Influencing Concussion Reporting Behaviors in High School Athletes

“Be Honest.  Speak Up.”  This phrase is repeated throughout the concussion portion of every ASA™ Program.  Every effort is made to encourage athletes in attendance to be truthful about their concussion symptoms or those of their teammates.  Research has shown that returning to play while still suffering concussion symptoms can lead to more severe and potentially catastrophic head/brain injuries, yet there are still occasions where high school athletes return to play with lingering concussion symptoms.  The question remains, “Why?” 

A recent study in the Journal of Athletic Training attempts to better understand factors that influence concussion reporting in high school athletes.  The researchers hypothesized that improved concussion knowledge and a positive attitude are motivational factors that should increase concussion reporting.  Over a two-year period (2008 – 2010) high school athletes across six sports were asked to complete a survey (167 athletes participated) regarding their knowledge, attitudes, and beliefs about concussions.  Participants were also asked to document previous concussions and concussion-like symptoms and whether or not they reported them to a coach or medical personnel. 

Results of the study show that concussion still continue to be under-reported by student-athletes because of a lack of recognition of concussion signs and symptoms and a negative attitude toward reporting potential concussions.  Specifically, the following was noted:

• Of the 167 athletes who completed the survey 89 reported having at least one concussion or "bell ringer."  Of these 89 athletes only 15 (~17%) reported ALL signs and symptoms to a coach or medical personnel.

• These 89 athletes went on to describe 84 concussions (48% were reported for evaluation) and 584 “ bell ringers” (only 12% were reported for evaluation) demonstrating a significant gap in understanding of what a concussion is.

• In order of most to least cited, the top five reasons for not reporting concussion or concussion-like symptoms included:  1) not believing signs and symptoms were serious enough to report; 2) did not want to be removed from the game; 3) did not want to let down teammates; 4) did not want to let down coaches; and 5) not knowing event was a concussion.

• Athletes still demonstrate a gap in understanding signs and symptoms associated with potential concussions, especially those that are less common or could indicate another condition such as nausea. 

• A majority of athletes still do not believe concussion are serious.  Additionally, they feel the need to down play their symptoms and struggle with feelings of embarrassment when deciding whether or not to report a potential concussion.

For m,e this study bring two major points to light that must continue to be reinforced during concussion education for athletes, parents and coaches.  First, the term “bell ringer” must be removed from the conversation when discussing concussions.  A concussion is a concussion, period.  If an athlete is having concussion-like symptoms s/he should report it and evaluated for a potential concussion.  Coaches, parents and medical professional should not use the term “bell ringer” when talking about concussions or performing clinical evaluations.  It is obvious that the term takes away from the seriousness of a brain injury and students may continue to compete despite their symptoms.  Concussion are serious injuries and this should be emphasized with all parties.

Secondly, the study demonstrates that with increased knowledge around signs and symptoms of concussion students are more likely to realize they may be suffering from a concussion and report it.  Creating an environment where it is expected that symptoms will be reported and taken seriously will minimize the likelihood that student-athletes will downplay their symptoms due to feelings of embarrassment.  Coaches and parents can be most influential in this area and should pay extra attention to the culture they create around toughness and injuries.  It should be very clear that concussions are not injuries that can be “played through.”

Anecdotal personal reports and data collected by A4IA shows that the ASA™ is helping to increase concussion reporting among high school athletes.  Most recently two athletes at Torrey Pines High School reported concussion symptoms to their athletic trainer for evaluation a week after completing the ASA™ curriculum.  Basic analysis of pre-/post- ASA™ Program testing show that students are unaware of many of the signs and symptoms of concussion (similar to those cited in the highlighted study), but also believe you must lose consciousness to suffer a concussion.  Finally, many did not realize that exercise can cause the return of concussion symptoms and that returning to play while still suffering from a concussion can lead to prolonged concussion symptoms or even second impact syndrome (SIS).  ASA emphasizes all signs and symptoms of concussion, the seriousness of these injuries and the potentially catastrophic consequences of participating with concussion.  Following the completion of the ASA™ Program athletes demonstrate a more clear understanding of concussions based on the available post-test data.  They understand that you only lose consciousness in 10% of concussions, can describe second impact syndrome (SIS) and know the importance of a gradual return to play program.  Most of all, they know it is critical to report their symptoms and be evaluated.

