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Sports Concussion - Your Silent Invisible Opponent

Online Health Chat with Dr. Richard Figler and Robert Gray, MS, ATC

August 12, 2011


Introduction

By some estimates, as many as 3 million sports-related concussions occur annually in the United States, affecting youth, college, amateur, and professional athletes alike. Every athlete faces the potential of a sports-related concussion.

And there’s growing evidence that undiagnosed or poorly treated concussions can significantly prolong the initial recovery period and affect brain health later in life in some athletes. Physicians, health care providers, coaches, and trainers are more than ever recognizing the seriousness of concussions and the importance of adequate evaluation and treatment before sending an athlete back into the game.

A concussion is a short-lived brain injury caused by a bump, blow, or jolt to the head. A variety of symptoms, such as headaches, nausea, blurry vision, dizziness, depression, or change in sleep patterns, to name just a few, may develop immediately or several hours after the injury. There is rarely structural damage to the brain, and most concussions occur without a loss of consciousness.

Athletes who suffer a concussion are three to five times more likely to suffer a second concussion in the same season.

About the presenters

Richard A. Figler, MD, is a primary care sports medicine physician. He is board-certified in family medicine with a Certificate of Added Qualification in Sports Medicine. Dr. Figler is the primary care sports medicine team physician for John Carroll University and Solon High School.

Robert Gray, MS, ATC, received his undergraduate degree from Mount Union College in Alliance, Ohio, in 1975, and in 1977 he received his MS in Athletic Training from Indiana State University.

Think you may have a sports-related concussion? Cleveland Clinic Sports Health Concussion Program offers evaluations and management for sports-related concussions from our experienced team. For same-day appointments, call 877.440.TEAM or visit sports-health.org.

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Richard Figler, MD, and Robert Gray, MS, ATC. We are thrilled to have them here today for this chat. Let’s begin with some of your questions.


The injury

Rob: What is the difference between a concussion and a TBI (traumatic brain injury)?

Dr__Richard_Figler: Really there is no difference between the two. Both are considered injuries to the brain, virtually synonymous.

Far_Horizons: Is the location of the injury directly related to the concussion? Meaning, if a ball hits me in the forehead, does it cause a concussion right there or somewhere else in the brain?

Dr__Richard_Figler: Blows to the head can predict what types of symptoms you may have with the concussion, as different parts of the brain control different functions. There are times when the force of the hit can cause a concussion on the part of the brain that was directly struck, or there can be a "counter coupe" injury, which would affect the opposite side of the brain from which the head was struck.

furth: Where is the worst area of the brain to have a concussion?

Dr__Richard_Figler: There are symptoms that we think predict a longer recovery from a concussion. Typically, this is when the back of the brain is affected, possibly from a fall on the back of the head. The symptoms that are typically predictive of a prolonged recovery are balance issues, fogginess, neck pain, and difficulty concentrating.

abigail: I received a concussion when I was hit with a softball in the jaw. How is the mouth/jaw related to injuries in the brain?

Dr__Richard_Figler: That depends on where you were hit. The jaw will typically absorb some of the blow from the ball and not allow it to transfer to the brain. However, if you are hit in the right place, it can definitely cause a concussion. We think -- although evidence is lacking -- that some of the force can be absorbed in a mouthpiece.


Symptoms

Alaska: What are the symptoms of a concussion?

Robert_Gray_ATC: Symptoms reported by athletes include:

  • Headache
  • Nausea
  • Balance problems
  • Double or blurry vision
  • Sensitivity to light and noise
  • Fatigue or drowsiness
  • Changed sleep patterns
  • Trouble comprehending and/or concentrating
  • Depression
  • Irritability, nervousness, or sadness
  • Feeling "just not right" or in a "fog"
  • Difficulty paying attention

Alaska: Do symptoms show up right away, or is it possible that they might not show up for several days.

