Concussion

By Michael Yorio, MD

Concussion Management

A concussion is a traumatic brain injury that alters the way your brain functions. Most occur from a blow to the head. Concussions can also occur from whipping the head and having the upper body violently shaken. There are several sports in which concussions are common, which include, but are not limited to, football, soccer, hockey, basketball, and boxing. “For an athlete suffering from a concussion, it is important to seek the assistance of an appropriate health care provider who is knowledgeable with the management of concussions and their return to sport.”, states Dr. Michael Yorio, the Jacksonville Jaguars Internal Medicine Physician and Internal Medicine/Sports Medicine Physician at the Jacksonville Orthopaedic Institute in Jacksonville, Florida.

Click here physiology of a concussion to read more on the physiology of a concussion.

The American Medical Society for Sports Medicine defines a concussion as a traumatically induced transient disturbance of brain function. In other words, an impact on the head or body that negatively affects normal brain function that will eventually improve over time.

Symptoms

Symptoms can include but are not limited to:

• headaches and problems with concentration
• decreased balance and coordination
• dizziness
• nausea
• vomiting
• fatigue
• sensitivity to light
• hindered sleeping patterns
• loss of memory

Should any of these symptoms be present, a concussion may be possible. If you suspect a concussion, immediately seek the medical attention of a physician or medical professional.

How do you tell if you or your loved one has Signs of a Concussion?

Not every head impact causes a concussion, and not all concussions are the same. So how do you know if you or your child may have sustained a concussion? There are three important things to do if you suspect you or your child may have one:

1. Remove from activity and rest – this is a very important first step. If a concussion is present, removing from play helps protect the individual from an additional and potentially more severe injury and it starts the recovery process.

2. Talk and observe – talk to your child and ask them if they have any concussion symptoms, and while you are talking to them assess if they seem like themselves or seem a bit off. If you are the one sustaining the injury, talk to someone, and see if you have any symptoms consistent with a concussion while talking and thinking.

3. When in Doubt, Sit Them Out – many times an athlete will say they are fine, but they seem off or their actions show otherwise. Don’t try to make the determination about the presence of a concussion yourself; let an appropriate health care provider decide whether or not a concussion is present. As noted in the Heads Up program through the Centers for Disease Control and Prevention (CDC.gov), “It’s better to miss one game than the entire season”.

Causes of Concussions

Concussions are caused when the brain comes in contact with the skull either from direct contact or rapid movement such as whiplash. This contact of the brain and skull can result in bruising and inflammation of the brain. This inflammation is the cause of the concussion symptoms such as, dizziness, disorientation, headache, nausea, fatigue, and vomiting, among others.

The most common causes of a concussion are related to impact associated with contact sports such as football, baseball, soccer and hockey.  Other causes are related to motor vehicle accidents and other trauma.

Risk Factors

There are many variables to sustaining a concussion. However, some factors may put an individual at an increased risk for one to occur. The highest risk factor for one to occur is history of a previous concussion. In addition to a history of a concussion, other risk factors may include:

• High-risk activity
• High level contact or collision
• Motor vehicle accident
• Falling
• Physical abuse
• Head injury
• Contact sports
• Alcohol consumption
• Exercising in hot weather and becoming dehydrated
• Read how to prepare for exercise in hot weather
• If you have a child in sports and would like to read more about concussions

Possible Complications

Similar to other types of injuries, the best predictor of subsequent concussion is a history of at least one concussion. Among collegiate football players, patients who self-reported 3 or more concussions were 3.5 times more likely to sustain a subsequent injury than players with no concussion history, whereas those with 2 concussions were 2.8 times more likely. An increased risk for subsequent concussions in high school athletes with a history of concussion has also been reported.

In a prospective investigation, football players with a concussion history were nearly 3 times more likely to sustain another injury, whereas non-football players were 1.2 times more likely. Therefore, current recommendations suggest that modifying factors including repeated concussions over time, multiple concussions within a short time frame, sustaining concussions with lessening force, or increasing severity of injury, should result in a more conservative management approach. Proper management will reduce the risk of a repeat injury.

