Concussions In Sport

With the high profile concussive injury to Sidney Crosby in 2011, it changed the landscape of concussions in sports. Individuals inside/outside of the sporting community were all wondering about concussions, and an increased awareness of the issue took place. We were all aware that concussions were a risk in sports, but looking back most people in amateur/recreational/professional sport could remember a time when they had their “bell rung”.

Was actually is a concussion?

A concussion, defined by the latest Concussion Consensus Statement (Zurich, Germany 2013), is a complex process affecting the brain induced by biomechanical forces. These forces change the way our brain functions, by causing a temporary dysfunction in the involved nerves (the brain is a collection of nerve cells). The nerves stretch and there is a deformation of the cells, allowing certain chemicals leek out of the cells, causing dysfunction. It may be caused either by a direct blow to the head, face, neck or elsewhere in the body where an impulsive force is transmitted to the head. This means that a hard hit to the torso in a given sport may actually cause a concussion, regardless of the hit or impact directly involved the head.

Also, most concussions do NOT cause a loss of consciousness (less than 20% of individuals “black out”). As most people feel that you only had your “bell rung” if you don’t lose consciousness, this makes determining if one occurred difficult for the coach, trainer, parent, or even the athlete as they have this “concussion = loss of consciousness” mindset. Combine this with the fact that the injury has no true issue shown on any medical imaging (X-ray, CT scan, or MRI), this makes the situation even more convoluted.

What symptoms are common with a concussion?

There is a very wide range of symptoms that individuals might have. These are included, but not limited to:

• Headache
• Dizziness
• Neck pain
• Nausea or Vomiting
• Loss of balance
• Poor coordination
• Trouble focusing on objects or words
• Poor concentration
• Feeling “foggy”
• Confusion
• Amnesia, or poor memory
• “Flashing lights”
• Blurred or double vision
• Seeing “stars”
• Irritability or emotional changes
• Ringing in ears
• Slow to follow direction
• Decreased playing ability
• Easily distracted
• Vacant stare
• Drowsiness/fatigue
• Difficulty falling asleep
• Feeling “off” or not like oneself

These issues might be difficult to notice at first, especially because some of the symptoms are emotional and psychological, not physical symptoms. I can remember my good friend from university who had a history of concussions growing up (he played in the OHL before going to university). He went on a road trip with some of his friends for a week to go rafting up in Ottawa, and all of them decided to go bungee jumping while on their trip. Fast forward a couple days, and we noticed he was “off”. He was moody, easily irritable, and just not himself. He concussed himself while bungee jumping, and because it wasn’t an activity that most people wouldn’t associate getting a concussion from, and he didn’t experience the classic symptoms (headache, nausea, dizziness, vision issues), it took him a while to put the puzzle together.

What should I do as a coach/trainer/parent if one is suspected?

The first thing that should come to mind is “when in doubt, sit them out”. Symptoms such as headache and dizziness are common yet can also occur in a variety of other sport-related issues (e.g. dehydration, heat-related illness). To complicate things further, the appearance of symptoms may be delayed for several minutes or even hours after the initial injury. Therefore, as a general rule of thumb, if a player presents with one of the symptoms listed previously and has the mechanism of a head injury, treat it as a concussion. Also, don’t think that a concussion can only occur from a “big hit”, as an injury may happen in a more subtle situation/impact (and as stated earlier, may not directly involve the head). Similarly, don’t assume if an athlete is playing a non-contact sport is unlikely to get a concussion. High school girls’ soccer has a high rate of concussion incidence, usually when players are jumping for a ball and have a collision with another player.

If an athlete is not acting normally, having problems remembering plays or following instructions, they may have sustained an injury. Once an injury is suspected, there should be absolutely NO return to play on the same day as the injury, regardless of the level of athletic performance. The consequences of having the athlete sustain a second impact injury are too high of a risk, regardless of the situation or in-game implications of the athlete missing the rest of the game.

Parents, coaches, and trainers should be aware of the symptoms scale/checklist. People who are closer to the athlete will be able to pick up subtle changes and be obvious to those people if the athlete is struggling with a simple question or is acting unusual/different. If it is not that apparent, a sideline concussion evaluation should be performed by a coach/trainer. The most commonly used tool is the Pocket Concussion Recognition Tool, which trainers can easily store in their pocket for quick access and be used as a guide, and is readily available online. A more detailed evaluation is known as the Sideline Concussion Assessment Tool (SCAT), Version 3 (the newest edition). It evaluates symptoms, cognition (mental processing) and assesses physical capacity (neck range of motion, etc.). This should be used as a basic guideline, and is not designed to take the place of a more comprehensive evaluation by a medical professional.

If you are approaching an athlete on the ice, court, field, etc., be sure to rule out any red flags prior to initiating a concussion screen. Some major red flags are:

• Athlete complains of neck pain
• Deteriorating conscious state
• Increasing confusion or irritability
• Severe or increasing headache
• Repeated vomiting
• Unusual behaviour change
• Seizure or convulsion
• Double vision
• Weakness or tingling / burning in arms or legs
• One pupil larger than the other

In all cases, the basic principles of first aid (danger, response, airway, breathing, circulation) should be followed. Do not attempt to move the player (other than required for airway support) or remove their helmet (if present) unless trained to do so. If transported to a hospital, imaging may be utilized. It is not used to confirm/deny a concussion, but to rule out more severe trauma such as bleeding within the brain or skull or fractures of the skull or neck. If a concussion is suspected after a sideline evaluation, seek a more comprehensive evaluation by a health care practitioner, be it a medical doctor, sports medicine physician, or a manual therapist (chiropractor, physiotherapist, etc.) who has the proper training in assessment and treatment of concussions.

We understand now, more than ever, that just because we can’t see the injury, it doesn’t mean that something’s not wrong. If we suspect a concussion, what do we do to/where do we turn to help with the injury sustained?

The next article will discuss concussion testing, the utility of having baseline testing, and post injury protocols – return to school, return to play.