can occur in almost any sport included basketball, cheerleading and baseball.
Are girls different than boys?
Yes, it appears that girls have a greater risk of sustaining a concussion and tend to take longer to recover.
What are the signs and symptoms of sports concussion?
Concussion symptoms may occur immediately after the impact, develop within the first few hours, or can persist for days and even weeks after the initial event. Immediate symptoms include; vacant stare (befuddled facial expression), delayed verbal and motor responses (slow to answer questions follow instructions), confusion and inability to focus attention, disorientation (walking in the wrong direction, unaware of time, date and place), slurred or incoherent speech, gross observable decrease in coordination (stumbling, trouble with tandem gait), emotions out of proportion to circumstances, memory deficits (exhibited by the athlete repeatedly asking the same question that has already been answered, or inability to memorize and recall 3 of 3 words or 3 of 3 objects in 5 minutes), or any period of loss of consciousness. It should be noted that loss of consciousness is not a common symptom occurring in less than 10% of all athletes. Within the first few hours the athlete may experience intermediate symptoms of headache, dizziness, loss of equilibrium or vertigo, lack of awareness of their surroundings and nausea or vomiting. As the concussion progresses late signs and symptoms develop and can include; persistent low grade and sometimes even severe headache, (may include sensitivity to light and noise), light-headedness, poor attention, concentration and memory, heat Intolerance, easy fatigability, sleep disturbances, irritability, anxiety and/or depressed mood which are often unrecognized, sleep disturbances and decreased reaction time and balance which are the last symptoms to resolve.
What should I do if I think I have sustained a concussion or feel that one of my teammates has sustained a concussion?
Immediately report the symptoms to your coach or if available athletic trainer. Anyone suspected of suffering a concussion should be immediately removed to play and never be allowed to return on the same day. The athlete then needs to be monitored for progression of neurological symptoms and should not be left alone. They should be evaluated by a physician as soon as possible and not be allowed to return to play until cleared by a physician certified in the management of concussed athletes after which time they should complete a graded return to play protocol.
What types of testing are used to evaluate athletes with suspected sports concussion?
The best test is still a comprehensive detailed history and neurological exam. It is important that you let your doctor know if you have any prior history of concussion (of any kind i.e. falls, sports) as well as any prior history of headache, ADD/HD, problems with your cervical spine (neck) and any history of neurological disease. It is also best to have a baseline exam perform so that if you do sustain a concussion then the physician will have something to compare to as you recover. Most professional and college sports teams and many high school teams use computerized neuropsychological testing, (see our program for services offered). These tests include IMPACT, Headminder Concussion Resolution Index (CRI), CogSport, and the Automated Neuropsychological Assessment Metric (ANAM). Athletes are tested by a trainer or neuropsychologist prior to the start of the season and then during the season if a concussion is reported. These tests are useful tools for evaluating athletes and despite being validated with formal neuropsychological testing should never be used as the sole means for returning an athlete to play, and should never be substituted for a comprehensive history and neurological examination as they can be influenced by a lack of initial effort (i.e. pre-season) whereby the athlete will actually score better after sustaining a concussion. These tests also do a poor job addressing associated symptoms i.e. headache, sleep disorders. Reaction time testing if available, is marginal and does not simulate game conditions. And finally the tests are also influenced by symptoms such as headache and lack of sleep which are very common with concussion. For other more cutting edge testing please see our concussion management program section.
What steps are necessary before I return to play (RTP)?
Before an athlete can be considered for return to play they must be completely asymptomatic, off of all medications, with a normal neurological exam and all pre-concussion testing returned to baseline. All current RTP guides are based on consensus opinion. What this means is that a group of experts get together and attempt to come to an agreement as to what is bested for the athlete. This differs from most guidelines which are based on controlled clinical trials, i.e. what is termed evidence based medicine. As a result it is always best to air on the side of caution when returning an athlete to play. The most widely used RTP guidelines are Zurich 2008. No athlete should ever return to play on the same day they have sustained a concussion. Return to play protocol following a concussion follows a stepwise process based on a full clinical and cognitive recovery before. Each step involves the athlete gradually increasing their physical and cognitive activity. With this stepwise progression, the athlete should continue to proceed to the next level if asymptomatic at the current level. Each step should take 24 hours in adults and 72 hours in young and high school age children, so that an athlete would take approximately one week to proceed through the full rehabilitation protocol. If any post concussion symptoms occur while in the stepwise program, the patient should drop back to the previous asymptomatic level and try to progress again after a further 24-hour period of rest has passed.
What happens if I return to play before my concussion has resolved?
The biggest risk is that an athlete will sustain another concussion after which time the symptoms will take exponentially longer to resolve. In rare cases especially if an athlete is allowed to return the same day they may experience what is called “Second Impact Syndrome” where the brain swells uncontrollably resulting in permanent catastrophic neurological injury and even death.
What are the long term effects of concussion in sports?
There are some preliminary data to suggest that repeated concussions and sub concussive events can lead to early dementia in athletes. The most widely publicized studies are related to Chronic Traumatic Encephalopathy which is at this point is only accepted by physicians and the scientific community as a neuropathological diagnosis (there is not enough data to say that a clinical syndrome exists). The research was performed by my former colleague Dr. Ann McKee and her group at Boston University School of Medicine who has studied the brains of retired and current professional and amateur athletes from sports such as football, ice hockey and boxing. She found pathological changes which were similar to those of patients with Alzheimer’s Disease. She also looked at the spinal cord of a subgroup of patients and found that these patients had pathological changes consistent with ALS (Lou Gehrig’s Disease).
Sports Concussions • Neurological Trauma
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