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Family Health Magazine - ACTIVE LIVING

Concussion in Sport
Protect players from serious injury

You are the coach of Joshua, a 17-year-old hockey player. During a game, he is forcefully body checked into the boards. He is wearing a helmet with a full face shield. The right side of Joshua’s helmet hits the glass and he falls to the ice. He gets up slowly, but continues to play. When Joshua’s shift ends, he skates back to the bench. He seems okay.

Concussions can occur in any sport. They are more common in ice hockey, football, rugby, soccer and other activities involving contact or collision. However, concussions can happen in non-contact sports.

Thanks to extensive clinical and lab research, we now understand much more about this injury. Still, the science is in its infancy. It is important to know that concussion can happen without losing consciousness or memory. In fact, more than 90 per cent of sport-related concussions do not result in loss of consciousness.

Having one concussion may increase the risk of experiencing another. What’s more, mounting evidence suggests that more damage may be done each time. Athletes who have had one injury are often easily hurt again. They may also experience more severe symptoms that take longer to resolve. Problems with brain function, including memory and thinking processes, may increase with each concussion. However, no one knows how many concussions are too many. It is hard to say at what point an athlete should permanently stop playing contact sports.

Assessment

When you ask Joshua what happened, he replies that he got his ‘bell rung.’ He does not recall exactly how it happened, but says his vision was blurry for a few minutes and he has a mild headache. He insists that he is fine and wants to keep playing.

Signs and symptoms of a concussion

If any one of the following symptoms or signs is present, suspect concussion.

Memory or orientation problems

Physical symptoms

  • Unaware of time, date or place
  • Unaware of the period or score of the game
  • Confused
  • Dizziness, headache, nausea, vomiting, ringing in the ears
  • Vision changes (loss of field of vision, double, blurred, ‘seeing lights’)
  • Slurred speech, feeling ‘in a fog,’
  • sensitivity to light and/or sound
  • Difficulty with memory and concentration, poor coordination and balance

Unusual behaviour

Steps to take

  • Slow to answer questions or follow directions, easily distracted
  • Displays unusual emotions (crying or laughing)
  • Personality changes
  • Mistakes in playing behaviour (such as skating in the wrong
    direction or shooting on own net)
  • Poor playing performance
  • A player that shows any sign of concussion must not be allowed to continue in the game.
  • Do not leave player alone, in case condition becomes worse.
  • Have player evaluated by a medical doctor.
Adapted from Heads Up for HITS Handbook

A concussed player may experience many symptoms, including:

  • headache
  • low energy or fatigue
  • dizziness
  • nausea
  • confusion
  • neck pain
  • double or blurred vision
  • unsteadiness
  • sensitivity to light or sound
  • feeling ‘in a fog’
  • ringing in the ears
  • vomiting
  • slurred speech

Athletes tend to downplay symptoms and often report that they feel fine. If you suspect concussion, ask the athlete to grade himself on a scale of zero to 100 per cent. An athlete who admits he is less than 100 per cent is often more willing to report symptoms that account for not feeling perfect.

Ideally, a player’s status should be assessed in a quiet area away from other coaches, teammates and distractions. Watch for problems with memory. Athletes may not be able to remember events leading up to the injury (retrograde amnesia) or create new memories afterward (anterograde amnesia).

Assess orientation, concentration, and coordination. Your player should know his name, the current time, date and place, and what is happening in the game or activity. For instance, ask about the period of play, the score, or who scored most recently. Assess concentration by having him say the months of the year in reverse order, or spell ‘world’ backwards.

Finally, check co-ordination by having the player stand with feet together, arms stretched out in front with palms facing up. Have the player close his eyes. If he is unable to stay balanced, co-ordination and balance sense may be impaired.

When you assess Joshua, he is unable to recall the score of the game. He does not know what period it is and cannot repeat all the months of the year in reverse order. His co-ordination seems okay. Although he has a headache, he says he is ready to play again. You are uncomfortable about letting him back in the game.

