HOW DO YOU TREAT A CONCUSSION?

The best treatment for a concussion is the reduction of intellectual stimulation of the neurons. This can only be done through physical and cognitive rest that is sufficient enough to give the brain time to repair the damage through a natural healing process. The amount of time that is sufficient can never be determined. It is different for each injury.

If we fail to identify the signs, symptoms or behaviours consistent with concussion, a student-athlete may be greatly at risk of suffering serious long-term and/or life-altering consequences if he/she is injured again before the original symptoms have resolved.

There is general agreement among experts that the symptoms of “most” concussions, if treated with appropriate physical and cognitive rest, will resolve within two weeks, but the recovery time may be longer in children and adolescents. It should also be noted once again with emphasis that there is no way to predict how long it will take a student-athlete to recover from a concussion. Each person is different. No one can look at a person with a concussion and make a prediction that “you will be better in seven days”. That is a statement that no parent/guardian should accept. It is better to wait until you hear “it appears to be seven days since you were last observed to have any symptoms”.

Our goal as parents/guardians, school leaders, coaches, and classroom teachers is to reduce the number of concussions that are not identified by being more diligent in our efforts to recognize the signs, symptoms and behaviours consistent with concussion and then implement an effective rehabilitation protocol in order to give the brain time to recover from the injury. If we can prevent concussions from going undetected, there is less chance of a student-athlete returning to play while his/her brain is in a vulnerable state from symptoms of the first concussion.

The best way to make sure that we properly identify the signs, symptoms and behaviours that are consistent with concussion is to make sure that we have done a good job of preparing student-athletes, parents/guardians, classroom teachers, coaches, and school and minor sport administrators. This means that we must create a training and awareness program that is more than just a sheet of paper with a lot of symptoms listed in a column. We must make sure that everyone understands how the brain works; how a concussion affects the functioning of the brain; how to spot the signs, symptoms and behaviours consistent with concussion; and how to provide a high standard of care and rehabilitation for a student-athlete who suffers a concussion.

THE CHALLENGE OF HIDDEN SYMPTOMS

The greatest challenge when it comes to identifying a concussion is that so few symptoms are visible to the casual observer. Many times the symptoms of a concussion may not be identified until there is increased exertion which causes symptoms to worsen. It may be something as simple as the ringing of a bell to change classes or the ringing of a phone that triggers a symptom. Or it may be the student-athlete returning to play in a game within the next several days that causes the symptoms to present themselves.

Studies have shown that as many as 4 out of 5 professional athletes do not even know that they have been concussed so imagine how difficult it is for an adolescent or young adult to be able to understand what is going on in his/her brain? Imagine, they do not even realize they have a concussion, but they often show signs of the injury. In other words, the people around them may be more aware of the concussion than the person him/herself.

This is why one of our goals is to make sure that all adults who are involved in any way with student-athletes are as prepared as possible to look for the signs, symptoms and behaviours consistent with concussion and then take appropriate action to remove the player from further play to avoid the possibility of further damage. We must all become “concussion symptom detectives” when dealing with student-athletes. We cannot leave this responsibility in the hands of any one person. We must belong to a “concussion management team” where each individual has equal responsibilities for the identification of concussions when they occur.

We recommend that even if there are no apparent signs and the student-athlete reports no symptoms, if a coach, teacher, the parent/guardian and/or the School Leader has a strong suspicion that a particularly hard blow to the body or head area may be cause for concern, then it should be at the discretion of any one or more of them to initiate the protocols and request that the Coach remove the player from further action. This may not always sit well with the student-athlete who feels fine after the hit and argues that he/she is all right. It may even be seen as over reacting, but this is something that all partners must agree with and understand right from the beginning.

You should always err on the side of caution. Even if it means going through the steps of the rehabilitation protocols to find out that there is no evidence of concussion, it is worth the inconvenience for a week to be sure that there is little risk of long-term damage to the student-athlete.  

One should never be upset with a person who initiates the protocol. It will be clearly understood that you are acting out of care and concern for the student-athlete and if it turns out to be a false alarm, we won't be upset. We will be happy that there is no damage.  

There is, however, absolutely, positively no excuse for ignoring obvious signs and symptoms. We feel that with so many “partners” looking out for the safety of the student-athlete, someone will see a sign or recognize a symptom if it comes up. The last thing we want anyone to say is that they “should have noticed” or “should have paid attention” to signs and symptoms. Concussions are brain injuries. Your brain controls everything that goes on in your body and your mind. Permanent damage may change your life forever, so we won’t take any chances.

