Concussion & Concussion Management for Athletes Guidelines for Recreational, Amateur, Elite and Professional Athletes of All Ages
Dr. Brian Hunt, M.D. July 2003 Director, BC Chapter, ThinkFirst Canada
Some Facts About Concussion:
- A concussion may be caused by a direct blow to the head, face, neck or elsewhere on the body.
- You do not have to lose consciousness to have a concussion
- A concussion alters the way your brain functions and can cause significant impairment
- Symptoms are often subtle ad may include one
or more of these symptoms:
- Sleep disturbance
- Poor concentration, coordination skills
- Persistent headache, particularly with exertion
- Fatigue
- Nausea
- Loss of balance, vertigo, dizziness
- Feeling stunned or dazed
- Double vision
- Ringing in ears
- Slurred speech or stuttering
- Emotional and personality changes, e.g. depression, irritability, inappropriate behaviour
- Altered judgment
- Denial of injury
- Pallor
- An athlete who displays any of the symptoms of concussion should seek medical attention immediately.
- Management/Coaches and trainers should be responsible in assessing an athlete who has had a concussion. & quot;WHEN IN DOUBT, SIT THEM OUT& quot;
- Never return to play while symptomatic. A stepwise program for & quot;Return to Play& quot; should be followed
Management/Rehabilitation of Concussed Athletes
- The player should not be allowed to return to play in the current game or practice.
- The player should be medically evaluated as soon as possible following the injury.
- The player should not be left alone; regular monitoring for deterioration is essential.
- Return to play must follow a medically supervised stepwise process.
When To Return To Play
Medical attention is always advised before return to play.
Concussion management for return to play should be stepwise as follows:
As soon as the athlete is asymptomatic at each level of activity, they can proceed to the next level If the post-concussion symptoms occur, the athlete should drop back to the previous asymptomatic level and try to progress again in 24 hours. If, after several attempts to progress, the post-concussion symptoms continue to recur, please consult a physician.
STEP ONE: No activity, complete rest, mental and physical
STEP TWO: Light aerobic exercise such as walking, stationery bicycle
STEP THREE: Sport-specific training (e.g. skating for hockey players, running for soccer players.
STEP FOUR: Non-contact training drills
STEP FIVE: Full-contact training after medical clearance
STEP SIX: Wait or grace period before game play
This grace period is a period of time equal to the time that has been required for the athlete to reach Step Five and remain symptom-free after full-contact training. The athlete is advised to continue training but not to return to Game Play until this grace period has ensured that the recovery is complete.
Management of Persisting Post-Concussion Syndrome Symptoms
The following is recommended if symptoms persist:
- PSYCHOMETRIC TESTING - counselling, coping techniques, meditation techniques
- PHYSIOTHERAPY ASSESSMENT - for balancing and coordination skills (non-fatiguing)
- MRI or FUNCTIONAL MRI Scan - for reassurance, and baseline MRI
Concussion and the Management of Concussion
Dr. Brian Hunt, M.D.January 2004 Introduction Definition of Concussion
Concussion can be defined simply as a shaking or jarring of the brain producing a transient loss of awareness which may be so brief that the concussed individual is unaware of any lapse in consciousness.
In a statement published, by a number of leading researchers in the field of concussion, a summary and agreement statement of the First International Symposium on Concussion in Sport, Vienna, 2001, was produced and printed in total in the Clinical Journal of Sports Medicine, Vol. 12, pp 6-11, 2002. These authors identified five major points in defining concussion. Most importantly, is the premise that one need not directly strike their head in order to suffer concussion. Many individuals who experience a whiplash type of injury have also suffered a concussion; often unrecognized either by the individual or witnesses. Most concussions occurring in this manner do not produce any noticeable symptoms following the concussive blow. Thus, the outdated belief that one needs to be visibly witnessed to lie motionless following a blow to the head or that the Glasgow Coma Scale needs to be reduced in order to establish a diagnosis of concussion, is now unacceptable and considered erroneous.
