Concussions
WHAT YOU NEED TO KNOW ABOUT CONCUSSIONS
Johnny is a junior student athlete who plays football at a
local high school. Early in the season
while tackling an opposing player, the two hit helmets in a violent
fashion. Suddenly, Johnny saw “stars”
and staggered to the sideline. The
awaiting medical staff assessed his neurological status by asking him questions
about what day it was, what the score was, who were they playing and who the president
was. He failed them all. His bell had been officially rung. However, he quickly cleared the clouds in his
head and within 15 minutes was completely normal again. Wisely, the athletic trainer took his helmet
and held him out of play for the rest of the game.
Throughout the week he continued to have persistent
headaches, which he thought nothing of so he did not mention it to his parents,
coach or trainer. That next Friday he
was involved in another tackle which was relatively minor in character. However, this time Johnny didn’t get up. After several minutes the medical staff was
able to revive him and get him to the side line. He recovered, but subsequent follow up shows
that he has short term and long term memory loss, has difficulty paying
attention in class, and not surprisingly, has difficulty maintaining his honor
roll status. His life has changed
forever.
Concussions in High School Sports
Traumatic head injuries occur commonly in sports. A whole spectrum of severity can occur with the most common condition being a concussion. A concussion occurs when the soft brain tissue, which is encased in a cushion of fluid inside the hard bony cranium, becomes injured from an external force. Certain areas are injured and become temporarily dysfunctional. Loss of consciousness occurs when there is injury to the reticular activating system, a portion which governs consciousness. Amnesia occurs when the memory center is traumatized. Other symptoms associated with concussions include confusion, disorientation, dizziness, headache, nausea, vomiting, inability to focus, visual disturbances and disequilibrium. Rotational and acceleration forces on respective vital brain structures results in some or all of these symptoms.
Concussions most commonly occur in collision sports such as football, hockey and lacrosse, but also can be seen in any of the other high school sports. Over 300,000 concussions are reported in high school sports per year. It is estimated that per year 1 in 10 football players will experience a concussion. Certain student athletes appear to be at risk: females, younger athletes, and those with developmental deficiencies. Those who have had a prior concussion are at increased risk. It is important to note that each subsequent concussion lowers the threshold for further concussions.
Second Impact Syndrome
When a concussion occurs the metabolic needs of the brain tissue increase. Neurochemical processes occur which necessitate increased need for nutrients. Paradoxically, at the same time, the blood supply to the brain is diminished due to spasm of the blood vessels. This discrepancy between supply and demand can occur for up to a week after the injury. Because of this the athlete is susceptible during this time. If he sustains another hit during this window, the discrepancy magnifies and can result in swelling which can increase pressure within the enclosed rigid cranial vault. Herniation of the brain stem may occur resulting in severe neurologic injury and possible death. This dreaded phenomenon is referred to as “Second Impact Syndrome”. Short of this devastating event, permanent cognitive deficits can occur which may inhibit performance in school, work or activities of daily living. In an attempt to avoid these aftereffects, medical professionals have developed various diagnostic and management strategies to manage these head injuries.
Various medical organizations, nationally and internationally, have addressed the issue of concussion in sports by developing evaluation tools to give medical professionals who deal with athletes the appropriate guidelines to assess their patients. These include classifications of concussion based on their severity. For instance, in a Grade I concussion a “Bell Ring” is when an athlete is temporarily disoriented or exhibits dizziness after a traumatic head injury. A grade II concussion involves amnesia and a Grade III concussion is characterized by loss of consciousness. Grading the concussion establishes parameters for treatment. Historically, an athlete with Grade I concussion was allowed to return to play after 15-20 minutes of clearing his symptoms. With a Grade II injury the athlete is removed from play and may be out a week or so. Grade III concussions are kept out of action for up to a month. Although helpful, these schemes are not without fault and research has continued to find a better method to prevent further injury to the brain.
Research Findings
Neuropsychologists at the University of Pittsburg have researched these first and second impact injuries closely providing many helpful findings. First, they have found that the physiologic changes mentioned above can be present for up to a week, thereby leaving the athlete susceptible during that time period. Also, they have shown that the most critical symptom with respect to severity is not loss of consciousness as one would suspect, but amnesia or temporary memory loss. Amnesia correlates with more severe and persistent symptoms. Interestingly, the loss of consciousness did not correlate as much with more severe symptoms. This recent evidence has caused neurophysiologists to reconsider our evaluation and management schemes.
ImPACT
Their basic rule is that the athlete should not return to play until their symptoms completely resolve. These symptoms include overt symptoms as discussed above and neurological signs picked up on an exam, but also more subtle neurophysiological symptoms which may be only picked up in specific testing. Therefore, they developed a neurophysiological test that is given to the athlete before the season to develop a “baseline”. This test involves such things as remembering numbers in sequence, recreating geometric patterns from memory and the like. Typically, after a concussion these skills take a bit longer to resolve than the overt and neurological symptoms and are harder to evaluate. Therefore, the test, called ImPACT, is a tool used to clarify whether the athlete has returned to his “baseline”. He therefore cannot return to play until this milestone is achieved. This test has been validated and is widely felt to be more helpful than prior schemes.
To that end, ImPACT, has been implemented in numerous venues including the NFL, NHL and in many colleges and high schools. As Medical Director of the Athletic Trainers in Jefferson County, I have asked two local neurophysiologists, Steven Schmitz and John Kirk to implement this for eighteen of the high schools in Jefferson County. Currently, all schools have implemented this program to varying degrees and has been termed the “Sports Concussion Management Program” by our neurophysiologist friends. The program has been funded by Panorama Orthopedics and St. Anthony Hospital Trauma and Head Injury Foundations. There has been enthusiastic response to this program by the parents of the athletes, especially after the unfortunate death of a Grandview High School freshman from a head injury sustained while playing football.
Sports at a high school level offers many positive rewards for student athletes, but unfortunately injury can occur. Head injuries represent one of the more worrisome injuries that spark fear in the minds of family members who may be watching a particular event. By consistent reevaluation of how we are treating these injuries, we can move forward and manage them in a more thoughtful and helpful way.