It’s a small step, but an impactful one.  As the number of athletes who have completed the ASA™ training grows the gap in concussion knowledge decreases.  Ideally concussion reporting will increase and studies that currently demonstrate concussion under-reporting rates ranging from 40% – 50% will be a thing of the past.  It is important to be sure that concussions are being reported more consistently whether or not there is an athletic trainer available, parents and coaches must continue to educate themselves in concussion recognition and management too.  Be familiar with the available resources and if you have questions ask someone trained in concussion recognition and management.

Submitted by Heather L. Clemons, MS, MBA, ATC

Key Concussion Statements Released

Two prominent organizations have released statements regarding sports-related concussions in the last week or so.  The first statement released was the Consensus Statement on Concussion in Sport:  The 4^th International Conference on Concussion in Sport Held in Zurich, November 2012 and the second was the Summary of Evidence-Based Guideline Update:  Evaluation and Management of Concussion in Sport:  Report of the Guideline Development SubCommittee of the American Academy of Neurology.  This week’s blog post will attempt to highlight some of the key points and additional resources associated with these statements. Where possible I will discuss what it may mean for concussion management moving forward.  Since the publication of these documents, a variety of posts and/or stories including opinion and reaction have been published.  It is not the purpose of this blog post to provide my personal opinion on each statement, but to highlight the key information presented in each and allow informed readers to develop their opinions based on their understanding of this available information.

DEFINING CONCUSSION:

While each statement defines a concussion using different language, the key components are the same.  A concussion is a brain injury as the result of a direct or indirect force to the head resulting in functional changes to the brain.

4^th INTERNATIONAL CONFERENCE ON CONCUSSION STATEMENT (Zurich):

Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces.  Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilized in defining the nature of a concussive head injury include 1) direct blow to head or face, or indirect blow to the body; 2) results in rapid onset of short-lived impairment neurological function; 3) may result in meuropathological changes, but the acute clinical symptoms reflect a functional disturbance rather than structural injury; ad 4) results in a graded set of clinical symptoms that may or may not involve loss of consciousness.  Resolution of the symptoms typically follows a sequential course, but may be prolonged in some cases.

AMERICAN ACADEMY OF NEUROLOGY (AAN):

Concussion is recognized as a clinical syndrome of biomechanically induced alteration of brain function, typically affecting memory and orientation, which may involve loss of consciousnesss (LOC).

According to the 4^th International Conference Consensus Statement a majority (80 – 90%) of concussions resolve in 7 – 10 days, but can be longer in children and adolescents.  Very few concussions present with loss of consciousness.

CONCUSSION DIAGNOSIS: 

Diagnosis of concussion should be made by a licensed health care professional (LHCP), [athletic trainers fall into this category] according to both the AAN and Zurich statements.  The Zurich statement provides a much more detailed list of signs and symptoms that can lead to a diagnosis of concussion including: physical and/or emotional symptoms, physical signs, behavioral changes, cognitive impairment, sleep disturbance. 

CONCUSSION ASSESSMENT TOOLS:

The Zurich statement recommends the SCAT3 and Child SCAT3 when initially evaluating concussions.  The Sport Concussion Assessment Tool (SCAT) is a combination of injury history, Graded Symptom Checklist (GSC), cognitive function assessment, Standard Assessment of Concussion (SAC), and Balance Error Scoring System (BESS).  The AAN statement does not discuss the SCAT3 specifically, but does address some of the included assessments on an individual basis with moderate to high effectiveness with regards to recognizing concussion. AAN does recommend a combination of assessments work best, but does not recommend a specific combination of assessments.

Both Zurich and AAN reiterate that CTs cannot diagnose a concussion, but may be useful in ruling out more serious traumatic brain injuries (TBI).

