A new consensus on concussion injuries was published in the April 2017 edition of the British Journal of Sports Medicine. In October of 2016 a group of experts met in Berlin to poor over the evidence up to that date and come up with a best evidence based consensus on concussion injuries. The authors worked to affirm a definition of concussion, it’s causes, the signs and symptoms, the evaluations to perform, when to pull a player from play, and when to return a player from play. Our ultimate take away from this document is if you have you are not sure about a concussion injury or not pull the athlete out of play.
The issue of concussion is complex and the authors of this report acknowledge this. There is no clearly defined way to determine if a player has had a concussion, especially when the athlete is not knocked unconscious. We have normal values for blood pressure or resting heart rate but there is nothing like this for a concussion. There is no blood test or imaging study which can be done to prove an injury occurred or when determine when the brain is healed. The authors go on to define a concussion as “a traumatic brain injury induced by biomechanical forces.” We typically think of a concussion occurring after a blow to the head but it can also occur without any significant contact with the head. Check out this video of hockey player Brooks Orpik suffering a concussion after getting checked into the boards. He takes a hit that the NHL doesn’t consider a risk for concussion. This type of injury is what complicates the diagnosing of a concussion, even though he has symptoms of a concussion his injury isn’t what is typical so it is often missed.
Signs and symptoms of a concussion include loss of consciousness, headache, mental fog, neurologic deficit, altered gait, poor balance, irritability, slowed reaction time, and drowsiness to name a few. While it might seem obvious to spot a concussion or an athlete who had a concussion that doesn’t mean we spot them all. Not all games are played on national television and not all concussion’s happen in games. We know that somewhere around 33% of concussion occur during practice where there are fewer eyes watching athletes which leaves room for these to be missed. Here is video of a cyclist suffering a fall and concussion who is allowed to continue racing until the team boss looked at the video footage and ordered him to be pulled out of the race. This video clearly shows what an injured athlete can look like and also how an athlete will fall back on his or her competitive nature to continue playing despite this injury. Many times an injured athlete will deny an injury to avoid being pulled from a game, especially an important one.
There are simple sideline evaluations that most coaches are trained to use to determine when to pull a player. The consensus report mentions the SCAT5 tool which they recommend at the sideline but an athlete that tests positive still needs further evaluation by a physician, urgent care, or emergency department. Ultimately the consensus report give us the opinion that if you have doubt about a concussion it is safer for the athlete to take them out for evaluation by a physician than to return them to play.
The best thing to do to mange a concussion injured athlete is to have proper prevention strategies. This starts with a good baseline examination. The baseline testing that is most commonly done today is flawed. This is a whole blog topic by itself but the ImPACT test that your athlete has likely done has problems. If you want to know more, let me know, I would be happy to talk about this in detail. There are better baseline exams out there, we use one in our office, this is approved by the FDA and similar agencies in Canada, 16 countries of the EU, and Australia. With a good baseline exam in hand if your athlete gets injured we have something valid to measure them against to help determine if an injury occurred and when to return them to play. I would be happy to discuss this with you too if you want to know more. Other things to understand is using correct form in play like no leading with the head to tackle in football. Each sport is working on best practices guidelines for play to avoid injury, spend some time reading what is going on at the national levels. Look into what they are doing in Europe as well because Europe tends to be ahead of the US in safety for the athlete.
We offer a workshop on concussion called Concussion Roulette-TM. We have given this in house but we offer it also to sports clubs, school boosters, or where ever there are parents who want to know this issue more and what they can do to keep their athlete safe. If you want us to come give this talk to your group let me know, I would be happy to see if we can speak at your next meeting. Email me here at email@example.com to set that up.