Dr. Jeff Hersh: Learning the signs of a concussion can prevent severe brain injury
Q: I coach kids who play football and want to learn more about concussions. What can you tell me?
A: A head injury is evaluated based on the patient’s risk factors and their symptoms. The very young or old, those with a concerning mechanism of injury (such as ejection from a car), people on blood thinning medications, those with certain symptoms (such as a seizure after the injury, prolonged loss of consciousness, significant other injuries from the trauma, etc.) or other factors causing increased suspicion should be sent for emergency evaluation and may require a CT of their brain.
The American Academy of Neurology defines a concussion (considered a mild head injury) as a temporary alteration in mental status from trauma, whether or not there is a loss of consciousness. In fact, the vast majority of concussions do not involve any loss of consciousness.
The alterations of brain function from a concussion may manifest as:
A vacant stare
Changes in verbal or motor responses, such as slurred speech, unsteady gait or poor coordination. These changes can be subtle, such as answering questions normally but with a delay.
Confusion, such as not knowing what day, month or year it is, or not knowing where they are or what happened. The confusion may be subtle, such as feeling like being “in a fog.”
Loss of memory, which most commonly includes the traumatic event, but often includes things from before or afterwards. This may be subtle or obvious (such as the patient asking the same question multiple times).
Inappropriate emotions or reactions to the situation
Sensitivity to noise or light
Headache, dizziness, nausea or vomiting
Loss of consciousness
Note that severe symptoms or deterioration in the patient’s status requires emergency evaluation.
One and a half to four million sports related concussions occur each year in the U.S. This large range reflects the fact that many (possibly most) concussions are not diagnosed. One in ten athletes participating in contact sports sustains a concussion every season, with some sports being even higher. Of course concussions also occur from motor vehicle accidents, falls, assaults, injuries at work, combat (for our soldiers) and other causes.
The first step in diagnosing a concussion is having a high index of suspicion. Many methods have been developed to identify alterations in brain function (such of those noted above), including scoring systems based on the subject’s answers to questions to assess:
Orientation, such as location and date
Immediate memory, for example by giving a series of numbers to be memorized and immediately recited back
Delayed memory, for example by naming objects to remember and specify 15 minutes later
Concentration, such as reciting the months of the year in reverse order
Coordination, tests similar to those the police use to identify drunk drivers may be used, possibly done with and without physical exertion
Symptoms, such as headache, dizziness, etc.
The severity of a concussion may be estimated by many methods, none of which has been shown to be perfect. As an example, I will discuss one conservative method that delineates severity of concussions by assigning a “grade”:
Grade 1: No loss of consciousness and symptoms lasting less than 15 minutes
Grade 2: Loss of consciousness less than 1 minute or symptoms lasting 15 minutes to 24 hours
Grade 3: Loss of consciousness over 1 minute or symptoms lasting more than 24 hours
Recommendations in the literature exist but none are known to be definitive, so each young athlete should be evaluated on a case-by-case basis. Example guidelines (which I cannot specifically endorse due to the limited data supporting them) include:
Young athletes sustaining a concussion should be removed from the game due to concern for “second impact syndrome” (although some experts question this), where a second head injury on top of a concussion can result in severe brain injury.
For grade 1 concussions the athlete can be considered for return to play after they are completely symptom free (at rest and with exertion) for at least one week.
An athlete suffering a grade 2 concussion or a second grade 1 concussion may be considered for return to play a minimum of two weeks later, and only if they are symptom free (both at rest and under exertion) for at least one week.
A grade 3 concussion should be sent for emergency evaluation. Return to play should not be considered for at least one month and until they are symptom free for at least a week.
After a second high-grade concussion, the athlete should be evaluated for removal from further contact sports.
In order to best advocate for our young athletes we need to take the risks of concussions (including cumulative effects from multiple concussions, increased risk for developing seizures, development of chronic symptoms such as headaches, neurological symptoms, etc.) seriously. We need to protect our children by ensuring they wear appropriate headgear and their games are kept under control and played to minimize injuries; this is one of the ways referees and coaches can make a positive impact.
Jeff Hersh, Ph.D., M.D., can be reached at DrHersh@juno.com.