By Don Brady and Flo Brady
Sport-related concussions (SRC) are not limited to specific age ranges, professional athletes, or gender. The primary focus of much of SRC research pertains to the assessment, management, and return to play (RTP) of the concussed athlete. This article will highlight some major issues of SRC along with some controversies that presently exist within the field. Readers are encouraged to discuss specific SRC concerns with qualified and knowledgeable healthcare providers who are familiar with the person suffering from a concussion.
The concepts of concussion, mild brain injury, mild head injury, and subtle brain injury are frequently utilized as synonyms within sports. The "silent epidemic" is a phrase that has been assigned to concussions because the injury is not often directly visible (Goldstein, 1990). Anderson (1992) coined the expression, "the NFL’s quiet career killer," to reflect the devastating impact that concussions have when National Football League (NFL) players are forced into retirement from the sport. As with many constructs utilized in scientific research, the term concussion has had various operational definitions throughout its history. Two definitions of concussions are: (a) "traumatically induced alteration in mental status that may or may not involve loss of consciousness" (Kelly & Rosenberg, 1998, p. 577) and (b) "a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces that may or may not involve loss of consciousness" (Aubry et al. 2002).
A recent sports- and recreation-related concussion estimate is that 1.6 million to 3.8 million concussions occur annually (Langlois, Rutland-Brown, & Wald, 2006). An analysis of SRC research reveals that concussions occur on a relatively common basis within the pediatric population.
Primary and Secondary Consequences: The Many Faces of Concussions
The uniqueness of each concussion results in multiple and complex symptoms; thus, there are many faces of concussions, as no two concussions are similar. Potential SRC concussion symptoms comprise a longer list of symptoms than are often noted on various common SRC symptoms checklists. Some SRC symptoms are: various types of headaches (e.g., migraine, occipital neuralgia, due to scalp lacerations), light and noise sensitivity, slowed information processing (e.g., taking longer to think), impaired concentration, difficulty remembering, tinnitus (ringing in the ears), blurry vision, depression, anxiety, personality change, lack of motivation, fatigue, sleep disturbances, vertigo (dizziness that causes a sensation of whirling which results in a loss of balance), nausea, and inappropriate social responses (Evans, 1994; King et al., 1995; Lovell et al., 2006).
A concussion should not be viewed as a brief occurrence, but as both a short-term and potentially long-term process where primary and secondary brain injury occurs. The adverse and destructive consequences of a concussion may follow a continuum from subtle to grossly overt. Altered cell functioning and cell death along with subtle to more visible physical, cognitive, and emotional impairments reflect a potentially diverse range of lifelong negative consequences of concussion. Substantial credible experimental and clinical evidence pertaining to the adverse effects of concussion indicate that the brain is injured as a result of a concussion (Holbourn, 1943; Hovda et al., 1995; Gronwall & Wrightson, 1975; Gronwall, 1991; Ommaya & Gennarelli, 1974: Strich, 1961). Expressions such as "just a ding" and "had his bell rung" serve to minimize, discount, and invalidate the adverse implications of sustaining a concussion. Further evidence of the potential seriousness of a concussion was reiterated by Kieslich et al. (2002) when they reported that minor brain injuries were related to strokes occurring in children.
Cumulative effects of concussions. The cumulative effect of concussions supports inferential conclusions that the brain sustains further permanent injury when multiple concussions occur. That there have been numerous professional athletes to sustain multiple and, eventually, premature career-ending concussions provides further support and clinical evidence for the adverse cumulative effect of concussions. The names of some notable retired professional athletes follow include Ted Johnson, Taylor Twellman, Steve Young, Troy Aiken, Al Toon, Harry Carson, Brett Landos, Mike Richter, and Merrill Hoge.
Assessment and Management After a Concussion Is Suspected or Occurs
The athlete should be removed from play/sport activity and medically evaluated/assessed in a timely manner if a concussion is either suspected or sustained. The old adage, "When in doubt, sit them out," applies. Pressure to allow the athlete to prematurely return to competition, especially in the "big game," must be ignored.
An athlete’s concussion or suspected concussion should be promptly assessed and managed on an individual basis within a multidisciplinary approach by qualified healthcare providers who possess accurate and in-depth concussion knowledge. It should be noted that numerous and conflicting expert and consensus viewpoints/guidelines have been published for managing a concussion. However, these guidelines lacked a scientific foundation and related clinical evidence and the discontinuance of the guidelines has been recommended. Some RTP guidelines were also influenced and biased by apparent conflicts of interest such as financial gain, prestige, and multiple relationships (Brady, 2004; Goldberg, 2009; Huizenga, 1994; Kelly & O’Shanick, 2003). Despite the different perspectives and resulting controversy, Putukian and Echemendia (1998) pointed out that the athletes’ health should remain the first priority when making RTP decisions.
