On September 2008, American football player, Anquan Boldin, had a violent helmet-to-helmet collision, while he was on field. While attempting to catch a long pass, he was hit in the back by another player and then suffered a blow on his face from another player, knocking both of them unconscious (Bolohan, 2011). While the other player regained consciousness after a few minutes, Boldin was placed on a stretcher and had to be carted off the field. A few days later, his coach announced that he would be out for an indefinite period and that due to the blow; he has suffered a concussion along with fracture of paranasal sinuses. As a part of his treatment, he had 40 titanium screws and 7 plates put in his face to facilitate healing of the fracture. However, he was back on stage in just three weeks after the incident (Bolohan, 2011).
While doing some reading on traumatic head injuries, I also came across news of several former players like Junior Seau, Dave Duerson, and Andre Waters committing suicide. All of these players were found to have had chronic traumatic encephalopathy, a disease in which the brain degenerates (Glauber, 2011).
In an interesting research by Kevin Guskiewicz, who is one of the winners of the MacArthur Foundation, there was a strong link between multiple head injuries (concussions) and depression, dementia, and lastly Alzheimer disease, which is brain degeneration (Guskiewicz, 2011).
This prompted me to further gain knowledge on what traumatic brain injury, or more appropriately termed as a concussion, is all about.
Athletes want to win every game and do not want to let their nation down. So they try to get back to play even if they are injured, or even without adequately resting. We can admire a player’s attitude of returning to play, but it is easy for players to not take an injury seriously particularly the one they cannot see. Many players fail to recognize the seriousness of concussions and how severely they can impact their lives in the short term as well as long term.
- Why is it necessary to learn about concussion?
The most common cause of concussion in the literature has been cited to be an accidental trauma with a high-impact sport’s injury, as the second cause. A difficult-to-handle problem with concussion is that it is an invisible injury. We cannot see it and it is not even seen on conventional brain scans (CDC, 2010). There are several other reasons why players do not want to report traumatic brain injuries to their coaches or trainers e.g., they do not want to leave the game, they do not want to let their team down, they did not want to appear weak to the coach, they did not realize that it is a concussion, or they did not take it to be serious enough to attract medical attention (CDC, 2010).
A traumatic brain injury or a concussion of any severity is an adverse event that can have an adverse impact on the learning ability of the child in the short term as well as long term (Sady, 2011).
Concussion can be in the form of a direct or indirect blow on the head that may result in some kind of neurological impairment like loss of consciousness or amnesia or confusion (Sady, 2011). It may resolve spontaneously; however, it is typically followed by cognitive, physical, and emotional symptoms (Sady, 2011). The outside forces shake the brain inside the skull setting off cascade of mechanisms inside the brain resulting in reduced blood supply to the brain resulting in several symptoms (Sady, 2011).
- Hard facts about concussion (CDC, 2010)
- All concussions are an injury to the brain
- They are serious
- Most occur without losing consciousness
- Can occur in any kind of sport
- Recognition of concussion is an important step in preventing further injury or even death
- Players who have concussion once are at an increased risk for another concussion; a repeat concussion that occurs before the brain has fully recovered from the first episode of concussion, can slow the recovery period or increase the likelihood of having a long term problem
- Young children and adolescent are more likely to suffer a concussion as compared to adults
- Young children also take longer to recover than adults (CDC, 2010)
- Statistics in US
In the United States, every year, approximately 1.7 million people sustain a concussion, which accounts for 1.365 million emergency (ER) visits every year and approximately 275,000 hospitalizations (Daneshvar, 2011). Approximately, 75% of these injuries are minor and are classified as mild TBIs or mild traumatic brain injuries. These figures; however, may not be correct as many individuals suffering from mild or moderate TBI do not seek medical care, especially in most of the cases when the injury is not accompanied by loss of consciousness. Apart from burden of injury, concussions also have significant direct and indirect economic consequences, estimated at over $60 billion annually in the US alone (Daneshvar, 2011).