RECOGNIZING SIGNS, SYMPTOMS & BEHAVIOURS

We are going to provide you with a comprehensive review of the most universally accepted signs, symptoms and behaviours consistent with concussions. Some of them require more explanation than others. Most are pretty straight forward. At this time we are not so concerned about the proper classification of the signs, symptoms and behaviours consistent with concussions. Whether it is a sign or a symptom or a behaviour is not important. Whether it is a physical symptom or an emotional symptom is not important.

What is important is that no matter whether you are a parent/guardian, a school leader, a coach, a classroom teacher, a health care provider or a student-athlete, you should be aware of the signs, symptoms and behaviours that are consistent with concussions so that you can take appropriate action in order to reduce the chance of receiving a second concussion before the symptoms from the first one have resolved.

SIGNS TO LOOK FOR

If you notice any of the following signs immediately or shortly after an incident in a game or practice, then you should suspect a possible concussion. We should remind you that a concussion is a brain injury that can occur anywhere, not just in sports. Therefore, while we will be focusing on signs, symptoms and behaviours consistent with concussions that are sport-related, these are the same signs, symptoms and behaviours that can be found in all other areas of life as well.

With respect to sport-related activities, we recommend that you remove the student-athlete immediately from play if he/she:

·        appears to be dazed or stunned immediately after the incident, even if only for a few seconds. This might be evidenced by the student-athlete trying to get to his/her feet and falling down or stumbling around for a few seconds. Usually the person will catch his/her breath, take a few moments and then regain his/her senses. However, it will be clear that there was something wrong immediately after the incident;

·        seems to be confused about his position or assignment during the game or on the bench. This will often be noticed by the coach or a line mate when the student-athlete discusses the incident or the coach talks to the player about his/her assignment. If a player is hit pretty hard during the shift, a coach should come up and start up a conversation to check on the response of the player;

·        is not sure of the score, the period, the opponent, the time, etc. when questioned by coaches. This is a quick test that can be done during the game. It may sound silly, and I know that there are many players who cannot tell you the score of the game at any given time, but when you ask all of the questions the player should know the period and who he/she is playing. If the player cannot answer those simple questions, then you must take that as a sign. And if the person gives you the correct answer later, don’t just assume that everything is fine again;

·        seems to move clumsily on the field/ice or around the bench/dressing room, displaying balance issues. It is easy to pass this type of motion off as being normal, but if it is being displayed shortly after a blow to the body or head, then we must assume it is a possible concussion. A person who is carefully observing the movement will be able to determine whether or not it is a natural movement;

·        responds to questions with a bit of hesitation or not at all, demonstrating a delay in processing information. If it takes the person an uncharacteristically long time to answer questions, especially if he/she stars blankly as if thinking about the answer. You must know the player when you are observing this particular sign or symptom. Some players characteristically take a long time to respond, but if it is unusual, then you must accept this as a sign that something may be wrong and then do some other tests before allowing him/her to continue playing;

·        seems irritable or displays uncharacteristic mood/personality changes which are out of the ordinary. This may happen right after the incident or it may be something that is noticed in the hours and days following. Parents will often notice that their child is easier to get upset, more argumentative, less tolerant of siblings, etc.; It is too easy to pass this off as being emotional after losing a game, or from being hit during the game. Do not ignore these behaviours. The part of the brain that controls these functions is connected to just about every other part of the brain. So if the behaviour is uncharacteristic it is an excellent sign that something is not working properly;

·        can’t recall the play where he got injured, even if he says he is fine. Memory loss at the time of injury is common due to the chemical cascade that is produced. Don’t just ask a simple question like “do you remember what happened?” and accept the answer “he hit me from behind”. Take a couple of minutes and become a detective. Have the player give you details and even ask him/her to repeat the details to see if there is consistency;

·        can’t recall what happened after he got injured. Once again this will require some prompting to ask what the player did after he got hurt. And you must be careful not to give him clues or put words into his mouth. Of course you must also know what he did after he got injured or you won’t know if he is correct. This can simply be about being helped off by a couple of players, the referee, or the trainer. It might be that his helmet fell off. See what he can remember and if he can’t recall then this is another sign;

