As high school and college sports seasons kick off this fall, coaches, fans, parents (and athletes themselves) might think of concussions as a risk relegated to football players. But as researchers dig deeper into data on head injuries, they are finding elevated rates of concussions in other sports as well. Female soccer and basketball players at the high school level and, at the college level, men’s wrestling and ice hockey, as well as women’s ice hockey, all have higher rates of head injuries than football players, according to one large study.
“Studies that looked at NFL players and boxing-related injuries initially brought the issue of concussions to light,” says Yale Medicine neurologist Charisse Litchman, MD. “Now, it’s a growing field and we know more about it.”
In particular, more attention has focused on concussion risk and repercussions among kids ages 12 and younger. “Within the last five years, we have realized that mild traumatic brain injuries—concussions—can cause problems for children down the road,” Dr. Litchman says.
A large Canadian study in 2016 found that about one-third of patients ages 5 to 18 who had concussions experienced lasting psychological and behavior problems, referred to as persistent post-concussion symptoms (PPCS).
Some national sports organizations have changed their rules to offer kids more protection as awareness of this vulnerable population has grown. Four years ago, the U.S. Soccer Federation made hitting the ball with your head, called heading, illegal in both games and practice for players ages 10 and younger.
Despite regular news coverage about concussions, there are still myths around how they can be detected and the best recovery approach. Yale Medicine experts agree that with greater awareness, parents, coaches, and athletic trainers can help potentially concussed athletes take precautions.
“Got my bell rung”
Any action that causes your head to move quickly in any direction can cause a concussion. When this happens, the brain, suspended in fluid, knocks against the skull, causing brain tissue to stretch or twist. Those twisting and stretching motions damage axons, which are nerve fibers attached to neurons that conduct electrical signals, or messages, to other cells in the body, researchers believe. This, in turn, sets off a series of biochemical changes in the brain, causing momentary disorientation and other problems immediately after the injury, and sometimes longer.
So, if the brain can be injured by one of these sudden movements, how can parents and coaches spot an incident that puts players at risk for concussions?
Be on the alert for sudden stops (or deceleration), like when a player trips over tangled feet, landing suddenly on the ground. Any head-to-head collision, or a hit with an elbow or stick, that causes the head to whiplash can result in a concussion. A head injury can also happen if a player’s neck is struck forcefully. Always pay attention to how the head moves during player contact.
“What we’ve come to realize in recent years is that the presentation of concussions—how they show up in individuals—is varied,” says orthopedic surgeon Elizabeth Gardner, MD. As head orthopedic surgeon for Yale University athletics, Dr. Gardner stands on the sidelines at Yale’s football and men’s lacrosse games and provides immediate assessments of possible concussive injuries.
A blackout or loss of consciousness only occurs in a minority—less than 10 percent—of concussions. Athletes are more likely to feel a ringing sensation in their head or ears, which they might shrug off with a dismissive “got my bell rung” and try to keep playing. Some players might experience severe symptoms, like noticeable disorientation, nausea or vomiting (one time), dilated eye pupils, or trouble balancing.
But signs of a concussion can also be subtler, such as a headache, dizziness, sensitivity to light or noise, numbness, fatigue, feeling anxious, depressed or groggy, or just an overall feeling of something that’s not quite right.
There’s no single test that can diagnose a concussion. However, on the sidelines of a game or when a player is injured during practice, a medical professional may rely on the Sport Concussion Assessment Tool – 5th Edition (SCAT5), which assesses neurologic functions like balance and gait, and tests a player’s memory, to decide if a player needs further evaluation, says Dr. Litchman. The SCAT5 includes the Glasgow Coma Scale, a widely used brain trauma measurement tool that includes examining a player’s eyes, ability to talk, and motor responses. Other tests include asking the injured person to count backwards and list months of the year in reverse order.
Depending on the total symptoms and severity, the athlete may be sent to the emergency department. “Unfortunately, the state of Connecticut does not require a medical professional to be present at sporting events other than high school football,” Dr. Litchman says. When parents or other adults are responsible for sideline assessment, the evaluation is likely to be less formal. Several smartphone apps exist that claim to help nonmedical professionals assess potentially concussed athletes, but the Food and Drug Administration (FDA) advises the public not to use these apps because their safety and effectiveness have not been proven.
A concussion, or worse?
Emergency department (ED) physicians gather additional information to determine which diagnostic tests are necessary. Concussions, also called mild traumatic brain injuries, cannot be detected through computerized tomography (CT) scans, though these tests may be done to see whether there is bruising or bleeding in the brain. “You can’t see a concussion on a CT scan. A concussion by definition is a nonstructural injury,” says emergency medicine physician Edward Melnick, MD. He developed a tool for medical professionals, called Concussion or Brain Bleed, that provides talking points doctors can use with patients to discuss why a CT scan is likely not necessary for low-risk concussive injuries.
Certain “red flag” symptoms could mean additional brain injury beyond a concussion, such as brain bleeding, Dr. Melnick says. “If a person is not acting like himself or herself, seems very sleepy, has vomited two or more times, or shows any seizure-like activity, then a traumatic brain injury should be considered.” Also, any patient taking medication for a bleeding disorder should be evaluated thoroughly if they have a concussion, due to a higher risk of complications, he adds.
Immediate, short rest period can help with recovery
Concussions take, on average, six days to improve and most athletes can return to their sports within two weeks—as long as they follow general guidelines for recovery, says Dr. Litchman. Though it used to be common practice, it’s not currently advised to “cocoon” the injured athlete away from light and any activity for a week or more. “Now, we know that a return to noncontact activity is likely beneficial,” Dr. Melnick says.
The broad recovery guidelines for a sports-related concussion are one or two days of rest, followed by a gradual introduction of light physical and cognitive activity that feels comfortable and does not result in such symptoms as a headache or dizziness. Recovering athletes can request educational accommodations, including attending school for a half a day before going back full-time. Other temporary adjustments could include taking mini breaks during classes and tests, avoiding extremely noisy environments, and having extra time to finish assignments. During the recovery period, parents should make sure their child avoids aspirin and other anti-inflammatory medications because these could increase the risk of bleeding.
“For concussions in general, we don’t have too many options in terms of telling patients what to expect or how to treat it,” Dr. Melnick says.
However, he adds, during the recovery stage, it’s extremely important to avoid getting hit in the head again. Even a very mild injury can cause significant damage to an unrecovered brain.
“The worst thing is a getting a second brain injury before the first has healed,” Dr. Melnick says. “This second injury can be more severe with less force—just look at highlight reels from hockey games. A player might be on the ice briefly after a hit, and then after a second hit, they are out for the entire season. The brain is the most complex organ in the body. We are only beginning to understand what happens when it is injured,” he explains.
Persistent post-concussion symptoms
If symptoms aren’t getting better after a week or two, depending on their severity, an athlete who has suffered a concussion should see a neurologist for additional testing for possible PPCS, Dr. Litchman says. A neurologist will test for cognitive, visual, and balance problems, and may prescribe rehabilitation therapy.
Researchers are studying links between concussions and lasting pituitary dysfunction. The pituitary gland, located under the brain and behind the bridge of the nose, is responsible for regulating hormones throughout the body. Damage to the pituitary gland can cause such symptoms as extremely dry skin and excess hair loss, mood changes, and cardiovascular problems. If these signs are present, a visit to an endocrinologist for hormone testing may be recommended.
“There’s so much more we know now about concussions,” Dr. Litchman says. “I always say, ‘When in doubt, get it checked out.’”
That’s sound advice for all athletes—including football players.