Dr__Richard_Figler: More than likely, symptoms will occur within minutes. Some, however, may take several hours to appear. Symptoms can change days later and others can develop. Typically, this occurs when the brain is stressed either cognitively (such as reading) or physically (such as running). So, some people who have suffered a concussion won't have very noticeable symptoms until they "stress" the brain.

gmatt99: I’m a parent of a youth athlete. Many times our kids play sports without athletic trainers on the field. As parents and/or coaches, what signs and symptoms do we need to look for, and how can we evaluate the seriousness of the injury while on the field (i.e., determining if the child can continue playing)

Robert_Gray_ATC: We offer fact sheets for parents, coaches, and athletes that can be downloaded at clevelandclinic.org/concussion. These guides offer information on signs, symptoms, action plans, and more.

Lisa1: Does a severe headache usually occur with a concussion

Dr__Richard_Figler: There are a variety of symptoms that occur with a concussion, and headache is the most common symptom, the severity of which -- especially if the headache goes from mild and increases significantly in severity -- is of most concern. Any headache that gets significantly worse can be a sign of a structural injury, such as a bleed.

Other common symptoms of a concussion are dizziness, noise and light sensitivity, loss of balance, fogginess, difficulty with sleep, trouble concentrating, and fatigue or drowsiness.

marys: My son had a concussion about one month ago. He still has headaches. Is this normal? How long should headaches last? What can we do about them? He is 15 years old.

Dr__Richard_Figler: The fact that he had a concussion a month ago and is still having a headache is bothersome. Typically, symptoms of a concussion last about 6 to 10 days. I would recommend that you identify the "triggers" of his headaches -- such as TV, video games, exercise, or reading -- and avoid them. I would also recommend that he see a physician for an evaluation. He may struggle with school coming up as well.

playdo: How long do the symptoms of a concussion last? Hours? Days? Weeks? Months?

Robert_Gray_ATC: The symptoms can vary depending on the severity of the concussion. That is why it's very important to seek medical advice.


Age

astevensgb: I'm 33 and pretty active in sports (soccer and basketball). Does age play a factor in concussion risk?

Dr__Richard_Figler: Age does play a factor in concussion. We know that the high school athlete has a higher risk than the college-aged athlete, and the college athlete higher than the professional athlete. We think it is due to the development of the brain over time that may "protect it." The developing brain is definitely at more risk. So, at 33, you are still at risk, but it is lower than when you were in high school.

andre: Are adolescents more prone to concussions?

Dr__Richard_Figler: Yes. Adolescents are at higher risk due to their "immature" brains. The brain is still laying down its neural pathways, and the neck is typically weaker as well, which may increase the risk of concussion.

momma: Kids start playing sports at an earlier and earlier age all the time. Are there guidelines for when a child should start playing a particular sport in terms of head injuries? Are head injuries more dangerous for younger players?

Robert_Gray_ATC: Kids have to "listen to their bodies." There are no specific guidelines, to my knowledge. Yes, head injuries are more dangerous in the younger athlete.


Evaluation

creekview: Can you tell me about ImPACT?

Dr__Richard_Figler: ImPACT is a neuropsych test that will establish a baseline for the athlete. The test takes approximately 25 to 30 minutes to complete and can be taken at a clinic, high school, or at home.

MI_EMT: Without an X-ray, are there criteria to diagnose a probable concussion to help determine evacuation to a hospital?

Dr__Richard_Figler: The criterion for transferring to a hospital basically depends on the symptoms. Prolonged loss of consciousness (greater than one minute), a neck injury, or focal neurological symptoms -- such as one sided weakness -- are reasons to send the athlete to a hospital. X-ray would not help.

jetsu: What are the guidelines for a student athlete to return to play after a concussion?

Robert_Gray_ATC: Before the athlete can return to play, he or she must be totally symptom-free and return to his or her baseline scores. Once the athlete has returned to baseline, he or she should start a five-day program, increasing activities while monitoring symptoms. If any symptoms return, the athlete should return to complete rest.


Treatment

MI_EMT: What pain medications are appropriate for a concussion?

Dr__Richard_Figler: In the acute phase of concussion, no medications should be given to relieve the pain. In essence, it will "mask" the symptoms, which could allow someone to participate with a concussion, which should never occur. Tylenol, after proper diagnosis, can be used, but not to mask symptoms (similar to injecting a joint with an anesthetic – such as lidocaine - and allowing someone to play), and should not be given just to cover up headaches. Symptoms need to be monitored closely. Aleve and ibuprofen (NSAID type medications) should not be used initially, as they may increase risk of bleeding.