·        seems easily distracted with poor concentration. Unfortunately, it may take a while for you to notice this. One of the ways of testing concentration is to take the player aside and start explaining something to him in the dressing room. See if he/she is distracted by what is going on around the room. You must know what the player was like in these areas before the injury. Some student-athletes are always easily distracted, so this has to be something that is uncharacteristic;

·        has a vacant stare or seems to have glassy eyes. This is a sign that should be hard to miss. If the player simply stares off into space or is fixated on the play in an uncharacteristic manner, then don’t pass it off. Once again, it is important for coaches to be looking for this sign immediately after an incident. It is also something that a parent/guardian may notice at home following the game.;

·        is slurring his speech. Keep listening for this sign while talking with the player to test his memory of the incident. It is important to do this before the player goes back into the game following the incident in question. This may be difficult to do during the heat of the game, but nevertheless, it is important to take the time;

·        seems to be having minor convulsions or seizures. This is serious and should be easy to spot, but they may be minor in nature. However, this kind of reaction is cause for going to the hospital right away;

·        seems fatigued or says he/she feels like sleeping. This is a very common sign that something is wrong. A coach or parent/guardian should be able to recognize unusual fatigue during or following a game, especially among adolescents who usual have plenty of energy;

·        has slower than normal reflexes. A person with a concussion takes longer to react to normal activities, so if you toss a ball at a person with a concussion he/she may have trouble reacting fast enough to catch it. This is a good test that can be administered on the sidelines or even at home.

Parents/guardians are reminded that some of the above signs may not be evident during the game, or you may notice only one of the signs. However, if you notice that the student-athlete is complaining about feeling fatigued while driving home, ask some questions that may provide you with further evidence of a concussion. Don’t just allow your child to pass it off as being tired from playing a hard game. For example, once you are home you can ask your child what the score of the game was; who he/she was playing; what happened when the injury occurred; etc. If your child is unable to recall or hesitates with the answering of obvious questions, then you know that you must make sure he/she completely shuts down for the rest of the night and you should be prepared to initiate the appropriate protocols. You should also let the coach know immediately if you feel that protocols should be initiated.

SYMPTOMS TO LOOK FOR

Besides the “signs” that may be evident, if the student-athlete reports any of the following symptoms, the School Coach or the Community Coach must remove the player from further play. Symptoms will usually be identified by the student-athlete but he/she may not articulate the symptom clearly. We must be able to "read' the student-athlete.

The following self-admitted symptoms are absolutely serious enough to assume a concussion has occurred and the Concussion Identification Protocol should immediately be put into action. We remind coaches, parent/guardians and teachers that you may have to prompt these responses with questions to the student-athlete.

If the student-athlete:

·                     complains of headache or pressure inside the head, even if it is only a slight pain. Keep in mind that headaches are one of the most common symptoms of a traumatic brain injury. Migraines may be experienced following a concussion and if the student-athlete had migraines before the injury they may be much worse following the injury. Headaches are often a sign during rehabilitation that excessive stimulation is being experienced by the brain as a result of cognitive and/or physical exertion and therefore is a signal to reduce the progression;

·                     complains of dizziness or trouble keeping his balance. This is another very common symptom after a concussion is experienced. The student-athlete may feel off balance, especially during activity or immediately following and it will usually be temporary. However, during rehabilitation, if dizziness returns it is a signal that more rest is needed before continuing the recovery progression;

·                     is feeling nauseous or feels like vomiting. This nausea or what some describe as a kind of motion sickness is another common symptom after a traumatic brain injury.

·                     complains of vision problems; Damage to the neurons that control vision is common in concussions. The vision affects balance, response time, etc. So any complaint about vision is serious and could indicate a concussion.

·                     complains about feeling sluggish, foggy or groggy; This could be caused by the increased demands being made by the brain for energy to repair damaged areas, but it will also be due to the fact that the energy demand is not being met.

·                     states that he is unusually sensitive to light or noise;

·                     has sleep difficulties. Most student-athletes who suffer from a concussion will experience some sleep disruption for at least several days following the injury. Some sleep more; some sleep less; some sleep during the day; some need frequent short naps during the day; some wake up frequently during the night; some feel fatigued, both mentally and physically regardless of the amount of sleep they receive. It will take some time following an injury for a person to return to pre-injury levels of energy and student-athletes will often have trouble maintaining energy levels once they return to school.

