New information about the serious consequences of too-soon return to play after concussion is challenging traditional macho attitudes that once surrounded this sports injury. The old mantra “if you can walk, you can play” is being replaced by this mandate to coaches: “When in doubt, sit them out.”

In September 2010 the American Academy of Pediatrics issued an important report on sports-related concussion in children. In July 2010 Massachusetts passed legislation that addressed youth sports concussion. Both call for taking a concussed athlete out of play for the rest of the game or practice.

Sounds easy, but the injured athlete may not even be aware he or she has suffered a concussion. You can’t see a concussion like you can a broken bone. And most concussions occur without loss of consciousness. Also, concussion is a functional injury, not a structural one, so imaging studies like CAT scans are usually normal.

Headache is the most common complaint after concussion. Nausea, problems with balance, vision or sensitivity to light or noise also occur. Symptoms may be just a vague “I don’t feel like myself” sensation. Cognitive symptoms include difficulties with memory, concentration or remembering, confusion or forgetfulness. Emotional symptoms like sadness, anxiety and irritability can occur as well. If you suspect your child has experienced a concussion then it is important to let his coach know and get him evaluated by a doctor.

The new law also mandates that anyone involved in school sports, including the parents of student athletes, be trained in the recognition, management and prevention of concussion. The Brain Injury Association of Massachusetts and the Centers for Disease Control and Prevention both have information
available on their websites including on-line trainings and downloadable educational videos.

One thing you will learn at these websites is that once the diagnosis of concussion is made, an athlete must sit out the remainder of the game or practice and be medically cleared before returning to play. Just as a broken ankle needs rest to heal, so does an injured brain. The athlete should engage in no physical activity until he is symptom-free at rest. Physical activity includes not just sports but also gym class, weight training, and even sexual activity.

Another important feature of concussion management is what is called cognitive rest. Attending school and doing homework, especially math and foreign languages, can worsen symptoms and should initially be avoided. School nurses, principals, and teachers can all play a role in students’ recoveries by allowing temporary leaves, reduced hours and workloads. Students should not take standardized testing during recovery from brain injury. Extra time should be given to complete assignments and make-up work. Understanding and support is needed as these kids can look perfectly fine and the temptation may be to keep expectations consistent with past performance.

Once an athlete is symptom-free, return to play needs to be gradual. First, light aerobic activity can be allowed like swimming, walking or riding a stationary bike. Then, sports-specific exercise can be added. Then drills can be introduced, though without contact at first. A player needs to stay in each rehabilitation stage for at least a day and must return to the lower level of activity if any symptoms recur. An athlete needs medical clearance to return to full-contact training and finally, regular game play.

These new guidelines grew from the recognition that the effects of concussion are cumulative. Athletes
with a history of concussion have three times the rate of subsequent concussion than athletes without brain injury. Coaches and doctors need to remember to ask about non-sports-related head injuries such as motor vehicle accidents or falls. After all, the brain doesn’t know how it was injured. Hopefully the guidelines will prevent many cases of second-impact syndrome and post-concussion syndrome.

So all of us-coaches, parents and doctors-need to get in the game and learn the new rules. Go, team!
(But safely!)


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From issue: 26/11-12