If any symptoms are reported, whether minor or severe, remove the athlete from the game immediately. If the assessment is abnormal in any way, the athlete should not be left alone. Watch for worsening symptoms or change in level of consciousness. A doctor should evaluate the player as soon as possible. If there is any doubt, keep the player out!

The Sport Concussion Assessment Tool (SCAT) is a most helpful document which can be downloaded from www.thinkfirst.ca (click on Concussion Education).

Table 2
Steps for returning to play after a concussion

Step 1

Complete rest until no symptoms are experienced for 48 hours

Step 2

Low intensity exercise, like stationary cycling, for 15 minutes

Step 3

Higher intensity exercise, such as running figure eights or lines for 20 to 30 minutes, with short bursts of sprinting or; all-out effort mixed in.

Step 4

Sport specific practice and drills, but with no body contact, one-on-one battles, or any activity that could lead to contact or collision

Step 5

Full practice, including one-on-one battles and body contact

Step 6

Return to game play or activity after medical clearance

Recovery

You decide to pull Joshua out of the game. His parents take him to the dressing room. After he has changed, they go to the hospital emergency room for further evaluation.

The next day you phone Joshua. He tells you he slept badly, still has a headache and just does not feel right. Then he asks if he can practice this evening.

Safely returning to play is a critical part of properly caring for a concussion. A concussed player should not return to practice or play if any symptoms are present. Insist on rest from all physical activity until completely symptom-free for at least 48 hours. It is important to stress that rest is to be absolute rest. This means no sports, no exercise, no weight lifting, and no exertion with activities of daily living.

Resting the mind is also important. Symptoms can be made worse with activities such as prolonged computer use, video games, listening to loud music and watching movies. A gradual progressive step-by-step return to play plan should be followed.

Each step should take one day (24 hours). If any symptoms occur with exertion at any time during the steps, the athlete must return to rest until symptoms stop for at least 48 hours. Then, start again from step one!

In addition to being symptom-free, and then passing the return-to-play steps, you must ask whether the athlete feels ready to go back to the same environment that caused the injury. Hesitancy or feeling tentative is a sign that the athlete may not be fully recovered. Do not allow a return to play until confidence is also back.

An athlete may be unable to progress through the return-to-play steps without symptoms, or have a history of many previous concussions. In this case, a doctor familiar with managing sport concussions should become involved.

For more detailed information about concussions in sport, check out the following information sources

www.thinkfirst.ca

Position Statement on Concussion Management from the Canadian Academy of Sport Medicine

www.casm-acms.org

Heads Up for HITS
Handbook published by the Sport Medicine Council of Alberta

www.sportmedab.ca

Prevention

Joshua returns to play after completing the steps and does not have another concussion during the season. After practice one day, he asks whether he can prevent getting another concussion.

Given the nature of sports, it is not possible to prevent all concussions. However, there are ways to lower the risk and severity of a concussion.

Since the helmet worn when the concussion happened may have been weakened, consider replacing it. The age and fit of all equipment should be checked to make sure it offers the best possible protection.

Using full facial protection and a custom-fitted mouthguard that covers the molars should be considered in contact sports. Recent research has shown that in comparison to a half-face shield, a full-face version may lessen the severity of impact. Mouthguards protect the teeth, lips, gums and jaw. They may also shield against concussion by reducing forces transmitted to the brain.

Athletes, parents, and coaches should all understand the signs and symptoms of concussion so that any future injury is recognized early and managed properly.

FAMILY HEALTH is written with the assistance of
Alberta College of Family Physicians
FAMILY HEALTH is written
with the assistance of
The College of Family Physicans of Canada
Alberta College of Family Physicians
While effort is made to reflect accepted medical knowledge and practice, articles in Family Health Online should not be relied upon for the treatment or management of any specified medical problem or concern and Family Health accepts no liability for reliance on the articles. For proper diagnosis and care, you should always consult your family physician promptly. © Copyright 2015, Family Health Magazine, a special publication of the Edmonton Journal, a division of Postmedia Network Inc., 10006 - 101 Street, Edmonton, AB T5J 2S6    [AL_FHc08]
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