NEUROPSYCHOLOGICAL TESTING:

Zurich recommends that neuropsychological assessment should not be the sole basis of management decisions, but should be seen as an aid to the clinical decision-making.  Formal NP testing is not required for all athletes, but when used should be utilized by trained neuropsychologists and should be one part of the return to play (RTP) decision-making process for the medical professional caring for the athlete.  Baseline testing was not considered a mandatory aspect of assessment, with insufficient evidence to mandate such testing according to Zurich.  Baseline may be appropriate in individual cases, but not as a standard of practice at this time.  AAN recommends that when NP is used that it be interpreted by a qualified neuropsychologists and should not be used in preadolescents as evidence to support such use is lacking.

CONCUSSION EVALUATION PROCESS:

According to Zurich when an athlete shows any features of a concussion a player should: 

1. Be evaluated onsite by a LHCP,
2. If no HLCP available player should be safely removed from play IMMEDIATELY,
3. Assessment of concussion should be made once first aid concerns have been addressed (rule out neck injury),
4. Do not leave the player alone following injury; should be consistently monitored for the first few hours after injury, it is possible that symptoms could worsen during this time,
5. Should not return to play on the day of injury.

AAN provides a very similar recommendation regarding concussion evaluation.  It provides additional emphasis on not returning athletes to play on the same day they have been suspected (not diagnosed) of having a concussion, particularly for adolescent athletes.  AAN also emphasizes that athletes must ultimately gain medical clearance for a LHCP in order to begin the return to play process.  Many states now also require these steps as part of their concussion management protocols as part of a legal mandate.

CONCUSSION MANAGEMENT AND RETURN TO PLAY:

Zurich emphasizes BOTH physical and cognitive rest until acute symptoms resolve. This seems particularly important for adolescent athletes and modification of activities such as texting and watching television should be considered as part of the cognitive rest component.

Both Zurich and AAN recommend a graded RTP program prior to full medical clearance and return to sport.  Zurich recommends a minimum of 24 – 48 hours of rest (symptom free) prior to beginning return to play protocol.  Also, child and adolescent athletes should not return to sport until they have returned to schools successfully.  A specific graded RTP protocol is provided in the Zurich statement, but it should be individualized and progressed only when the athlete is symptom free following completion of the current stage.  Children and adolescents recover more slowly and the RTP should take a more conservative approach.

OTHER INFORMATION:

When it comes to other factors likely to affect the likelihood of concussion or prolonged symptoms from a concussion both Zurich and AAN agree that a previous history of concussion makes an athlete more susceptible to future concussions.  The AAN statement goes on to list other factors that may increase risk including being a male in collision sports such as football or rugby.  Some evidence demonstrates that female athletes are at greater risk for concussion in soccer and basketball as compared to their male counterparts.  Body checking in hockey is also likely to increase risk.  Zurich lists several factors as “modifying factors” and conveniently lists them in a table as part of their statement. 

Understanding the role of protective equipment in the prevention of concussions has come into further focus and according to both Zurich and AAN there is currently no evidence that shows mouth guards or helmets prevent the occurrence of concussions.  Mouth guards do prevent dental and orofacial injuries, while helmets can reduce forces placed on the brain, but this does not translate to preventing concussions.

The ability to predict whether an athlete is at increased risk for prolonged or chronic impairment following diagnosis of a concussion is difficult at best.  According to the AAN statement there is some evidence that shows that elevated post concussion symptoms, lower SAC scores, and BESS deficits could be associated with more severe or prolonged postconcussive impairments.

The AAN goes on to recommend that education of school-based professionals (coaches, teachers, administrators, etc.) by LHCP trained in understanding concussion and their prevention is critical.  The LHCP should also be involved in the education of athletes and parents regarding the risks, recognition and management of concussions.

SUMMARY:

After reviewing both statements it seems there is much that Zurich and AAN can agree on when it comes to diagnosing and managing concussions.  The Zurich statement seems to be focusing on sports-related concussions as a whole and does include some additional information about CTE and other topics not addressed by AAN.  The AAN statement clearly focuses on concussions as it relates to children and adolescent athletes whereas Zurich includes information about this population as part of a greater athlete population.   In the end I think the AAN has it right when it recommends education of school-based professionals who will be dealing with concussed athletes in some way.  I would argue that education is the one biggest tool we have to improve prevention, diagnosis and management of sports-related concussion whether they happen to a child or a professional athlete.