·                     says he/she is feeling confused;

·                     says he/she is just not feeling right;

·                     says he/she is seeing stars;

·                     complains about a ringing in his/her ears;

·                     is unable to recognize people or places;

·                     complains of a weakness or numbing in the arms or legs;

·                     is more emotional than usual;

·                     has trouble balancing;

Once again, we remind everyone that these symptoms may not present themselves right away. It may be minutes, hours or days before the symptoms occur. It is also possible that a parent/guardian may not even be aware that their child was injured in the game if he/she was not in the stands. However, because your child participates in a sport where the risk of concussion is high, if he/she suddenly begins to complain about feeling confused, or there is a sudden change in the child, you really should not pass it off as nothing. You should communicate your findings to the appropriate authorities so that the rehabilitation process can be initiated. Remember that it is always better to be safe than sorry.

EMERGENCY WARNING SIGNS & SYMPTOMS

We recognize that it may be very difficult to get in to see a doctor right after a game or practice. Therefore, it is going to be up to the parent/guardian and/or coach to make a judgement call with respect to the urgency of seeking medical attention. There is no hard and fast rule to guide you in this matter. You are going to have to consider the nature of the symptoms and decide if they seem serious enough to go to the hospital immediately or wait until the next day.

The following should be helpful:

·        If the student-athlete was knocked unconscious, even for a short period of time, then it is important to go to the hospital and get checked out. This is especially critical if the student-athlete was hit in the head and perhaps has a large bump as a result. You want to make sure that there is no fracture to the skull or internal damage. For a blow to be forceful enough to cause a person to lose consciousness, it must have been significant.

·        If the student-athlete begins to go into convulsions or has some seizures during the night, then by all means, get to the hospital for a check up. These symptoms are not all that common and could indicate serious complications.

·         A headache that keeps getting worse as the time passes is a signal that perhaps something serious is going on inside the skull and you should have a doctor take a look immediately.

·        If the student-athlete continues to get more and more confused then immediate attention is warranted. Once you stop the physical and cognitive activity, symptoms should begin to get better. If even after resting the symptoms continue to get worse, then that is a sign that there may be complications. It is not always the case, but it is something you should not pass off and ignore.

·        When you get home there is nothing wrong with allowing your child to go to sleep, however you should check him/her through the night to listen for breathing problems or to see how he/she is sleeping. If you have any concerns wake your child up and examine for more signs and symptoms. If you have trouble waking your child up do not hesitate to bring him/her to the hospital immediately to be checked out.

·        Vomiting is not unusual following a traumatic brain injury, however, if your child continues to vomit during the night, then this is another indication that there may be something more serious going on. I would recommend that you bring your child to the hospital for a quick examination.

We want to acknowledge that symptoms of a brain injury may get worse during the hours and days following the incident. However, it is fairly easy to tell if the worsening of the symptoms should be cause for concern. A parent/guardian usually can tell when something is not right with their child. Go with your intuition and don’t second guess yourself. It is well worth the time in the waiting room to get an examination if you are concerned.

EXECUTIVE FUNCTIONS

The frontal cortex of the brain, which is located in the forehead area, has been accepted as the region of the brain that is most involved in behaviour, personality, and decision making. This is what we call executive function, or a set of mental processes that helps one connect past experiences to perform activities such as organizing, planning, remembering details, and managing your time and space. It allows one to differentiate between good and bad, better and best, same and different, consequences of actions, goal-setting, predictions of outcomes and expectations and perhaps most importantly for classroom teachers, the ability to suppress socially unacceptable urges that could lead to negative consequences.

The neurons in the frontal cortex extend throughout all areas of the brain, so if one suffers a brain trauma it is quite likely that there will be areas of the frontal cortex that will be affected. Even if the actual damage is found in some other part of the brain, the communication between those directly affected functions and the frontal cortex will be disturbed.

While a student-athlete is going through the rehabilitation process following a concussion, teachers and parents/guardians may find that the problems with executive function aggravate the symptoms and result in all sorts of behavioural and personality disorders. For example, common everyday things might just be more difficult to do. Working memory may be seriously affected and it might be difficult for the student-athlete to do what once came natural.

