Online Health Chat with Richard Figler, MD, and Jason Cruickshank, ATC, CSCS

Wednesday, August 27, 2014

Description

One to three million sports-related concussions occur in the United States each year, yet growing evidence shows that many athletes, coaches and parents do not realize how serious these injuries can be. If a concussion is suspected, it’s important for the athlete to be evaluated before returning to activity. Effective injury management can allow athletes to return to competition sooner and more safely. Join our chat and have your questions answered by our Sports Concussion experts.

It is crucial to know the signs and symptoms of a concussion, but it is equally important to know what to do after an athlete has suffered a bump, jolt or blow to the head.

An injured athlete should come out of the game or practice to be tested on the sidelines by a person trained in concussion symptoms. An athlete with concussion symptoms should not play again that day and should not play as long as symptoms last. The athlete might need to wait one to two weeks or longer before being cleared to play again.

Most people make a full recovery after a concussion. How quickly they get better depends on how severe the injury was, how healthy they were before the injury and how well they follow their treatment plan. In all cases, rest is one of the most important treatments for a concussion because it helps the brain to heal.


About the Speakers

Richard Figler, MD, is a staff physician in the Center for Sports Health within the Orthopaedic and Rheumatologic Institute and Co-Medical Director of the Concussion Center at Cleveland Clinic. He specializes in sports medicine, sports concussions, acute and chronic sports-related injuries, and pediatric and adolescent sports-related injuries. He is also Team Physician for Solon High School and John Carroll University. Dr. Figler is board-certified in family medicine with a Certificate of Added Qualification in Sports Medicine.

Jason Cruickshank, ATC, CSCS, is a graduate of Baldwin Wallace University with degrees in Athletic Training and Fitness Management. He is a board-certified Athletic Trainer and a NSCA-certified strength and conditioning specialist. Jason has a background in the evaluation, treatment and rehabilitation of sports injuries, as well as in athletic performance enhancement. Currently, he is the Concussion Center Coordinator, where he is responsible for the coordination of athletic trainers working with physicians, the documentation of testing procedures, the coordination of physicians’ testing practices and return to play protocols.


Let’s Chat About Sports Injuries and Concussions in Kids

Moderator: Welcome to our chat today with Cleveland Clinic specialists Richard Figler, MD, the Co-Medical Director of the Concussion Center, and Concussion Center Coordinator, Jason Cruickshank, ATC, CSCS. We are thrilled to have both speakers available to share their knowledge and expertise about sports injuries and concussions in kids.

Let’s start with our questions.


Concussion Fundamentals

H8tc: Which sports put a child at greatest risk for getting a concussion?

Richard_Figler,_MD: Contact sports typically put children at highest risk for getting a concussion. These include football, ice hockey, girls/boys soccer and wrestling.

alecman: What exactly is a sub-concussive blow, and how many times does a person have to be hit before showing signs of an injury?

Richard_Figler,_MD: Every individual is different. Many athletes can be hit in the head (soccer ball, football plays) without sustaining a concussion. In theory, these "sub-concussive" hits can potentially accumulate and reach a threshold when they would cause injury. To date, however, this has not been shown to be true. When it comes to an accumulation of hits potentially showing signs of an injury, there is no set number or force of impact over time that has been shown to result in a concussive injury.

jerry: What is post-concussive syndrome?

Richard_Figler,_MD: It is a constellation (pattern) of symptoms that can include emotional, physical and cognitive dysfunction. These symptoms typically result from the initial head injury causing the concussion and can last anywhere from weeks to months after the initial injury. The symptoms include headaches, dizziness, disordered sleeping, decreased ability to focus, loss of concentration, emotional lability (frequent or intense moods) including mood swings, depression, anxiety and irritability.

aknapp: Is there any role diet can play in the recovery of a concussion?

