Put Me Back In Coach!

Dave was the quarterback for my college fraternity's football team.  Though it was flag football, Dave got knocked down a lot, and several times hit his head on the ground.  For days he would act confused, repeat questions over and over, and finally recover. He graduated to go on to fly Navy jets and finally got a helmet to wear!  Dr. Blake McDonald, a Family Practice resident at the University Hospital and Clinics here in Lafayette, discusses concussions this week: pay attention! Concussion is an injury caused by a blow to the head.  This injury impairs neurologic function: concussions interfere with coordination, thinking, emotions, and sleep.  They eventually heal, but it takes time. Concussions aren't bleeding in the brain or skull fractures- they aren't detected by CT or MRI scans.  They can be measured by neuropsychological tests, where the patient interacts with a computer program or a paper-and-pencil test.  In other words, concussion is a functional injury, not a structural one. Concussions are a big problem, bigger than statistics report.  About 144,000 people per year visit ERs for concussions, but one review estimates that there may be up to 3.8 million recreation and sports concussions per year in the U.S.  And that doesn't include injuries in grade school and middle school athletes. Football is the riskiest sport for concussions in high-school boys, soccer and basketball for girls.  Rugby, ice hockey, cheerleading, and lacrosse also probably have high concussion rates, but their data are limited since these are often club activities rather than official school sports. Headache and impaired coordination are the main physical symptoms of concussion. Loss of consciousness is another physical sign, but this only happens in 10% of concussions- you don't have to be knocked out to have a concussion! Concussions also affect cognitive function- the ability to think and remember. Kids with concussions have trouble with homework, concentration, and thinking clearly.  Memory is also impaired- a concussed child may not remember what happened for some time before and after the injury.  Some kids have short term memory loss, asking the same question over and over. Besides causing physical symptoms and thinking deficits, concussion can affect emotional stability.  Concussed kids are often tearful and depressed.  They can be emotionally "labile," meaning one minute they are acting silly, the next minute moody. Kids with concussions sleep a lot.  This worries parents who have heard not to let head-injured kids sleep.  But sleeping late and napping with a concussion is part of normal healing. So how can we help concussions heal?  Management involves avoiding activities that slow natural recovery.  This means allowing time for physical, cognitive, and emotional recovery, and not worsening things.  Even the NFL now recognizes that if you send an athlete back out who has impaired coordination, concentration, and thinking, they stand a greater chance of getting more hurt. Cognitive and physical rest are the mainstays of management.  Cognitive rest means staying home from school.  Upon return, concussed kids may need shorter school days and reduced work.  They may need more time for assignments or tests.  If headaches return, the child may need to be out of school longer.  Videogames and computers can worsen symptoms too. To be allowed to return to full school work or sports, the child must be symptom-free- no headaches, normal coordination, no trouble thinking or remembering, no more fatigue or depression.  This can be a problem with motivated athletes who hide their symptoms to stay in the game.  Coaches, teachers, and parents need to be vigilant.  If a kid hits her head and then seems impaired, the approach is simple: "when in doubt, sit them out!" Coaches and trainers should be aware of sideline tests for concussion to detect impairment. When kids do return to school or sports, they need a "graduated" increase in intensity.  This means slowly increasing class work and home work.  In sports, it means slowly increasing physical intensity, then adding complexity (like adding drills and plays), then scrimmaging, then full play.  Worsening symptoms during that time mean "back off!"   Though there's been much prevention talk about mouth guards, better headgear, altered sports rules, the best tools to prevent and treat concussions are education and recognition- for athletes, parents, coaches, trainers, teachers, administrators.  And doctors and nurses too!