Assessing Concussions is Not Always Easy

Assessing Concussions is Not Always Easy

by Daniel Rancier MD – 


Injuries are not only a part of sports but also a part of life. People fill up emergency rooms with twisted ankles, broken bones and damaged noses. Those are all physical injuries. Whether they were incurred on the playing field or just in everyday life, these injuries are easily diagnosed and have a clear path to recovery.

However, what if the injury is not so easily seen, such as a concussion? How can it be quickly determined that a player has received a concussion? Well, there are signs and symptoms. However, they’re not so easily recognized. And in many cases, some symptoms may take days or even weeks to appear.

So, what exactly is a concussion? The Centers for Disease Control and Prevention (CDC) provides this description;[1]

A concussion is a type of traumatic brain injury—or TBI—caused by a bump, blow, or jolt to the head or by a hit to the body that causes the head and brain to move rapidly back and forth. This sudden movement can cause the brain to bounce around or twist in the skull, creating chemical changes in the brain and sometimes stretching and damaging brain cells.”

 Although medical providers consider a concussion a “mild” brain injury, it can still have long-lasting effects and is considered severe.

Much more is known about concussions today than in the past, and efforts to ramp up communication and education regarding the signs and symptoms are on the increase. But many times, in the heat of an athletic contest, coaches, trainers and even parents don’t pay close enough attention to the potential symptoms including physical, balance, cognitive and behavioral.

According to the 5th international conference on concussion in sport held in Berlin:[2]

“The diagnosis of acute SRC involves the assessment of a range of domains including clinical symptoms, physical signs, cognitive impairment, neurobehavioral features and sleep/wake disturbance. Furthermore, a detailed concussion history is an important part of the evaluation both in the injured athlete and when conducting a pre-participation examination.

The suspected diagnosis of SRC can include one or more of the following clinical domains:

  1. Symptoms: somatic (e.g., headache), cognitive (e.g., feeling like in a fog) and/or emotional symptoms (e.g., liability)
  2. Physical signs (e.g., loss of consciousness, amnesia, neurological deficit)
  3. Balance impairment (e.g., gait unsteadiness)
  4. Behavioral changes (e.g., irritability)
  5. Cognitive impairment (e.g., slowed reaction times)
  6. Sleep/wake disturbance (e.g., somnolence, drowsiness) “

 Some of the more common symptoms shown are some of the ones that may be the hardest to see. For example, feeling dazed, confused or having a slurred reply to questions are common. But without looking closely at the individual and asking a few pointed questions, most people won’t notice anything wrong. Some players might explain that they were “dinged” for a minute but feel alright now. This temporary dazed feeling is a clear sign of at least a mild concussion, and the athlete should be removed from play.

More serious but less common signs of a concussion can include nausea and headaches, having balance issues, sensitivity to sound or light, and tingling or numbness of an extremity. Nausea you can see, but the other symptoms are not readily noticed without the player sharing the information.

One thing that is easily seen is if the person has a loss of consciousness after a hard hit. But in an article published by the Neurologic Rehabilitation Institute at Brookhaven Hospital[3] , it’s noted that loss of consciousness, actually occurs in only less than 10 percent of concussions. The symptoms of a concussion that are more likely to appear are less easy to notice. They include feeling dazed, stunned, or confused, as well as slow or slurred speaking. Other symptoms include feeling sluggish, sad, or irritable, headaches, nausea, balance problems, sensitivity to noise or light, and tingling or numbness.

If the player does suffer a loss of consciousness, even temporarily, he or she should never be allowed back into a practice session or game until they have been cleared by a healthcare professional.

And here is another scary thing about concussions. Many times, symptoms may not occur until some time after the injury happened. In an article published at momsteam.com[4], it’s noted that children, or teens, when compared to adults, appear more likely to experience a more noticeable delay in the onset of symptoms so that the severity of the concussion – even the diagnosis itself – might not be fully apparent until days after contact. It also suggests that the younger the child, the more delayed their symptoms may be, and the longer it may take to recover from those symptoms.