Pathophysiology of Concussion
There are numerous hypotheses put forward to explain the pathophysiology of concussion. Early experimental work in the laboratory confirming that the concussed animals had a transient drop in brain temperature during the concussion and recovery phase has led many researchers to focus on the metabolic activity of the synaptic transmitter agents. In other words, the electrical chemical energy required to produce transmitter substances to cross the synaptic gap between neurons is believed to be temporarily disrupted as a result of the jarring or shaking effect to the brain. If one accepts this hypothesis, it is important to recognize that all individuals have a reserve of transmitter substances available that may be reflected in the initial delay of the concussed individual demonstrating signs and symptoms of concussion. Only when the synaptic transmitter substances have been fully metabolized and the concussive blow has ceased production of new synaptic transmitter agents, will the individual and witnesses be aware of a change in the brain function. This is an extremely important concept when dealing with athletes in the sports arena where there is a belief that the athlete may have been concussed. The athlete needs to be observed for a period of time to be certain that there is not any delayed loss of awareness or loss of normal brain function while the normal reserve of synaptic transmitter substances are being utilized. In other words, initially, the concussed individual will be perfectly normal in their response to questions, but in a delayed fashion become confused and incapable of reacting normally. It is on this basis that the sideline assessment of an athlete must be a minimum of five minutes before declaring their recovery is sufficient to be safely released from a one to one direct observation and monitoring.
An individual who has suffered concussion mayor may not experience post-concussion symptoms. The number of symptoms experienced by the individual and a degree in which they are experienced will vary considerably, depending on an individual's genetic make-up of the brain and their previous history of concussions as well as the degree of abnormal kinetic energy directed to the brain. Typical symptoms of concussion include headache, dizziness, nausea, loss of balance, feeling stunned or dazed, having blurred or double vision, ringing in the ears, slurred or stuttered speech, sleep disturbance, poor concentration, and emotional and personality changes, and in particular mental depression.
Dr. Karen Johnston, in her research work at McGill University has identified that while a concussed individual is suffering post-concussion symptoms, their functional MRI Scan will remain abnormal. In other words, she can demonstrate that the oxygen metabolism of the brain is abnormal during the symptomatic phase of concussion. She has also identified that for some time after a concussion, even with an individual returning to a normal state without symptoms, there can be abnormal measurements in the brainwave production.
An individual's response to concussion will vary, as already mentioned. It has been recognized that in a major brain injury and an individual's recovery, there is a considerable genetic difference based on the protein composition of the cytoskeleton of the brain. It is also believed that there is a genetic difference in an individual's synaptic transmitter substance production and its ability to recover. This explains the difference in an individual's response to concussions. There is, in addition, a hypothesis that children who are more susceptible to experiencing the effects of concussion can be recognized at an early stage based on their response to blows and jarring of the head in a playground and the tendency of the child to suffer motion sickness. More research in this area is required before this hypothesis can be translated into a fully understood relationship.
Of importance is the ongoing research being performed at universities throughout the world with the monitoring of athletes who suffer repeated concussions. Pre-concussion psychometric testing or brain function testing forming a baseline can be compared to the brain function following a concussion in an athlete. Researchers have identified that with a simple "ding" or in other words, "seeing stars" for a brief second or so following a blow to the head, the brain function can be delayed in its recovery, up to 48 hours in some individuals. This of course, challenges the wisdom of sideline evaluation of a concussed athlete and then permitting them to return to the same contest. There is a likelihood that a number of athletes are being subjected to increased risk of brain injury due to the effects of successive concussions. In other words, it is known that if one is not fully recovered from the effects of the concussion, and their baseline brain function has not returned to normal, that there may be, in some cases, eight times the potential brain damage occurring which will result in permanent, cognitive deficits in some individuals. Researchers have also shown that where an individual has not recovered from the initial concussion, there is six times the likelihood that they will experience a second concussion, when allowed to return to an athletic contest where body contact is involved.
Symptoms of Concussion / Post-Concussion Syndrome
It is now recognized that the symptoms of concussion and their resolution is far more valuable in determining when an individual should return to sport or be placed at a risk of striking their head than the grading of concussion.
