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September, 2000 Anyone who watches football on TV has seen incidences of concussion. The player "had his bell rung," the announcer will say flippantly after a particularly violent collision. For years this casual attitude toward concussions was common. Coaches and teammates would urge the injured player to "shake it off" and return to the game after a brief rest. Fortunately, in the wake of premature retirements of star athletes such as Steve Young after a series of concussions, awareness of the potential seriousness of concussions has risen. Concussions, even mild ones, are not a lighthearted matter. Neurosurgeons and other brain injury experts emphasize that although some concussions are less serious than others, there is no such thing as a "minor concussion." Prevalence of concussions Concussions are a common occurrence in sports. More than 300,000 American athletes, most of them in high school or college, sustain concussions or other mild to moderate brain injuries each year, according to the Centers for Disease Control (CDC). Fully one-third of these brain injuries occurs in football. Reasonable estimates find that from 4 to 20 percent of college and high school football players will sustain a brain injury over the course of one season. The risk of concussion in football is three to six times higher in players with a previous concussion. Concussions also can occur in car accidents, bicycle mishaps and in falls around the home, especially among toddlers and the elderly. Because a concussion is a jarring of the brain, a healthcare professional needs to be consulted and proper period of rest is necessary. But in most cases a single concussion should not cause permanent damage. What is a Concussion? A concussion is an injury to the brain, usually caused by a blow to the head that results in temporary loss of normal brain function. Most people assume that concussions involve a loss of consciousness. Not true. In most cases, the person with a concussion never loses consciousness. The formal medical definition of concussion is: a clinical syndrome characterized by immediate and transient alteration in brain function including alteration of mental status and level of consciousness, resulting from mechanical force or trauma. Concussion means a change in mental status. Those with concussions often cannot remember what happened immediately before or after the injury. They may slur their speech or exhibit confusion. Paramedics and football trainers who suspect a concussion ask injured people what year it is or direct them to count backward from ten in an attempt to detect altered brain function. A concussion can affect memory, judgment, reflexes and muscle coordination. The speech and balance of the injured person may also be impaired. Confusion is a particular hallmark of concussion. The three principal features of confusion are:
The specific symptoms of a concussion include: headache, vision disturbance, dizziness, loss of balance, confusion, memory loss, ringing ears, nausea and difficulty in concentrating. If any of these occur after a blow to the head, a healthcare professional should be consulted. What is the exact cause of a concussion? The brain normally floats inside the skull, cushioned gently by the surrounding spinal fluid. The brain consists of a gelatin-like substance, vulnerable to outside trauma. The skull protects the brain against trauma but does not absorb the impact of a violent force. An abrupt blow to the head, or even a rapid deceleration, can cause the brain to slosh inside the skull and bounce against the inner wall of the skull. There is a potential for tearing of blood vessels, pulling of nerve fibers and bruising of the brain substance. Sometimes the blow can result in microscopic damage to the brain cells without obvious structural damage visible on a CAT scan. This damage can lead to brain swelling. Since the brain cannot escape the rigid confines of the skull, severe swelling can compress the brain and its blood vessels and limit the flow of blood. Without adequate blood flow, the brain does not receive the necessary flow of oxygen and glucose and can suffer a stroke. Brain swelling after a concussion has the potential to amplify the severity of the injury. A blow to the head also can cause a more serious injury to the brain. A contusion is a bruise of the brain involving bleeding and swelling in the brain. A contusion visible on a CAT scan often implies the brain underwent a greater degree of force than a concussion. A skull fracture occurs when the bone of the skull breaks. Sometimes the broken skull bones cause bleeding or other injuries by cutting into the brain or its coverings. A hematoma is a blood clot that collects in or around the brain. If active bleeding persists, hematomas can rapidly enlarge. Like brain swelling, the increasing pressure within the rigid confines of the skull due to an enlarging blood clot can cause serious neurologic compromise and even threaten a person''s life. A hematoma can be a surgical emergency. Hematomas that are small can sometimes go undetected initially but cause symptoms and require treatment several weeks later. The warning signs of a serious brain injury are:
