Thankfully, there is increased awareness and knowledge about concussions these days. With that increased awareness also comes a lot more questions, and so I thought it would be good time to send out a Concussion Awareness Eblast.
A concussion is a brain injury. The brain gets injured by changing directions rapidly within skull, and in a sense gets ‘squished’ against the inside walls of your skull. This injury can occur without hitting the head (car racing for instance) and can also occur without an athlete losing consciousness (roughly 10% of concussion involve a loss of consciousness). The brain injury leads to changes in chemistry within the brain, and this leads to functional disturbances that we can observe as symptoms.
For those athletes who have never experienced a concussion, it can be quite challenging to acknowledge the initial injury and continually remind yourself you are injured, because there are no obvious physical limitations to movement, such as a cast for a broken arm. You can’t see a brain injury, and thus it can be easy for coaches, parents or athletes to allow concussions to go unrecognized, especially with so much time, effort and love for the sport that all parties have invested.
Recognizing a Concussion:
Because the brain has a role in so many different aspects of bodily functions, we need to be on alert for a variety of symptoms in order to recognize a concussion. Disorientation or ‘having your bell rung’ is often the initial presentation, and anyone close to an athlete at the time of concussion should be on high alert for this presentation. Headache, dizziness, changes in memory, hearing or visual changes, nausea, confusion, poor reaction time, poor balance, and loss of consciousness are some of the hallmark signs and symptoms. Long term, be on the lookout for changes in sleep patterns, low moods, anxiety, irritability, poor concentration, sensitivity to light, fatigue, or simply ‘not feeling right’ since the injury.
Remember, there need not be a loss of consciousness and you need not see an athlete hit their head to diagnose a concussion. Any fall in which an athlete hits their head and/ or demonstrates any of the above symptoms or ‘just doesn’t seem right’ should be assumed to have a possible concussion.
Concussions must be taken seriously:
1- In rare cases, the injury can quickly deteriorate and become life threatening.
2- Because brain function is impaired, the individual could be at risk of hurting themselves or others if attempting to continue skiing or drive their car for instance.
3- The athlete that goes back to sport when they still have signs or symptoms of concussion puts themselves at risk for an even greater injury, including long term brain damage or early death. Thus, we must always err on the side of caution when deciding when to return to sport.
Stop Skiing, Monitor for Deterioration, and Seek Medical Attention:
At WMSC we encourage the staff to be highly suspicious of concussions, and use a ‘when in doubt, sit it out’ philosophy. If a concussion is suspected, athletes are not to be left alone, and they are to be escorted down the hill safely, and driven to the medical clinic for assessment. Basic first aid and spinal awareness principles are emphasized for the initial response to these injuries, and Ski Patrol is notified for any athlete that has sustained a loss of consciousness or other overt injury. While medical doctors are tasked with the job of diagnosing a concussion, I encourage all families or friends to take an active roll in monitoring the individual for signs and symptoms that may not have been apparent in the medical setting. This sometimes means returning to the doctor with a new list of symptoms and second opinion if a concussion diagnosis was not made initially.
Severe Concussions vs. Mild Concussions
Many athletes might think, “I only had a mild concussion, so I am ok to get back out there.” This is dangerous thinking. There is currently no grading system for concussions, and all concussions should be considered equally serious, regardless of the severity of symptoms.
Use a Graded Symptom Score ASAP after injury:
A graded symptom score is simply a list of possible signs and symptoms of concussion, with numbers assigned to each symptom; it helps to expose symptoms an athlete might not be aware of, and provides some objectivity for assessing the athletes in the 72 hour period following injury. Ideally, the symptom checklist is performed at set times, immediately following the injury, 2 hours after the injury, 24 hours, 48 hours, 72 hours and perhaps at longer intervals after the injury if necessary. A modified version of the post concussion symptom checklist can be found as part of the SCAT 3, which you can download here. Also, symptom scores can be found as part of the many concussion apps that are currently available for smartphones – for example, the PRR app: http://www4.parinc.com/Products/Product.aspx?ProductID=CRR_APP .
Return to Sport:
Currently, there are limited treatment options for concussion – cognitive rest and physical rest are the cornerstones of treatment. Athletes that attempt to do too much cognitive or physical activity while experiencing symptoms, risk prolonging their healing time.