Most present day return to sport programs rely on symptoms rather than the grading of concussion. For research purposes, and for helping to determine an individual's margin of safety for suffering repeated concussions, the grading of the concussion is of value. This raises the new concept that each individual has a margin of safety for experiencing concussive blows to the head beyond which repeated blows to the head, even of a very minimal nature will immediately render the individual symptomatic. Even where repeated concussions are properly managed, and the individual has returned to their baseline function, there is still an additive effect over a lifetime. In individuals who have suffered serious, previous traumatic injuries to the brain, it has been generally noted that their margin of safety for suffering concussions is substantially reduced.
When one attempts to analyze the symptoms of concussion, it is evident that many of the symptoms are arising from dysfunction of the frontal lobes of the brain. Although the earlier attempts to understand brain function. tried to isolate areas of the brain responsible for a specific function, it is now recognized that this is a far more complex physiological system utilizing all parts of the brain simultaneously. Nevertheless, the personality changes and loss of emotional control as well as the impaired balance, reduced coordination skills and altered judgment are deemed primarily frontal lobe functions. These are the symptoms that are frequently identified in the individual who ahs suffered concussion.
The hypothesis offered for the involvement of frontal lobe vs. other areas of the brain is that the frontal lobes are the furthest distance from the brain stem and therefore suffer the greatest sheering effect when there are rotational and linear acceleration-deceleration forces to the brain. It can also be hypothesized that the greater distance from the brainstem to the frontal lobes requires a greater number of neuron synapses, thus a greater likelihood of synaptic disruption.
When one reviews the symptoms and signs of the post-concussion syndrome, it is realized that a number of the symptoms are the same as those of the symptoms of concussion. It is still not fully agreed as to when an individual is continuing to experience symptoms of concussion and when the diagnosis of post-concussion syndrome is established. Many clinical psychologists and physicians dealing with symptomatic concussed athletes believe that as long as the symptoms following concussion are improving in a gradual stepwise fashion, the diagnosis of concussion is correct. Once the individual is failing to improve, and in some cases, the symptoms are increasing, the diagnosis of post-concussion syndrome can be established.
Post-concussion syndrome symptoms and signs include persistent headache (especially with exertion), dizziness, vertigo, irritability, fatigue, inability to concentrate, impaired memory, visual disturbances, altered balance and coordination, altered judgment, inappropriate behaviour and denial of injury.
The belief that the symptoms of concussion will only improve and not increase in degree is no longer accepted. It is now well recognized that individuals can move into the severe stages of post-concussion syndrome that further causes emotional and mental dysfunction, leading to the post-traumatic stress disorder. It is incorrect to dismiss the diagnosis of concussion and post-concussion syndrome based on the fact that the symptomatology has increased. In many cases, individuals becoming increasingly disabled is a result of the condition not being recognized initially, and therefore not treated.
One of the problems which arises in establishing the diagnosis of concussion and post-concussion syndrome is the inability of the injured individual to express themselves as to their symptoms. Many symptoms of concussion are very vague and in a child, it can be extremely difficult to understand the difficulties that they are experiencing. Small children, following concussion, often complain of stomach upsets and abdominal discomfort. A child may experience abdominal cramps and vomiting and the treating physicians or parents mistakenly believe that the cause is a gastrointestinal upset and not the result of a concussion.
Treatment of Concussion, Ppst-Concussion Syndrome
The treatment for the symptoms of concussion is to place the brain at rest. Physical exertion increases the symptoms of concussion and the duration of concussion. It is also now recognized that mental stress will also increase and prolong the symptoms of concussion and lead to the post-concussion syndrome. This is extremely important when advising symptomatic individuals who are attempting to continue with their work or studies.
One of the most important aspects of treating concussion is that it should be recognized immediately that the individual has suffered a concussion and that treatment be instituted promptly. Although it is believed that with rest, which includes ample sleep, an individual should recover quickly, it has been discovered that many concussed individuals lose their normal sleep patterns and do not obtain the deep sleep required for brain recovery. Many individuals are repeatedly awakened and suffer unusual nightmares. Early recognition of sleep disturbance is very important. Aggressive treatment including strong medications for sleep and the utilization of meditation techniques to place the brain at rest have been effective.
