Concussion Management Program

What is a concussion?

A concussion is a functional brain injury that does not create any structural findings on imaging studies such as CT scans or MRIs.  Concussions are described as minor brain injuries.  However, they are “minor” only in the sense that “major” brain injuries cause much more severe neurologic symptoms such as paralysis, coma and death.  “Minor” brain injuries are still serious injuries.

How do concussions happen?

Concussions can occur from a direct head impact (e.g., a helmet-to-helmet impact in football, a soccer ball hitting a player’s head, a basketball player hitting their head on the floor, or a cheerleader striking their head during a stunt), or an indirect injury (e.g., an athlete can be struck in the chest, throwing the head forward).  In either case, the sudden impact or motion disrupts the brain’s function, leading to a wide range of symptoms.

What are common concussion symptoms?

Common early symptoms include brief loss of consciousness, amnesia, headache, dizziness, poor balance, and nausea.  Longer loss of consciousness (more than 30 seconds) and vomiting can occur, but these also are associated with more severe brain injuries. Other symptoms include moodiness, anxiety, depression, low tolerance for frustration, a sense of mental slowing or fogginess, poor concentration, poor appetite, poor sleep, and poor memory. 

When do concussion symptoms develop?

Early symptoms may begin immediately after an impact.  However, in some cases, symptoms can take a few hours to develop.  In some cases, athletes don’t recognize the link between symptoms and an impact.

Is there anything that makes concussion symptoms worse?

Concussion sufferers often report their symptoms are made worse by bright lights, loud noises, attempts to concentrate, and use of phone, computer or TV screens.  

Who can diagnose and treat a concussion?

Concussions are diagnosed and treated by a wide range of medical providers.  Within the Harris Orthopaedics and Sports Medicine (HOSM) team, the initial diagnosis is made by sideline medical staff (generally athletic trainers).  Patients are referred to HOSM’s office for further evaluation by physicians and physician assistants specially trained in concussion management.  When necessary, concussion patients can be referred for MRI and CT imaging, and for further evaluation by neurologists and neurosurgeons.

Concussion treatment is a team effort.  That team includes the patient and their family, coaching staff, teachers and school administrators, athletic trainers, physical therapists, physicians and advanced practice providers (PAs and NPs).  Each person in that team plays a critical role in ensuring athletes with concussions recover as quickly as possible.

How are concussions diagnosed?

Concussions affect the brain’s function, and diagnosis is based on evaluation of brain function.  Medical staff will evaluate the symptoms reported by the patient, their family, their coaches, and their teachers; the patient’s performance on neurologic exams; and the patient’s performance on standardized neuro-cognitive tests (ImPACT tests).  The combination of all this information is used to diagnose a concussion, and to monitor how the concussion improves over time.

What is ImPACT testing?

ImPACT (Immediate Post-Concussion Assessment and Cognitive Test) is the most widely used concussion management test in the US, and is offered at no charge to athletes whose schools are covered by Harris Orthopaedics and Sports Medicine.  It provides valuable information on a patient’s ability to recall words, shapes and patterns; to distinguish between patterns; and also assesses a patient’s reaction time.  The test includes internal controls to reduce the chance of a patient “cheating” on the exam.  ImPACT data allows HOSM staff to have an additional evaluation tool that can help decide when to refer on to neurology or neurosurgery.  Further information about ImPACT testing is available at their website, https://www.impacttest.com/about/.

Are there any problems diagnosing concussions?

Unlike some other conditions, concussions, by definition, don’t create any abnormal findings on x-ray, CT or MRI images.  Symptoms can sometimes by subtle.  That combination means that patients and their acquaintances (friends, team mates, coaches, teachers, etc.) might not always recongnize that a serious injury has occurred.  Concussions can be confused with other conditions.  Because symptoms can be confused with other problems, and because symptoms can be subtle and hard to see, and because improper treatment can cause serious long term problems, it is best to assume a concussion occurred if there is any chance it did occur. 

How long do concussions last?

Most concussions resolve within a month.  However, in some cases, it may take many months for concussions to clear up.

What are the most important things a patient can do to help a concussion clear up?

Be honest about symptoms and follow treatment recommendations.  It is difficult to receive optimal treatment if the patient is not honest about their symptoms.  Patients who don’t follow treatment guidelines risk prolonging their concussion. 

Why is it important to properly treat a concussion?

Concussions are brain injuries.  Even with proper treatment, concussion victims are at risk for prolonged headache, decreased athletic performance, moodiness and poor ability to concentrate.  Those symptoms affect not only the patient’s ability to function as an athlete, but also their ability to function as a productive member of society.  Proper treatment reduces (but doesn’t remove) the risk of these problems.

How are concussions treated?

Brain and body rest.  Concussion victims should avoid any task that requires significant concentration (e.g., reading, taking tests, doing homework, driving, use of power tools) or use of video screens (e.g., smart phones, TV, computers).  They may need to avoid noisy areas, crowded areas, or areas with bright light.  Concussion victims also should avoid significant exercise.  Concussion victims should be bored.  If concussion symptoms last more than 2 weeks, it may be okay to begin light aerobic activity such as walking that doesn’t raise heart rate, so long as activity doesn’t worsen symptoms. 

