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Keys to protecting athletes from concussions

Concussions are dangerous, and finally garnering due media attention unfortunately for the wrong reasons. Proper protocols are still a mystery for most youth and high school sports teams. At least five high school athletes died from complications from concussions last year, and who can forget the Ohio State football player who took his own life after complaining of concussions. The real scary news is that most concussions are never reported, despite more than 3 million being recorded every year by the Center for Disease Control. Here are the keys to preventing, detecting and protecting athletes from concussion.


Do

Do know the risks, symptoms and baseline scores prior to the season

The concussion protocol begins prior to the season, giving the team the ability to recognize the risks and symptoms of concussions.

All 50 states now mandate a certain amount of concussion education at various levels. However, it is not monitored closely, and some teams get away with having a simple one-page disclosure signed by the parents. While that’s progress, it’s far from where we need to be. Every athlete, coach and parent should watch a video training or read a concussion book or article, and verify they understand the material.

The most important factor about signs and symptoms of concussions to know is that they may not materialize until several minutes, hours or days after the injury occurs. A concussion may occur from any of the following:

  1. Head to head contact
  2. Head to ground contact
  3. Head to body contact

Non-head contact due to a sudden change in direction, like a Whiplash

Here are symptoms to look for:

  • Loss of Consciousness -- This is the most obvious, and scariest, sign of a concussion.
  • Confusion -- The most common symptom is temporary confusion, often associated with a “dazed” look or vacant stare. A confused, concussed individual probably won’t talk much. If the individual does talk, the words may be jumbled, rapid, or generally non-sensical and irrelevant.
  • Amnesia -- Amnesia is temporary memory loss that can be divided into two types:
  • Retrograde Amnesia: Forgetting things that happened before the incident.
  • Anterograde Amnesia: Inability to remember facts after the concussion.
  • Disorientation -- A concussion can affect your ability to know where you are, what day it is, and what you were doing at the time of the injury.
  • Delayed Verbal/Motor Response -- Slow, slurred or incoherent speech as well as inability to move or walk normally can be associated with concussion.
  • Inability to Focus -- A concussion may be evident if you have trouble paying attention, focusing on the conversation or game situation.
  • Headache -- When due to concussion, headaches are very similar to migraine and may be accompanied by nausea, vomiting, and sensory sensitivity.
  • Disequilibrium -- Experiencing a problem with balance, and feelings of dizziness.
  • Visual Disturbances - Your vision may become blurred, doubled or overly sensitive to light.
  • Nausea/Vomiting -- May occur in the absence of headache.
  • Emotional Lability (mood swings) -- When hits occur to the sides of the head, or temporal lobes, you may notice anger outbursts, inappropriate laughing, extreme sadness or overt stubbornness not typical of the individual.
  • Sleep Disruption -- Excessive drowsiness or inability to sleep are usually delayed symptoms of a concussion presumably due to disruption of the sleep pathways rising up through the brainstem, and imbalance of the neurotransmitters.

Next -- and this is extremely important -- every player should take a “baseline” test measuring cognitive, emotional and balance scores. Taking this test assumes there is no concussion currently present, so the scores give a good measuring stick for later in the season if and when the player needs a check-up from the neck-up. By re-taking the baseline test, variances in the scores may appear and help the medical professional determine the level of risk and severity of the concussion.

Do use a sideline assessment aid, and get players’ medical contacts

Going into the practice and game season, every team should do at least three things:

  1. Nominate a “concussion coordinator” to implement and oversee concussion management activities. This may be an athletic trainer or volunteer parent or coach. On the professional level, the teams use neurologists, but I’m assuming that’s not going to be a possibility on lower levels.
  2. Identify a sideline assessment tool the concussion coordinator can use to apply on an athlete suspected of having a concussion. The tool should include both cognitive and balance measures, and ideally be able to pull up baseline test scores for comparison.
  3. Should a concussion be suspected, the player’s parents and medical team should be immediately contacted. Therefore, collect all appropriate contact information.

Should you suspect a player has a concussion, here are general guidelines:

Better to wait, than be sorry.
A loss of consciousness may be the most obvious symptom, but also not the most likely to occur. Only one in ten concussions result in a loss of consciousness. Therefore, onlookers have to be highly tuned into possible signs of a concussion. Symptoms can vary depending on the individual and where the brain suffers trauma. But generally, be aware of a glazed-over look in the eyes and perhaps signs of confusion within a few seconds.

If there is any hint of this, ask the athlete if they can stand and walk/skate to the sideline unassisted. Now, the waiting game begins. Give it at least two minutes before conducting any concussion assessments. Record and report the results and wait again. Don’t let the athlete, or coach, try to talk themselves back into action.

Wait some more.
The least popular decision is to wait, perhaps another 30 minutes and conduct another concussion assessment. During this period of time, the brain is rapidly trying to heal itself, flooding blood and oxygen to the injury. Other functions may be compromised. Decision-making could be influenced. And further injury to the brain is the enemy, not the opponent on the field. Sometimes, concussion symptoms show up the next day. So, even if the athlete passes the sideline assessment, unless a trained medical professional has determined that there was no concussion, just the suspicion that a concussion may have occurred warrants that the player must sit out for the rest of the day.