Once symptom free, there should be a gradual introduction of cognitive and physical activities – most guidelines suggest this occurs over a period of 5-7 days. As with much of the concussion management guidelines, these guidelines are somewhat arbitrary and expert based rather than evidence based.
Once an athlete has gradually increased their physical activity in a risk free environment, and has still not experienced any symptoms of concussion, they are ready to see their physician to be ‘cleared’ for their return to sport.
Neuropsychological (NP) Assessments, Baseline Testing, and the SCAT:
The amount of interest from club parents and board members regarding baseline concussion testing has been significant, and so I have included a more lengthy discussion about them below:
Evaluating a concussion is challenging because it relies heavily on subjective reporting from patients, and there are few objective tests like X-rays or blood tests that we are used to relying on for other types of illnesses or injuries. Several tests have been developed to evaluate concussion in athletes: some focus on balance, others on reaction times, thinking abilities, memory and more. Most of these concussion assessment tools work best when they have a recent baseline to measure to compare to.
A popular test with professional athletes has been an online test known as the ImPact test – the benefit to such a test is that because it utilizes technology and it is very lengthy and comprehensive, it might be able to detect sings or symptoms of concussion when no other method was able to. The downside to this test and others like it, is that they aren’t perfect, and they can sometimes give false information; a false negative could lead an athlete to return to snow too quickly, and put them at risk. Based on ImPact’s numbers, it is possible that perhaps one athlete every year could benefit from the use of these tests, but I would question whether that one athlete is really getting meaningful benefit. Until we see more convincing evidence of the clinical utility of these newer, more comprehensive concussion assessment tests, and given their cost and low convenience, I do not recommend them for the entire WMSC membership.
I do not discourage NP tests and other comprehensive baseline testing. So long as the test is not being used as an inclusionary test, and parents want to have extra information that can be used to possibly exclude their child from sport, then the test probably won’t do any harm. It is possible that the extra information attained from performing a baseline test could help parents make better decisions in the event of a concussion, especially in the athlete that may have already experienced a concussion in the past.
Currently the SCAT-3 is the most utilized concussion assessment tool, used by medical doctors and trained health care providers. It is a standardized form that is readily available to anyone. It is designed for use immediately after a concussion, but it can also be used as a baseline concussion tool. At WMSC, we utilize the BESS (balance) test as part of our physical testing, and this test is part of the SCAT3. Also, we utilize a validated test for reaction time that involves dropping a puck attached to a stick. These baseline tests are sensitive to brain injury, coaches can easily perform them, they can be performed frequently (as baseline tests should be as recent as possible), and they are inexpensive. As with the NP tests, the challenge with them is that coaches and athletes are not interpreting a negative test to mean the athlete does not have a concussion. Coaches and athletes should not be dropping poles or sticks on the side of the hill to evaluate whether athletes have had a concussion.
As you can see this is a very tricky topic to navigate, and as with any area of medicine in which we know very little about the problem, there are bound to be mistakes made. I will attempt to reevaluate the evidence each year on this topic, and have ‘primer’ discussion with the coaches to ensure our concussion management protocols are fresh in everyone’s minds.
In Summary, Some Key Points:
- 90% of concussions will not be accompanied by a loss of consciousness (LOC), making the diagnosis challenging. Always be on the lookout for disorientation, changes in memory, head and neck pain, and mood changes if an athlete has fallen and possibly hit their head.
- The brain is in charge of multiple body systems, therefore symptoms of concussion can be extremely variable, and severity of symptoms does not adequately reflect the severity of brain injury.
- When an athlete sustains a possible brain injury, referral is immediate, because the rare and life threatening emergencies will usually happen within the first hour or two after a trauma.
- The athlete that goes back to sport when they still have signs or symptoms of concussion puts himself or herself at risk for an even greater injury, including long-term brain damage or early death. No single test or protocol for concussions is perfect, and thus we must always err on the side of caution when deciding when to return to sport.
Have fun out there and good look with your racing everyone!
Dr. Ryan Oughtred, ND
Whistler Mountain Ski Club, Sport Science and Conditioning Manager