Richard_Figler,_MD: The literature is sparse and studies are ongoing, but much of the information that we have regarding diet and concussion is extrapolated from data on brain health/neurocognitive well-being and nutrition, especially in the elderly. Some of the more researched supplements on diet include fish oils, turmeric, green tea extract and resveratrol. Any supplements taken should be in addition to a well-balanced diet high in fruits and vegetables and low in saturated fat and processed foods.

iaschoolnurse: What are the long-term effects of a concussion?

Jason_Cruickshank,_ATC,_CSCS: In most cases, there are no long-term effects of one concussion. Patients can suffer from daily headaches, neck pain, difficulty with concentration and focus, loss of short-term memory, dementia, mood changes, motor changes in their extremities, disordered sleep and personality changes.

iaschoolnurse: I am from a small rural community. How do you know if a health care provider is experienced in the evaluation and management of concussions?

Jason_Cruickshank,_ATC,_CSCS: I would ask local providers. Most physicians who have a Certificate of Added Qualification (CAQ) and have gone through a sports medicine fellowship have experience in the evaluation and management of concussion.

pftmom: What should parents/coaches be aware of post-concussion? Once the brain is fully developed, are there still risks for post-concussion syndrome if the injury occurred as a teen?

Jason_Cruickshank,_ATC,_CSCS: The biggest thing to monitor with a patient post-concussion is if they are progressing. If the athlete is having lingering symptoms, a thorough medical intervention should occur. The patient can sometimes be their own worst enemy in the fact that they deny or push through symptoms because they feel they may be letting someone down, they are worried about their academics or are just plain stubborn about modifications to their daily lives. The best thing to do is ask directed questions about if they are having headaches or other concussive symptoms and whether or not they are taking the time to rest, recover and re-approach their activities. Once the brain is fully developed, the risk from post-concussion syndrome does decrease, but the patient is at an increased risk of future injury due to lowered threshold.

aknapp: How many concussions are too many? In other words, when should an athlete be encouraged to retire from a sport?

Jason_Cruickshank,_ATC,_CSCS: One concussion is too many, but we don't have that silver bullet yet to prevent them completely. In regard to retirement, there are many factors at play. No consensus guidelines are out there for the retirement of an athlete. We look at factors affecting each athlete, like number of injuries, length of recovery for each individual injury, proximity of each injury and susceptibility. After those factors are assessed, we will make appropriate recommendations to the athlete.

doctorfrosty: What is currently the common belief/thought of what happens to the brain during a concussion?

Richard_Figler,_MD: There is a very complicated cascade of events (beyond the scope of this webchat) that happens when brain trauma occurs, including a shifting among cells, axonal/neuron stretching and the brain/body's natural response to healing the tissue (just like it does in any other place in the body). The brain tries to heal itself, but further trauma including increased activity or other hits to the head can throw the healing cascade off, making it much more difficult for the brain to heal itself.


Symptoms/Recognition

Luchiana: What are the definitive signs and symptoms of a possible concussion? Sometimes my son comes home complaining of a headache, but it could be that he is just dehydrated. What should I be looking for?

Richard_Figler,_MD: There are numerous signs and symptoms of a possible concussion. These include headache, dizziness, lightheadedness, balance problems, sensitivity to noise or sound, nausea, vomiting, neck pain, visual disturbances including blurry vision or double vision, fatigue, looking dazed or stunned, feeling mentally foggy or slowed down, forgetfulness, confusion, difficulty remembering, trouble concentrating, feeling "out of it", personality changes, anxiety, irritability, sadness, depression, feeling more emotional, and nervousness. They also include disordered sleep patterns such as insomnia, sleeping more are less than usual and easy fatigability with mental and physical activities.

Any athlete with headaches who is involved in contact sports or who has any of the other symptoms noted above may warrant a further evaluation for concussion.

JkN: How are schools and coaches being trained to recognize the signs of a possible concussion; and if they suspect an injury, what should they do?