Young_Dave: Is there any cure for a concussion besides rest?

Dr__Richard_Figler: There is no doubt that rest helps a brain recover from a concussion. There is research going on to determine how much rest is needed, but each concussion is treated individually. Typically, mental and physical rest is advocated. There is also research going on looking at medications that may be useful to prevent the progression of concussion, based on the physiology of what happens when the brain is initially concussed, and to help the brain "heal" more quickly. Prevention, by abiding by the rules -- wearing the proper equipment and making sure everyone (whether it is yourself or a teammate) recognizes the symptoms of concussion -- is key.


Risks

keller: What are the dangers of repeated concussions, especially to a younger athlete? Can this have an effect on them later in life?

Robert_Gray_ATC: Yes, especially in the younger athlete. The immature brain is more prone to dangers if the athlete has not completely healed from the first injury. Second impact syndrome and post-concussive symptoms can exist. To answer your question about later in life, research is looking into this.

Paddleboarder: Is there any way to tell if you will develop post-concussion syndrome? Is there any way to prevent it?

Robert_Gray_ATC: If you return to competition too soon, without your symptoms being resolved, you run the risk of developing post-concussive syndrome. Prevention: return when ALL symptoms are gone

connie: Is it true that some effects of concussion are not known until perhaps years later? You hear about former football players, etc., who have gotten seriously ill and died early (people like Mike Webster of Pittsburgh).

Dr__Richard_Figler: There is research to suggest that those with multiple concussions can be at higher risk for depression, but we do not know a certain number that is "safe." We believe that the multiple concussions that can occur over years of playing football can lead to dementia and structural brain injuries (as evidenced at autopsy). Unfortunately, we cannot predict that as of now. The good news is that concussions are taken much more seriously now, and we think that players such as Mike Webster may not have returned to play with the concussion guidelines we have today. Hopefully, and only time will tell, this will decrease the risk of problems for the younger generation.

govie: What is the correlation between concussions and seizures? If someone has a seizure after getting a concussion, does this mean that the concussion is more serious? What exactly does it mean?

Dr__Richard_Figler: Rarely does a seizure happen with a concussion, but when it does, it is scary. Research shows that when the seizure occurs as soon as the head is hit, there is no increased risk of seizures long term. The seizure at that point may be "protective." If the seizure happens after (hours to days) the hit, then it is much more worrisome.


Prevention

Porcupine: Can mouth guards prevent concussions?

Robert_Gray_ATC: There is no research to indicate that mouth guards will prevent concussions. Mouth guards are designed to prevent dental injuries not injuries to the brain.

Abigail: I was wearing a helmet when I got a concussion playing softball. What precautions should one take when fitting a helmet?

Robert_Gray_ATC: A helmet should be secure and not move around when you shake your head. The helmet should be secure but not uncomfortably tight.

Lakeside: Which sports experience the most sports concussions? Can they be prevented and how?

Dr__Richard_Figler: Football is responsible for the most overall concussions given the number of athletes (approximately 1.14 million) that play every year. Concussions in football can only be prevented by not getting hit in the head. Unfortunately, this is very difficult in football. Helmets can help decrease the risk of skull fractures, but none have shown the ability to prevent concussions. There is some evidence that neck strength can help "absorb" some forces and may help decrease the risk of concussion, but there needs to be more research on this.

connie: You mentioned earlier that increased neck strength may provide additional protection. How do you make your neck stronger?

Dr__Richard_Figler: There are some exercises that can be dedicated to neck strength. The research being done is looking at which muscles may be more effective. This is where more research needs to be done. Some personal trainers, physical therapists, or athletic trainers may be able to help. Stay tuned.


Research

sarah: I recently read that Cleveland Clinic was awarded an NFL Charities Grant. What type of research is this funding?

Robert_Gray_ATC: The grant will be used to support the work our Spine Research Laboratory is conducting that is specifically focused on determining the factors that affect youth safety and on helmet protection related to sports concussions.

Ham: What kind of research is being done in this area? Is there any research being done to determine how long a concussion or post-concussion will last?

