Use Your Head: Diagnosing and Treating Concussions

Concussions are a common injury in contact sports. Individual events of concussion can range from a mild head injury all the way to emergency situations. Recent medical evidence on the possible long term serious consequences of repeated concussions forces us to be much more careful dealing with concussions.

As we currently understand a concussion, the injury is a change (probably chemical) in brain function induced by acceleration-deceleration and shearing forces on the soft brain inside the hard skull, rotational forces being more damaging than straight linear force. Actual structural changes are not demonstrated by imaging (CT, MRI) in the case of a concussion. Repeated concussions or a single severe concussion have the potential to induce long term changes in the brain function.

On the good side, most who suffer one or more concussions will not have long term effects. On the bad side, some will. Unfortunately, at this point in time, we do not have a 100% way of predicting which skater will have long term consequences from concussions, although amnesia for events before injury suggests a more serious concussion. We are left with the options of careful monitoring of the skater and ensuring that brain healing has time to take place.

Diagnosis

If an event occurs during which a skater's head is violently shaken, the skater might have a concussion. The event does not have to involve a direct head blow, in fact, most concussions don’t result from direct blows. The symptoms, which occur in various combinations and severity are: headache, “pressure in the head,” neck pain, nausea, vomiting, dizziness, blurred vision, amnesia for events before or after the injury, balance problems, sensitivity to light and/or noise, feeling “slowed down,” feeling as if “in a fog,” “don’t feel right,” difficulty concentrating, difficulty remembering, feeling fatigued, confusion, drowsiness or trouble falling asleep, more emotionality than normal, irritability, and nervousness.

The victim of a concussion will demonstrate difficulty in balance, concentration, mental function, and behavior. Note: a loss of consciousness is not actually a common symptom, resulting in under-reporting of concussions. Please, if you suffer the symptoms or signs above, report them to your medical team.

If there is a loss of consciousness, evaluation in an emergency room (ER) is needed. Evaluation in the ER may include brain scans and referral to a specialist in neurological injuries. If there is no loss of consciousness, the severity and number of symptoms will determine whether the skater will need to go to the ER. ALL skaters with symptoms and signs of a concussion must be evaluated by the team medical personnel and be excluded from play that day.

There is a useful free evaluation form (SCAT2) which can be used to evaluate and to follow a concussed skater. The whole document is available at www.nata.org/jat in the Journal of Athletic Training, 2009:44 (4):434-448. This article also gives a full discussion on concussions. There is a short, on-the-field evaluation form as well as a longer evaluation form for initial evaluation and follow-up. Other forms such as Impact are available but are not free. It is important to remember that other serious brain injuries can begin with mild concussion-like symptoms and progress within hours to a dangerous situation. That is why a “concussion” must be evaluated by medical personnel.

Treatment

First, because more serious brain injuries (such as bleeds into the brain) can start out with symptoms similar to a concussion but not show up right away, the injured person should be monitored by someone for 24 - 48 hours. It may be necessary to waken the victim every 2 - 3 hours during the night to ensure their sleep is normal sleep, not unconsciousness.

Nausea or vomiting may occur after a concussion, so the injured skater should have a bland, mainly liquid diet for 24 - 48 hours. Because of possible problems with concentration, confusion, and mental slowness, the victim should not drive or operate dangerous equipment for 24 - 48 hours. Prevention of another brain injury until the brain heals the first one chemically is critical.

Second Impact injury (another injury to the brain before healing has occurred) can result in dangerous and chronic dysfunction of the brain, including death. The skater must rest mentally and physically until the signs and symptoms have fully resolved and do not re-occur upon resuming mental and physical activity.

Rest is the only actual treatment for concussion. This includes both physical and mental rest. The harder part is resting the brain, but it is the most important part of “treatment.” This involves not using the brain for anything other than basic life functions until the symptoms subside. Initially for a day or two, a quiet, dimly-lit environment is beneficial. Reading, tasks requiring mental effort and concentration, watching TV, and the like should be avoided till the symptoms subside.

Ideally, this involves time off work. Physical rest is also needed. If the symptoms subside but re-occur on resuming mental and normal physical activity, rest must be resumed. Pain treatment for the head or neck pain may be needed. Rest and ice bags will often be sufficient. If not, acetaminophen (Tylenol is one brand) is all right. Aspirin and NSAIDS (ibuprofen, naprosyn, and the like) must be avoided because they promote bleeding.

Although bleeding is not a result of a concussion, the concern is that a more serious injury involving bleeding may present with concussion symptoms initially. Sedative and narcotic medicines must be avoided because they mask important symptoms or cause symptoms that mimic head injury such as dizziness, lethargy, or nausea. If the skater is on regular medications (prescription or over the counter) for another, unrelated medical condition, a doctor must be consulted as to whether the medicine is OK to continue. Alcohol and hard drugs are absolutely contra-indicated.

Return to Play (RTP)

Because each concussion is so individualized, the RTP must be individualized for the skater. Blanket rules don’t work well. In general, the milder the concussion, the sooner RTP can happen. The timeframe may be a week to as long as several weeks. But it must be under the supervision of the skater’s physician. The key determinant is that the symptoms and signs must have resolved completely AND must not start up with the resumption of normal, non-sport activities.

Once that is true, gradual return to sport-related, but non-contact activities is instituted. If the skater remains symptom-free, the skater can gradually return to contact sport activities. There are instances where the skater will be well, return to contact sport activities but have a relapse of symptoms some days to weeks later even without a new head trauma. This is known as a post-concussion syndrome and requires further medical evaluation with a neurologist.

Prevention

It is obvious that complete prevention of concussion in contact sports is not possible. But the use of a well-fitted, well-made helmet and mouth guard helps reduce the likelihood. This is also the reasoning behind prohibiting hits above the shoulders and using the head to block. There is evidence that increasing the neck strength may reduce the forces generated in falls by reducing the violent shaking of the head. This is still being investigated, but strong flexible neck muscles are helpful in reducing neck injuries in any case.

Preventing the long term consequences of repeated concussions requires that skaters be honest in reporting symptoms in the first place and following the medical advice carefully. This will give the best chance for the brain to “heal” and allow the best chance for the skater to return to derby safely and soon. Some investigation into using neuropsychological testing before and during the sports season as guides to diagnosing and managing concussion is being done. This is not currently available widely due to the time and expense involved.

In short, use your head, report your symptoms, and don’t lose your head.