Richard_Figler,_MD: All athletes, parents, referees and coaches are required by Ohio law to take an online class that educates them about the signs and symptoms of concussion. This increased awareness through education allows those around the athlete to recognize the injury not only at that time of the injury but also after the injury happens, even if there are relatively subtle signs. Any athlete during practice or a game who demonstrates signs or symptoms of a concussion should be pulled from that activity. They should then be evaluated by a health care provider experienced in the evaluation and management of concussions. When in doubt, sit them out.


Diagnosis/Treatment

iaschoolnurse: What is the proper sequence of events when a student athlete has a concussion? I am a school nurse and we utilize ImPACT for testing. Obviously a student should see a health care practitioner first, but then do they need to have a post injury ImPACT test that is back to baseline before starting physical therapy? What exactly do the health care practitioners do with the ImPACT test report that I give them? Thanks.

Jason_Cruickshank,_ATC,_CSCS: The sequence is as follows: injury, practitioner diagnosis and intervention, rest and recovery, return to school/learning, neurocognitive testing of recovery (ImPACT) and return to play. Only after a student athlete is asymptomatic and at full recovery of mental faculties should they begin a return to play protocol under the supervision of a medical practitioner (ATC, PT, MD, etc.). Health care practitioners utilize ImPACT to compare an athlete's results versus their baseline and/or normative data for age, sex, etc. Once an athlete returns to baseline or what is considered "normal," they can return to full school and full athletic participation.

hosr: If a concussion is suspected, what is the next step? What type of physician should the child see for diagnosis, treatment and follow-up care?

Richard_Figler,_MD: The first step if a concussion is suspected is for the athlete to be pulled from the activity to avoid any further potential trauma and for safety of the athlete. Appropriate physical and mental rest should be initiated, and this typically means avoiding mental or physical activity that worsens or provokes symptoms. The athlete should see a health care provider who is experienced in the evaluation and management of concussions; this includes physicians who practice sports medicine, as well as family medicine physicians, pediatricians, physical medicine and rehabilitation specialists, and neurologists.

aknapp: What do you find are the most effective tools for a clinician to use to diagnose and treat concussions?

Richard_Figler,_MD: There is not one perfect tool to diagnose and treat concussions, but education about the signs and symptoms is the cornerstone. There are good tools that assist in the diagnosis, however, and they include SCAT3 (which includes a symptom checklist, balance testing, memory function and recall). Be comfortable with the tool you choose to use. Experience in diagnosing concussions helps, but if there is ever any doubt about a concussion diagnosis, it is ALWAYS better to err on the side of caution. "When in doubt, sit them out." When it comes to treating concussions, there are a few keys that we use. First and foremost is rest. For the first few days it may be near complete rest but after that it is important to utilize relative rest. The stagnant brain becomes more stagnant and the overactive brain becomes more stimulated and symptomatic. We try to have the athletes do some activities as long as it does not worsen their symptoms and subsequently prolong the recovery process. The key is to recognize the symptoms, stop the activity, rest, recover and then return to the activity. No athlete who has continued symptoms should be allowed to return to play prematurely.

sallyl: I had a whiplash and concussion four months ago (hit from behind in an auto accident) and continue to suffer neck pain in the occipital area. Massage helps relieve the pain. Any other suggestions? Why is that area so tender?

Richard_Figler,_MD: Persistent neck pain is a common complaint in both auto accidents and concussions. The head is bent back and forth on the cervical spine and resultant neck muscle injury/irritation can take place (the occipital area). Massage can help, as can vestibular therapy (therapists that specialize in cervical pain and associated dizziness symptoms), soft tissue immobilization, myofascial release, heat, ice, anti-inflammatories and appropriate neck position when doing daily activities (computer/TV). Occasionally, the back of the neck (where the neck/skull meet) can be injected by someone trained in doing so to relieve some of the pain associated with the injury. There are times when the nerves can be irritated as well, such as the greater occipital nerve, and that may respond to some of the above treatments, too.

doctorfrosty: How much emphasis is given in the evaluation of the cervical spine in the incident of a direct or indirect head impact? And in evaluation of the symptoms, what assessment of the cervical spine is standard?