- Things to watch out for following concussion
Clinically, the signs and symptoms just after an episode of concussion are similar in children and adults (Daneshvar, 2011). After a concussion, physical symptoms can include headache, fatigue, light/noise sensitivity, blurry vision, and can also affect the learning of the child. Sleep disturbance is also common following a concussion. Anxiety is common further leading to frustration and depression. There may be decreased learning and memory, decreased attention (Sady, 2011). While most of these symptoms resolve spontaneously and on its own, some symptoms may linger. Importantly, no two concussions are similar or have similar presentation or similar outcomes (Daneshvar, 2011).
- Watching out for ‘Danger signs’
When the blow or jolt is severe, it can result in a dangerous blood clot and may exhibit any of the following symptoms – one pupil larger than the other, repeated nausea or vomiting, slurred speech, seizures, unusual behavior, even a brief loss of consciousness, restless, confused, or agitated (CDC, 2010).
- Risk factors for concussion
Risk factors for a concussion can be either those that predispose a person to concussion, those that delay the recovery period, and those that increase the risk of catastrophic injury (Finnoff, 2011). Risk factors that predispose a person to concussion include female gender, history of previous concussions, and fatigue from physical exertion. Certain factors such as female players, players with a history of concussion, and those with cognitive impairment are at an increased risk of poor outcome after concussion. If the player has a history of anxiety or depression, it increases the risk of post-concussive fatigue, anxiety, depression, and subjective cognitive complaints, but it is unknown whether they increase concussion susceptibility (Finnoff, 2011). Concussions usually result in reduced attention and difficulties with memory and learning; therefore, a player with a baseline learning disorder may experience an exacerbation of their learning disorder after a concussion. Players who exert themselves too much after a concussion have delayed recovery (Finnoff, 2011).
The most significant adverse outcome of a concussion is death. Autopsy has revealed extensive cerebral edema without a space-occupying hematoma. However, it is often seen that death is more common in players with a recent history of concussion. Thus, it often is referred to as “second impact syndrome,” risk factors for which include young age (18 years or younger), recent concussion, and continued post-concussive symptoms. Any patient who meets these criteria should not be allowed to return to sports until the symptoms have subsided (Finnoff, 2011).
- What role a school plays in concussion
Schools, across the country, need to conduct programs for concussion awareness, education, and management. It also needs to pay attention towards the process of academic return of the child. Children spend most of their time engaging in cognitive activity like classroom work and homework. Some of these activities take place at home while some in the school environment. Thus, schools must play an important role in management of such cognitive activities to enable recovery from concussion (Sady, 2011). A school that is equipped with concussion policies and procedures implemented before a child sustains an injury is better prepared to manage a successful return (Sady, 2011).
Child who has suffered a traumatic brain injury must be restricted from physical activity or any sort of playground activity like sports until his treating doctor provides a clearance and allows him to return to play. This will ensure protecting the child from another blow to an already vulnerable brain. Physical activity during the recovery period can also cause the symptoms to get worse (Sady, 2011). It is essential that the schools keeps a track of the child’s recovery period and communicate with the coach or athletic trainer about the student’s cognitive progress. After the confirmation of recovery by the treating doctor, the child should be able to participate in typical academic activities like attending full day school hours, with no return of symptoms. This can aid in providing important information about the child’s post-concussion neurometabolic status (Sady, 2011).
