What parents and coaches MUST know about concussions

If you are a parent or a coach, here are some concussion related questions to ask yourself.  Do you know the correct answers?

True or False?
  • There must be some sort of loss of consciousness and/or headache to be a true concussion.
  • You can sustain a concussion even if you do not hit your head.
  • Concussions typically are diagnosed by using MRI or CAT scans.
  • It is OK to give Ibuprofen, Aspirin, or Tylenol to your athlete to help alleviate their headache.
  • A student should take a short leave of absence from school while highly symptomatic following a concussion.
  • Adolescents generally take longer to recover from a concussion than adults do.
  • As soon as the athlete is symptom-free, they have healed from his/her concussion.
Concussions are still a far-too common problem for youth participating in athletics.  While in most cases, there is minimal that could have been done to prevent a concussion from occurring, as parents, coaches, and healthcare pros we can do a ton to make sure that someone does not return to activities that they shouldn’t prior to fully recovering.  According to the CDC, roughly 300,000+ adolescent sport-related concussions are sustained annually.  Also, let’s not forgot that we must also manage non-sport related concussions properly as well, in people of all ages.  It is important to note that younger people typically take longer to recover than adults, so we must keep this in mind as we are guiding their recovery.The most dangerous risk stemming from a concussion not being properly cared for is Second Impact Syndrome (SIS), when a second concussion occurs before first one heals (BAD STUFF!).  The most common cause of SIS? Improperly managed concussions.  Much research is currently being conducted on the long term consequences of repeated concussions. These significant long term-neurophysiological effects, such as chronic cognitive impairments and Chronic Traumatic Encephalopathy (CTE – physiological, structural changes occur, symptoms mimic Alzheimer’s),can occur with repeated or poorly-managed head injuries.
So, what exactly is a concussion?  Scientifically-speaking, it is a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces (direct or indirect) that results in onset of impairment of neurological functions that typically spontaneously resolve, however in some cases may be prolonged.  Concussions are not diagnosed with xrays, MRIs, or CT scans (these tests should only be used to look for “worst-case” red flags in worst-case concussions).  The most common symptoms of a concussion are: headache, dizziness, and confusion.  It is important to note that loss of conciousness only occurs in ~ 5% of cases.

Here are some signs/symptoms that a parent or coach may observe:

  • Loses consciousness
  • Appears dazed, stunned
  • Confused about assignment/forgets plays
  • Unsure of game/score/opponent
  • Moves clumsily or appears “drunk”
  • Answers questions slowly
  • Memory loss (before or after hit)
  • Behavior/Personality changes (such as increased irritability or anxiety)
  • ADHD-like signs, depression, mood swings
  • Changes in academic/cognitive performance
Here are some signs/symptoms of a concussion that the affected person may report:
  • Headache
  • Nausea/vomiting
  • Dizziness, balance problems, or unsteadiness
  • Double or fuzzy vision
  • Sensitivity to light or noise
  • Feeling sluggish, groggy, or foggy.
  • Sleep disturbances
  • Confusion
  • Concentration or memory problems, trouble with school work
  • Does not “feel right”
Medical management of concussions/traumatic brain injuries continues to evolve as more and move research is performed.  But for now, here is what you need to know:
  • First and foremost – REMOVE the person from participation in ANY physical activity if any indication of concussion is present, and make sure he or she is evaluated by an appropriate medical professional (such as a certified athletic trainer (ATC) or a physician or nurse trained in concussion management) before a return to activity determination is made.