Second-Impact Syndrome

A primary concern of returning to play too soon by pediatric athletes is second-impact syndrome, or malignant cerebral edema, which occurs after a second impact while the patient is still symptomatic from a previous injury to the head or body. The condition is characterized by diffuse cerebral swelling with catastrophic deterioration. Many athletes that suffer from second-impact syndrome never recover to full health.

*Information adopted from National Athletic Trainers’ Association Position Statement: Management of Sport Concussion.

Concussion Testing and Diagnosis

Numerous testing methods are available for concussion management. When testing an athlete that has a suspected concussion, it is important to follow specific test and procedures for management. All assessments should be conducted by licensed health care professionals who are comfortable treating concussions. Many state laws have been passed to regulate concussions. Seek out the latest positions from the state legislator to ensure the actions are within state law. Some examples of concussion testing may include:

• Self-Report Symptom Assessment: used to collect subjective symptom information from the athlete using a variety of complex scales and checklist.
• Motor Control: used to assess gait, postural control and abnormal limb movement. These tests are perhaps the most common concussion assessment tool.
• Mental-Status Testing: These tests consist of assessing the mental status of an athlete by asking questions of orientation about time, location, and other personal questions like “what is your birthday?”
• Neurocognitive Testing: These tests include information processing, planning, memory, and reaction time.
• Read more about computer testing and the return to play protocol for concussions

Concussion Treatment at JOI

Treatment of concussions consists of time and rest for symptoms to reside and supervised return to activity. The first stage of return to play begins with no activity while symptoms subside. Once symptoms have not been present for greater than 24 hours, stage 2 consists of light aerobic exercises at 70% maximum, such as walking, swimming, or riding a stationary bike. The next one will begin stage 3, consisting of sport-specific balance and coordination based non-contact exercises. Stage 4 consists of strength training through resistance exercises and non-contact complex agility, balance, and coordination drills that cognitively load the individual. In stage 5, the individual begins returning to full-contact practice to restore confidence and simulate game situations. After completion of stages 1-5, a physician may be cleared for return to competition should they feel they are ready.

How Long Does a Concussion Last?

A concussion can take a short period of time or many months to fully recover. Once diagnosed with a concussion, the individual is better when they are better. There are some findings upon diagnosis that may identify individuals at risk for a prolonged recovery from a concussion. “For an athlete suffering from a concussion, it is important to seek the assistance of an appropriate health care provider who is knowledgeable with the management of concussions and their return to sport”, states Dr. Michael Yorio, the Jacksonville Jaguars Internal Medicine Physician and Internal Medicine/Sports Medicine Physician at the Jacksonville Orthopaedic Institute in Jacksonville, Florida.

What are some resources or guidelines to educate parents about Concussions?

A helpful resource for patients, parents, coaches and health care professionals is the Centers for Disease Control and Prevention website section under concussions (www.cdc.gov). In one site there are educational materials, printable posters and information for those interested in gaining a basic understanding of mild traumatic brain injuries and warning signs of what to look for in an athlete or child with a concussion. There is also a free concussion training program for health care professionals and coaches to improve identification of concussions and creating safer environments for kids. Another resource would be the NCAA Sports Science Institute, which includes a number of the latest data and recommendations regarding concussions. It can be found on the NCAA website (www.NCAA.org) under Health and Safety.

What kind of concussion lifestyle changes to expect vary case by case. After sustaining a concussion, rest and hydration are two of the most important factors affecting the recovery of brain function. Modification of your activity level and cognitive function until full recovery can help reduce the risk of prolonging symptoms. Re-hydration after the injury is also important. Six to eight glasses of fluids per day is a recommendation for hydration.

Dr. Yorio of JOI has a Concussion Clinic and a return to the sports program.  For physical therapy after a concussion with JOI Rehab, please call 904-858-7045.

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By: Jon Stiffler, PTA