ADDITIONAL RESOURCES:

SCAT3

Child SCAT3

AAN Sports Concussion Took Kit

(this includes some fact sheets and the new app)

HERE is Beth at a recent ASA event talking about the AAN Guidelines.

Submitted by Heather L. Clemons, MS, MBA, ATC

INFECTIOUS MONONUCLEOSIS (MONO) AND SPORTS PARTICIPATION

Infectious Mononucleosis (IM), better known as “mono” is a medical condition that affects thousands of athletes annually.  This condition can present itself in a variety of ways and will often resolve on its own without complications, but there is the rare risk of splenic rupture.  Splenic rupture if not addressed immediately via surgical removal of the spleen can be fatal.  Given this possibility, it is important for sports medicine professionals and parents to take reasonable precautions based on available evidence when returning athletes to activity following IM.

The American Medical Society for Sports Medicine has developed and published a consensus statement regarding infectious mononucleosis and athletic participation.  The citation for the positions statement is as follows:

Putukian, M., O’Connor, F.G., Stircker, P.R., McGrew, C., Hosey, R.G., Gordon, S.M., Kinderknecht, J., Kriss, V.M., and Landry, G.L. (2008).  Mononucleosis and athletic participation:  An evidenced-based subject review.  Clinical Journal of Sports Medicine, 18(4), 309 – 315.

According to this statement, currently there is no evidence to suggest that IM is more prevalent in the athletic population than in the non-athletic population.  The infection is most common in adolescents and young adults with an average infection rate of approximately 15% of the previously unexposed individuals.

Some of the major highlights from the article:

HISTORY AND PRESENTATION:

•           The condition is typically spread through oral secretions often spread by sneezing, sharing drinking glasses or food.
•          Symptoms can last anywhere from 4 – 6 weeks, some cases have been known to last as long as 3 months
•          Most common symptoms include fever, lymphadenopathy (swollen glands) and pharyngitis (sore throat).  Other symptoms can include headache, rash and spleenomegaly (enlarged spleen).
•           Keys to referral for further evaluation would be prolonged fever and lymphadnopathy

COMPLICATIONS:

•            Severe complications only occur in approximately 5% of all IM cases
•           The most familiar complication is splenic rupture, but there are others
•           Splenic rupture is estimated to occur in 0.1% - 0.2% of all cases and can occur spontaneously, meaning a specific trauma is not required to cause rupture
•          Typically most ruptures occur within the first 3 weeks of illness, and about half of those were spontaneous

RETURN TO PLAY GUIDELINES:

•          Exact guidelines for return to play are difficult with IM because there is no ideal laboratory or imaging technique that can confirm the status of the spleen or the resolution of the illness via virus levels
•          Based on current available evidence regarding the potential for splenic rupture return to non-contact activities can be a gradual progression assuming the athlete no longer has a fever and can tolerate aerobic activities
•          For return to contact activities, suggestions are much more difficult; minimally the athlete should be held out for at least 3 weeks where the likelihood of rupture is believed to be minimal and other indicators are present to allow for a safe return

Returning athletes to activity following a bout with IM can be highly challenging given the lack of clear return to play guidelines.  Parents should be aware that when returning from activity the risk of splenic rupture is very rare decreases significantly after 3 weeks based on current research, but it is never zero until the illness has completely resolved.  Parents should also be aware that physical exam for an enlarged spleen is highly ineffective.  If examination of the spleen is deemed necessary the standard evaluative technique is ultrasound, but a computed topography (CT) scan is also a possibility depending on the needs and preference of the physician.  Be sure to address any concerns you have with your athlete’s physician as they prepare to return to activity following a bout of IM. 

Whether splenomegaly (enlarged spleen) is of concern or not, the athlete’s return to activity should be gradual, based on their level of fatigue and other symptoms.  A gradual fitness program means progressing not only from shorter to longer periods competing in activities, but also considering the intensity of exercise.  This means, progressing how hard the athlete is working from 50% or so up to 100%.  The program can be progressed over several days to weeks depending on how the athlete responds to training.  The key to remember is that the degree of fatigue the athlete experiences the day after a training session will let you know whether s/he can handle an increase in activity (whether that is time or intensity) or not.

Submitted by Heather L. Clemons, MS, MBA, ATC