Concussion in Sports
Did you know that a concussion occurs every 4 minutes in Canada? One of the primary goals of the BIAPEI is the prevention of traumatic brain injury. In accomplishing this goal, it is our intention to provide up-to-date information about concussion; what treatment is necessary, and what guidelines should be followed for return to activity following concussion(s).
Facts About Concussion
A simple (first degree) concussion is defined as an altered state of consciousness (without a loss of consciousness), resulting from a blow to the head or whiplash, with symptoms lasting no more than fifteen minutes. This corresponds to a Grade One concussion using the American Academy of Neurology guidelines. Any cognitive deficits that arise from a simple concussion will disappear within 24 hours.
A complex (second degree) concussion is defined as an altered state of consciousness resulting from a blow or whiplash where there is brief loss of consciousness or symptoms lasting longer than fifteen minutes. This corresponds to a Grade Two or Grade Three concussion using the American Academy of Neurology Guidelines. For a first time concussion, symptoms of a complex concussion are generally reversible and cognitive deficits will disappear within 5 to 7 days. Only one in two complex concussions will lead to a doctor's visit or emergency room visit. Almost no one with a simple concussion will be seen by a health care professional.
Someone who experiences a concussion is four times more likely to experience a subsequent concussion. The more concussions an individual has the longer it takes to recover from a concussion. Symptoms may eventually become irreversible. There is no rule on how many concussions an individual must have before symptoms become permanent.
Approximately 144,000 Canadians (or 1.5 million Americans) will receive a complex concussion each year. This estimate of the number of people who suffer a concussion does not include severe brain injuries that generally result from automobile crashes.
The vast majority of concussions occur for young people. The average age for a first concussion is 10. One third of youth will have a concussion before they leave high school. Young people who actively participate in organized sport have a much greater likelihood of experiencing a concussion. Some youth who experience a concussion will end up with learning disabilities.
Approximately 20% of concussions will result from organized sports activities with the remainder resulting from motor vehicle accidents, work related accidents, accidents in the playground or from interpersonal crime.
Risk of concussion in sport is higher in contact sports (e.g. hockey, football, rugby) but
non-contact sports present considerable risk, as well. For example, soccer presents the risk of
concussion from unintentional contact or from repeated contact through heading the ball. Skiing and
horseback riding are sports that do not involve contact but which present high risk for concussion. Risk of concussion in sport is only slightly reduced for women versus men even though young women
more often participate in non-contact sports.
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What is a Concussion?
A concussion is a change in mental status resulting from mechanical forces on the brain. A blow or jolt to the head can cause the brain to move within the skull. This movement of the brain causes biochemical changes in brain cells. A concussion is not necessarily accompanied by a loss of consciousness. However, the concussed individual will experience symptoms such as disorientation, poor coordination, or vision difficulties.
Severity of a concussion is determined by the length of time these initial symptoms of concussion last. The Canadian Hockey Association (CHA) established a grading scale and return to play guidelines designed for amateur sports, particularly for youngsters. In the case of a simple concussion, the symptoms do not last longer fifteen minutes. If the symptoms persist longer than fifteen minutes, or if symptoms reoccur with exercise, or if the individual experiences unconsciousness, then the individual is said to have experienced a complex concussion. The guidelines require that anyone who experiences a concussion must see their doctor. For complex concussions they require the affected individual to be examined by a physician as soon as possible. Further, the guidelines require that a concussed individual should not return to play, or participate in any high-risk activity without the approval of a physician.
Research has now shown that although an individual may recover from the initial symptoms of the concussion within a few minutes, there are subtle changes in cognitive abilities that persist. Individuals that experience a simple concussion will return to normal cognitive functioning within 24 hours. Individuals do not recover from a complex concussion before seven days. Individuals that sustain a second concussion during this natural recovery period are at extreme risk for second impact syndrome. Second impact syndrome is characterized by symptoms that persist for months, and has even been associated with death.
In rare instances, symptoms of concussion persist more than seven days, even without second impact syndrome. For reasons we do not know, the biochemical changes that occur in the brain cells do not get corrected. This is referred to as post concussion syndrome. Although rare it is far more common among those that have multiple concussions or second impact syndrome.
The symptoms of post concussion syndrome fall into three broad categories: physical complaints,
behavioural changes and thinking problems. Physical complaints include headache, dizziness/balance,
fatigue, problems with vision, sensitivity to noise or light, or problems with sleep. Behavioural
changes include moodiness (depression), irritability (anger), or an inability to sit still. Thinking
problems include difficulty making decisions, “foggy” thinking, or problems recalling
simple words. Any or all of the symptoms may be present. There is considerable difference between
individuals and which symptoms will be present. All symptoms are more likely to be present when the
individual attempts any strenuous activity. Assessment of post concussion syndrome involves an
interview by an experienced clinician. Results of neuropsychological tests and radiologic tests may
or may not confirm the interview results.
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Treatment for Concussion
A physician should examine anyone that experiences a concussion. The return to play guidelines for the Canadian Hockey Association, the International Ice Hockey Federation and many other sports organizations require approval of a physician before return to play. However, more than eighty percent of concussions occur outside of organized sports and many individuals with concussions return to high-risk activities before the concussion has healed. The first component of treatment of a concussion is to be examined by your physician. The second component is to avoid activities that could produce a second concussion.
Physicians will tell you that there is little that can be done for a concussion other than rest. However, the physician is trained to look for signs that the concussion may also involve a hemorrhage. There are many tiny blood vessels in the brain that can be severed by the same forces that cause the concussion. For this reason, someone with a concussion should be carefully watched for any possible deterioration in function.
Most simple concussions, where the initial symptoms do not last more than a few minutes, will clear in about twenty-four hours. However, the individual with the concussion should be cautioned that any physical activity might cause the symptoms (e.g. headache, dizziness, foggy thinking) to return. If symptoms return then the concussion is considered to be a complex concussion.
A complex concussion is any concussion where the symptoms extend beyond fifteen minutes or where the individual experiences a loss of consciousness (however brief). Complex concussions take a minimum of seven days to clear. The individual should not return to high-risk activity until he or she has been symptom free for at least one week. This includes being symptom free during periods of reasonably strenuous activity. During the week or more of recovery the individual should get plenty of rest. Unfortunately, there is no known treatment that can speed up the recovery period.
If symptoms of the concussion persist beyond a couple of weeks, it means that the brain has not
healed itself. Persistent symptoms of concussion are referred to as post concussion syndrome. People
are often told that there are no treatments available for post concussion syndrome. However,
treatment options are available and can be extremely helpful in alleviating symptoms. This is
important because the post concussion syndrome can often prevent successful return to work or school
activities. These symptoms can be very debilitating even though, for all intents and purposes, the
individual appears fine.
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Return to Activity
If you have any of the signs or symptoms of concussion listed above after a blow to the head or body, you should not go back to play the day of the injury. A health care professional, experienced in evaluating for concussion, needs to let you know when it is safe to return to play. If your concussion involves memory loss or loss of consciousness, you may not be able to return to play for 1 to 2 weeks. After a severe concussion, you may not be able to return to play for a month. If this wasn't your first concussion, your return to play may take even longer.
A player returning too early could suffer from "second impact syndrome," which can be fatal. A
second blow to the head, even a minor one, can cause a loss of control of blood flow to the brain.
Never return to a sports activity until you are cleared by a doctor.
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