What is a Concussion?
A concussion is a traumatically-induced transient impairment of brain function. It is a subset of mild traumatic brain injury that is generally less severe on the brain injury spectrum. Existing research suggests that it is a metabolic or functional rather than anatomic or structural injury to the brain, and involves a complex pathophysiologic process. These are caused by trauma; usually when an athlete’s head contacts another object or comes to an abrupt halt (i.e. whiplash), causing the brain to rebound off of, or twist up against, the inside of the skull. These shearing forces, sometimes referred to as “brain slosh,” can damage blood vessels and neurons, leading to impaired neurological function and a variety of symptoms.
Symptoms of a Concussion
This is not a complete list of signs and symptoms. One or more of these symptoms alone do not necessarily mean one has a concussion. Symptoms may not manifest for 24-48 hours after an injury. A concussion should only be diagnosed by a licensed healthcare professional such as an athletic trainer or sports medicine doctor.
Athletes removed from participation should be monitored in case mental status starts to deteriorate. Home care should include continued monitoring of concussion signs and symptoms. Parents or roommates should refer to a list of symptoms that would indicate a deteriorating condition. These red flag symptoms include, but are not limited to:
- a decreasing or fluctuating level of consciousness
- repeated vomiting
- numbness or tingling in arms or legs
- increasing confusion
- slurred speech/difficulty speaking
- worsening headache
- unequal pupil size
- inability to recognize people or places
Common advice previously given to those caring for a concussed individual, such as frequent awakening, is no longer recommended. If loss of consciousness is a concern, the athlete should be imaged and observed in a hospital setting; otherwise, sleep should not be interrupted, as it is likely restorative. The production of melatonin (which occurs during sleep), as well as the consumption of omega-3 fatty acids and maintaining a good level of hydration can all aid in recovery.
Athletes with a concussion should avoid medications containing aspirin or non-steroidal anti-inflammatories (NSAIDs), which decrease platelet function and potentially increase intercranial bleeding, and mask the severity and duration of symptoms.
IT’S OKAY TO:
use acetaminophine (Tylenol) for headache relief
use ice on head or neck for comfort
eat a carbohydrate-rich diet
go to sleep (unless otherwise indicated by a healthcare professional)
rest (no strenuous activity/sports)
NO NEED TO:
check eyes with a flashlight
wake up frequently (unless otherwise instructed)
stay in bed
drive a car/operate machinery
engage in physical activity that make symptoms worse
engage in mental activity that make symptoms worse
Treatment & Recovery
Initial treatment typically involves prescribed physical and cognitive rest. There is some emerging evidence that active, targeting approaches may be more effective for certain patients, especially if they fit into a concussion clinical profile (vestibular, oculomotor, cognitive, etc). In 90+% of the population, symptoms resolve in 7-10 days.
Return to Learn
Athletic trainers are working to standarize guidelines for a “return-to-learn” program. If the athlete develops increased symptoms with cognitive stress, student-athletes may require academic accommodations such as reduced workload, extended test-taking time, or days off/shortened school day. If computer use exacerbates symptoms, sometimes printing things off is better than staring at a computer screen for extended periods of time. Light stimulates the brain, so this and other stimuli (sound, school, certain environments) can make symptoms worse. Some athletes have persistent neurocognitive deficits following concussion, despite being symptom-free. Consideration should be made to withhold an athlete from contact sports if they have not returned to their “academic baseline” following their concussion. Although concussions are no longer graded, the severity of a concussion is based on the nature, burden and duration of symptoms, the frequency and past history of concussions, and the presence of prolonged symptoms. A concussion with symptoms not resolving after 2-3 weeks should be referred to a concussion specialist.
Return to Play
Return to play after a concussion should not begin until the athlete is completely symptom-free and back at school full-time. It should be individualized, gradual and progressive, and should consider factors that may affect individual risk and outcome. If exertional tests (biking, jogging) do not provoke symptoms, the athlete can then participate in sport-specific skills that allow return to practice, but should remain out of any activities that put him or her at risk for recurrent head injury. Returning to sports before a brain injury has completely healed can put an athlete at risk of Second Impact Syndrome (SIS). The incremental return to activity should be gradual and medically supervised, in order to include a step-wise increase in physical demands, sport-specific activities and physical contact. The athlete should be monitored periodically throughout and after these sessions to determine if any symptoms develop or increase in intensity. Before returning to full contact participation, the athlete is usually reassessed using a neuropsychological test - at Byron Center we use Sway Medical to aid in our decision-making. If all scores have returned to baseline or better, return to full participation can be considered after further clinical evaluation.
Byron Center Return-to-Play Protocol
1. No activity, complete rest – once symptoms diminish, progress to step 2.
2. Light aerobic exercise (walking, stationary cycling) in a single plane
3. Sport-specific training drills including multiple planes of motion
4. Non-contact training drills – must pass Sway Test before progressing to step 5
5. Full-contact training drills – clearance by physician required before step 6.
6. Game play
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NATA Concussion Webpage
NATA Position Statement: Management of Sport-Related Concussion
NATA Concussion Infographic
AMSSM Position Statement: Concussion in Sport
ACSM: Sport-Related Concussions
ACSM: Consensus Statement: Concussion (Mild Traumatic Brain Injury)
NCAA: Concussion Diagnosis and Management Best Practices
Sport Science Institute: Diagnosis and Management of Sport-Related Concussion Best Practices
MHSAA Concussion Protocol
Center for Physical Rehabilitation Concussion Info Page