Concussion: A Heads Up for Coaches & Parents

Concussion is common and it can be fatal, as the case of a 13 year old, B.C. boy who was skateboarding without a helmet and died after hitting his head, demonstrated this summer. Concussion has also been controversial, as medical science has been slow at adequately addressing issues such as when an athlete can return to sport after a concussion.

So just what is concussion? “The message we are trying to get out to coaches and families is that you can still be awake but concussed. If people are confused or have some memory loss, they have been concussed,” says Dr. Chris Honey, an associate professor of neurosurgery at the University of British Columbia. “By definition, concussion is temporary and reversible. But multiple concussions are a bad thing.”

The definition of concussion has been changed lately to reflect more modern thinking,” says Dr. Karen Johnston, a Montreal neurosurgeon who chairs the Concussion in Sport group, (CIS) which recently revised 35-year-old concussion guidelines in time for this year’s Winter Olympic Games and the World Cup of Soccer. “In the past, we thought that you needed to be knocked out to have a concussion – that is not true. It can be as mild as a ding, where you have a transient alteration in your sensation, which may go away very quickly or may take a prolonged period to go away. We need to have more respect for this injury. The effects of any one concussion may seem quite transient, but it is not at all uncommon for some people, after a mild injury to have some fairly persistent symptoms. No one injury should be treated as though you know what the outcome is going to be.” The degree of concussion is now also receiving a lot of attention.” The whole concept of serious concussion is really controversial right now; people used to think the most serious concussion was when you were knocked out. But we have lots of proof now that shows that’s not true. In fact, a concussion when you are not knocked out, but when you still have headaches a month later is probably a more serious injury than if you were knocked out and felt fine the next day,” says Johnston.

It is important to remember that concussions are not limited to direct hits on the head: they can also result from a blow to the body, such as from body checking in hockey, “where you just shake the head around, because it is attached to the body. “That’s a relatively new way of thinking of this,” says Johnston. Johnston thinks that media coverage of high profile athletes and locker room discussion “from teammate to teammate,” as well as initiatives such as the Smart Hockey Program have generated increasing public awareness of the dangers of concussion. However, she admits, “We have a long way to go, because there are large groups of kids who have very little supervision. In the professional leagues, they all have team doctors and trainers who have been taught about concussion, but at the local arena on a Friday night, you’ve pretty much got coach and parent. So our goal is to impact on those populations, because that is where most of the injuries are happening – in the non-professional leagues.

Helmets help prevent concussion in some sports – there is “pure evidence” that bicycle helmets, for instance, prevent injury, says Johnston. But for kids, the main issue with helmets is “they have to be comfortable and look cool,” she says. Mandating helmets in sports often results in resistance and Johnston says that responsible adults have to reinforce the rules – and not just for kids. “Adults, as role models, should be protecting themselves too.” So what should parents, teachers and coaches do when a child has hit their head, playing at school or at the arena? The first challenge is recognizing the concussion, says Johnston. “Although you can lose consciousness, that is the very rare case. If somebody is knocked out, they are going to get looked after. It is the myriad of other injuries that get ignored.” The adults seeing the child after the injury “have to have a high index of suspicion” and ask specific question, including:

• Do you have a headache?
• Do you feel sick to your stomach?
• Did you feel dizzy after that – did you see stars?

Even if you are not certain that there has been a concussion, the child who was playing a game, “must sit out – if in doubt, take them out.” The athlete then needs to be evaluated by a doctor and monitored, says Johnston. When should a child return to sport, given the dangers of succumbing to a second concussion? Honey is unequivocal: “If you are still under the effects of one concussion and suffer a second, the results can be devastating. What would seemingly be a trivial second concussion can be more than cumulative – that’s called Second Impact Syndrome and that is basically what we are trying to prevent.” While Second Impact Syndrome is well recognized in neurosurgery, coaches need to be more aware of its implications, says Honey. “Where the hockey player comes off the rink – he’s never unconscious but is clearly confused and he sits out for a shift or two then he’s back in the same game – they’re playing with his life doing that sort of thing.” "The child who returns to sport too soon risks debilitating long-term cognitive problems, says Johnston. " “My concern is for the impact of ongoing, persistent symptoms at this point in the athlete’s life, particularly when you are talking about kids or young adults. If these kids are having headaches, dizziness, lack of concentration, problems with memory, fatigue, and insomnia on a regular basis, this has a big impact on their day-to-day life, in terms of their socialization and their academics. I have seen many, many kids who lose a year of school simply because they have headaches every day, so it is very serious.” The CIS guidelines stress a step-wise return-to-play program, based on progressing to the next level when the child is symptom-free. If the athlete experiences post-concussion symptoms, they should return to the previous asymptomatic level for at least 24 hours.

The six levels are as follows:

• No activity, when free of symptoms, proceed to next level.
• Light aerobic exercise such as walking or stationary cycling.
• Sport-specific training, such as running for soccer.
• Non-contact training skills.
• Full-contact training after medical clearance.
• Game play.

(Adapted from return-to-play protocol, Summary and Agreement Statement of the 1st International Symposium on Concussion in Sport, Vienna 2001).

Johnston is currently working on several research projects using sport-specific rehabilitation for progressing between the above levels. “Sometimes symptoms can come back with any kind of exertion; if symptoms come back at any point, you slow down, backtrack and resume in a more gradual fashion. We don’t know why symptoms come back with exertion, but the longer you have been symptomatic, the more likely your symptoms will return with exertion. So it’s very important that you don’t go straight from sitting on the couch for a couple of weeks back to the game.” Johnston says that there are several things that coaches can do at the beginning of each sport season, including having athletes undergo pre-season medical examinations to establish baseline data.

For coaches, free sideline evaluation forms for use in the event of a suspected concussion are readily available, such as McGill University’s ACE questionnaire, or the Standardized Assessment of Concussion (SAC). These are simple to use, check-off type surveys. “Everyone has access to them, they can be performed by non-neuropsychologists – the trainer, the coach or even the parent – and its recommended by the CIS group which is the largest group of expertise consensus on this topic. There will come a time in the near future when if you are not using (such evaluation forms) perhaps should not be doing the job you are doing, coaching and looking after kids in contact sport.”

Heather Kent is a Vancouver freelance medical writer. She is a regular contributor to the Canadian Medical Association Journal and numerous other North American health and medical publications.

Copyright held by SportMedBC. For information contact info@sportmedbc.com.