Richard_Figler,_MD: With any head injury, first and foremost a more severe brain injury (such as a subdural or intracranial bleed) or spinal cord/cervical spine injury needs to be ruled out before a concussion can be diagnosed. Including questions about numbness and tingling, weakness, and neck pain can help in diagnosing underlying, more severe neck injuries. The cervical spine is initially evaluated with questions and then palpation and an appropriate full neurological exam. Any concern would warrant further radiologic evaluation. After the athlete has been cleared of a more severe injury, the neck can be evaluated at follow-up. It is typically injured during head impact. This can result in neck pain that can persist even when the concussive symptoms have resolved.


Prevention

WGmom: I have three boys who play football. Mouthpieces and helmets are standard equipment. What are some things parents and players need to know to ensure a proper fit? Should I see my dentist to have a custom mouthpiece made or are the ones at the sporting goods store sufficient? My son had three concussions throughout high school and had to sit out his senior year. He is asymptomatic (no headaches or light sensitivity since the weeks after the incident last summer). He is 18 and will be going away to college in the fall. What else should we be aware of post-concussion? Would activities like riding roller coasters be dangerous to do now? Once his brain is fully developed, will he still be at risk for post-concussion syndrome?

Jason_Cruickshank,_ATC,_CSCS: Helmet fit is very important to every sport. First thing to remember when fitting a helmet is that they are not sized like hats. Instead, they come in small, medium, large, etc. In regard to helmet fit, ask: is it snug with no air in it and does the athlete have to pull the helmet open so it will drop on to his/her head? A snug helmet will move with the head better and require less customization to ensure proper fit and that it stays in place. A loose helmet can bob up and down and spin during a big collision, risking not only a concussion but facial and neck injury. Next, while the helmet is in place, you should make sure that you have a one to two fingers-width space over the eyebrows on the forehead. This should coincide with the earholes lining up as well. If they do not, then the helmet needs to be rotated back toward the neck, or some padding needs to be added. Adding the chinstrap should occur while the mouth is closed and the mouthpiece is in place. The strap should be tight with little to no slack. It only needs to be loose enough for the athlete to put his/her mouthpiece in and take it out. This is the most commonly missed item with helmet fit because athletes loosen the straps so they are more comfortable when talking on the sidelines. The result, when they go in to play, the helmet can pop off of their heads because it is not adequately secured. The final bit of helmet fit is adding air (for the majority of products out there). Add only enough air to align the helmet without adding too much pressure to the head. Air bladders should be checked daily by players and frequently re-inflated, as they deflate over the course of a practice.

Mouthguards are always better as a custom fit, although they do not need to be. However, athletes tend to be more compliant with wearing them when they fit perfectly. A boil-and-bite mouthguard you get at the sporting goods store is more than sufficient; just make sure it is boiled for proper molding and fit. When this is not done, the mouthguard can be uncomfortable and easily knocked out of the mouth. A mouthguard out of the mouth does not protect the teeth, which is its purpose.

In respect to your son, it sounds as if he has been asymptomatic for some time. As long as he has had the adequate recovery time for elimination of symptoms, his risk for post-concussion syndrome will be lower. In regard to him riding a roller coaster, provided he has no neck pain or symptoms stemming from his neck, he can find an easy and smooth roller coaster to start and gradually progress to more thrill-seeking coasters as symptoms permit. It is suggested that full development of the brain will lower the risk of post-concussion syndrome; however, there are also examples where multiple injuries across the course of one's lifespan increases the risk of future concussion due to a lowered threshold for new injury. So, care should be taken to minimize risk in future activity participation.

aknapp: What is your opinion of all the helmet sensors entering the market recently, knowing helmets don't actually protect against concussions, and the addition of the hit count sensor that measures predetermined G forces (20 is the measure they are using) to determine possible concussive blows to athletes?