Dr__Richard_Figler: There are numerous studies going on across the country in areas such as helmet safety, ways to decrease the risk of concussions, ways to prevent the long-term effects of concussions, and ways to assure that the athlete is "safe" to return. Unfortunately, the length of recovery is variable, and most of the studies are retrospective. We are looking at how to decrease the symptoms by intervening sooner, depending on what symptoms the athletes have initially.

silve9: Has there been any research to show whether or not one or more concussions can lead to depression in kids that play sports?

Dr__Richard_Figler: We have no idea if one concussion will lead to depression. We do see that kids who have numerous concussions (probably more than three) or who are out for a prolonged period of time - several months -- are a bit more likely to have some depression, but this is usually due to being away from school or sport. Those who are older who are found to have depression are football players, boxers or hockey players who played years and years. More than likely, they had numerous concussions that were undiagnosed and they just continued to play.


General questions

Nicholas: Is it a myth that someone with a concussion should be woken from sleep at regular intervals?

Robert_Gray_ATC: That is a myth. The athlete should get sleep, but you should check on the athlete periodically to make sure that his or her breathing habits have not changed. But if the athlete falls asleep shortly after receiving a concussion or is unarousable, this is a concern, and the athlete needs to be evaluated immediately.

erik: If you get a concussion, are you more likely to get another one the next time you are hit in the head?

Dr__Richard_Figler: Once you sustain a concussion, you are at a higher risk for subsequent concussions - typically about three to five times. The highest risk of another concussion is if someone returns to play prior to their symptoms completely resolving. This will more than likely prolong their recovery as well, and can result in prolonged symptoms, and even catastrophic events. No one should return to play if they are still having symptoms from a concussion.

Charlie: Regarding post-concussion syndrome, what suggestions do you have to continue your daily life?

Robert_Gray_ATC: Identify and avoid triggers. So, if symptoms increase with reading 10 minutes, decrease to eight minutes. Or if they increase with bright light, you may want to lower the lights or wear sunglasses.

Rhonnygirl: My son has had two concussions from playing football and rugby. He did not lose consciousness with the first concussion, but he did exhibit neurological changes and short-term memory loss. The second concussion resulted with temporary loss of consciousness and a headache for approximately six weeks. He is insistent on continuing to play contact sports. What can he do to prevent further concussions, and when it is time to hang up his cleats?

Robert_Gray_ATC: Our recommendation is to have your son see a medical professional for a complete and thorough physical evaluation by someone well versed in concussion evaluation and management.

thepuppins: If an adolescent is hit hard in the head (or an adult), at what point should they go to the ER instead of just going to their PCP?

Dr__Richard_Figler: Great question. If an athlete has any worrisome signs, such as prolonged loss of consciousness or focal neurological signs, or if he or she is getting worse, is not arousable, or has weakness or numbness that persists, he or she should probably be seen in the ER.

Sand_dunes: Are the schools trained in how to recognize a concussion? What about general recreational programs? How are they trained?

Dr__Richard_Figler: Great question. There is great variability of training on a variety of levels. Some schools have athletic trainers who are well equipped at recognizing symptoms of a concussion. There are some physicians who are well trained at taking care of concussions. Unfortunately, there is no standardized training to become an "expert," but the field of primary care sports medicine has been leading the field in education of physicians in the management of concussions. There is discussion of a bill that could push, possibly, for more "formal" education.


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Richard Figler, MD, and Robert Gray, MS, ATC, is now over. Thank you again, for taking the time to answer our questions about 'Sports Concussion.'

Dr__Richard_Figler: Thank you so much for your time. I hope you all received the answers you were looking for.

Robert_Gray_ATC: Glad to be here today. Great questions!


More Information

Think you may have a sports-related concussion? Cleveland Clinic Sports Health Concussion Program offers evaluations and management for sports-related concussions from our experienced team. For same-day appointments, call 877.440.TEAM or visit sports-health.org.

You may request a remote second opinion from Cleveland Clinic through the secure eCleveland Clinic MyConsult Web site. To request a remote second opinion, visit www.eclevelandclinic.org/myConsult.

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This chat occurred on 8/12/2011

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