When my son was in 8th grade, he played football as a defensive lineman. One rainy October evening, he got hit in the head. As he came off the field, his eyes couldn’t focus, his speech was blurry, and he was dazed, though he never lost consciousness. Our athletic trainer ran through her checklist of symptoms and sent him to the hospital emergency room. He had suffered a concussion from a helmet-to-helmet hit.
On the way to the emergency room, I kept thinking how lucky we were to have an athletic trainer and coach who knew just what to do. It was scary, but we were lucky.
Traditionally, concussions have often been brushed aside as mere dings or as “getting the bell rung,” part of a culture that believes that toughing out an injury, even a serious injury, is a virtue. Players have been encouraged to “shake it off” and return to play despite suffering symptoms of concussion similar to those my son experienced. In fact, for some time coaches, players, and parents have mistakenly believed that a player needed to lose consciousness to have sustained a concussion. But concussions by definition differ from other sports injuries, not just because they’re difficult to detect and treat, but also because they are a significant problem. In fact, the Centers for Disease Control and Prevention estimates that 1.6 to 3.8 million sports-related concussions occur in the United States each year.
Since 2003, research has continued to refine the definition of a concussion. The American Academy of Neurology defines a concussion as “an alteration in mental status following a trauma that may or may not result in a loss of consciousness.”
Basically, when a player hits her head the brain shifts and moves with the force of the impact, often hitting the ridged skull bones that surround it. It’s similar to a container of gelatin: If shaken, the gelatin hits the side of the container and may shift back into place, but is damaged. With concussions, scientists are learning that the brain is forever changed upon impact, and those changes never completely heal unless the brain is given time to rest and recover.
Sports With the Highest Concussion Rates
Contact sports pose the highest risk for causing concussion. Football has the overall highest incidence of concussion injury despite the fact that contact rules changed in 1976.
Editor’s Note: On June 13, 2012, Pop Warner Little Scholars, Inc., an international organization that offers football and other sports programs for youth ages 5-16, announced new rules of play in the U.S. that limit contact between football players in response to “developing concussion research.” Complete details on Pop Warner’s concussion-related football changes are here.
For girls, soccer represents the highest incidence rate, even over cheerleading, basketball, and lacrosse. And though boys’ sports account for 75 percent of all concussions, girls are in fact more susceptible to concussions because of physical differences such as neck strength and head size.
Increased awareness of concussion is due in part to increased education and media coverage about the danger of concussive events. More than 35 states have enacted laws about “concussion management,” with encouragement from the National Collegiate Athletic Association, the National Athletic Trainers’ Association, the National Federation of State High School Associations, and the CDC. Most states have adopted what are considered the model features of concussion management—those patterned after legislation in the state of Washington, where Zack Lystedt lived and played football.
Lystedt, then a 13-year-old football linebacker, was hit hard during a middle school game and suffered a concussion that went undetected. His coach had him sit out a few plays, but then put him back in the game. Lystedt collapsed at the end of the game and required two brain surgeries to survive. He also endured a week on life support, three weeks in a coma, and a yearlong stay in a rehabilitation facility. Some 28 months after his injury, Lystedt testified before Washington legislators in support of a concussion safety bill. The bill became the Zackery Lystedt Law and remains a model for every piece of concussion management legislation that has been enacted.
Effective concussion management laws contain three principles: informing and educating youth athletes, parents, and guardians about the risks of concussion and requiring them to sign a concussion information form; benching youth athletes who appear to have suffered concussions during play or practice; and requiring a youth athlete to be cleared by a licensed health-care professional trained in the evaluation and management of concussions before returning to play or practice.
One reason concussions often go undiagnosed is that symptoms can be elusive or deceiving. Sometimes symptoms arise days after the actual head impact, so players may not complain because they think those signs are from stress or fatigue. Sometimes players may not even realize that they’ve sustained a head injury because impact can occur not just from head-to-head contact but also from repetitive impact like heading a soccer ball or getting a whack on the head by a hockey stick.
