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Physicians Update

 
Spring 2012

Concussion is ‘Truly Brain Injury’and Should be Treated as Such

It used to be that high school athletes in contact sports who got their "bell rung" during competition would be sent right back out onto the field. It is clear today that many of those rung bells were actually concussions, and the approach to athletes suspected of having them errs much more on the side of caution.

"Physicians, coaches, athletes and parents should all understand that concussions are truly brain injuries, and that the recognition and proper response to them when they first occur can help prevent further injury and even death if there is underlying brain trauma," says UCLA sports medicine specialist and UCLA team physician John DiFiori, M.D.

California and many states have passed legislation to require that a high school athlete with a suspected concussion be removed from play and not allowed to return until he or she is cleared by a physician experienced at evaluating head injuries.

A common misconception is that an athlete need not be removed from play if he or she hasn't been knocked unconscious. "Less than 10 percent of sports-related concussions involve loss of consciousness," says pediatric neurologist Christopher Giza, M.D. "You can't tell until you evaluate the athlete - checking memory and balance and asking about symptoms."

The main symptom for most concussions is headache. Symptoms also can include dizziness and balance problems, nausea or vomiting, sensitivity to bright lights or sounds, feeling "foggy" and slow to respond to questions, and looking or acting confused. Some concussion sufferers experience amnesia related to the event and/or other memory problems, and some become inexplicably emotional.

In some cases the onset of symptoms may be delayed. Even if an athlete appears fine, he or she should be observed for at least 20 minutes if there is any cause for concern, Dr. DiFiori says.

Whenever there is concern about a concussion, the athlete should not return to the field of play that day, even if his or her headache symptoms resolve after a short period of time. "We know that cognitive and balance effects, for example, may persist for days," Dr. DiFiori explains. "That athlete needs to be fully evaluated by a healthcare professional with training and skill in this area."

Diagnosis is based on a comprehensive physical examination that includes an evaluation of neurologic function and balance, as well as testing of cognitive processing and recall. Taking a good history is important. "We want to know if the patient has had a head injury before - even if it wasn't formally diagnosed," Dr. DiFiori notes. For older patients in particular, that means asking whether they have ever had a "dinger" or had their "bell rung" - terms once used for short-term concussive symptoms.

After a diagnosis, the patient should avoid physical activity as well as cognitive tasks that may exacerbate his or her post-concussive symptoms. If activities such as playing video games or games on handheld devices aggravate symptoms, for example, this may slow the recovery. Children recovering from a concussion may even need to reduce their class work or obtain academic support.

Most concussive symptoms resolve spontaneously over seven-to-14 days. Patients with worsening or prolonged symptoms, persisting for three-to four weeks, unusual symptoms, or who have had multiple concussions should be referred, suggests Dr. Giza. UCLA is in the process of establishing a concussion clinic in Santa Monica.

Dr. Giza suggests a graded return to play: a period of physical and cognitive rest followed by light aerobic activity (walking, swimming or stationary cycling) at 70 percent maximum heart rate, then aerobic activity with movement (jogging, running), then sport-specific drills with no head impact, including light resistance training. After medical clearance, the athlete can participate in normal training, and ultimately return to normal game play.

Physicians should be more cautious in clearing patients who have a history of prior concussions, Dr. DiFiori notes. Athletes who have had a prior concussion are up to three times more likely to sustain another one, and to have a more prolonged recovery from any subsequent concussions. Of particular concern are concussions that recur within the same season, often a sign that the athlete was cleared to return too soon. Studies have found that approximately three-fourths of same-season concussions occur within seven days of the first one, when the athlete is most vulnerable. Particularly concerning are the potential long-term neurological effects of multiple concussions, which include a greater risk for cognitive impairment and chronic headaches.

Although isolated cases of athletes who develop serious problems as a result of multiple concussions grab the headlines, Dr. Giza notes that the vast majority of concussions resolve on their own. "We need to recognize when it happens, protect athletes from having a repeat injury, and allow the athlete to recover," he says. "But we also know that the natural course is that they're going to get better."

NCAA Funds Study of Sports-Related Concussions 

Drs. John DiFiori and Christopher Giza are participating in a National Collegiate Athletic Association (NCAA) multisite study of sports-related concussions. The study aims to better understand the long-term consequences of sports-related concussions.

 





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