Feature Article:::...

Concussions serious injury, must be treated with care

By: Vanessa Gilley, P.T., A.T.C.

Have you ever had your bell rung? Have you ever hit your head and gotten dizzy and nauseated for a few minutes?

Well, you probably had a mild concussion. Concussions can be dangerous, especially for a young athlete playing a contact sport such as football, soccer, baseball, softball and basketball.

The brain is located in the skull which is made up of eight bones and 14 facial bones. The brain is surrounded by cerebrospinal fluid, which gives the brain a “cushion” from normal activity such as walking and running.

A concussion is a mild traumatic brain injury (MTBI), the most common and least serious type of traumatic brain injury. It is an immediate and transient impairment of the brain to function properly.

The concussion is an injury caused by either an acceleration force or deceleration force. Acceleration injury is defined as a forceful blow to a moveable head, usually resulting in maximal injury beneath the impact. Injury can also occur when the head is moving and it hits an immovable object such as the ground or a wall, called impact deceleration. The maximal injury occurs on the opposite side of the impact.

There are many different symptoms that are described when a patient has a concussion. Symptoms can include, but not be limited to, loss of consciousness, headaches, dizziness, irritability, difficulty in concentration, confusion, nausea, vomiting, vision disturbance, and retrograde or anterograde amnesia.

Retrograde amnesia is when the athlete cannot remember events or things prior to the injury, such as what they had for breakfast that morning or what play they were running. Anterograde amnesia is when the athlete cannot remember things post-injury, such as what happened after they walked off the field.

Delayed symptoms can last weeks to months, and may include fatigue, depression, anxiety, lightheadedness, decreased memory and personality changes.

Researchers have defined stages to concussions in many different ways. One of the easiest to understand is as follows:

Mild concussion or Grade 1 is no loss of consciousness, no post-traumatic amnesia, and post-consussive signs and symptoms lasting less than 15 minutes. Grade 1 concussion symptoms include a dazed look, some dizziness, small headache and confusion.
Moderate or Grade 2 concussion has a loss of consciousness for no more than five minutes or post-traumatic amnesia for greater than 30 minutes, but less than 24 hours. The grade 2 concussion may have signs and symptoms that last for up to one week. Grade 2 concussion symptoms can include amnesia, confusion, headache and irritability.
Severe concussion or Grade 3 has loss of consciousness for greater than five minutes or post-traumatic amnesia for more than 24 hours and post-concussive signs and symptoms for more than seven days. Grade 3 concussions demonstrate retrograde amnesia, headache and irritability.

When an athlete is unconscious, the injury must be treated very seriously. The athlete should be treated as if he or she may have a cervical spine or neck injury. If the athlete loses consciousness, generally, he or she should be taken to the emergency room to be checked by a physician.

If you are a coach or parent of an athlete and you suspect a head injury, you want to observe for the signs and symptoms mentioned above. Ask questions such as what happened, how long the person was unconscious, and if they have had a previous concussion. You also want to ask the injured person about what he or she should know, such as What did you have for breakfast? What is your middle name? Where are we? What sport are you playing? What month is it?

Ask the athlete to repeat and then remember three simple words such as car, book and tree. Observe the athlete as he or she speaks, noticing if there are slurred words, trouble remembering words, or nonsensical words or statements. The athlete may also demonstrate emotional changes in the time after the initial injury, such as crying and apologizing for what happened.

If the athlete has trouble with the above, these are signs and symptoms of a concussion. He or she should be checked by physician.

Return to play for the athlete with a concussion should be determined by physician clearance, but general rules are as follows:

Grade 1 or mild concussion may return to play if asymptomatic for at least 15 to 20 minutes.
If the athlete had a grade 2 concussion, he or she must be asymptomatic for at least one week prior to return to competition.

A grade 3 or severe concussion is held out for at least one month and may return to play if asymptomatic for one to two weeks.

If the athlete has had two or more concussions, return to play is far more conservative. If the athlete has had a second grade 1 concussion then he or she may return to play within two weeks if asymptomatic for one week. After the second grade 2 concussion, the athlete is held out for one month and may return after one to two weeks asymptomatic. Termination of the season occurs with the third grade 1 concussion, third grade 2, and second grade 3 concussion. The athlete may be considered to return to play the next season if asymptomatic and with clearance from physician.

Asymptomatic is defined as “having no headache, dizziness, no impaired orientation, or concentration or memory disturbances.”

If return to play is considered the athlete must be able to complete five steps prior to return to game situation. The athlete must first be asymptomatic, and then be able to complete light aerobics such as jogging, biking without increasing symptoms. Third, the athlete may compete in sport specific drills such as running routes on a football field, running the bases for baseball or softball. The athlete must then be able to perform non-contact drills such as running a play on the football field or shooting a soccer ball.

If all previous steps are asymptomatic, the athlete may then participate in full contact drills after medical clearance. If continued asymptomatic, the athlete may return to full sport.

Each stage is recommended to last 24 hours with return to step one if symptoms recur.

After an athlete has one concussion, research states that he or she is four to six times greater to having a second concussion and three times greater to have another in the same season. If an athlete has a second head injury or concussion prior to symptoms resolving, they will be diagnosed with second impact syndrome.

Second impact syndrome is defined as “rapid swelling and herniation of the brain after the second injury occurs prior to symptoms of the first concussion resolving.”

The second concussion may be minor and may not even require a blow to the head — a blow to the chest may cause enough force to snap the athlete’s head. This second injury causes a “disruption of the brain’s blood autoregulatory system, which leads to swelling of the brain and an increase in intracranial pressure.” In other words, the brain will swell and cause the symptoms to return. Research shows that second impact syndrome is life-threatening and may have up to 50 percent mortality (death) rate.

If second impact syndrome is suggested, the athlete needs immediate medical attention. The best way to manage second impact syndrome is to prevent it from happening by not allowing the athlete return to competition unless completely asymptomatic for at least one week and with medical clearance from physician.

Remember that head injuries are very serious. Although concussions may not cause severe signs and symptoms, if not taken care of properly, it may lead to death or very serious consequences. If you have any concerns, it is always better to err on the side of caution when dealing with a head injury and see physician for clearance.
References and definitions from wikipedia.com, “Magee’s Orthopedic Physical Assessment” and “Arnheim and Prentice’s Principles of Athletic Training.”

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Vanessa Gilley, P.T., A.T.C., is a physical therapist and athletic trainer at the Sullivan Center for Wellmont Holston Valley Medical Center.