Concussion: Everything Has Changed

TASA ID: 3711

Key Points

• Most concussions resolve quickly (7-10 days). However, there are times when symptoms may persist for weeks and even months.
• Younger athletes take even longer to recover. It is not uncommon for middle school aged athletes to need a month or longer before they return to activity.
• Once an athlete has had a concussion, they are much more likely to have more.
• Currently, there are no standard structural imaging studies that will reveal an abnormality.
• An athlete must be symptom free at rest and upon exertion in order to fully return to activity.
• Allowing an athlete to return to activity before they are fully recovered can have devastating consequences.
• Many states are requiring schools to adopt a concussion management policy.

Although this title may be slightly overstated, it is true that much of the way in which we identify and manage concussions has changed dramatically. This has occurred in large part as a result of recommendations provided by the International Consensus Conferences on Concussion in Sport (1). Here are some of the things we have learned as a result of this group's work and additional concussion research:

1.       A concussion is defined as a complex pathophysiological process affecting the brain. The injury may be caused either by a direct blow to the head, face or neck as often results from spearing in football, or indirectly with an impulsive force transmitted to the head, as it might occur in a hard shoulder-to-shoulder collision at home plate without direct contact to the head.

2.       A concussion typically results in the rapid onset of a short-lived impairment of neurological function that resolves spontaneously. However, in some cases, symptoms and signs may evolve over a number of minutes to hours and last for days or weeks.

3.       A concussion may result in neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury. Although advancements are being made, currently no abnormality is seen on standard neuroimaging studies. A thorough exam, constant monitoring and follow-up evaluation are the current standard of care for this injury.

4.       A concussion results in a graded set of clinical symptoms that rarely involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course. In some cases, symptoms may be prolonged. The majority (80-90%) of concussions resolve fairly quickly (7-10 days), although the recovery time frame may be longer in children and adolescents. It is not uncommon for middle school aged athletes to require 3-4 weeks until full recovery is made.

5.       Returning an athlete to activity too soon can have devastating consequences. An athlete whose symptoms have not fully resolved and whose brain has not yet healed completely may die as a result of "second impact syndrome." Typically, when an athlete is still experiencing symptoms and returns to play prematurely, the athlete sustains a second head injury.  These injuries could include, diffused cerebral swelling, brain herniation and death (2). Repetitive head trauma from participation in sports such as football, ice hockey and boxing can result in a permanent change in brain function, including memory loss, early Alzheimer's disease, Parkinson's disease and emotional disturbances (3).

To better safeguard the health of student athletes, many states have enacted legislation requiring school districts to develop a concussion management policy. Presented below is a summary of what the policy contains.

1.      Coaching education programs - Each year a coach must complete a concussion management course.

2.      An informational meeting for all athletes/parents prior to the season to include concussion risks, symptoms and management procedures.

3.      A concussion information form sent home with each student athlete to be reviewed and signed by student and parent and returned and filed at the school.

4.      All medical personnel authorized to evaluate and treat an athlete with a concussion and determine a timeline for safe return to play, must have completed training in concussion evaluation and management.

5.      All athletes who have sustained a concussion will be removed from activity and may not return to play until:

a.       They have written clearance from a licensed physician.

b.       They are symptom free at rest and upon exertion.

c.        They have completed a gradual return to play protocol under the direction and supervision of a licensed medical/health care provider trained in the evaluation and management of sports concussions.

6.       The establishment of a "Concussion Committee" to provide ongoing evaluation and establish appropriate in school modifications until the student has completely recovered and is cleared to return to a normal academic and athletic schedule. Committee responsibilities include:

a.       Communication with the parent regarding the concussion plan of care.

b.       Ensuring physical rest for the athlete - This is essential to permit healing and promote recovery. Communication should be provided to the physical education department to excuse the student from class. Attention must be paid to out of school activities also and inform the parent/student of the need to refrain from these as well.

c.        Ensuring brain rest as well - This is critical to enable the student/athlete to recover. This may entail modification of electronic device use, alteration of school activities such as half-day schedule and allowance of frequent breaks during class. Communication needs to be provided to the classroom teacher regarding appropriate modifications. In some cases, it may be necessary to develop and implement a 504 plan.

 I cannot overemphasize the importance of thorough and timely communication among all professionals involved with the student/athletes concussion care. The physician, parent, school nurse, athletic trainer, athletic director, coach, teacher, and counselor all play an important role in ensuring a full and successful recovery for the student/athlete.

This article discusses issues of general interest and does not give any specific legal or business advice pertaining to any specific circumstances.  Before acting upon any of its information, you should obtain appropriate advice from a lawyer or other qualified professional.

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 REFERENCES

1.       McCrory et al. "Consensus Statement on Concussion in Sport", Clinical Journal of Sports Medicine. 2013;23(2):89-117

2.       Bey, Tarag and Ostick, Brian, "Second Impact Syndrome" Journal of Emergency Medicine. 2009 February; 10(1): 6-10.