Kristine Karlson, MD
Posted January 20th, 2011
Think concussion and what sports come to mind? Likely football, where injury statistics are easy to keep, and professional players sustain very public injuries. But large numbers of athletes participate in winter sports at many levels from elite skiers to the backyard ice rink. Winter sports are risky in terms of concussion because they all involve speed, slippery surfaces, hard objects, and the potential for lack of control. So winter is an especially good time to think about concussions.
A concussion is an injury to the brain, occurring as a result of sudden deceleration. You do not even need to have your head hit something to get a concussion, it can occur from deceleration of the brain within the skull. The result is a “brain bruise”, which can cause symptoms ranging from mild headache to longstanding difficulty with mental and even physical function.
When someone has a head injury, the first and most important task is to recognize that there may be a problem and remove the athlete from the event. Not just for a short time, but for the rest of the day. As time goes by, it may become clearer that the injury was either mild or dangerous, but that decision cannot always be made immediately.
Deciding to take someone with a head injury to the hospital is easy if there was a severe injury, prolonged loss of consciousness, neck injury or bleeding from the head. Whether to seek care for less severe injury is sometimes a harder decision. Skiers are aware of the death last winter of actress Natasha Richardson, who declined care despite worsening, and died of bleeding into her head hours after an apparent mild head injury. She ignored the so-called “red flags” for possible severe brain injury. They are worsening of headaches, changing level of consciousness, seizures, weakness, slurred speech, and vomiting. If any of these symptoms are present either immediately or in the 24-48 hours after a head injury, immediate medical care is necessary.
Concussions are not diagnosed by head CT or MRI scan. If a physician in the Emergency Department determines that a severe head injury is unlikely, they may decide against getting a CT scan. There are good reasons to decide against getting this test, including a relatively high dose of radiation exposure. Most athletes with concussion never get or need a CT scan.
Concussion symptoms help physicians decide when an injured athlete is ready to return to sports. They can be broken into several categories. The first is physical, and includes headaches, light and noise sensitivity, dizziness, balance and coordination trouble. The second category is mental function, which includes concentration and ability to do school or work mental activities. The third is emotional issues – concussed athletes can be more irritable and emotional in general. The fourth category is sleep, which includes trouble falling asleep or sleeping either too much or too little.
Physicians who manage concussions follow symptom improvement in these categories to determine return to school, work or sports. We get help from so-called neuropsych tests, most commonly a commercial product called ImPACT. This may be purchased by schools and other groups so that athletes can be tested at their baseline at the beginning of the season, then re-tested after injury and the comparison used serially to see how they are improving. Individuals can seek baseline testing as well for a fee (this is offered at the DHMC Sports Concussion Program).
The average recovery time for athletes with concussion is in the 7-10 day range. Once symptoms AT REST have all resolved, the athlete is ready to start a graduated return to sports. If at any time during this gradual return the symptoms recur, they are not ready to progress. A successful return to sports program lasts at least 5 days.
Some people do not get better from concussion as fast as this, and slow recovery is hard for them and those around them. After all, they don’t LOOK injured. But special accommodations for schoolwork (more time for tests, defer major assignments, etc) may be necessary when the brain is not functioning normally. People with persistent balance trouble or dizziness may benefit from working with a specially trained physical therapist. A psychiatrist may help with the emotional issues, and a neurologist may help with the physical symptoms and sleep issues.
The bottom line with concussions is to take yourself out after a head injury, assist with getting others to stop if they are injured. Seek medical attention for “red flag” symptoms immediately. Seek care from a physician trained in concussion management to help direct return to sports. And please be patient while your or a teammate’s brain heals.
Dr. Karlson works in family medicine and sports medicine at DHMC in Lebanon, NH. She serves as a team physician for local schools, Dartmouth College, and the US rowing team. She was a team physician for the US Olympic Team in 2008. She is a three-time world champion and 1992 Olympian in rowing and can be found Nordic skiing, biking and running depending on the season.