Any person who pays attention to the sports or the news has likely heard the current media scrutiny of concussions in all sports, from the professional to the youth level. With the increased attention being given to concussions right now, Athletic Trainers are finding greater amounts of misinformation making it to the masses. This article will address concussions and how they will be managed by the Athletico Athletic Training staff at Oakville High School.
A concussion is an injury to the brain that is caused by a blow to the head or body which causes the brain to be violently rocked back and forth or twisted inside of the skull. The resulting injury causes the brain to function abnormally. We typically see concussions in contact sports such as football or wrestling, however, concussions can occur in all sports, including (but not limited to) soccer, basketball, and cheerleading. Anytime there is a significant impact to the athlete’s head or body, there is a potential for a concussion to occur.
When an athlete has a concussion, we often note problems with concentration, memory, and focusing. They often feel fatigued, have a headache, or feel nausea, and they may be sensitive to bright lights and loud noises. Sometimes, they may feel more irritable or experience emotional changes.
The majority of concussions get better quickly, most often within 2 weeks. In rare occasions, it may take weeks or months for the full resolution of a concussion.
Athletico and Oakville High School have established a protocol to handle every concussion and their subsequent return-to-play. This protocol meets or exceeds all of the requirements set forth by the Missouri State High School Activities Association and the Missouri Legislature in regards to the appropriate management of concussions.
When an athlete suffers a suspected concussion, the Certified Athletic Trainer (ATC) will be called upon to evaluate the athlete. In the State of Missouri, there are a select few professionals who have received approval to manage and determine return-to-play status due to the complexity of concussions. These include Certified Athletic Trainers (ATC), Physicians (MD or DO), Physician’s Assistants (PA-C), Nurse Practitioners (ARNP), and Neuropsychologists. Further, the healthcare professional who manages and determines return-to-play for a concussed athlete must be trained in the evaluation and management of concussions in accordance with state law. Chiropractors and ER physicians are not permitted to manage concussion care and determine return-to-play status. The athlete will be initially evaluated by the Athletic Trainer using a version of the Standardized Concussion Assessment Tool (SCAT), an organized collection of tests that has been recognized as one of the best options for the evaluation of a possibly concussed athlete. The SCAT tests things such as present symptoms, memory, concentration, and balance to determine the presence of a concussion. It also screens for more serious brain injuries through a thorough neurological exam. If the athlete is found to have a concussion they are immediately removed from activity and will not be permitted to return to sports until they have completed the return-to-play process. The Athletic Trainer will make every attempt to contact the athletes parents or guardians to inform them of the injury. The athletic trainer will also notify the athlete’s coaches and the school nurse.
In the days following a concussion, the athlete will be required to check-in daily with the Athletic Trainer, at which time they will be asked to score their current symptoms. As long as the athlete reports any symptoms associated with a concussion, they will not be permitted to progress to the next phase of the return-to-play protocol. In select circumstances, such as severe or persistent symptoms, the Athletic Trainer may choose to refer the athlete for further assessment with a physician who specializes in concussion management; in these cases, the Athletic Trainer will communicate with the athlete’s parents and help to get the athlete scheduled with an appropriate physician.
When the athlete becomes symptom free, they will begin a graded return-to-play process under the supervision of the Athletic Trainer. There are 5 phases of this process:
-Phase 1: Light aerobic exercise (walking, stationary cycling; no resistance training permitted)
-Phase 2: Sports-specific exercise (running-type drills; no resistance training, no contact
-Phase 3: Non-contact training drills (passing drills, resistance training)
-Phase 4: Full contact practice (cannot use game-time in place of this phase)
-Phase 5: Return-to-Competition
Through each phase, the athlete is monitored for the return of any concussion symptoms. The athlete must remain symptom free during the activity and for the 24 hours following the activity. If any symptoms occur at any point, the activity is stopped; the athlete’s symptoms will be monitored and they will be allowed to begin from the most recent phase once they have been symptom free for a 24 hour period.
No Oakville High School athlete will be permitted to begin athletic activities under any circumstance until they are symptom free and have completed the graded return-to-play process outlined above. In cases where the athlete has been seen by his or her personal physician and received approval to begin practice activities, the athlete will still need to complete all steps of the return-to-play process outlined above in accordance with state law, MSHSAA rules, and Athletico policy. Regardless of approval status from a personal physician, the athlete will not be allowed to begin the return-to-play process if they have been diagnosed with a concussion and they remain symptomatic.
What should I do if I think my child has a concussion?
If an athlete is suspected of having a concussion, he or she should be immediately removed from activity; continuing to play sports or work out can make symptoms worse, lengthening recovery time, and can even increase the risk of serious further injury and death. Call your Athletic Trainer immediately. If serious symptoms, such as vomiting, severe headache, or difficulty answering simple questions or staying awake are noted and the Athletic Trainer is not available to evaluate the athlete, he or she should be evaluated in the Emergency Room.
Should my child be seen in the ER if they have a concussion?