While designing and implementing a concussion program in school, three steps are to be taken into consideration (Sady, 2011):
- Establishing policies and procedures
- Educating personnel in the school
- Implementing plans for children who suffer concussion
Plan for every child may be different and will need individualization involving the cooperation of school. An ongoing assessment of the condition would be needed with adjustments in the plan, as needed, based on the course of recovery. Each plan should involve the injured child, his parents, and a carefully coordinated team of personnel of the school (Sady, 2011). The school personnel may be one single person or may be a combination of an athletic trainer, teachers, school nurse, guidance counselor, school psychologist, or a social worker. The school nurse or the athletic trainer is responsible for tracking symptoms regularly, looking for improvement or worsening of the concussion, and to communicate changes to his parents, teachers, or doctor etc (Sady, 2011). The counselor or psychologist is essential for coordinating accommodations and using the symptom log to guide adjustments. The child’s teacher is responsible for attending to the cognitive effects of injuries e.g., keeping a track of learning abilities of the child or keeping a track of the child taking longer time than unusual to complete tasks or assignments (Sady, 2011).
The gradual return of the child to normal life after suffering a concussion is still a challenge. Once a student is declared recovered and given permission to return to school work, the child may overdo physical and mental activities in an attempt not to lag behind in the classroom, thus putting them at a risk for prolonging their recovery (Sady, 2011). Teachers often believe that if the child is back to school he is fine and capable of completing all school work. It is essential to educate the teacher that symptoms and neuropsychological deficits can resolve at different times for different people, so teachers should make themselves aware of the fact that a student who is reported to be symptom-free may not yet be able to perform fully at pre-injury levels or successfully return to their full workload (Sady, 2011). Besides, a child who has been absent in the school for many days may be expected to stay after the school hours or receive extra tutoring to catch up on the academic school work. Again, careful coordination among teachers and guidance staff is the best way to avoid these risks (Sady, 2011).
- A trainer’s/ coach’s role in prevention and preparation
A coach can play a key role in preventing the traumatic injury. A coach should encourage parents and players to sign the concussion policy statement at the beginning of each sports season (CDC, 2010). One can see to it the school has concussion policies in place even before initiation of first practice. An action plan can be well in place before the practice season starts. Action plan can include identifying a healthcare professional to treat injuries that can occur on the playground, handy information or “Heads Up’ sticker on signs and symptoms of concussion and emergency contacts readily available, making sure the other staff is aware of the plan and is appropriately trained in using it (CDC, 2010). A coach is also responsible for monitoring the health of the player by asking relevant questions and insisting on medical evaluation. During the sports season, safe playing techniques should be encouraged and players asked to follow the rules (CDC, 2010). A coach is also responsible for making sure that the players are wearing the right protective equipment such as helmets, shin guards, padding, mouth, and eye guards. The equipment should be worn correctly and consistently and should fit properly. If a player suffers a concussion, his brain needs time to heal; therefore, a coach also has to see to it that the player is not allowed to return to play until a healthcare professional trained in evaluating concussions gives a green signal (CDC, 2010). He should also teach his players that rest is the key after a concussion and that it is not smart to play when the wound has not healed completely; and also emphasize on the fact that playing with a concussion can prove to be dangerous. A coach should keep a track of the player’s concussion and also simultaneously discuss with other staff, the need for prevention and need for improvement in concussion policies (CDC, 2010).
- What research is being done to prevent concussion?
A few months ago, an international team of researchers updated the Consensus statement on concussion related to sports. The consensus will serve as a guide for sports coaches, doctors, nurses, and other health care providers. It focused on the immediate and later signs and symptoms of concussion and emphasizes that loss of consciousness is not a necessary criteria to remove an athlete from a game (Sifferlin, 2013). Consensus also states that children should not be allowed to return on the field on the day they suffered a concussion. Additionally, the consensus also reported lack of evidence of usefulness of mouth-guards and helmets in preventing concussions. These can only offer protection against injuries to the head and face, but likely do little to protect against a serious internal damage the brain from a concussion. In fact, players get a false sense of security with the use of such equipment and this encourages them to behave more aggressively and recklessly on the ground (Sifferlin, 2013).
In an attempt to make football safer, NFL and General Electric (GE) have decided to research on treatments for concussion. There is a $40 million worth joint investment promised by NFL and GE towards concussion research (Glauber, 2011).