SIGNS OF EXECUTIVE FUNCTION PROBLEMS

A student-athlete who is recovering from a concussion may have difficulty with one or more executive functions. It is important for parents/guardians to watch for some of the following changes in children who are participating in high risk sports. We want to emphasize that you should continuously monitor for any of the following issues at all times during the season, not just when you suspect a concussion. It is very important to remember that some of the signs, symptoms and behaviours consistent with concussion do not present themselves immediately and may take days to evolve:

If a classroom teacher or a parent/guardian notices any of the following signs, symptoms or behaviours, especially if they come about suddenly and are quite different from what has been previously observed as normal, then it is important that further investigation be done to determine if this may be a sign of a brain injury.

A student-athlete may have difficulty with one or more of the following if they are suffering from the effects of a concussion.

• Short-term and long-term planning of projects and assignment;
   
• Keeping track of time-lines and completing projects and homework on time;
   
• Communicating orally or in writing in an organized, sequential manner;
    
• Memorizing and retrieving information from memory;
   
• Initiating activities or tasks, or generating ideas independently;
   
• Remembering information that is used in a conversation, even while speaking;
    
• Remembering the phone number or email address while dialing or texting;
   
• Engaging in group discussions, even around the kitchen table or with family members; 
   
• Begin to shout out answers in class;
    
• Be reluctant to ask for help in class;
    
• Keeping track of several things at once – multi-tasking
    
• Have trouble paying attention or remaining on task, even with simple matters
    
• Be slow to respond to questions or to retrieve information during a conversation:
    
• Shifting his/her attention from one task to another or from one subject to another in school;
    
• Keeping his grades up in certain subject areas; 
    
• Refraining from impulsive behaviours that are inappropriate; 
    
• With mood changes that occur spontaneously without warning or reason;
    
• Avoiding feeling depressed or unhappy;
    
• With his/her attitude towards authority and may become defiant;
   
• Maintaining a clear mind and may seem confused.

These are generally behaviours that one must observe over a period of time in order to look for patterns. They may be more helpful during the rehabilitation process to determine when the symptoms of concussion are resolving. In other words, a student-athlete who is suffering from a concussion may all of a sudden begin to have trouble with one or more of the above executive functions. However, if the classroom teachers make appropriate accommodations these problems should gradually clear up and the student-athlete will return to normal, pre-injury levels of performance. It is critical that accommodations be made during the rehabilitation stage in order to help the brain recover from the injury.

The section below on the possibility of concussion being a “spectrum disorder” has significant implications when executive function deficiencies present themselves.

IS CONCUSSION A SPECTRUM DISORDER?

Some studies on concussions are beginning to show evidence that we may be dealing with a spectrum disorder when we examine the cognitive deficiencies of traumatic brain injury. For example, let’s consider that at the lower end of the spectrum a person has minimal brain damage from brain trauma, while at the higher end a person has a maximum amount of damage and has serious life-threatening symptoms.

It has been customary to describe a concussion as being mild, moderate or serious, so in a way concussions have always been considered to be part of a sprectrum.

The spectrum disorder theory explains the degree of concussion by imagining a “continuum” where the “degree needle” is constantly moving between points in mild and serious stages as the brain experiences new trauma and recovers from previous injuries.

There are times, for example, when the brain may be subject to a very small force which causes minor damage. No symptoms of concussion are produced, but the “degree needle” moves a little further from the absolute lower end of the spectrum. Over time the “needle” will move up or down the spectrum, depending on the number of what we may call sub-concussive blows received. A sub-concussive blow would be one that produces no observable signs, symptoms or behaviours consistent with concussion.

If there is sufficient cognitive and physical rest following a sub-concussive blow, the needle may begin moving back towards the lower end of the spectrum. However, if there hasn’t been enough time for recovery before the next sub-concussive injury is experienced, the needle may end up being moved further up the continuum towards the upper level of the spectrum.

After the accumulation of a number of sub-concussions, the needle will move into the “tipping point” area, causing signs, symptoms or behaviours consistent with concussion to emerge. When that happens, we say that the student-athlete has suffered a “concussion” and must rest until he/she recovers to the point where the symptoms have disappeared. In a short period of time the symptoms will subside and the student-athlete will be said to have recovered from the concussion.

However, questions are now being raised about whether the concussion has really healed. In fact, it could be that the “needle” has moved far enough towards the lower end of the spectrum so that the symptoms no longer present themselves. Any further trauma to the brain will cause the needle to begin moving along the continuum towards the upper level until once again it reaches the point where signs, symptoms and behaviours consistent with concussion occur once again.

