Concussion Symptoms and Testing

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When talking about Title IX, the discussion centers on the increased participation of girls in sports and that's a good thing, but there may be a statistic that is less exciting. While football is king in causing sports head injuries in young athletes, girls' soccer can proudly boast being in second place, beating out hockey, basketball, and wrestling. Regardless of the activity, it is estimated that there are more than 300,000 sports-related concussions every year in the U.S., and that number is likely on the low side. Regardless of whether it's a boy or girl, the number of concussions diagnosed in the past 10 years has increased by more than 50%.

Concussion can be an easy diagnosis when the athlete gets knocked out on the field or is slow to get up, but often, concussions are subtle and even the athlete isn't aware that the brain has been shaken. Being unconscious is not a requirement for diagnosis of a concussion, and symptoms can be delayed by many hours from the trauma that has irritated the brain. The symptoms of a head injury may be as subtle as a child having a hard time concentrating in school, having difficulty with homework, or being more irritable at the dinner table. Recurrent headaches, dizziness, and lethargy are more easily recognizable by parents or friends. While the medical literature uses the term minor head injury, there is nothing minor about a brain that has been concussed.

More typical symptoms of a concussion include:

  • headache,
  • dizziness,
  • nausea,
  • a dazed feeling,
  • irritability, and
  • visual problems.

The diagnosis of a concussion is made on clinical grounds and the taking of a good history. It's based on the mechanism of injury (if it's known), the symptoms, and a normal physical and neurologic exam. Imaging the brain with CT scan or MRI is less than helpful and a normal scan result may lull the athlete, parent, and even the doctor into a false sense of security. There are reasons to do CT scans and they are the same rules that apply in any trauma. Is the patient not fully awake? Are they vomiting? Is there evidence of a skull fracture? The CT is looking for blood and swelling; it isn't looking for loss of function.

Treatment for a concussion is time. Physical and mental rest is needed to allow the brain to recover and in today's teenage world, it is a major challenge to achieve. Computer and video screens that flash ever changing images and smartphones filled with text messages stress the brain to keep up with all the input. Resting the brain may require limiting internet and phone time and, for a child or teen, the treatment may seem like a terrible fate. For high school athletes, seasons are short, and both parents and kids realize that being out two or three weeks may mean missing half a season. Dealing with the frustration with brain healing may be an important part of the treatment support that a doctor, team trainer, or coach may offer. It may be an important reminder that some professional athletes have lost a year or some time period in their career because of a “minor” head injury and concussion.

Return-to-play guidelines stress that no player should return immediately to the field of play after a potential head injury. This is a major philosophy change that has occurred over the last several years, because formerly a knock on the head was considered a rite of passage and not playing was a sign of character weakness. Usually, decisions about practice and games take days and repeat neurologic testing. The reason is pretty clear. It is very difficult to determine how well the brain functions. Testing whether a patient can count or how well they follow a finger with their eyes works well in the movies but in the real world, the subtle changes in how the brain reacts and thinks can be missed by even the best doctor or trainer. Many team doctors use computer testing, for example the IMPACT test program, to measure subtle changes in concentration and mood. Others rely on clinical judgment and neuropsychological testing to decide who can play and who can't. Regardless, the brain has become the focus of the return-to-play decision and not the athletic potential of the body.

High school athletes mimic the pros they see on television, and the lessons are changing. Players are being taken off the field because of concussion and not being allowed to return. Teammates have become their brothers' keepers and watch out for players who might not realize that they have been concussed. Chronic traumatic encephalopathy (CTE) is on the mind of every NFL player. Perhaps it should be on the mind of every parent with a kid playing competitive football or soccer.

REFERENCES:

ImPACT® Test. < http://www.impacttest.com/>.

Marar, Mallika, et al. "Epidemiology of concussions among United States high school athletes in 20 sports." The American Journal of Sports Medicine 40.4 (2012): 747-755.

Stiell, Ian G., et al. "The Canadian CT Head Rule for patients with minor head injury." Lancet 357.9266: 1391-1396.


Last Editorial Review: 5/21/2012