The Weber State University (WSU) students have been researching a project that could help protect sports players from concussions. The research has many components such as blood work, video monitoring, cognitive tests, and a new sensor on the player’s helmets that measures the impact of injury when they sustain a crash (DeMoss, 2013).
In another research, a group of researchers have developed new potential to reduce sports-related concussion injuries that involve a simple collar to be worn by players, instead of helmets. The collar applies a pressure on blood vessels of the neck to increase blood flow to the brain in an attempt to reduce the movement of the brain inside the skull, if there is a blow (Cole, n.d.). This is because it is known that helmets provide a limited protection. It is not only sportsmen who can benefit from this collar, but can also be used by the army men to reduce concussions. Army men generally suffer from 12 to 15 concussions at a time, in spite of wearing a helmet, and death is almost certain after such an injury. In such case, a collar seems to be appropriate option in an attempt to protect the brain (Cole, n.d.).
Bolohan S. Nine Athletes Who Played Through Heinous Injuries. The Smoking Jacket. 2011. Retrieved from: http://www.thesmokingjacket.com/humor/famous-sports-injury-performances; Accessed: 09th April 2013
Glauber B. NFL, General Electric ally to fund concussion research. Newsday. 2011. Retrieved from: http://www.newsday.com/sports/football/nfl-general-electric-ally-to-fund-concussion-research-1.4795608; Accessed: 09th April 2013
Guskiewicz K. MacArthur 'genius' tackles concussions in football. Los Angeles Times. 2011. Retrieved from: http://articles.latimes.com/2011/sep/20/news/la-heb-macarthur-concussions-football-20110919; Accessed: 09th April 2013
Heads Up. Concussion in High School Sports. Center for Disease Control and Prevention. 2010, Retrieved from: http://www.cdc.gov/concussion/pdf/coach_guide-a.pdf; Accessed: 09th April 2013
Sady M, Vaughan C, Gioia G. School and the Concussed Youth – Recommendations for Concussion Education and Management. 2011. Phys Med Rehab Clin N Am. 22, 701 – 719. Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3208828/; Accessed: 09th April 2013
Sady et al’s paper provides knowledge on injury and post-injury management particularly of cognitive activity in the school environment. It includes the design and implementation of school-wide concussion education and management programs.
Daneshvar D, Riley D, Nowinski C, McKee A, Stern R, Cantu R. Long Term Consequences: Effects on Normal Development Profile after Concussion. 2011. Phys Med Rehab Clin N Am, 22, 683 – 700. Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3208826/; Accessed: 09th April 2013.
Daneshvar et al’ paper realizes the need to develop effective diagnoses of concussion, its treatment, and education plan to reduce further incidence of the injuries.
Finnoff J, Jelsing E, Smith J. Biomarkers, Genetics, and Risk Factors for Concussion. 2011. PM R 2011;3:S452-S459. Retrieved from: http://www.laketahoesportsmed.com/pdfs/FinnoffConcussion.pdf; Accessed: 09th April 2013
Finnoff et al’s paper discuss the risk factors associated with concussion and its poor outcome and gives practical suggestions for the application of this information in clinical practice.
Sifferlin A. Helmets and Mouthguards Don’t Prevent Concussions. TIME Health and Family. 2013. Retrieved from: http://healthland.time.com/2013/03/13/helmets-and-mouthguards-dont-prevent-concussions/; Accessed: 09th April 2013.
DeMoss J. WSU to research concussions in snow sports. Standard Examiner. 2013. Retrieved from: http://www.standard.net/stories/2013/01/06/wsu-research-concussions-snow-sports; Accessed: 09th April 2013
Cole C. Researchers Develop New Potential Solutions to Concussions. Chicago Health. N.d. Retrieved from: http://chicagohealthonline.com/current-articles/neurology/researchers-develop-new-potential-solutions-to-concussions/; Accessed: 10th April 2013