Advances & Insights: Neurosciences
What the news means for you
James A. Jagger, MD
Stricter regulations could help prevent concussions
We’re seeing more young athletes with concussions in the UK Sports Medicine Clinic, partly because coaches, trainers, parents and the athletes themselves are better educated about the dangers. The patients we see are involved in a multitude of sports – soccer, football and most any sport where there is the possibility of running into another player or getting hit in the head with something. It’s important they get the proper attention to determine if they can safely return to sports.
“The rule is, when in doubt, put them out. This refers to all levels of play.”
Legislation is pending in Congress and in the Kentucky General Assembly that, if passed, would significantly protect athletes under the age of 18 who suffer a sports-related concussion. These bills are much like the Zachary Lystedt concussion law enacted in Washington state. The law is named after a teenager who suffered a serious brain injury while playing football in October 2006. Because no one recognized the signals of his trauma, Zachary continued to play and later collapsed with life-threatening injuries. Under the law, approval is now required from a health care provider before young athletes who have suffered a head injury can re-enter play.
In the past, athletes with brief symptoms were put back into the game after 15 minutes if they became asymptomatic and had a normal exam. Now, if you take them out of the game when you suspect concussion, they’re done for the day. The rule is, when in doubt, put them out. This refers to all levels of play.
Recognizing a concussion
The symptoms of concussion include staggering, grogginess, dizziness, vomiting and headache. Oftentimes, with experience, you can look at the athlete’s eyes and you know: They have this blank look, this flat affect when they are concussed. If the athlete is older than 18, symptoms resolve over 15 minutes of observation and all tests are normal, he or she might be allowed to re-enter the game at the college level and above.
It’s so important to protect these young people because their brains are still so immature that there is an increased risk of another concussion. For example, if a high school athlete sustains a concussion, he is three times more likely to get another that same season. The threshold for being concussed gets lower and lower. It takes less force and less impact to cause a second or third concussion.
“If a high school athlete sustains a concussion, he is three times more likely to get another that same season.”
Another thing we worry about is the second-impact syndrome, which typically occurs only in those 18 or younger. If they are still suffering from the first concussion and go back into the game while still having symptoms, another blow to the head can cause swelling in the brain and death.
What is a concussion?
A concussion is a form of traumatic brain injury and shouldn’t be taken lightly. One of my pet peeves is hearing somebody call a sports concussion “a mild traumatic brain injury.” The adjective “mild” implies no serious or dangerous complications. We hope they’re all mild, but you can’t assume that.
“A concussion is a form of traumatic brain injury and shouldn’t be taken lightly.”
A concussion is a neurophysiologic trauma. It affects the physiology of the brain without leaving a permanent mark. You don’t have damage that can be seen on a CT scan. There are some chemical changes that take place in the brain, but these are mostly electrical changes in the brain or neurons.
We don’t know exactly what happens with the child’s brain. We evaluate concussions based on symptoms and cognitive testing. If the patient has no further symptoms after testing, they’re entered into a return-to-play program. After 24 hours of no symptoms, they’re allowed to do light exercise. If they develop a headache, we’re back to ground zero. If there is no headache, they may do more intense running and exercises, building up but with no collisions allowed. After they do well under controlled circumstances, they’re allowed contact. Typically, it takes three to four days to return to contact and collision. This is the protocol we’ve been doing at UK for 10 years, at all age levels.
Sports Concussion Clinic
There are only a handful of sports concussion clinics in the United States. At UK, we have world-class resources that we’re using to develop a multidisciplinary Sports Concussion Clinic. It will provide health care as well as education on the prevention and treatment of concussions. The program will be composed of health care providers in areas such as neuropsychology, rehabilitation medicine, radiology, research and sports medicine.
Dr. Jagger, of the UK Orthopaedics & Sports Medicine, is head team doctor for UK Athletics and assistant professor of surgery in the UK College of Medicine.
Sports-related concussions a danger to young athletes
Head injuries among youngsters playing sports, particularly basketball, appear to be on the rise, according to several recent studies. This is especially disturbing since adolescents and teens, with their still-developing brains, are at higher risk for long-term developmental and cognitive problems after such injuries. In response to the growing evidence, federal and state legislation is being considered to better address how to prevent and treat sports-related concussions in children.
“Adolescents and teens are at higher risk for long-term developmental and cognitive problems after [head] injuries.”
A study conducted by Nationwide Hospital in Ohio found the number of traumatic brain injuries (TBIs) increased by 70 percent among young basketball players from 1997 to 2007. At the same time, there was a drop in the number of other injuries, such as sprains, strains and lacerations.
The retrospective study, published in the Sept. 13, 2010, issue of Pediatrics, looked at 4.1 million basketball-related injuries in children and adolescents from ages 5 to 19 who were treated in emergency departments. Over the 11-year study period, the number of TBIs doubled for boys and tripled for girls. The study authors speculated that bigger, stronger players may account for the dramatic increase of TBIs among girls.
Another study, conducted at Rhode Island Hospital/Hasbro Children’s Hospital, examined emergency department visits for sports-related concussions in all sports among young athletes. Using the National Electronic Injury Surveillance System and All Injury Program, they looked at half a million emergency department visits for concussions in children ages 8 to 19 from 2001 to 2005. About half of these concussions were sports related, and most were sustained by 8- to 13-year-olds.
The top five concussion-generating team sports were football, basketball, baseball, ice hockey and soccer. Football and basketball accounted for the majority, but that could be related to the increased numbers of participants, the authors noted.
Management and prevention strategies
The number of TBIs in young athletes may actually be greater than research had shown, the authors of the Ohio study note. They found that more than one-third of the players didn’t recognize concussion symptoms or report them to trainers. “To address the problem of TBIs and to manage them effectively, education of coaches and athletes is vital,” they stated.
More research needs to be done in determining when a young athlete is able to safely return to play following a concussion, the authors of the Rhode Island study said. Several strategies for return-to-play decisions are being examined at the high school, collegiate and professional levels. These include neuropsychological testing, functional MRI, visual tracking technology and balance dysfunction tracking.
Many concussions are caused by head contact with other players or with balls. Decreasing the mass and air pressure of basketballs and soccer balls in particular is one preventive measure suggested.
“More than one-third of the players didn’t recognize concussion symptoms or report them to trainers.”
At a recent Mayo Clinic hockey summit, participants proposed a total ban on contact at the head at all levels of hockey; mandatory education of coaches, parents, referees and physicians about how to recognize, treat and prevent concussions; and prohibiting athletes from returning to play until they are cleared by a doctor.
The two recent Pediatrics studies have several limitations. Both examined data only from emergency departments. Visits to a doctor’s office, urgent treatment center, or care given at home or by coaches and trainers was not considered. Also, athletes and caregivers underreported concussions, lowering the overall estimates.
Additional research is needed, the researchers concluded, to provide guidance in management, prevention strategies and education for practitioners, coaches, parents and athletes.
- Emergency department visits for concussion in young child athletes, Pediatrics, v. 126, no. 3, September 1, 2010, pp. e550-e556
- Basketball-related injuries in school-aged children and adolescents in 1997-2007, Pediatrics, v. 126, no. 4, October 1, 2010, pp. 727-733
- Head injury, Health Information, UK HealthCare
- Traumatic brain injury, MedlinePlus, National Library of Medicine
- UK Sports Concussion Program, UK HealthCare
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