Concussion symptoms vary greatly, and a youth who’s had a concussion may experience some or all of the following: a headache that persists or gets worse; drowsiness and difficulty waking up; decreased recognition of people and places; unsteadiness on the feet and requiring assistance for walking; slurred speech; and confusion and irritability, especially in an otherwise typical child.
That’s why evaluation by a trained health-care professional is so essential. In many school athletic programs, a professional athletic trainer will evaluate a player for symptoms if a concussion is suspected. However, not all schools, especially those in rural areas, have an athletic trainer on staff.
Student Athletes, and Parents, Must Be Educated About Symptoms
In addition to checking a young athlete for symptoms of concussion, a school’s trained health-care professional is also the person charged with making sure parents fully understand concussion issues.
Historically, education has been the single most effective method of identifying concussions, which is why concussion education programs for parents are vital. So is individual counseling by health-care professionals, for both parents and their young athletes, says Marjorie Albohm, president of the National Athletic Trainers’ Association.
“An athletic trainer is educated and trained to recognize the signs of concussion and to perform the appropriate evaluation to determine return-to-play status,” Albohm says. She adds that they’re also the ones who must “fully explain [to parents and athletes] the consequences of these injuries and what needs to be done to keep athletes safe and injury free.”
Keeping a player on the sidelines after he has sustained a concussion is sometimes the most difficult challenge an athletic trainer, coach, parent, and young athlete will face. Sidelined players worry about being replaced on their team or losing their competitive advantage when sitting out. Although a player might feel fine after a short period of time, the brain is still recovering. Some parents refuse to believe or accept the decisions of the athletic trainer or team physician, taking matters into their own hands by finding a new doctor to get the return-to-play release they want. Because not all doctors are fully trained in concussion management—or do not treat concussions on a daily basis—physician education, especially in rural communities, is still a work in progress, says Bob Colgate, vice president of the National Federation of State High School Associations.
“We have parents out there who [are] doctor shopping,” Colgate says. “If one doctor doesn’t clear a player to return to play then [the parents] will look for another doctor who will. That is a sad fact.”
That’s why concussion education has to be a two-way street, he says. “Athletes have to be informed of the symptoms so they are more apt to report that they have these signs,” Colgate explains. On a positive note, he says, “Experts are telling us that our educational efforts are making inroads. Kids are coming forward. But the next step is to make sure that they are not being returned too soon.”
“Sit It Out” Becomes New Guideline
In fact, return-to-play time requirements aren’t currently mandated, nor are they expected to be. Colgate says that’s because each injury and each player are different and require a different return-to-play plan.
That said, a new medical consensus statement recently released from the American College of Sports Medicine may help. The statement reads in part, “Under no circumstances should an athlete suspected of, or diagnosed with, a concussion return to play the day of their injury.”
One way of determining when a player can safely return to play is a test administered at the beginning of the sports season. The test is part of a concussion management plan, something more and more schools are enacting. These plans specify the steps that must be taken when a student athlete sustains a head injury and/or shows symptoms of concussion.
The test, a “baseline concussion test,” is a computerized test given to a student athlete preseason. The test measures the student’s brain and reaction to a series of computerized tasks involving verbal and visual memory, attention and reaction times, working memory, and non-verbal problem solving. The test takes approximately 20 minutes and can be given by the athletic trainer, school nurse, or other health-care professional. This baseline test then provides a marker for a health-care professional to compare against any future cognitive injuries the player may sustain.
As the parent of a son who sustained a concussion, I know firsthand that a sports injury can be very traumatic. Often when it comes to returning to play, parents must be the “bad guys,” telling their child that he must sit out the rest of the game to give his brain time to recover. That’s why being informed about concussions is critical for all parents.
Our student athletes need to be informed as well—and they also need to be upfront with parents about their symptoms and possible concussive events. In my case, I didn’t know that when my son attended a football camp during the summer following his concussion, he sustained a second concussion. He simply didn’t tell me until much later. But now I know exactly what symptoms to look for—and I can tell you that I’ll be watching both of my sons closely as they begin their wrestling and soccer seasons. And I’ll make sure that their coaches and trainers are watching closely, too.