Concussion

By Mike Magee, MD

Fall is upon us, and with fall in the United States comes football. What many parents of high school students are unaware of is the special -- and at times, avoidable – risk that their children are exposed to. And I’m not speaking about broken bones, cuts or bruises.

The special risk is concussion, a trauma-induced alteration in mental status often accompanied by confusion, amnesia, or rarely loss of consciousness after a blow to the head.^{1, 2, 3} You may believe your teenage football player has never had one. But you may be wrong. In fact one study of more than 1,500 high school varsity players in Wisconsin revealed that 47 percent of the players who have had concussions never revealed them to coaches or parents.⁴ Why? The reasons varied. About a third of the players felt the incident wasn’t serious enough to report. About 40% didn’t want to leave the game. And about 20% didn’t want to let their teammates down.⁴

What these kids don’t know is that these seemingly insignificant events can lead to serious disability and even death. In fact, in the past 10 years, at least 50 high school students in more than 20 states have suffered death or serious head injuries during football games. Now, that may not sound like a lot, with some 12-million American teenagers currently suited up, but of course, if it’s your kid, it’s an enormous number.⁵

The first thing to be aware of is that the problem is seriously underreported. If you ask athletic trainers how common concussion is, they’ll say it affects about five percent of a team’s players. If you ask the players themselves anonymously if they’ve had a concussion, 15% will say yes during the course of any given season. But if you omit the word “concussion” and instead ask if they’ve experienced some of the myriad of symptoms (headache, dizziness, feeling dazed and confused, trouble balancing, nausea, vomiting) that together define concussion following a blow to the head, 50 percent in any given season admit to one, and 35 percent admit to two.⁵ Each year, about 128 out of every 100,000 U.S. citizens suffer concussions, making the injury extraordinarily common.¹ Most are the result of sports or bicycle accidents. When you suffer a concussion, the force of a blow to the head can cause the brain to impact the inside of the skull. Studies over the past century have revealed that with impact, the cortex or major portion of the brain, which is fixed below by the brain stem, rotates from back to front. The force of impact and rapid deceleration can bruise the tissue and also disturb the transmission and functioning of nerve cells in the midbrain. These rotational forces are left to be responsible for the confusion, dizziness, and sometimes the brief loss of consciousness that can occur with concussion. Amnesia for actions that occurred shortly before and shortly after the event is also common, with the cause for this unknown. The sensation of being dazed or “star struck” after an impact, but without loss of consciousness, is generally viewed as the mildest form of concussion.¹

The presence of an experienced on-duty sports-trained physician at high school football games is less common than the more-visible ambulance on the sidelines. Only 42% of high schools have a certified athletic trainer on staff.^5,6,7 Robert Sallis, president of the American College of Sports Medicine, has this to say: “It’s crazy. High schools hire a zillion coaches before they wonder about hiring a trainer. If you hire a head football coach, that next hire should be an athletic trainer.^5,8

Even with experienced personnel on the sidelines, there remains no full consensus on the evaluation and recommendations for return to play for high school athletes.^1,3,8,9 Most believe that evaluation and care must be individualized, considering the age; sport; site type, duration and severity of injury; prior history; diagnostic tests; and response to exercise. In general, mild transient confusion that clears within 15 minutes with testing is less significant, especially as a first occurrence, compared to injuries where symptoms do not clear within 15 minutes, and certainly injuries where loss of consciousness occur. Testing for milder injuries includes the use of word-list repetitors, recollection of game events, normal finger-to-nose tests and gait, and checking for normal neurologic signs. In the more severe injuries, more formal neurologic exam or brain-imaging tests may be required to rule out the rare possibility of brain bleeding. ^1,2,7,8,9

So what can you, as a parent of a high school contact sport player do? First, question your child about the symptoms of concussion to see whether he or she has experienced a concussion. Second, find out if your program has a certified athletic trainer and qualified medical personnel on the sidelines. Third, speak to the coach on his policy on concussions, including how they evaluate players on the sidelines, who gets referred to a doctor or hospital, and how they decide who can play again and when. Just asking the questions may increase the safety for your kid and others. And finally, check out the web sites of the America College of Sports Medicine and the National Athletic Trainers Association.^7,8 They are filled with great information.

References

1. Rapper AH and Gorson KC. Concussion. New Engl J of Med. 356:2, 166-172, Jan. 11, 2007.
2. Cantu RC, Herring SA, Putkian. New Engl J of Med. 356:17, 1787-1789. April 26, 2007.
3. Cantu RC. An Overview of Concussion Consensus Statements since 2000.
4. McCrea M et al. Under-reported concussion in high school football players: Implications for Prevention. Clinical Journal at Sport Medicine. 14(1): 13-17. January 2004.
5. Schwarz H. “High School Players Stay Silent on Concussions Raising Risk.” New York Times. A1. Sept. 15, 2007.
6. National Athletic Trainers Association.
7. WATA. 10 tips to reduce the severity of sports related concussion in high school and college athletics.
8. ACSM Team Physician Consensus Statement. Concussion (Mild Traumatic Brain Injury) and Team Physician: A Consensus Statement.
9. Cantu RC, Herring SA, Putukian M, Stricker PR, et al., "Concussion." N Engl J Med. 16 April 2007; 356:1787-1789.