I have been asked to write about concussions from time to time. I attempted a chapter on concussions for a book at some point, over the next few weeks I will post this chapter, as I wrote it, no matter how horrible it is. After all I am not an author, but at least you can take a look. This particular chapter deals with concussions in the sport of football. We all should know this injury can be sustained in any sport. Because football is the biggest draw of sporting eyes I felt it was best to present it in this way. (Part I, Part II & III) *All sources will be posted after last portion is up.
Detecting a Concussion
Although the injury is “invisible” there are ways to identify and detect a concussion. In fact this is one of the few injuries where modern technology – x-ray, MRI, CT scan – cannot “see” the injury, rather those diagnostic tools are used to rule out much more severe injuries; such as skull fractures or bleeding on/in the brain. Medically speaking any blow to the body and/or head that results in signs and symptoms is classically diagnosed by a physician as a concussion[i].
In the field as an athletic trainer trying to root out those concussed conditions are slightly more difficult, weather conditions and things like lighting notwithstanding, the individual and those surrounding him/her make detecting a concussion very difficult at times.
Most athletes are competitive by nature and have a very hard time coming off the field for any reason, let alone an injury; something that would show weakness. Now try getting that athlete off the field when there is nothing for the general public, coach, or teammates to see. A lot of what goes on with detection as an athletic trainer has to do with observation of the actual hit/hits, but usually being outnumbered 40-50:1 makes watching every play and every hit nearly impossible. This makes second-hand information VERY important; such as a teammate saying “Joe is acting weird out there,” or a coach saying “Joe missed three straight assignments, someone get his head out of his ass.”
Athletic trainers must be “Junior CSI’s” at the beginning of the process, gathering as much information and facts as possible, and here is the kicker, AS FAST AS POSSIBLE. Using Joe as an example, we have heard two comments from two different sources, this does not mean a concussion, rather time to take a look, it could be something as innocuous as Joe having a bad day because his girlfriend broke up with him. Asking any assistants you have working with you as to what might be going on with Joe is a beginning step, in lieu of assistants coaches and players are your best resource. Upon preliminary questions we have found out Joe made a huge tackle and was “slow” to get up and back to the huddle.
Now that we have determined the play and general time frame the questions can be more pointed such as; “Coach on second down Joe made a tackle in the open field did you notice anything?” Now, remember that coach is well, coaching he hardly has time to recognize who is tugging at his shirt, let alone give you two seconds. That is where the coach must and will give you the respect you have earned and answer your question.
“Yeah, helluva tackle, laid that kid out and saved a first down, he was a little slow to get up though, he needed some help.”
“Was he grabbing his leg or something?”
“No, he shook his head and squinted his eyes and grabbed his nose, ya know?” RED FLAG! At this point we have gathered enough “circumstantial evidence” to warrant him coming out for a quick check. At this point, Joe has been out there for AT LEAST three plays (remember the first comment from the coach) since the hit in question, putting him in danger if in fact he has a concussion. Here comes even more difficulty and resistance from everyone involved.
“Coach I need to check out Joe, you have a sub for him?”
“What! He’s not hurt he is walking and running around.”
“I NEED HIM OUT, NOW, he is showing signs of a concussion, I need to check him out, if he is fine you will have him back.”
“Coach, we will talk about it later, GET HIM OUT, please.”
This is where education and awareness of this injury is very important, because if the coaching staff and players themselves know about concussions the above conversation is completely different, and perhaps does not even occur. If the coach is aware of signs of a concussion and sees his player grab his head and miss an assignment he would KNOW to pull him for a check. Even if he does not pull Joe, perhaps he is wrapped up in coaching, when we come over and ask for his removal there is no questioning. Maybe some can be as lucky as I am; as our current coaching staff allows me to make subs for players the moment I feel it is necessary for an injury evaluation, no questions asked. We have finally got Joe off the field and to the sidelines for an evaluation, on our time. The most important thing being that if Joe does have a concussion he is out of harms way.
As you might imagine, Joe is very upset about coming of and talking to us, the berating begins as he trots off the field. Even though players are upset and don’t want to be pulled from a game they usually respect decisions and directions given to them. The first thing I do is ask for his helmet, avoiding him avoiding me and getting put back in, and tell him to get a drink and sit down. After a few seconds of observation and cooling off it is time for the evaluation to begin, being a mainly subjective injury the questions; how and when they are asked are key to detecting the injury.
“Are you hurt?”
“No, I want to go back in!”
“Do you have a headache? Or anything else?”
“No, I told you let me back in.”
“Tell me what happened on the play where you made that open field tackle.”
“What play?” RED FLAG, however adrenaline and the moment can create a quick lapse in memory.
“The one where you hit #34 saving a first down.”
“Oh yeah, I lit him up, get me back out there!”
“Why did you need help getting up?”
“I just got the wind knocked out of me.”
“Why did you grab your nose and squint your eyes, Joe?”
“I always do that, I AM FINE.”
“OK, if you are fine how bout we do some tests?”
“Whatever will get me out there faster.” This first line of questions does a couple of things, it establishes a baseline of disposition (agitated with possible memory issues) at the current time as well as comparing “current Joe” with “regular Joe” that we know during practices and school. The second thing these questions do, is allow for more cooling off and getting Joe back to a “restful” state prior to testing.
