Defining and Dealing With Concussions

Standard neurological evaluation includes testing of memory, cognition, orientation, concentration. In the athletic setting, it’s important to know the player’s usual mental abilities. Often the best questions to determine memory and orientation are related to the game itself — how far into the game are we? What field are we at? Who scored last? What play was running, and how did you get hit?

The athlete should be asked about headache and dizziness. Coordination, sensation, and muscle control should be carefully assessed. Provocative testing (testing after exercise — sprint, pushups, situps, knee bends) should also be checked.

Return to Play
An athlete with a concussion that followed by complete recovery (no symptoms at rest or with exertion) may be allowed to return to play after observation. A second concussion in the same game results in the player being pulled out of the game. CT or MRI is recommended in all instances where headache or other symptoms worsen or last longer than a week. It has been recommended that 3 significant concussions terminate the season, and no contact sports for three months, and then only if asymptomatic.

A more severe concussion with loss of consciousness requires immediate removal from play, and observation over the next 24 hours. One week after symptoms resolve, contact sports can resume. No contact sports are allowed for at least a month after a second such injury.

If a player does not regain consciousness in 3-5 minutes, he should be immediately taken to a hospital. Return to play is permitted at 1 month after being asymptomatic for 2 weeks. A second severe concussion should raise significant doubt as to continuation of any contact sport.

Second impact syndrome
This syndrome is controversial, with debate among experts about whether this occurs. Some feel that if a second head injury occurs before the first is completely resolved, significant permanent problems or death can occur. A mortality rate of nearly 50%, and injury rate of almost 100% is quoted. The risk of a second concussion is 4x higher after the first injury.

Post-concussion syndrome
An athlete may continue to have poor memory and concentration, headache, dizziness, fatigue, irritability after a concussion. This may take weeks or months to resolve, and is known as post-concussion syndrome. No contact sports should be allowed until ALL symptoms have gone for at least a week. Another injury before complete recovery could result in death from second impact syndrome. Neuropsychological testing with a pre-injury baseline is very helpful in this situation. Such testing can be accomplished at the time of the pre-participation physical.

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