Which is why the parents of young athletes need to be aware of any changes in their child and need to take seriously any symptoms that are noticed, regardless of how long ago the event may have occurred. Even though there could be a myriad of signs, some of the ones to look out for are changes in speech, balance, thinking, behavior, attention, or emotional response. Also, check for signs of confusion, headache, vision changes, dizziness, ringing in the ears, or nausea.

Parents should also be aware not to underestimate other possible signs such as a drop in grades at school, sleep patterns that have changed or out of character emotional changes from your child. And just one of these symptoms could be a cause for concern.

But whatever the sport, one big clue for those watching the event, whether it is a coach, trainer, teammate, official or parent, is actually witnessing a hard hit that could have caused damage to the brain. The hit doesn’t have to be direct-to-the-head to cause a concussion. Any hit hard enough to cause the head to snap or to hit the ground or another player could have the same effect.

Regardless of who witnesses the hit, it’s in the athlete’s best interest that they are checked out for any possible symptoms before being allowed to return to play. Most players prefer to shrug off a big hit, not only to display their toughness but to get back into the game.

So the parent’s role becomes critical, not just in helping to diagnose symptoms of a concussion, but to monitor the progress or deal with worsening symptoms. There is no better place to observe concussion symptoms and the athlete’s behavior than at home. Here are some important things that parents can do to help.

Monitor

Keep an eye on your child whether they have shown symptoms of a concussion or not, especially if they received hard contact during their event. As mentioned, there are times that symptoms don’t appear right away and are delayed. If your child has been diagnosed with a concussion, monitoring them closely and taking action if symptoms have worsened.

If symptoms worsen, such as increasing headaches, vomiting, unable to stay awake or increasingly slurred speech or numbness and tingling, then get medical attention immediately. These could be a sign of a more serious medical condition.

Manage

Parents should take control of their child’s activities to be sure they are getting the appropriate rest following a concussion, no matter how mild. This will include not just physical rest, but also cognitive rest. Many experts differ on the amount of rest from both a physical and cognitive perspective is needed. And there may not be a set amount of time. It will most likely vary depending on the person and the severity of the injury. Some will argue that removing the child from an activity they enjoy, will only make them more anxious and depressed. But the common theme is to provide some rest from both activities and then gradually increase exercise and mental activities that will not put them at risk for any further damage until all symptoms have cleared.

Keep Track of Medications and Diet

Most researchers and medical personnel believe that acetaminophen or codeine are preferred medications for pain relief. Although no studies have documented any harm from use of aspirin or nonsteroidal anti-inflammatories (NSAIDs) after a sport-related concussion, the standard recommendation against their use is based more on a theoretical risk.

Keep your child away from any drugs, alcohol or sleeping pills following a concussion. These can interfere with recovery, and even though sleeping issues could be present, the use of a sleeping pill is discouraged.

Make sure that a regular, well-balanced diet is available during the recovery process. A proper diet can provide valuable nutrients to the body which can help the overall healing process.

As you can see, diagnosing a concussion is not as easy as that of a physical injury. More diligence is required by all people involved. This includes coaches, athletic trainers, officials, teammates and even parents. Many sports leagues have instituted concussion protocols to help with the issue.

Unfortunately, concussions continue to happen, and due to the nature of contact sports, will most likely continue. But how accurately we diagnose the initial injury, and what is done to treat it and ensure a proper recovery, can make all the difference. However, if a player with a concussion returns to play before a full recovery, then the odds of a second and more severe injury increase.

So even though education and awareness have increased, it needs to continue. Everyone involved in the activity needs to be on high alert and fully trained to understand even the smallest symptoms of a concussion. Rules and protocols also need to be monitored for their effectiveness and updated as required.

Hopefully, by doing these things, we can help improve the early and accurate diagnosis of concussion symptoms. Although it still may not ever be as easy as diagnosing a physical injury, the overall goal is to increase the awareness and accuracy of finding concussion symptoms as quickly as possible.

[1] https://www.cdc.gov/headsup/basics/concussion_whatis.html

[2] McCrory P, Meeuwisse W, Dvořák J,    et al. Br J Sports Med 2017;51:838–847.

[3] http://www.traumaticbraininjury.net/why-concussions-are-so-hard-to-diagnose/

[4] http://www.momsteam.com/health-safety/concussion-signs-symptoms-delayed-onset-more-common-in-children-teens

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