The spectrum disorder theory explains why once a student-athlete suffers their first concussion, he/she is much more vulnerable to suffering second and subsequent concussions from even less force than was needed in order to cause the first. This may be explained by understanding that it takes a while for the “degree needle” to move from the lower end of the continuum to the point where symptoms emerge. However, after a rehabilitation period which includes cognitive and physical rest, the “degree needle” only moves to the point where symptoms subside and everyone concludes that the absence of symptoms mean that the concussion has healed. In fact, the healing is still going on and may not have reached the original starting point. Therefore, it will take fewer sub-concussions to produce symptoms of a second concussion and so on. A significant enough force may end up moving the needle to new levels never before experienced, thus making the recovery period even longer and slower. Eventually, the “needle” will move so far along the spectrum that the symptoms may never disappear and the student-athlete will suffer from life-long post-concussive symptoms.

If the spectrum disorder theory is valid, then the signs, symptoms and behaviours consistent with executive function disorders may be a warning sign that the student-athlete is approaching a danger zone. They may become “warning signs” and in much the same way as scientists can predict earthquakes, we may be able to predict potential concussions and then take appropriate action to reduce the risk of a full scale injury from happening.

This will require a whole new approach to dealing with traumatic brain injuries. It means that we may have to initiate concussion management protocols even prior to the occurrence of an incident during a game or practice. It is hard to imagine how hard it will be to keep a student-athlete out of a game because of the increased possibility of concussion. Right now we are having problems keeping them out of action even after there is clear indication of a concussion.

However, if we accept the spectrum disorder theory, we must also accept the principle that all student-athletes have some degree of traumatic brain injury, with most having a degree of injury that hasn’t quite reached the “tipping point”.

EMOTIONAL OR PSYCHOLOGICAL SYMPTOMS

It is not uncommon for a person who has suffered a traumatic brain injury to display symptoms that are emotional or psychological in nature.  When this happens, the care givers, including parents/guardians, classroom teachers and coaches must do whatever they can to overcome or alleviate these psychological issues since they can cause or exacerbate other symptoms.

·        Anxiety is an issue that is common following a traumatic brain injury. The student-athlete may admit to having flash-backs about the injury if it was particularly traumatic. He/she may also worry about losing his/her school year or position on the team. In this case it may not be so much the injury that is causing the anxiety, but more from the stress of experiencing the injury in the first place. It is important to remember that everyone is going to experience some level of anxiety, but it becomes a concern when it interferes with other normal, day to day functioning. This is why it is critical that appropriate accommodations be in place with respect to returning to normal activities at school and at home. You must avoid increasing stress levels which will lead to further anxiety. 

·        Depression is common with injured student-athletes. There is, however, a difference between depression and unhappiness or sadness. For adolescents, playing on the school team means everything. It is what defines them in the eyes of their friends. When suffering from an injury that others cannot understand or see, it is often extremely depressing for the student-athlete and can interfere with the rehabilitation process.

·        Irritability often accompanies a traumatic brain injury. Student-athletes become short-tempered and have difficulty with their relationships which then makes it even more difficult to recover. People must give concussion victims “more rope” and not react negatively to some of the comments and arguments that ensue. It is not the same person, but in time that old friend will return.

·        Personality changes often accompany traumatic brain injury. A person may find that things that usually were of interest and enjoyable are no longer so. This might not seem like the same person because it isn’t. These are signs and symptoms that you must recognize if you are a parent/guardian or classroom teacher because they could be signals that the student-athlete has suffered a concussion.

BALANCE IMPAIRMENT

There are a number of simple tests that can be done at school, on the sidelines or at home that will determine if the student-athlete has any problems with balance. One of the common symptoms of concussion relates to balance, so these tests can certainly uncover evidence of a traumatic brain injury. The best source of these tests is the SCAT2 (Sports Concussion Assessment Tool).

1.      Have the student-athlete stand up straight with both feet together and hands on his/her hip. Then ask the student-athlete to close his/her eyes for 20 or 30 seconds. See how steady the student-athlete stands. It is always a good idea for the parent to do this test before the season begins in order to get a baseline performance to compare with once an injury occurs and a concussion is suspected.

2.      Have the student-athlete do the same drill but raise and bend the left leg first for 30 seconds and then do the same with the right leg for another 30 seconds. Once again close the eyes and you can see how well the person does with this test.

