Frequently Asked Questions about Concussions
The discussion of concussions dates back to 600 AD when Dr. Rhazes discussed the difference between severe head trauma and “concutere,” which means shaking of the brain. In the 1980s, Dr. Cantu introduced grades of a concussion -- a concept that has more recently been abandoned and further defined by common features established by a panel of experts of the International Symposia on Concussion in Sport (ISCS) Group in Vienna (2001), Prague (2004) and Zurich (2008). The following highlights the most recent guidelines and frequently asked questions (FAQs) in regards to concussion management.
- A concussion is a brain injury and should be taken seriously.
- Concussions rarely involve a loss of consciousness and often result in signs and symptoms that occur hours to days later.
- It is estimated that more than 50% of high school athletes will suffer a concussion by the time they graduate.
- A 2009 survery (by Nessler) estimated that more than 40% of younger athletes return to play too soon.
- In a study by Guskiewicz, it was found the majority of repeated concussions occur within the first 10 days of the original concussion.
- Recognizing a concussion and proper response when they first occur can help prevent futher injury or even death.
According the Zurich (2008) guidelines, a concussion is “a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces3." It is considered a type of brain injury caused by a direct blow to the head or other part of the body that results in a rapid movement of the brain within the skull. Whether a bump, blow or jolt, a concussion can interfere with normal brain function that results in common features:
- Can be a direct or indirect blow to the head or other part of the body causing “impulsive” forces transmitted to the brain;
- Sudden onset of symptoms that, in most cases, gradually disappear with rest -- usually within 7-10 days;
- May cause a disturbance in normal brain function but no detectable structural damage (e.g., brain scan with MRI or CT scan);
- Typically does not involve a loss of consciousness (less than 10% of the time) and symptoms gradually disappear although a small percentage have symptoms that linger, known as "post-concussion syndrome."
There are a number of symptoms associated with a concussion that are often classified as physical, cognitive and/or behavioral. The table1 below summarizes the more commonly recognized symptoms as well as behavior (emotional) changes and sleep disturbances related to concussions. If any blow or jolt (even "ding") is observed and any of the below changes are present then a concussion should be expected and appropriate management provided.
COGNITIVE/ THINKING SYMPTOMS
|Headache||Confusion||Feeling sad||Difficutly falling asleep|
|Dizziness||Memory loss||Feeling nervous or anxious||Sleeping more than usual|
|Nausea||Difficulty concentrating||Moodiness||Sleeping less than usual|
|Feeling 'unsteady'||Feeling 'slowed down'|
|Feeling 'stunned' or 'dazed'||Feeling 'foggy-headed'|
|Sensativitiy to light or noise|
|Feeling 'bell rung'|
|Blurry or double vision|
|Tinnitus (noises in the ear)|
|Diplopia (changes in vision)|
Anytime someone suspects a concussion, the athlete should be removed from activity and appropriately evaluated. It should be identified as soon as possible if emergency medical attention is needed. Ideally, the athlete could be evaluated by a qualified healthcare provider at the time of injury, which is usually an athletic trainer. The parents or guardians should be notified and also given educational materials regarding concussions, including what signs and symptoms to watch for at home. The athlete should not be allowed to return to play until he or she receives written clearance from a qualified healthcare provider, signs and symptoms of a concussion are no longer present and the athlete has completed a gradual "step-wise" approach with returning to activities.
What are the danger signs of a concussion? Any worsening of the signs or symptoms above would indicate the need to seek immediate medical attention. Below is a list of common danger signs associated with head trauma1:
- Headache that gets worse and does not go away
- Weakness, numbness or decreased coordination
- Repeated vomiting or nausea
- Slurred speech
- Look very drowsy or cannot be awakened
- Have one pupil (the black part in the middle of the eye) larger than the other
- Have convulsions or seizures
- Cannot recognize people or places
- Are getting more and more confused, restless, or agitated
- Have unusual behavior
- Persistent loss of consciousness (greater than 1 minute) although any loss of consciousness should be taken seriously
REST. REST. REST.
The first and most important step is REST -- physical, mental, visual and auditory. An athlete should not be allowed to resume activity following a concussion on the same day, until he or she is symptom free, and given the approval to resume activities by an appropriate healthcare provider. As symptoms begin to disappear then the athlete can progress to doing more activities. Again, this should be done gradually and not cause an increase in symptoms. Ideally, a "step-wise approach" would be carried out with an athletic trainer or other qualified healthcare provider.
What is a "step-wise approach?"
A step-wise approach begins with rest. When the concussed athlete does not have an increase in symptoms with daily physical or mental activities then he or she can begin light aerobic activities (e.g., walking, stationary bike, etc). This is commonly referred to as "Stage 2" of a return to play protocol. The intensity of activities are increased if the athlete can tolerate them without an increase in signs and symptoms. The stages eventually become more specific to the athlete's sport. Before returning to full contact, however, it is strongly recommended to receive a medical release. The final stage is "game day!"
The majority of athletes make a full recovery, especially when they rest following the injury and return to activities gradually. However, every athlete must be treated individually. Returning to play too soon can increase the chance of having long-term problems or a more serious injury, and even death. As noted by the Centers of Disease Control, "when in doubt, sit it out."