Rest: Physical, Cognitive, and Emotional
During the 1990s, some SRC experts concurred that athletes should not return to sports activities until they are asymptomatic for a designated period of time, both at physical rest and during physical exertion. More recently, the concept of cognitive rest was introduced as part of SRC management. Because the brain influences physical, cognitive, and emotional aspects of an individual, it seems logical and essential that the concept of emotional rest is also incorporated into this management framework. The concept of rest, along with its three components, needs to be more clearly operationally defined for application to concussion management.
Emotional rest may be defined as a state in which an individual’s feelings are serene and relaxed through having obtained a sense of inner peace. Wrightson and Gronwall (1999), pioneer clinicians in the area of SRC, perceived rest as an essential component of the treatment process. They emphasized the importance of learning to pace oneself, and subsequently rest in order to avoid fatigue and a subsequent return of symptoms, and to further enhance functional recovery. They noted that it was imperative to initiate rest at the onset of experiencing tiredness for an ample amount of time to ensure that the feeling of fatigue did not become more intense (p. 170).
The premature RTP while symptomatic is noteworthy since an athlete’s return to play before the symptoms ceased could result in significant brain damage or death as a result of the second impact syndrome. As Cantu (1998) reported, the second impact syndrome occurs when an athlete sustains another concussion before symptoms related to the initial concussion have dissipated.
Essential Concussion Facts
- Although concussions are common within the pediatric age group, there is a paucity of SRC research regarding this population (Purcell, 2009). The recognition, assessment, and management of concussions are not simple tasks. There exist many faces of concussions that require individualized healthcare provided by an interdisciplinary team of knowledgeable clinicians. Moreover, a concussion is a family affair. The brain injury adversely impacts the whole family system. Thus, it is important that all family members’ needs are addressed in the journey to functional recovery.
- Sports-related concussion impacts may be compared to motor vehicle accident impacts. Documentation exists within sports research that SRCs are at least comparable to motor vehicle related concussions. A professional boxer’s punches have been measured at 20 mph, the flight of a soccer ball at 70 mph, an average lacrosse ball between 80–100 mph, and the speed at which football players tackle a stationary player at 25 mph.
- Concern has recently been voiced regarding the destructive and cumulative effects of subconcussive hits to the head. An athlete does not have to be struck on the head to sustain a concussion. A concussion may also result from head (brain) trauma experienced via collisions, falls, or when a whiplash force is applied to the body (Cantu, 1996). An athlete also does not have to experience loss of consciousness to be diagnosed as having a concussion. It is estimated that approximately 10% of athletes who sustain a concussion experience loss of consciousness.
- A negative MRI or CAT scan finding does not mean an athlete did not sustain a concussion or have any brain injury. Neuroimaging techniques, neuropsychological testing, and computerized neurocognitive screenings are not always sensitive to detecting subtle brain injury. Thus, a false negative finding may be obtained due to the lack of sensitivity of the instrumentation employed. In order to avoid false negative findings, continued efforts need to be sustained for developing more sensitive and precise neurocognitive evaluative instrumentation and medical techniques to assist with this process.
- Prior concussions have been linked to depression, Parkinson’s disease, Alzheimer’s disease, and chronic traumatic encephalophy. Chronic traumatic encephalophy is a degenerative disease that affects the brain and is believed to be caused by repeated head trauma (concussions and subconcussive hits to the head).
- Because the neurological system and cognitive functioning continues to mature through adolescence, a subtle pediatric brain injury could adversely impact this development. It is also possible that a neurocognitive disability would not be detected until a later period of time.
- Although athletes may appear to have fully recovered from concussion, their brain may require more effort or energy to complete a task than was required prior to sustaining a concussion (Gronwall, 1989). Because the brain has been injured, the use of the concept of "functionally recovered" is encouraged over "recovered." Individuals recovering from concussions may typically display fatigue along with difficulty with concentration, memory, new learning, organization, insight, irritability, and emotional self-control (Wrightson & Gronwall, 1999). The developing brain of a child or adolescent appears to take a longer period of time to functionally recover from sustaining a concussion than does the brain of an adult.
- Unfortunately, at the present time, functional recovery from a concussion typically focuses on when an athlete is resuming participation in sports, ignoring how well the student part of the student-athlete is able to adequately function within the classroom, home, or social setting.
- Individuals who sustain a concussion should not drink alcoholic beverages or utilize street drugs during the functional recovery process. Use of alcohol and other drugs while functionally recovering from a concussion may not only impede the healing process but may also further damage the brain.
