Concussion and Sports (From 8/2/13)

The first week of August is now here, and to many of us, that means football is just around the corner. The NFL has been back at camp for several weeks, many colleges will have just started, and high school will be into the dog days soon as well. As a former athlete and football player myself, I can remember an ominous feeling that came on the 1st of August. It used to mean that summer was over, and I had to start thinking about going back to school. Worst of all, football 2 a days were drawing near. When I think back to those long hot days it brings back a lot of memories. Those who have been through it know that the only purpose 2 a days serve is to challenge your mind and body, by physically beating you down. Only after 2-3 weeks of grueling conditioning, heat, and physical hardening, could you earn the right to be a part of the team.

As an athletic trainer I now prepare for the coming season in a somewhat different way. August means preparing athletes to avoid injury and be prepared for their upcoming camp. Recently, there has been one particular area of focus for athletes:

CONCUSSIONS

This is an EXTREMELY hot button topic right now in athletics, and I think that it is important to address it, as there is a lot of confusion and misinformation about what concussions are, and how they should be managed.

What is a concussion?

Put simply, a concussion is a brain injury. Between 1.6 and 3.8 million concussions occur each year across all levels of sports. At least 1/5 of these occur in high school athletes. It is generally accepted that individuals participating in contact sports such as football, rugby, hockey or lacrosse are at the greatest risk for concussion, but other athletes and sports are also at risk, and may actually have a higher rate of concussion. Lawsuits brought by the NFL players association, as well as individual athletes and their parents, have brought attention to this issue recently. As a result, many changes in public policy, and the realm of sports have occurred.

It is especially important for parents of high school athletes to stay abreast of this information. In fact, all 50 states now have some form of legislation on the books regarding concussion and youth athletes. South Carolina’s law passed very recently (June 7, 2013), so many parents may be unaware of the changes involved. I will post a link to a copy of H*3061 at the end of this post for everyone to review. Major changes going into effect are:

  1. School districts must present you written information detailing the nature, risks, and effects of concussion and brain injury. They must also keep some form of written documentation that you have read and understand it.
  2. Any athlete with a suspected head injury must be immediately removed from play.
  3. Athletes who are removed due to suspected head injury cannot return to play unless they are medically cleared by a physician, physician assistant, nurse practitioner, or athletic trainer.
  4. If a concussion has been confirmed, that athlete cannot return to play unless cleared by a physician.
  5. All medical clearance must be documented in writing.

There are several key things to note here. School districts must provide parents and athletes with adequate information to make an informed decision about participation in sports. They are now also responsible for training coaches and volunteers to make the correct decisions about concussion and how it should be managed. This means that schools and school districts are 100% liable for any mismanagement of a concussion by a coach, referee or other person working at athletic events.

The next major change is that an athlete with a suspected head injury must be removed. The law is not clear as to what a “suspected head injury” is, but it is clear that an appropriate level of precaution must be taken. This means that any one showing signs of a head injury (confusion, loss of consciousness, poor coordination, loss of memory, etc.) must be removed. It is a very good thing that the law allows for a broad definition here. This allows some less serious cases to be caught before they become severe and dangerous.

Quite possibly the most important provision of the law here is the part that describes who is able to determine when the player can return to play. This protects players from coaches who use the “rub some dirt on it” or “walk it off” methods. While it is a coach’s job to insure the physical and mental toughness of his or her players, it is best to let a medical professional decide how severe an injury is, and the best course of treatment. There is a second part to this provision that is equally important to the first. This law dictates which medical professionals are qualified to assess a concussion. Physicians and athletic trainers are ultimately given the authority to make the final call under this legislation, and under certain circumstances physician assistants and nurse practitioners. It is important to make this distinction because not every health professional is qualified to assess a concussion. I have had many experiences with coaches upset by my decision to remove a player with a concussion. Many have attempted to seek the opinion of an unqualified professional to reverse my decision. Fortunately, South Carolina state law now protects us from such recklessness.

The last part of the law is important because it speaks to how an athlete who has been removed from play with a concussion must be treated. These players must be assessed by a physician, and given written medical clearance before they are allowed to return to play. Previously, the decision to hold an athlete out of participation was left to the parents (if younger than 18) or the athlete. This law will help to protect athletes, and ensure that concussions are managed properly.