Concussion victims should absolutely avoid anything that puts them at risk for another head injury.  A second head injury while suffering from a concussion could, in theory, lead to a severe exacerbation of symptoms.  In rare cases, second impacts can be fatal.       

As a patient’s symptoms improve, activity and academic restrictions are slowly removed.  When the patient has a normal neurologic exam and a normal neurocognitive test, has no symptoms, and has returned to normal schoolwork, they can begin a return to play progression.  In North Carolina, the legislature has mandated a minimum 6-day return to play progression that starts with light aerobic activity and ends with unrestricted full-contact play.  This progression matches the progression suggested by current research.  The return to play progression generally is directed by an athletic trainer and final return to play is authorized by a physician.  Final return to play authorization can involved a face to face office visit, but generally is done through a phone or email conversation.

Are there any risk factors for concussions or for concussion severity?

The greatest risk factor is participation in an impact sport such as football, or an activity where falls are possible, such as cheerleading.  47% of athletic concussions occur to football players.  Other sports where concussions are common include soccer (often from a ball kicked against the head), cheerleading (from falls during aerial stunts), and basketball (from head to head or head to floor collisions). 

Some research suggests that women are at slightly higher risk for concussion, as are patients with prior concussions (especially if the first concussion hasn’t completely resolved).  A history of headaches, depression, ADHD or learning disability does not clearly increase the risk of concussion, but these symptoms may make it more complicated to diagnose and treat concussions.   

Are there any dietary suggestions for concussion victims?

Decreased appetite is common in concussion patients.  However, the energy provided by food is needed for the brain to recover, so it is important to eat a healthy diet.  Proper diet will provide a concussion victim’s body with the energy and nutrients they need to heal.  Concussion victims should avoid eating a lot of fatty or fried foods, and also should avoid eating a lot of sweets.  Vegetables, complex carbohydrates, and proteins (meat or protein supplements) are generally a good bet.  If a patient’s appetite is markedly reduced, supplements such as Ensure shakes are worth trying, to help make sure patients eat enough calories.

Dehydration causes headaches and concussion victims, therefore, should try to stay well hydrated. Ideally, they should drink 6 or more 8 ounce glasses of water a day.  They should pay attention to the color of their urine, and ensure it stays clear to pale yellow in color. 

Concussion patients should initially not change their normal daily caffeine intake because rapid changes in caffeine intake can cause severe headaches.  However, patients that do drink caffeine should try to slowly cut back, so that they’re not using any caffeine within 2 weeks or so of their injury.

Are there any sleep suggestions for concussion victims?

Sleep is an important part of the concussion healing process.  Most patients who suffer a concussion complain both of being sleepy and also of having trouble sleeping well.  Teenage patients should aim for 10 hours of sleep a night, and may sleep longer if needed. Things that intefere with good sleep, such as computers, TVs and phones, should be turned off and, if necessary, removed from the bedroom.  For the first 2 or 3 days, napping during the day is okay.  After that, naps should be avoided so that patients are sleepy during their regular sleep time.  Prolonged day time napping can interrupt sleep cycles.  Although this won’t affect concussion recovery, it can make it harder to return to a regular daily schedule.

Are there any supplements that help concussion patients?

At this time, there are no high quality studies that demonstrate any supplement or vitamin improves concussion recovery.  A daily multivitamin won’t hurt, but there is no pill that seems to speed recovery.

Are there any medications that can help concussion victims, or medicines that should be avoided?

Tylenol is generally the best choice for headache from concussion.  NSAIDs such as ibuprofen or naproxen are generally avoided for the first few weeks.  Patients should try to use as little pain medicine as possible, and should try to stop using it as quickly as possible.  Melatonin (available over the counter) can be used for sleep.  In general, patients should continue all their normal medications when they have a concussion.   

Can concussion patients go to practice?

Patients who are not attending school cannot attend practice.  Once students attend school full time, they can consider observing practice under limited conditions.  While observing, they must be in a shaded area with no risk of accidentally being struck or having another head injury.  They may not participate in practice outside of taking notes (e.g., they may not carry water jugs or equipment, or assist in coaching).  If symptoms worsen at all, they must leave the practice and not return for 48 hours.  Athletes must be honest about symptoms because worsening symptoms will slow recovery.

Are you more likely to have a second concussion after you’ve had an initial concussion?

Maybe.  Some research suggests that after every concussion, the impact threshold for a future concussion is lowered, and that it becomes increasingly easy to have an additional concussion.  However, it is possible that the patients studied didn’t have time to fully recover from their earlier concussions.  Other data suggests that if a concussion is properly treated and the patient fully recovers, they are not at increased risk for concussions. 

Although the current data does not absolutely say if concussions become more likely, it does clearly indicate several important things.  First, if a patient has several concussions and each one takes longer to heal, or occurs with less impact, that patient is at higher risk for long term problems.  Second, if a patient has prolonged concussion symptoms or has several concussions in a short time frame, they are at higher risk for long term problems.  Because of this, patients who have two concussions in a season, or who have concussion symptoms for more than four weeks in a season, should consider staying out of play for the rest of that season.  If a patient has three or more concussions, they need to consider the risks associated with further concussions, and consider avoiding all impact sports.            

Where can I go for more information?

The Centers for Disease Control (CDC) offers a wide range of concussion resources through their Heads Up program.  Information can be found at http://www.cdc.gov/headsup/youthsports/index.html.

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