There are many questions we like to ask during the evaluation, but the common theme is symptom reporting, testing memory, recall, and base level brain function of the individual. We like to use a modified version of the Sideline Concussion Assessment Tool 2 (SCAT 2), figure 1[ii].
“Joe, are you having any symptoms, like a headache, vision disturbance, ringing in your ears, feeling sick?”
“I told you I am fine, just a little headache, and thing seem to be in a fog, no big deal.”
“I understand, where are we at?”
“Good, what quarter are we in?”
“Second, we are winning 14-0.”
“Alright, who did we play last week, and the score?”
“State College, and we won… I think… Did we win?”
“We won, it was a good game, doing good, now time to test your brain function, you ready?”
“Yeah, my head is starting to hurt more.” RED FLAG! Joe is starting to calm down and his body is sending signals that he is now beginning to realize, in my setting this would be grounds for removal, but for the sake of appeasing both Joe and the coaches we will continue with the line of questions.
“Joe, can you tell me the month, day, day of the week it is?”
“September, the 3rd, and its Saturday.”
“What year, and about what time is it?
“2011, and we kicked off at 2 so it is about 3:30 or so.”
“Now I am going to read a set of words, when I am done I want you to repeat them all back to me, in any order, got it? Here is the list, give them back to me when I am finished; elbow, apple, carpet, saddle, bubble… Your turn.”
“Saddle, elbow… apple… uh… was it saddle, yeah saddle like on a horse, and… carpet, I got them all, I am good to go, give me my helmet.”
“You are not quite done yet, but that was good. Great start, time to do some simple number stuff. I am going to read you some numbers, after I am done say the numbers back to me IN REVERSE order. Example I say 2-1-7 you say 7-1-2, got it? Here we go. 9-3-6”
“6-3-9, this is stupid.”
“0-7-4-1, that was tougher.”
“8-3… wait, 8-5-1… can you say them again?”
“8-5-7-2-3, ha nailed it, where is my helmet?”
“Not quite, you will get your helmet if you are cleared, are you ready for the next test? I want you to say the months of the year backwards; December-November-October and on, ready? Go.”
“December, November, October… September, August… June, May, no wait… July, June, May, February, January. DONE, I am good.”
“Sorry Joe you missed a couple of months, how is your head?”
“Just a headache, but these tests are making it hard for me to concentrate.”
“OK, we will move on to testing your balance.” We use the modified Balance Error Scoring System[iii] (BESS) without an unstable platform. “Joe, stand with your feet together, hands on hips and eyes closed, ready? Go.” Joe cannot hold his balance for longer than 3-4 seconds, he is opening his eyes and taking a step every once in a while. After 20 seconds it is time for the next stance. “OK, now stand on your non-dominant leg, hands on hips and eyes closed, ready?”
“I have a bad ankle, you know, I wont be able to do this.”
“Just amuse me and try, ready? Go.” During this trial he has zero control and cannot keep the stance for one second, and is even wobbly getting into position. This test is also done for 20 seconds and is futile. “The last one is for you to stand heel-to-toe with your non-dominant foot in the back, hands on hips and eyes closed, ready? Go.” This time Joe manages to sway grossly from side to side to keep his feet planted, however his hands come off his hips and his eyes open. “Thanks Joe, how bout we sit back down and finish this up, two more tests.”
“OK, hurry up I want to get back in there.”
“I want you to hold your hand out in front of you fully extended (either one), keep your eyes open and when I tell you, I would like you to touch the tip of your nose, five times as fast as you can. Do you understand?”
“Get into position, ready? Go.” Joe is going real fast, however he has missed his nose a couple of times, hitting his face. “Good, last test. I would like you to repeat the words I gave you earlier, ready?”
“No, wait, you didn’t tell me I had to remember those, what the heck, this is not fair!”
“I got them, elbow, saddle, orange, floor and bubble… Now we are done, I am ready, I am going back in.”
“Sorry to tell you Joe, you are not going back in, I believe you have sustained a concussion, you will not be allowed to return to the game and you will have to be assessed by a doctor tomorrow.”
The process is not done even though Joe will not be returning, there are emotions associated with concussion that everyone must be aware of, from anger to depression. Joe will be monitored by a responsible person for deteriorating symptoms for the remainder of the game and will be sent for an x-ray/CT scan to rule out a more severe injury. He will then be in a doctor’s care and he will have to follow-up with him regarding future diagnostic care, including neurocognitive testing.
The entire process above is truncated quite a bit if there is outward “gross” signs that an individual has been possibly concussed. Like an obviously broken bone, there are some instances where, without a doubt, a head injury has occurred. The most obvious is loss of consciousness; HOWEVER you do not have to lose consciousness to sustain a concussion, that situation should warrant activation of the EMS system in adolescents and youth so they can be transported to an emergency department. Other “gross”/observable signs are; unsteadiness on the feet, going to the wrong huddle, walking to the wrong sideline, or as we call in athletic training, the “gaze”. This disposition by the player is one of looking right through you while having a glassed over appearance to the eyes. If a player exhibits any one of the above signs they should be removed for a check, no questions asked, and one should assume until told otherwise by a medical professional they are indeed concussed.
When we are detecting for a concussion it all goes back to the initial definition of this injury; disruption of normal brain function. If there is a shift from normal then the player shall be considered concussed, and not allowed to return that day.
[i] (Mayo Clinic staff 2011)
[ii] (3rd International Concensus Meeting on Concussion in Sport 2008)
[iii] (University of North Carolina – Chapel Hill 2009)