Online Health Chat with Dr. Richard Figler and Robert Gray, MS, ATC
August 12, 2011
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
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.
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
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
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.
Alaska: What are the symptoms of a concussion?
Robert_Gray_ATC: Symptoms reported by athletes
- Balance problems
- Double or blurry vision
- Sensitivity to light and noise
- Fatigue or drowsiness
- Changed sleep patterns
- Trouble comprehending and/or concentrating
- 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
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
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
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
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.
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.
MI_EMT: What pain medications are appropriate for a
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.
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
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.
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
Robert_Gray_ATC: A helmet should be secure and not
move around when you shake your head. The helmet should be secure but not
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.
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.
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
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
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.
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
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!
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.
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This chat occurred on 8/12/2011
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