Seek medical help if these warning signs occur. Three Grades of Concussion There is no universal agreement on the grades of severity for a concussion. There are at least 16 different guidelines for concussion evaluation and return to play. Most guidelines recognize three different grades of concussions and share similar recommendations for return to play. The two sets of guidelines most adhered to in the United States were formulated by the American Academy of Neurology and by Robert C. Cantu, MD, Chief, Neurosurgery Service, and Director of Service of Sports Medicine, Emerson Hospital, Concord, Massachusetts. Dr. Cantu has worked for more than 30 years as a neurosurgeon and football team physician. According to Dr. Cantu, a Grade 1 concussion involves no loss of consciousness but the person suffers from impaired intellectual function, especially in remembering recent events and in assimilating and interpreting new information. Grade 1 concussion occurs most frequently (more than 90 percent of concussions) and often escapes medical attention. It is difficult for a physician on the sideline to recognize the player has sustained a Grade 1 concussion. A teammate often will notice the injured player may lose the snap count or forget what play was called. A Grade 2 concussion involves loss of consciousness for less than five minutes or a period of post-traumatic amnesia that lasts more than 30 minutes but less than 24 hours. A Grade 3 concussion involves a loss of consciousness longer than five minutes or post-traumatic amnesia that lasts longer than 24 hours. According to the American Academy of Neurology (AAN), a Grade 1 concussion involves momentary confusion, no loss of consciousness and the disappearance of concussion symptoms or mental status abnormalities in less than 15 minutes. A Grade 2 concussion involves momentary confusion, no loss of consciousness and concussion symptoms or mental status abnormalities that last more than 15 minutes. A Grade 3 concussion involves a loss of consciousness, either for a few seconds or much longer. Treatment The standard treatment for concussion is rest. For a headache, acetaminophen (Tylenol) can be taken. Post-concussive headaches are often resistant to stronger narcotic based medications. Most one-time concussions are mild and result in no long-term damage to the brain. When an Athlete Suffers a Concussion The question of when an athlete who suffers a concussion can return to the game depends on the severity of the injury. According to Dr. Cantu, an athlete who suffers a Grade 1 concussion may return to the game if he or she is asymptomatic at rest and exertion within 20 minutes of the injury. If post-concussion symptoms persist for more than 20 minutes, an athlete should be withheld from competition until free of symptoms at rest and exertion for at least one week. A second Grade I concussion mandates removal from competition for at least two weeks, and return is permissible only if the athlete is asymptomatic during rest and exertion for at least one week. If headache or other associated symptoms either worsen in the first 24 hours or persist longer than a week, a CT scan is recommended. Three Grade 1 concussions should end a player''s season. Following a Grade 2 concussion, an athlete may return to competition in a week if he or she feels no symptoms either during rest or exertion. After a second Grade 2 concussion, return to play should be deferred for at least a month and termination of the season should be considered. After a Grade 3 concussion, the athlete must not be allowed to play for at least a month. Return is allowed only if the athlete has felt no symptoms during rest or exertion for at least a week. Two Grade 3 concussions should end a player''s season. According to the AAN, athletes who suffer a Grade 1 concussion during a sports competition may return to play after 15 minutes if they show a complete recovery (no symptoms at rest or with exertion). The injured player should be examined immediately and at five-minute intervals until the symptoms disappear. A second Grade 1 concussion in the same game should result in the player leaving the game for good. Before the player can return to competition, he or she should show no symptoms at rest and exertion for a week and undergo a neurologic exam. A player who suffers a Grade 2 concussion should be not allowed to play again that day. The player should be examined at frequent intervals. A trained person should re-examine the player the next day. Before the player can return to competition, he or she should show no symptoms at rest and exertion for a week and undergo a neurologic exam. A player who suffers a second Grade 2 concussion should show no symptoms at rest and exertion for two weeks and undergo a neurologic exam. A player who suffers a Grade 3 concussion should be taken by ambulance to the nearest emergency department if still unconscious or if worrisome signs are detected. A thorough neurologic exam should be performed promptly and admission to the hospital should be done if signs of pathology are detected or if the player''s mental status remains abnormal. A player who suffers a Grade 3 concussion should not return to play until he shows no symptoms at rest and exertion for two weeks and undergoes a neurologic exam. A second Grade 3 concussion should mean a rest of at least one month. Post-concussion Syndrome People who suffer a head injury may suffer from poor memory and concentration, headache, fatigue and dizziness for weeks or months. This is known as post-concussion syndrome. Athletes should not return to play while experiencing these symptoms. Players who suffer repeated concussions should consider ending participation in the sport. Second Impact Syndrome Athletes who return to play too soon after a head injury are in danger of serious harm and even death. Second Impact Syndrome occurs when an athlete who suffers a mild head injury returns to play before the brain has fully healed and incurs a relatively minor second hit. The result can be a rapid, catastrophic increase in pressure within the brain. The athlete may suffer paralysis, mental disabilities and epilepsy or death. The CDC reports an average of 1.5 deaths per year from sports concussions. In every case, a concussion, usually undiagnosed, had occurred prior to the final one. Avoiding Head Injuries To avoid head injury, take these precautions:
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