Suggestions for Returning to Play, School, Home, and Socializing
The complex, varying, and individual central nervous system response to a brain insult and resultant concussion injury not only justifies but also requires a comprehensive assessment from a readily available and qualified multidisciplinary team of healthcare providers (McKeag, 2003). The utilization of a multidisciplinary team is particularly essential since consequences of a concussion include both neurological and nonneurological effects. Suggested members of this healthcare team may include the following: physician, neurologist, neurosurgeon, psychologist, neuropsychologist, school psychologist, teachers, school administrators, optometrist, ophthalmologist, coaches, athletic trainer, speech pathologist, occupational therapist, and physical therapist. Equally important is the carefully gathered input from close family members and significant others to assist in the concussion assessment and return-to-various-activities decision- making process. In order to fully protect the student-athlete’s health and corresponding safety, return to play, school, home, and socializing risks also need to be comprehensively assessed and thoroughly explained by the team.
Individual accommodations. Physical, cognitive, and emotional caution should be exercised for the injured student. The student component of the student-athlete should be prioritized over the athlete component: The student’s performance within the classroom setting should return to normal before engaging in any athletic related activities. Pressures to prematurely return to and succeed on the athletic field, in school, in part-time employment, and in socializing must be minimized. The amount of energy possessed by the concussed individual for each area of function has been reduced since the injury occurred (Wrightson & Gronwall, 1999). To allow for adequate breaks, a quiet area should be provided in each setting that the student is present. Nurse’s offices are often a hub of activity and overstimulating for the person who requires a low-traffic and tranquil setting. The new 3Rs apply to the essential ingredients of a tranquil setting: Relaxing, Reenergizing, and Refocusing (Returning to adequate focusing). It may even be advisable for the athlete to initially convalesce exclusively within a tranquil and low-stimulation setting at home to effectively obtain physical, cognitive (neurocognitive), and emotional rest.
Adjustments to school program. Suggested school adjustments include an initial meeting and periodic ongoing parent meetings with all teachers and administrators regarding the implications of the concussion on the student and ongoing communication between the school staff and family pertaining to the student’s level of functioning. Reduced course work (and possible withdrawing or taking incompletes from some courses) may be necessary to diminish cognitive demands and potential accompanying emotional stress. Adjusting the number of school days and hours attended each week, participating in less cognitively demanding classes, and putting into place individualized special education accommodations or 504 plans may also be necessary. Overlapping individualized concussion management plans should be written for return to play, school, home, and socializing to provide a consistent approach for the injured and suffering athlete. Furthermore, extensive concussion education is an essential cornerstone of effective concussion management within the school and home settings, and for the suffering student. Counseling formats may also need to be adapted to the presenting symptoms. For example, a shorter than usual session or the use of a low stimulation and/or noise-free counseling room may be necessary due to the reduced ability of the student to sustain attention and concentration.
Social activities. Numerous social activities may also have to be modified or eliminated. Participation in afterschool activities such as dances, house parties, memberships in various organizations, part-time employment, driving an auto or riding a bike, at-home responsibilities, and use of various modern technology such as cell phone talking and texting, computer and videogame use, music volume, and iPod use need to be closely scrutinized and discussed with the injured student. Physical, cognitive, and emotional demands could be excessive within all these various activities. Typical demands of adolescence also need to be revisited and discussed in a gentle manner. The serious implications of alcohol use and other street/recreational drugs after sustaining a concussion need to be shared by parents with their concussed child.
Prevention. Equal protective athletic equipment should be provided to both genders participating in the same sport. It seems essential that intensive and continuing concussion education become a cornerstone of effective concussion recognition and management. Just as patients are informed of potential side effects of medicines or risks involved in surgery so that they may make an informed decision about whether or not to have it, so should athletes be provided with the concussion awareness and knowledge necessary to make a wise choice about their participation in a particular sport. Educational seminars and websites geared for parents, caregivers, spouses, other family members, educators, coaches, and significant others should also be utilized to further aid in the dissemination of sports concussion information. Websites (e.g., http://www.biausa.org, http://www.subtlebraininjury.com, and http://www.headinjury.com), along with the creation of other informative resources, could provide easily accessible information for these individuals.
A statement written approximately 35 years ago, advocating for both the exercise of reasonable concussion healthcare delivery and reasonable caution, remains pertinent to the management of SRCs:
Doctors [and other health-care providers] do have a duty to convince controlling bodies and participants in sports where concussion is frequent that the effects are cumulative and that the acceptance of concussion injury, though gallant, may be very dangerous. (Gronwall & Wrightson, 1975, p. 997)
Sports team healthcare personnel need to focus primarily on the athletes’ health and well-being, and not minimize an injury or primarily concentrate on the players’ capacity to perform on the field.
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Don Brady, PhD, PsyD, NCSP, is a clinical and school psychologist in private practice. Flo Brady, BSW, has focused her work on children and family services at St. Catherine’s Center for Children in Albany, NY.