3.      The final balance test is to have the student-athlete stand toe to heel one foot behind the other, with hands on hips and eyes closed for 30 seconds. Repeat the procedure by switching feet. Observe how well the student-athlete does with this test.

Everyone will have their own sense of balance to begin with and it is unlikely that anyone will be able to pass these tests without moving. That is why it is important to do a baseline set of tests as part of the Preparation Stage. Make observations about how well the student-athlete performs the balance test while not injured. Then compare the results after the injury. If there is a significant deficiency, then you should seriously suspect a concussion and follow established protocol.

COGNITIVE IMPAIRMENT

It goes without saying that the best cognitive assessment is through a neuropsychological test such as ImPACT. However, if a parent/guardian suspects that his/her child may have a concussion, there are some simple little tests that can be performed at home at the kitchen table.

1.      First, simply ask a number of questions that your child should be able to answer easily.
What is the date today?
What is the day of the week today?
What year are we in?
What is your birthday?

2.      You can ask your child to perform a couple of tests that will demonstrate concentration skills.
List the days of the week backwards starting with Saturday.
List the months of the year forward and backward.

3.      You can then test memory by reading your child a list of words and asking him/her to repeat them back to you in any order. Do this with a few different lists.

4.      You can do the memory test with digits from 0 to 9.
List a string of three digits and ask your child to repeat them backwards.
Do this for a string of four and five digits.

Once again, if possible, you should do this kind of test before the season in order to establish a baseline. Your child may already find it difficult to say the months of the year in reverse order. Therefore, unless you have a baseline to compare with, it may be hard to determine if there is any significant decline.

If you are concerned with the answers, then your child may have a concussion and you should take appropriate action to initiate the concussion management protocol.

CONCLUSION

There are many signs, symbols and behaviours consistent with concussion.

All it takes is one of these for a person to be suspected of having a concussion.

If you spot one, the chances are that there are others that are going to present themselves over the next several days.

This means that the concussion management protocols should be implemented immediately and everyone begin the rehabilitation procedures so that the damage from the first concussion is contained and allowed to recover before any further damage is caused.

We know what to look for. Now we need to take action when we see the signs, symptoms or behaviours! And we must put in place procedures and protocols that make sense for this type of injury, keeping in mind the following:

1.      Diagnosing a concussion on the sidelines during a game is extremely tricky since it relies on the student-athlete being honest about revealing symptoms such as headache, nausea, dizziness, and blurred vision. It relies on the person evaluating the player recognizing signs of concussion. All of this is used to help a person determine if a student-athlete has a concussion.

2.      Determining whether a person has a concussion right after he/she takes a hit is further complicated because symptoms do not always show up immediately. Some of them present themselves over time, even days. That is why neuropsychological testing is done several days after the incident to give the symptoms time to develop. Because conditions can change, it is too risky for a person on the sidelines to make an informed decision. There is just too much risk that the student-athlete may appear normal while on the bench and then be put back into the game only to find out that he/she sustains a much more serious second concussion.

3.      It is impossible to determine the severity of a concussion at the time of the injury. Whether a concussion is mild or severe will be determined by the extent of the symptoms that evolve and by how long they take to resolve. And you can never tell at the time of the injury just how long it is going to take to heal. Therefore, you have to wait until the person completely recovers before you can make any statement about the severity of the injury.

4.      This is why we must do more than just have the student-athlete examined by a medical doctor. We must do more than have a health care provider or concussion expert on the sideline to examine a player suspected of having a concussion. We must have the parents/guardians observe for signs, symptoms and behaviours consistent with concussion at home. We must have the classroom teachers observe for signs, symptoms and behaviours consistent with concussion at school. We must use neuropsychological computer testing to compare baseline with post-injury cognitive functionability. We must involve the student-athlete in rehabilitation programs to prepare him/her for return-to-play, return-to-learn, and return-to-normal.

This is why we will always recommend that as soon as a single sign, symptom or behaviour consistent with concussion is spotted, the student-athlete must immediately be removed from play and the full extent of the concussion management program be initiated and followed through to the end. Only then will we be sure that we have done everything possible to reduce the risk of repeat concussions which could have life-altering consequences on the student-athlete.

CMP CONCUSSION MANAGEMENT PARTNERS INC.
Serving Canada & the United States
Offices in the Province of Ontario and the State of Michigan
email: rkirwan@infocomcanada.com   Phone: (705) 969-7215