Richard_Figler,_MD: Helmet sensors are an interesting addition to concussion evaluation. The technology, at this time, does not replace the clinical expertise of those trained in the evaluation and management of concussions. There is no specific number that indicates that a concussion will happen at a specific force, and there are several variables in place, including whether the athlete has had a previous concussion and whether the athlete is "ready" to get hit or has been blindsided. There are times when the unsuspecting athlete may take a minor hit and sustain a concussion, but the athlete who is "ready" to get hit will not sustain one. The helmet sensors will sense force to the helmet, and some of that force is dissipated within the helmet and the padding and not necessarily transmitted to the brain. Although the force is an important indicator, it may not always lead to a concussion. The fear is that the athlete will be pulled due to the force but not due to symptoms. The hope is that the athlete will be evaluated if there is an increased force delivered to the helmet. Cleveland Clinic is working on a mouthguard that will sense more of a blow to the head itself as opposed to just a helmet.

VB2gate: What criteria should we as parents be looking for in a football helmet to protect against concussions?

Richard_Figler,_MD: The football helmet should fit appropriately, be in good repair, be certified and then re-inspected during the course of the season for any signs of wear or breakdown.

SPORTSDR: Do you have a dentist on your team, and is there any scientific evidence that mouthguards used in sports prevent concussions?

Richard_Figler,_MD: We work in conjunction with our dental clinic and have dental staff as well as dentists in the community who help many of our athletes. The primary use of mouthguards is to prevent dental and oral trauma. To date, there is little evidence that mouthguards help prevent sports-related concussions.


Return to Activity

Mjk1: My 12-year-old suffered concussion symptoms after taking an elbow to his eye while wrestling with his friends. He then experienced what I would label as a severe concussion approximately three months later after being thrown from a golf cart and hitting his head on the concrete. Since that time, he has experienced concussion symptoms two additional times within the following four months. One time, he stood up and accidentally bumped his head into something, and the other time he doesn't remember having any trauma to his head but had been playing basketball for several hours. My question is: how can we determine when or if it would be safe to allow him to participate in a contact sport like football? He had a CT scan after the golf cart incident, but we have not taken him back in for additional evaluations since. We have not noticed any change in behavior or signs that would indicate lingering effects other than it seems like he gets the symptoms with much less of a trauma than might be expected.

Richard_Figler,_MD: CT scans only evaluate for signs of physical brain trauma, including bleeds of or around the brain. They do not diagnose concussions. Once someone suffers a concussion, they are at increased risk for another concussion. We believe that the threshold is somewhat lowered. The question is whether he is fully recovered after each of these injuries. The minor traumas that he has experienced that cause symptoms afterward would be concerning, and that he has not made a full recovery from the initial concussion or the subsequent ones. Given the number of injuries he has sustained, I would recommend that he is evaluated by a health care professional who is well-versed in the evaluation and management of concussions. They should be able to make a determination on the safety of his return to play contact sports.

aknapp: What are your thoughts about how to implement a successful return to play (RTP) protocol in athletes who do not have the benefit of an athletic trainer? This includes the vast majority of rec league kids whose brains are still developing and are particularly vulnerable.

Richard_Figler,_MD: Although the logistics may not be in place, you can still make it happen. Preferably, these young athletes are evaluated by a health care professional who is trained in concussion management and return to play. The athlete needs to be asymptomatic both with mental and physical activity and be off all medications prior to starting return to play/activity guidelines. Once they are cleared for physical activity, returning to activity will follow internationally accepted return to play guidelines that are well documented in the literature. The athlete should remain asymptomatic at all phases of their return to play guidelines. Although an athletic trainer is a bonus to have during the return to play activities, return to play can be done appropriately with these guidelines and appropriate monitoring.

iaschoolnurse: Should a student athlete be allowed to return to school immediately after a diagnosis of concussion?

Jason_Cruickshank,_ATC,_CSCS: Not necessarily. Most concussive symptoms don't set in for 24 to 72 hours, peaking at the 72-hour point. Every athlete’s injury is variable, however, depending on the severity, vulnerability and history of concussion. In many instances, it is preferable to accommodate the athlete with a half day of school to start and availability of a quiet place to go in the event that the stress of the school day elicits symptoms. The school nursing facility is a great place to allow a symptomatic athlete to rest, recover and reset back to their previous symptomology before continuing with the next class or the rest of the day.


