Concussion in the Athlete

1. Introduction
2. Causes and Symptoms
3. First Aid and Next Steps
4. Determining the Severity of the Concussion
5. Long-term Effects of Concussion
6. Conclusion

Introduction

Concussion is the most common head injury in athletics and is especially common in football. It can be a serious injury and a frustrating problem for athletes and physicians alike, and an improved understanding of concussions is critical for proper treatment and prevention of further injury.

The diagnosis and treatment of concussion has improved steadily, but there are still debates about how to care for players with these injuries.

Causes and Symptoms

Despite advanced head protection, blunt trauma to the head often occurs during football play and/or as the result of a collision in other sports such as soccer, baseball, or basketball. Naturally, boxing is a high risk sport when it comes to head injuries. Noncompetitive activities such as rollerblading, snowboarding, and skateboarding – or any other sport requiring a helmet – can also cause concussion.

Concussion is defined as a temporary disturbance or loss of neurologic function caused by trauma. Symptoms of concussion are dizziness, headache, amnesia (inability to remember the ”hit” or other events of the day), visual disturbance, loss of balance, and/or loss of consciousness (being “knocked out”).

First Aid and Next Steps

Initial evaluation of a player with head trauma begins with basic life support. The physician will assess that the patient’s circulation and breathing is intact, then he/she will attempt to determine if loss of consciousness occurred.

If the player is conscious and able to respond (as in the vast majority of cases), a brief neurologic evaluation is conducted. This begins simply by evaluating the patients’ motor strength and sensation in the arms and legs to ensure that a spinal cord injury has not occurred.

Next, overall cognitive function (the root of thought processes) is assessed by asking the athlete simple questions about where he is, what the score is, and similar questions.

If the player reports continued symptoms or worsening symptoms, he or she should be transported to the emergency room for evaluation. Also, many health professionals recommend that a player with more than momentary loss of consciousness be evaluated in the emergency room. Some symptoms are worrisome and might indicate that the patient may have a more serious condition, such as subdural hematoma, epidural hematoma, or diffuse axonal injury (bleeding in or around the brain). These symptoms include persistent unconsciousness (coma), altered level of consciousness (hard to arouse), seizure, vomiting, unequal pupils, neurologic (nerve) problems, and difficulty with balance or walking.

After any blow to the head resulting in symptoms such as dizziness, headache, amnesia, or brief loss of consciousness, a physician first determines whether the cognitive function has returned to normal and whether the neurologic evaluation reveals no problems. The next step is to determine the severity of the concussion and whether the player should return to play that day. This is an area of controversy.

Determining the Severity of the Concussion

Three classification systems are in place and are used by physicians to determine the severity of the concussion and “return to play” guidelines.

The three systems that are commonly used are the Cantu Guidelines, the Colorado Medical Society Guidelines, and the American Academy of Neurology Guidelines. These guidelines use parameters such as the duration of loss of consciousness, duration of confusion, amnesia, and presence of post-concussive symptoms to classify concussions into grades: mild, moderate, or severe.

The details of these classification systems are beyond the scope of this article, but several important points deserve mention:

• The most important point of these recommendations is that the player should be symptom free before returning to play. If an athlete has a mild concussion and has no further symptoms, he/she usually can return to play during the same game after observation for 15 minutes.
• Loss of consciousness rules out any possible return to play that day.
• If a player sustains a first moderate concussion or a second mild concussion, he/she should be held out for at least one symptom-free week.
• Most health professionals agree that a second severe concussion or a third concussion of any kind should end the athlete’s season.
• Persistent symptoms or severe symptoms warrant immediate evaluation by a neurologist as well as a brain imaging by way of CT scan or MRI. Some physicians believe in the importance of neurological testing regardless of the severity of the concussion.

Based upon a June 2007 conference on NFL player health and safety, the NFL Minor Traumatic Brain Injury (MTBI) Committee recently released a statement which included the following: 

1. If a player experiences a prolonged loss of consciousness, they should not be returned to play in the same game or practice.
2. The essential criteria for consideration of return to play remain unchanged. The player should be completely asymptomatic and have a normal neurologic examination (including mental status testing) at rest and after exertional testing before being considered for return to play.
3. Team physicians and athletic trainers should continue to take into account certain symptoms and signs that have been associated with a delayed recovery when making return to play decisions. These include posttraumatic confusion, problems with immediate recall, disorientation to time, place and person, anterograde and retrograde amnesia, fatigue, blurred vision and presence of more than three concussion signs and symptoms.
   

Long-term Effects of Concussion

Multiple concussions are known to cause neurologic damage that worsens over time. This has been extensively documented, particularly among boxers. Post-concussion syndrome can also occur. This is often distinguished by fatigue, headache, difficulty with concentration, or “feeling in a fog” that can persist for weeks or months after concussions.

Lastly, Second-Impact Syndrome can occur in athletes who return to play and receive a second hit before the effects of a first concussion are gone. Second-Impact Syndrome can result in severe swelling of the brain or even death.

Conclusion

In summary, concussion is very common in football and can often occur in other sports not usually considered to be “contact” sports. Attempts to prevent concussion include teaching proper blocking and tackling techniques and using state-of-the-art headgear.

When concussions occur, the on-field management of - and care for - these injuries is critical in order to avoid missing a more serious diagnosis. A player can often return to play in the same game after a mild concussion, but second and third concussions will often mean an extended period away from the game.

Prevention of multiple concussions is important in the overall health of athletes and to avoid complications associated with repeated head trauma.