How is a concussion diagnosed?

Typically, athletes who have suffered a concussion will present with confusion, amnesia, headache, aura, ringing in the ears, nausea, drowsiness, sensitivity to light or noise, temperature regulation difficulty or loss of consciousness. This list certainly is not all-inclusive, and should not be used as a diagnostic checklist. A 2011 study found that the traditional diagnostic criteria above may not be as useful as previously thought. Specifically, the study found that males and females may not even report the same types of symptoms with concussion. Males most often reported amnesia or confusion after a concussion, while females reported drowsiness and sensitivity to noise. Additionally, some studies have shown that females may actually have improved cognition and recall after a head injury, where males will typically a decrease.

Typically when performing a concussion assessment it is important to determine the base symptoms, but performing more advanced testing could provide more information on the location or severity of the concussion. Cognitive testing, cranial nerve testing as well and strength, coordination and balance testing will all likely create a good picture of what a concussion looks like. Once that information is obtained, it can help formulate a plan for management.

General Rules for Management:

  1. Monitor symptomatic individuals for 15 min. post injury
    a. If symptoms resolve within 15 min., return to play
    b. If symptoms persist, remove from play
    2. Athletes with concussion should be removed from play for a minimum of 7 days
    a. If symptom free after 7 days, return to play
    b. If symptoms persist, monitor for an additional 7 days
    3. Athletes removed from play by their second concussion within 1 year, must be removed from play for a minimum of 1 month
    a. If symptom free after 1 month, return to play
    b. If symptoms persist continue to monitor for an additional month
    4. Athletes removed from play by their 3rd concussion within 1 year, must be removed from play for the remainder of the season, and must undergo rigorous medical testing and monitoring for 6-12 months.
    a. If symptom free after 6-12 months, and medically cleared, return to play
    b. If symptoms persist, consider permanent removal from play
    5. Any athlete with 3 or more lifetime concussions should be removed from play at least 1 month with any subsequent concussion.
    a. If more than 3 concussion in 1 year, consider permanent removal from play
    b. If 3 concussions over the course of several years removal of at least 1 month.

Other things that parents and players should consider:

  1. Removal from classroom activities until symptom resolution
    2. Discontinue high levels of exertion until symptom resolution
    3. Participate in rehabilitation program guided by a physical therapist or athletic trainer
    a. Should address balance, strength or coordination impairments
    b. Should progress from low exertion to higher levels of exertion as symptoms resolve
    4. Previous concussions predispose athletes to future concussions, thus athletes with a high number of concussions should consider retirement.

Concussion is a brain injury and that must be respected. For far too long concussions have been treated as “no big deal.” As a parent, or an athlete you must remember that numerous concussions have been linked to memory loss, difficulty concentrating, poor coordination and physical performance, seizures, paralysis, early onset Parkinson’s, dementia and even death. Additionally, any concussed athlete who is not removed from play for an adequate amount of time runs the risk of SECOND IMPACT SYNDROME(SIS). SIS can lead to sudden death, seizure, persistent migraine, epilepsy, or permanent brain damage. For this reason, parents and athletes need to be aware of the risks and necessary steps to take when concussion occurs.

Additionally, parents need to encourage their local school boards, PTA’s and athletic departments to employ certified athletic trainers to cover their home sporting events. What is an athletic trainer? I’m glad you asked. Athletic trainers are medical professionals who have a bachelor’s degree with an emphasis in athletic training, and have passed the Board of Certification exam. They are specialists in diagnosing, treating and preventing athletic injury and are skilled in triage, and life saving care. Having an athletic trainer present at events ensures that athletes will receive adequate medical care, and be protected from unnecessary injury. Schools also benefit because coaches, referees and other volunteers are protected from liability when athletic trainers make return to play decisions. I would encourage all athletes and parents to contact your local school board or athletic department and make sure they employ a certified athletic trainer to protect your children.

Concussion Study
Full Text is available through this link in PubMed Central.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3017493/

South Carolina Concussion Law
http://www.scstatehouse.gov/query.php?search=DOC&searchtext=Concussion&category=LEGISLATION&session=120&conid=7335730&result_pos=&keyval=1203061&numrows=10

Patrick

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