WHAT IS A CONCUSSION
Mild traumatic brain injury (mTBI), or concussion, is the most common type of traumatic brain injury/ While typically not too serious in most cases, concussion has a serious risk of short and long-term sequelae. At the 4th International Conference on Concussion in Sport (Zurich, November 2012), a panel discussion took place to obtain a consensus-based definition of a concussion. The Concussion in Sport Group (CISG) defined a concussion as follows:
Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces. Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilised in defining the nature of a concussive head injury include:In essence, a concussion is a head injury with a temporary loss of brain function that may result in a variety of physical, cognitive, and emotional symptoms. Presently, concussion is a clinical diagnosis based largely on the observed injury mechanism (point of contact, force on head area, etc.), signs, and symptoms. The first step towards a diagnosis of a concussion is actual recognition of the injury.
The hallmark signs and symptoms of acute sports concussion include (but are not limited to):
- Loss of consciousness (LOC)
- However, the majority of concussions in sports occur without a LOC
- Problems with attentional mechanisms
- Manifested as (but not limited to): slowness to answer questions and follow directions, easily distracted, poor concentration, vacant stare/glassy eyed.
- Memory disturbance
- Balance disturbance
These symptoms may be apparent immediately after the head injury or other signs and symptoms of a concussion may evolve and appear gradually over several minutes. Additionally, over the course of the first 24 hours following a concussion injury, other signs and symptoms may manifest. However, it's important to note that there is a large range of these symptoms and they often vary, not all of these symptoms are seen in every case of sports concussion. The most common symptoms reported in concussion literature include:
- Somatic symptoms such as headache
- Cognitive symptoms such as feeling like in a fog
- Emotional symptoms such as lability
- Physical symptoms such as LOC and amnesia
- Behavior changes such as irritability
- Cognitive impairment
- Sleep disturbance (insomnia)
- Dizziness and balance problems
- Blurred vision
I'd like to focus on amnesia because it will come into play later. Amnesia is a common physical symptom associated with mTBI. Amnesia almost always involves loss of memory for the traumatic event but frequently includes loss of recall for events immediately before (retrograde amnesia) and after (anterograde amnesia) the traumatic event.
Since concussions are often hard to recognize and to diagnose, the Zurich Consensus on Concussion in Sport proposed diagnostic criteria for sideline evaluation. An athlete shows any of the following, they need to be removed from play and assessed.
- Initial obvious physical signs consistent with concussion (LOC, balance problems)
- Teammates, trainers, coaches observe cognitive or behavior changes in functioning consistent with concussion symptoms reported
- Any concussion symptoms reported by the athlete injured
- Abnormal neurocognitive or balance examination
Following a removal from play:
- Physician evaluated the player using standard emergency management principles, most notably to exclude severe head trauma or cervical spine injury
- Once first aid issues are addressed, assessment of the concussive injury should be made using the SCAT3 or other sideline assessment tools (NHL uses ImPACT concussion testing, read here: http://www.impacttest.com/about/)
- The player should not be left alone following the injury and serial monitoring for deterioration is essential over the initial few hours following injury
- A player with diagnosed concussion should not be allowed to return to play on the same day.
- It has been unanimously agreed that an athlete should not return to play on the same day of the injury. Studies have shown that athletes allowed back into play following a concussion may demonstrate neuropsychological deficits post injury.
CONCUSSION MANAGEMENT AND RECOVERY
The graduated return to play protocol following a concussion is a stepwise process and is outline below:
CONCUSSIONS IN THE SPORT OF SOCCER
Most people associate concussions with violent/physical sports, specifically American football, hockey and boxing. Of all sports played in the United States, football is the sport associated with the greatest number of traumatic brain injuries, but it also has the largest number of participants.
In the US, soccer is a sport growing in popularity. Between 1982 ad 2008, approximately 7.2 million men and 5.2 million women played soccer at the high school level and an additional 430,000 men and 322,000 women at the college level (Cantu and Mueller).
Recently, a study (Rosenthal et al) was published which analyzed data from High School Reporting Information Online (HS RIO), a national high school sports injury surveillance system. In this system, high schools across the nation with at least 1 certified athletic trainer were invited to participate. The trainers would log into the system and report injuries and athlete-exposures (AE) which was defined as 1 athlete participating in 1 competition or practice. The study used a sample of 100 schools for participation in the concussion rate study and focused on 9 sports: baseball, boys and girls basketball, football, boys and girls soccer, wrestling, softball and girls volleyball. These sports were chosen because data was available from 2005-2006 through 2011-2012.
The study reported the following rates:
"The HS RIO data showed a significant increase in overall concussion rate in the 7-year period of the study. The rates significantly increased in 5 of the 9 sports studied and showed increasing trends in the others. As can be seen from our results, the majority of the rate increase for all sports was observed after the 2008-2009 academic year."The graphs from the study shown below show total concussion rates for girls and boys sports from 2005-2006 through 2001-2012:
As you can see, the rate of concussions has increased in both boys and girls soccer. However, girls sustain a higher rate of concussions.
Another study (Gessel et al) also used the HSRIO data to survey the injury and drive targeted injury-prevention projects. The researchers determined that the risk factors for concussion in soccer differed significantly by sex. Concussions in soccer players most frequently occur as a result of head to head collisions in the act of heading the ball; 40.5% of the time in males and 36.7% in females. Girls soccer players sustain a greater proportion of concussions related to contact to the ground (22% compared to 6%) and contact with the ball (18.3% compared to 8.2%). Another risk factor for concussions in soccer is playing the position of keeper, with 21.7% of injuries to goalkeepers being concussions, compared with 11.1% of injuries to other positions.
Up to 50% of players admit to bending the truth about their symptoms to get back into action more quickly. It's imperative to teach them that a brain injury is not like any others, it could be irreversible. You can cause serious damage by not being honest about your symptoms and condition and by returning to play with a brain injury.