Not necessarily. If the athlete has been evaluated by the Athletic Trainer or Team Physician, it may be determined that it is safe for the athlete to go home. If the athlete is sent home, he or she should be monitored carefully by a responsible adult for unusual signs and symptoms for at least 24 hours. If your child has a concussion, the Athletic Trainer will call you and provide written instructions for the care of the athlete at home; these will include warning signs of a potentially more serious injury. It is important to realize that a concussion is a type of traumatic brain injury that involves more obvious functional problems rather than structural changes; as a result, concussions are invisible to standard medical imaging such as CT (CAT) scans and MRIs that may be performed in the ER. Further, MSHSAA rules dictate that an Emergency Room physician cannot clear an athlete for return-to-play from a concussion. Therefore, except in instances where concern for a more serious type of head injury is present, taking an athlete to the ER may lead to unnecessary use of time and expense.
What is the best treatment for a concussion?
Rest, but not just any kind of rest — Brain Rest. Unfortunately, the only way for a concussion to heal is to reduce the load placed upon the brain. This means that the athlete should be allowed to rest as much as needed. Exposure to loud noises, bright lights, computers, televisions, video games, and phones (even text messaging) can tax the brain too much and cause increases in symptoms. The athlete should reduce exposure to these types of stimuli after a concussion. They can be slowly added back as symptoms improve, but if symptoms return or worsen, they should be limited again. In some instances, the athlete may have to receive academic accommodations based upon the severity of their symptoms; these will be ordered after assessment by a physician specializing in the care of concussions.
What are the dangers of allowing my child to return-to-play before a concussion is completely healed?
There are significant dangers in allowing an athlete who has sustained a concussion to return-to-play prior to the concussion having healed. A concussed athlete is more likely to sustain a second concussion. This concussion is almost always worse than the first and may be season or career ending for an athlete. Another concern is Second Impact Syndrome, a condition in which a second impact to the head occurs prior to the full healing of an initial concussion. This secondary impact does not have to be as violent as the initial concussion causing impact to result in Second Impact Syndrome. The result of this second impact is a rapid, massive swelling of the brain. In cases of Second Impact Syndrome, these changes in the brain occur so rapidly that they almost always result in the death of the athlete, sometimes in as little as two to five minutes.
I keep hearing on the news that concussions are causing long-term brain damage in professional football players. Is this a risk for my high school aged child?
The media has recently given great attention to “Chronic Traumatic Encephalopathy” (CTE) in former professional football players. There is still very little known about this phenomenon. At this time, the long-term effects of concussions or the additive effects of “sub-concussive” impacts is unknown, though there is research currently being performed in this field. These “unknowns” are just another reason we take concussions and their care very seriously at Oakville High School and Athletico.
Do new football helmets or protective pads for the head help to prevent concussions?
The market is currently being flooded with products for athletes that claim to reduce the likelihood of sustaining a concussion, from new football helmet designs, to specially padded headbands for soccer players, and even padded baseball caps. It is important to realize that no helmet or padded device will eliminate the chances of an athlete sustaining a concussion. The new football helmets on the market have gone through substantial changes in the last 10 years in an effort to better protect the athletes that wear them. Though some of these design changes may better protect against certain concussion causing impacts, there is always a chance that a concussion can occur regardless of the helmet used. Every football helmet used must meet the same standards set forth by the National Operating Committee on Standards for Athletic Equipment (NOCSAE) meaning there is limited difference between the protective value of one helmet over the other. In fact, NOCSAE recognizes the dangers of football and the limited protection that a football helmet truly offers and requires that every helmet have the following warning attached:
HELMET WARNING STATEMENT:
NO HELMET CAN PREVENT SERIOUS HEAD OR NECK INJURIES A PLAYER MIGHT RECEIVE WHILE PARTICIPATING IN FOOTBALL
Do not use this helmet to butt, ram or spear an opposing player. This is in violation of the football rules and such use can result in severe head or neck injuries, paralysis or death to you and possible injury to your opponent. Contact in football may result in CONCUSSION-BRAIN INJURY which no helmet can prevent. Symptoms include: loss of consciousness or memory, dizziness, headache, nausea or confusion. If you have symptoms, immediately stop playing and report them to your coach, trainer and parents. Do not return to a game or practice until all symptoms are gone and you have received medical clearance. Ignoring this warning may lead to another and more serious or fatal brain injury.
Every football helmet must be reconditioned and re-certified by a professional reconditioner at least every two years. At OHS, the football equipment, both helmets and shoulder pads, are reconditioned and re-certified every year, exceeding this recommendation.
For more information on this topic, please visit: http://www.mshsaa.org/
One final note for parents regarding some of the other commercially available products which claim to reduce likelihood of a concussion is this: any product not approved and provided by the equipment manufacturer that is added on to a piece of safety equipment, such as stick in pads for helmets, will void the manufacturer’s warranty for that piece of safety equipment. Keep this in mind if planning to purchase such products.
What are some other resources if I want to learn more about concussions?
Every parent is asked to review the information provided by the MSHSAA in regards to concussions and return-to-play rules in Missouri. In fact, as a parent, this is one of the things that you acknowledge by signing the pre-participation paperwork. The link to this information is below:
You may also find this document from the National Federation of High Schools informative:
As always, any athlete or parent with questions about concussions or any other sports medicine topic should feel free to contact me.
Athletes, parents, and fans can follow OHS Athletics on twitter: @OHS_Tigers; Athletico Physical Therapy: @Athletico; and myself: @TrainerMike_ATC.
Bey T; Ostick B. Second Impact Syndrome. West J Emerg Med. Feb 2009; 10(1): 6–10.