General Questions

Harper43: I understand that a lot of concussions are the result of head-to-head impact. I have also heard a lot in the news about the new types of football helmets for greater protection. But what about soccer, where there are no helmets and often the ball is fielded off of the player's head. How dangerous is that play when considering concussions?

Richard_Figler,_MD: Given the number of balls soccer athletes hit with their heads, you would expect the number of concussions that occur with soccer to be higher due to these hits. But that is not necessarily the case. Typically, a skilled soccer player can redirect or hit a ball with their head without sustaining a concussion. When this activity is controlled, it lessens the risk of potential injury. Many of the concussions that occur in soccer are due to the ball unexpectedly hitting someone's head; an elbow, shoulder, foot or other body part striking another opponent in the head; or the athlete’s head striking the ground.

terryd: Please advise regarding the role of checking the temperature when doing neuro checks immediately after a head injury. Also how quickly can pupils change?

Richard_Figler,_MD: There is no role in checking temperatures in concussions. Depending on sports and environment, an athlete’s temperature may be elevated. Theoretically, temperature may be elevated after a concussion but there can be many variables that play into the temperature. This can be more in a more severe head injury such as bleeding around or in the brain. It is important to differentiate between heat related illnesses versus a concussion, as the symptoms can overlap including nausea, dizziness, headache, fatigue and disorientation.

Pupils can change immediately after a more severe brain injury. Typically, the pupils may dilate equally. If they are unequal (and they weren't in the past), it is more concerning.


Closing

Moderator: I am sorry to say that our time with Cleveland Clinic specialists Richard Figler, MD, the Co-Medical Director of the Concussion Center, and Concussion Center Coordinator, Jason Cruickshank, ATC, CSCS, is now over. Thank you for sharing your expertise and time to answer questions today.

Richard_Figler,_MD: Thanks for all the great questions today. Hope we were able to help. Stay well.

Jason_Cruickshank,_ATC,_CSCS: Thank you all for participating in this conversation on concussion today.


For Appointments

To make an appointment with Dr. Figler, Jason Cruickshank or any of our other specialists in the Center for Sports Health at Cleveland Clinic, please call 877.440.TEAM (8326). You can also visit us online at clevelandclinic.org/concussion for additional appointment options.


On Cleveland Clinic

Cleveland Clinic's Concussion Center, a collaborative effort between the Center for Sports Health and the Neurological Institute, is dedicated to evaluating and managing athletes who have suffered a concussion.

At the Concussion Center, we are committed to raising awareness about concussions to help ensure patients of all ages receive early and appropriate care. It is our goal to minimize long-term effects of concussions and further research to improve tomorrow’s care.

Cleveland Clinic concussion team on the sidelines:

Our team utilizes its vast experience taking care of athletes at all levels – recreational, high school, collegiate and professional – to provide customized care to ensure a safe return back to sport. Our certified athletic trainers provide care to athletes at more than 50 high schools and four colleges in Northeast Ohio.

Our team is made up of sports and exercise medicine physicians, neurologists, neurosurgeons, neuropsychologists, certified athletic trainers, vestibular therapists, radiologists, neuro-ophthalmologists and researchers, all dedicated to getting the athlete back to play safely.

Cleveland Clinic Concussion Center by the numbers

  • 6,000 baseline assessments performed annually
  • 1,200 + patients evaluated for concussions
  • 6 concussion-related active research projects
  • 61 athletic trainers
  • 83 physical therapists, including 17 with special training in treating dizziness and balance dysfunction

For Additional Health Information

On Sports Injuries and Concussions in Kids

Answers to common questions about concussions may be found at:

On Your Health

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A remote second opinion may also be requested from Cleveland Clinic through the secure Cleveland Clinic MyConsult® website. To request a remote second opinion, visit eclevelandclinic.org/myConsult.

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