Since it is now recognized that meditation is important for brain rest and rapid recovery from the effects of concussion, a recommendation for future athletes in contact sports would be training in meditation techniques prior to experiencing concussion. Often, a symptomatic individual following a concussion, finds their ability to learn meditation techniques is compromised.
The question of use of drugs and medication for the treatment of concussion is often raised. It is recommended that medication be used for disturbed sleep patterns in concussed individuals. Likewise, the use of analgesics and anti-inflammatories for headache and anti-nauseants for nausea and vomiting following concussion are acceptable. However, all medication which would mask the symptoms of concussion or post-concussion syndrome must be discontinued before the athlete or individual can be declared recovered and are cleared to return to the sports arena or their work or recreational activities which place them at risk for repeated concussions.
Obviously, one should discourage the use of alcohol or other drugs which effect brain function in an adverse fashion. On the other hand, in the severe cases of post-concussion syndrome, the psychiatrist and clinical neuropsychologists are advising and utilizing various medications to deal with the more severe problems of brain dysfunction, particularly severe mental depression.
Parents are encouraged to remain observant of their children during "unsupervised play" which might include sibling horseplay, neighbourhood skateboarding, etc. Many children suffer repetitive jarring or shaking of the brain during this type of activity.
Concussion Management in Athletes - Return to Sport
In the concussion management in sports, there are now handouts available that offer advice to the concussed athlete and their treating physicians. The most important point that Dr. Johnston and her group offer is that when an athlete, treating physician or trainer is in doubt regarding the individual, the athlete should be encouraged not to return to the contact sport until everyone is absolutely certain that they have recovered.
In the recovery from concussion, the athletes are to return to physical and mental activity in a steplike fashion. Of greater importance has been the identification that there should be a waiting period or a grace period between full contact training after medical clearance and return to full game or play. This is additional period is important in maintaining the margin of safety for repeated blows to the head. This grace period should be a time period equal in time to the period of time that was required for the athlete to be symptom-free, and remain symptom-free, after commencing a full contact training period.
Each progressive step for return to full game play may be taken as soon as the athlete or person does not experience symptoms as they increase the degree of physical and mental exertion. When an individual continues to suffer symptoms which are not resolving, or are increasing, it is very important for him/her to be seen promptly for assessment and counseling. This may require the help of the clinical Neuropsychologist as well as a specialized physiotherapy unit and in some cases, CT Scanning or MRI Scanning may be needed. Most physicians managing the post-concussion syndrome in individuals request a MRl Scan, not because it is anticipated that there will be an abnormality, but more to make certain that there is not a pre-existing unrecognized intracranial problem and also to establish a baseline to refer to in the case of future concussions or problems.
In some cases, an individual must be advised that they should no longer return to activities that place them at risk of repeated jarring and shaking of the head. Athletes are advised that they should not return to the sports arena when there is the presence of any permanent neurological deficits or symptoms, a history of repeated concussions over a short period, or a history of long duration for recovery. The presence of MRI, CT scan and/or functional MRl abnormalities needs to be considered in counseling on the wisdom of return to contact sports or high risk work or recreational activities.
Summary
The diagnosis and management of concussion and post-concussion syndrome is in constant evolution, based upon worldwide research in this field. The need for coaches, team managers, parents and treating physicians to be aware of the likelihood that an individual or child has suffered a concussion is most important. Upon recognition that a concussion has occurred, treatment and monitoring should be instituted immediately. When a child is recognized to have adverse reaction to shaking and jarring of the head in early childhood, the child should be encouraged to pursue non-contact sports and activities.
Research and monitoring of individuals who suffer repeated concussions will provide insight into the probability that they may have increased chances of developing Parkinson's Disease, early senile dementia and Alzheimer's Disease.
Your feedback is appreciated.