Appropriate concussion assessment involves:

  • Orientation assessment
  • Symptom checklist/assessment
  • Neurological testing (i.e. balance, coordination, reflexes, strength)
  • Cognitive testing (i.e. ImPACT, memory, pattern recognition)
  • Physiological stress (i.e. graduated return to athletics protocol)
  • REST is necessary.  This includes physical, cognitive, AND social rest (no going to the movies, attending loud sporting events, or riding on amusement park rides!)
  • Tylenol is OK to use to try and control the headache, but DO NOT give aspirin or ibuprofen (these may possibly increase bleeding in the brain)
  • Maintain a healthy diet and proper hydration.  Changes in appetite can occur post concussion.  Maintaining health eating and hydration habits allows the body to heal more efficiently.  Additionally, there is some research that has demonstrated a) delayed healing associated with highly saturated fat diets, and b) Omega 3-rich foods and supplementation may aid in expiditing the healing process.
  • Monitor symptoms daily, making note of any changes.  It is especially important to note which (if any) stimuli increase symptoms, and avoid these until completely symptom-free.
  • Maintain communication with others involved (i.e. parents, other coaches, school support staff. This is KEY when dealing with an athlete who is in school and/or participating on multiple athletic teams/clubs.
When should you seek emergency attention?

The injured person must be seen right away in an emergency department if they exhibit any of the following:

  • ANY loss of consciousness, convulsions, or seizures
  • One pupil larger than the other
  • Severe drowsiness or cannot be awakened
  • Headache and/or confusion that is getting progressively worse
  • Weakness, numbness, or decreased coordination
  • Repeated vomiting or severe nausea
  • Slurred speech or significantly unusual behavior
  • Difficulty recognizing people
Avoiding over-stimulation following concussion:
While research is still looking for ways to speed natural concussion recovery, this is a lot that can slow recovery.  Be wary of the following while recovering from a concussion (especially over the first few days following the injury)
  • Watching TV, playing video games, and using the computer or smart phone use can increase symptoms
  • Social situations where there is a high level of environmental stimulus (i.e. parties/social gatherings, shopping at the mall, listening to loud music)
  • Driving or traveling longer trips
Returning to school:
As your child is recovering from a concussion, it is important to note the limitations and recommended restrictions when returning to school.  Based on the child’s symptoms, it may be recommended by the healthcare provider that he/she not attend school the days following the concussion and be withheld from taking tests and completing homework, especially if highly symptomatic.  The overseeing healthcare professional should provide a note to the school nurse in situations when this is recommended. This short “leave of absence” is recommended to the high level of cognitive, environmental, and social stimulation that occurs during the school day and while performing school work – it’s not only physical rest that we have to observe!  Completing homework, taking tests, and the noisy hallways and high level of social interaction can be a recipe for increasing the time it takes to recover.  It is also important that the child’s guidance counselor be made aware of the head injury, so that information can be passed on to his or her teachers regarding any recommended academic accommodations while recovering.
Returning to physical activity:
If a concussion has been diagnosed, an adolescent athlete must meet the following criteria before returning to play:
  1. Pass ImPACT Computer Test or other acceptable neurocognitive evaluation (if available)
  2. Normal findings on thorough subjective, objective, and special test evaluation by an appropriate health care professional (ie ATC, Physician)
  3. Graduated return to athletics protocol completed (6 levels – see below) without a return of symptoms.  If no athletic trainer available to monitor this, must have written clearance by a physician to begin protocol after a 7-day symptom-free rest/recovery period.
  4. Written clearance by a physician for full return to activity

Graduated Return-to-Athletics Protocol Progression Levels (one level = minimum of 24 hours, must be symptom-free to progress to the next level.

Level 1 Complete “normal” day of cognitive activities (I.e. school day, studying, watching practice).  ESSENTIAL prior to starting exercise.
Level 2 Light aerobic exercise (less than 70% max heart rate).  NO resistance training.
Level 3 Sport-specific exercise
Level 4 Non-contact training drills (sport-specific).May initiate resistance training.
Level 5 Full contact practice/return to phys ed class (following medical clearance)
Level 6 Return to play (unrestricted)

Oh, and hopefully you got your answers by now to the questions I posed in the beginning.

Answers: (F, T, F, F, T, T, F)

Be safe and be smart.  Is one game worth a lifetime of struggles?

– RS

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Ryan Stevens, MPS, ATC, CSCS
e-mail: ryan.stevens@rwjbh.org


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