As leading experts in the field of concussions we at SCOI not only provide diagnostic, concussion evaluation and management services, but we also believe strongly in ongoing education and community service. Through our website, social media (such as Twitter and concussion blogs), lectures and the SCORE Concussion Program, we strive to continue to raise concussion awareness and educate the public about proper concussion management. Please read on for further information about concussions and all of the services that we offer at SCOI.
How common are concussions?
Every year there are about 300,000 cases of traumatic brain injury (TBI) that occur in the setting of sports and recreation. About 90% of sports-related TBIs are mild (mTBI) and may go unreported. The term "mTBI" is synonymous with concussion. Concussions are extremely common in football in the U.S. Football is responsible for ~250,000 concussions per year. It is most common at the high school level where ~20% of high school football players will sustain a concussion every season. Concussions also occur in ~10% of college football players and 13% in the NFL. We believe that the high rates in the younger athletes are due to smaller neck sizes and poor tackling technique. Concussions can also occur in any contact sport and are common in soccer, hockey, rugby and many other sports.
What is a concussion?
Many people believe that you must experience loss of consciousness (getting "knocked out") in order for it to be called a concussion. This is simply not true. The majority of concussions actually don't involve loss of consciousness. >90% of all concussions that are sustained in sports are considered to be “mild” and may be characterized by transient confusion and/or a brief duration of post-traumatic amnesia (PTA) but no loss of consciousness (LOC). The typical scenario would be a football player coming to the sidelines after a hit and saying he feels like he “got his bell rung” or “got dinged.” These episodes are in fact concussions and we encourage people not to use these terms because they may minimize the significance of the injury. The true technical definition of concussion is as follows:
"Concussion is defined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. Several common features that incorporate clinical, pathological and biomechanical injury constructs that may be used in defining the nature of a concussive head injury include:
- Caused either by a direct blow to the head, face, neck, or elsewhere on the body with an “impulsive” force transmitted to the head.
- Typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously.
- May result in neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance rather than structural injury.
- Results in a graded set of clinical syndromes that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course.
- Typically associated with grossly normal structural neuroimaging studies.” [like an MRI scan or CT scan]
It is important to note that since a concussion does NOT show up on an MRI or CT scan, just because these tests came back normal does not mean that the athlete didn't suffer a concussion. Just because the MRI or CT scan is clear, doesn't mean the athlete is.
What are the signs and symptoms of concussion?
Signs: (this is what a coach, athletic trainer, parent or other players may notice)
1. Any period of loss of consciousness
2. Disorientation or confusion
3. Slurred or incoherent speech
4. Difficulty paying attention
5. Delayed verbal and motor response
6. Vacant stare
7. Emotionality out of proportion to circumstance
8. Memory deficits
Symptoms: (this is what the athlete reports)
Early symptoms (minutes to hours)
- Visual changes
Late symptoms (days to weeks)
- Memory disturbances
- Poor attention and concentration
- Sleep disturbances
- Personality changes (easily frustrated)
- Persistent low-grade headache
If an athlete has ANY symptoms or signs of concussion, the athlete:
- Should NOT be allowed to return to play in the current game or practice
- Should not be left alone (regular monitoring for deterioration over next several hours)
- Should be medically evaluated by a medical doctor (not a chiropractor or nurse)
- Should follow a medically supervised stepwise process for returning to play
How is a concussion evaluated?
There are a number of assessment tools that can be used. Generally you want to include a mental status exam, a balance test, a full neurological physical exam and possibly neuropsychological testing. At SCOI we use the ImPACT system of computerized neuropsychological testing to evaluate for memory, concentration, attention, visual-motor and reaction time deficits. We are currently one of only three centers in the greater Los Angeles area that are Certified ImPACT Consultants (CIC). For more information on ImPACT please see: http://impacttest.com/about/background.
With all assessment tools and tests, having baseline tests are extremely important. Often times baseline testing is part of the pre-participation physical examination. Baseline formal neuropsychological testing should be considered in organized high-risk sports (such as football, hockey, motocross, etc) and in athletes with a previous history of concussions, which may identify athletes at risk for developing further complex concussions. Baseline testing with ImPACT is offered at SCOI at an extremely low cost.
How is a concussion treated?
For most simple concussions the most important aspect of recovery is physical and cognitive rest. Activities requiring physical exertion, concentration or attention may exacerbate symptoms and delay recovery and therefore should be avoided. This means that the concussed athlete should avoid sports, exercise, video games, computer use and in some instances should be held out of school or have academic accommodations made. Once the symptoms have resolved then a typical stepwise return to play protocol should look like:
- No activity. Complete rest. Until asymptomatic.
- Light aerobic exercise (walking, stationary bike)
- Sport specific exercise (hockey = skating; soccer = running) start light resistance training
- Non-contact training drills and increased resistance training
- After medical clearance: Full contact training
- Game play
What are the current high school regulations regarding concussions?
On May 7, 2010, the State CIF Federated Council passed Bylaw 313 which now requires a signed medical release before a student-athlete who is suspected to have sustained a concussion can return to play.
By law 313
A student-athlete who is suspected of sustaining a concussion or head injury in a practice or game shall be removed from competition at that time for the remainder of the day. A student-athlete who has been removed from play may not return to play until the athlete is evaluated by a licensed health care provider trained in the evaluation and management of concussion and receives written clearance to return to play from that health care provider.
What licensed health care providers are trained in the evaluation and treatment of concussions/brain injuries and authorized to allow the athlete to return to play?
The “scope of practice” for licensed health care providers and medical professionals is defined by California state statues. This scope of practice will limit the evaluation to a medical doctor (MD) or doctor of osteopathy (DO).
What experience do SCOI physicians have in managing concussions?
SCOI physicians have been managing concussions both on the sidelines and in the office for the past decade. We have experience with athletes from all sports and all ages ranging from childhood playground accidents to professional NFL players. In addition to the direct care of athletes we believe that proper concussion care also involves education and awareness. SCOI physicians have lectured extensively on concussions. From SCOI sponsored events to hospital grand rounds to national conferences, educating athletes, parents, coaches, athletic trainers, medical students and doctors is an important ongoing part of our dedication to proper concussion management. We also continue to write articles on concussions and have served as expert witnesses in landmark cases of concussion related lawsuits.
How is SCOI helping the community at large regarding the concussion crisis?
In addition to providing expert care, as well as ongoing education and awareness, SCOI has developed an outreach program through SCORE (Southern California Orthopedic Research and Education Center). The SCORE Concussion Program has partnered with the Wells Fargo "Play It Safe Concussion Care Program" to provide free baseline testing and concussion care to 10 local high schools. For more information on the "Play It Safe Concussion Care Program" please see: https://www.wellsfargo.com/com/insurance/concussion-care
If you would like to make an appointment with Dr Andrew Blecher (Van Nuys and Valencia offices) or Dr Richard Spelts (Thousand Oaks and Simi Valley offices) for a concussion evaluation or for baseline testing please call: (818) 901-6600.
For the latest updates and information on concussion in the world of sports medicine you can also follow us on twitter: @the_jockdoc