Do pull the athlete out of the game

If an athlete exhibits any typical symptoms, a general rule is when in doubt, pull them out. The worst thing that can happen is rushing the sideline assessment, returning the player to the game, and suffering a second concussion before the first one heals. That’s called Second Impact Syndrome and it has a scary 50% fatality rate.

So, pull the athlete aside for a play or two and allow the symptoms to materialize. Follow the guidelines in “Do, No. 2.” If a concussion is suspected, it’s time to kick-in the recovery protocol.

A recovery protocol begins with rest, minimizing mental and physical stimulation until the athlete is symptom free. The concept is “relative rest,” meaning the avoidance of any mental or physical activity that provokes the the athlete’s concussion-related symptoms.

Notice how careful you should be when treating a hard hit? A decision to allow a player to return to the game too soon has too many risks. Give it time. Give it rest. Follow a recovery protocol, monitor symptoms and then decide when to return.

While there is no standard recovery time from a concussion, guidelines from the American Academy of Neurology and endorsed by the NFL Players Association, find that athletes are at greatest risk of repeat injury in the first 10 days post-concussion. And research suggests that the more head injuries a person suffers, the more likely they are to suffer from chronic traumatic encephalopathy (CTE) and face complications later in life.

Do gain consensus to promote brain health over wins, losses

It takes a “team effort” to apply a quality concussion management protocol. Everyone needs to buy-in to the value of having a future, versus the short-term satisfaction of winning a game. A major culture shift needs to occur led by the athletic training staff while also involving the athlete, parents, coach, medical professionals, referees, even league officials.

Most times, the athlete tries to shake it off so that they avoid the sideline. Even if they do signal for a substitute, the myriad of modalities, opinions and toughness sports culture complicate the concussion decision making.

Since, most symptoms of concussions take several minutes, hours even days to materialize, we all need to be quick to push the “pause” button instead of pressing “send” and returning the athlete back on the field too soon.

Every athlete’s brain has a different threshold or margin for absorbing hits. For example, every athlete’s level of brain health varies based on a number of factors. These include: heredity and genetic factors, gender differences, prenatal health, history of prior brain trauma, nutrition, exercise, sleep, toxicity from alcohol and use and abuse, tobacco smoking, and presence of environmental toxins from drinking water, air they breathe, and chemicals from foods.

So, it’s wise to implement preseason education and baseline testing, having a quality sideline assessment ready and recovery protocol that tracks the athlete’s progress.


Don't

Do not move the unconscious person

In the event of loss of consciousness, don’t attempt to move the unresponsive individual and risk exacerbating the problem of a neck and spinal cord injury. During a loss of consciousness, the brain and body are experiencing a forced reboot, but the person’s pulse and breathing should continue. Should the individual stay unconscious for longer than a minute, call for help.

Do not let the player decide if they’re capable of returning to the game or practice

The best person to decide is not the one who has just experienced brain damage. Seems obvious, yet many times the coach will just ask if the player feels Ok to play.

However, if the player and coach both received pre-season training on the risks of concussion, they would realize the value of pulling the player out is worth more than risking life-long cognitive and emotional impairment.

Do not try to keep the concussed individual awake

Sleep is the best thing a concussed individual can do. After a concussion occurs, the brain is grappling to heal itself, repairing the neural signaling. During sleep, the brain has the best chance to do its work with the lowest risk of misfiring.

A recovery protocol begins with rest, minimizing mental and physical stimulation until the athlete is symptom free. The concept is “relative rest,” meaning the avoidance of any mental or physical activity that provokes the the athlete’s concussion-related symptoms.

Many times, an athlete can recover from a concussion in 7-10 days if they have not exacerbated the recovery process.

Do not rely on a well-fitted helmet to protect from concussions

There’s no such thing as a concussion-proof helmet. Despite being encased within the stone-like skull, the brain can be easily affected from outside trauma. It’s soft texture is impressionable. So when the brain bounces inside the skull, it doesn’t immediately spring back into shape.

The helmet can prevent injury to the skull, but not the brain. The brain floats unattached inside the skull in fluid. A “whiplash” effect can result in concussion even while wearing a helmet and when no contact is sustained.

However, the use of “impact sensors” that track and measure the velocity of hits sustained is a good thing to have. Over time, the team can track the number of hits any player has had, and determine a greater risk level. Soon, I hope science will discover the amount of force an individual can sustain without suffering from concussion injury.


Summary
Jumping cartoon

Concussions don’t have to be so mysterious. With proactive pre-season and in-season protocols, sports can be enjoyed with a much lower risk players having long-term brain damage. A cultural shift needs to occur, that places greater value on the individual’s development than on wins and losses.


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Harry Kerasidis, M.D.Founder, Medical Director

Harry Kerasidis, M.D. is one of only a few neurologists in the world specializing in the impairment of cognitive and emotional performance resulting from concussions. After 25 years treating hundreds of concussions, Dr. Kerasidis noticed existin...

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