This week, if you're somehow involved with the game of football, it's difficult to not hear someone talking about the NFL's new controversial guideline on extreme hits or tackles. Under penalty of suspension from the game, a player may not launch themselves at another player's head or neck with the intent of doing bodily harm. As the game gets faster and the players get larger, this may stem the aggression and number of injuries associated with the game. New guidelines are not only for the NFL. This past Monday, the University Interscholastic League, created by The University of Texas at Austin to provide leadership and guidance to public school debate and athletic teachers, recommended additional rules for athletes who suffer head injuries.
Approximately 1.4 million suffer sports-related injuries annually, according to a 2006 national sports survey. Some will be head injuries that can lead to concussion, particularly with contact sports such as football, soccer and hockey. Injuries can occur with players of either gender.
We asked Specially For Children pediatric neurologist Michael S. Reardon, MD, who sees patients at Dell Children's Medical Center of Central Texas, about what parents and players need to know about concussion.
"Statistics available for high school football players show that 20 percent will have at least one concussion during their four-year career," says Dr. Reardon. "There is also evidence that if a player has had one concussion, they are four to six times more likely to have another one."
The American Academy of Neurology defines a concussion as a trauma-induced alteration of mental status with or without loss of consciousness.
"That implies there is an absence of structural injury to the brain, in other words, something that can be detected on a CT scan or MRI. Although the injury is a reversible process and no damage to the structure of the brain, there is extensive research evidence that the brain is in a state of metabolic dysfunction that can take anywhere from several days to several weeks to normalize. While the brain is in this state, further trauma to the head can have devastating consequences. There is recent evidence that too much physical or cognitive exertion can aggravate the situation, leading to worsening of brain function and longer recovery time. Therefore, an athlete experiencing any ongoing symptoms of concussion should not be allowed to return to competitive contact sports," adds Dr. Reardon.
New Guidelines point to the following new criteria;
- Remove player with any signs or symptoms of concussion.
- Never return to play on same day.
- Medical evaluation following injury
- Rule out more serious injury/structural lesion
- Neuropsychological assessment (compared to baseline where available)
- Gradual, step-wise return to play once all symptoms and signs have resolved.
Signs & Symptoms of Concussion
Dr. Reardon recommends that anyone playing a contact sport who develops signs of concussion needs to be pulled out of the game or practice immediately and evaluated by a trainer. The player should not return to the field of play and immediately a full evaluation should be made. In an evaluation of the player, look for:
Signs observed by others
- Appears dazed or stunned
- Is confused about assignments
- Forgets plays
- Is unsure of game, score, or opponent
- Moves clumsily
- Answers questions slowly
- Loses consciousness
- Shows behavior or personality change
- Forgets events before play
- Forgets events after hit
Symptoms reported by players
- Balance problems or dizziness
- Double, fuzzy, or blurry vision
- Sensitivity to light or noise
- Feeling slowed down
- Feeling foggy or groggy
- Concentration or memory problems
- Change in sleep pattern
- Feeling fatigued
New Return to Play Guidelines
Dr. Reardon summarizes the basics.
Step-wise return to play after all concussion signs and
symptoms have resolved
- Light aerobic activity (stationary bike or jogging)
- Sport-specific training (sprints, weight lifting)
- Non-contact drills
- Full-contact drills/practice
- Competition/game play
- At least 24 hours between each step
- If any symptoms or signs return during activity, return to previously level for at least 24 hours
"There have been numerous guidelines developed to grade the severity of concussion at the time of injury, and hence estimate the time it will take to recover. What we know now is that this is highly variable from one individual to another, and therefore difficult to predict in the early stages. Recent research does provide some useful information. For instance, the presence of amnesia-much more so than loss of consciousness-predicts a more significant impairment with longer recovery time. It has also been demonstrated that even the mildest type of concussion- the so called "ding" or "bell-ringer" that seems to clear up within a few minutes, has been associated with impairment of cognitive function for up to one week. We also know that younger athletes as a whole take longer to recover than older athletes. The bottom line is, there is no way to predict ahead of time how long it will take an athlete to recover, and when it will be safe for him or her to return to sports. We have to wait and monitor until all symptoms and signs have resolved, and cognitive functioning is back to normal, then start the process of gradual increase in activity, making sure that symptoms don't return."
How Serious is Concussion?
"My personal opinion is that athletics are good for kids. It is more likely that athletes will get through school sports without significant problems than to have a serious injury. That said, if your child plays a sport like football, where tackling is part of the game, or soccer, where going up to head the ball is part of the game, the chance of having a concussion increases," believes Dr. Reardon. He summarizes the things parents and coaches should know about concussions as their student athlete participates in sports.
- It is important to take any symptoms or signs of
- A player should absolutely not go back on the field if
there are any symptoms of concussion or the observation was
made of a serious head strike. If it has happened before,
you need to be even more vigilant. If it happens a third
time, one should seriously consider whether or not return
to contact sports is the best choice for your child. There
is still debate in the literature about the extent to which
repeated concussions leads to long term neurological
problems for some people. The most critical thing is to
avoid re-injury while still in the recovery process.
- Eagerness to get back in the game can get in the way of
judgment. It's important to be firm about doing what is
- If a player has symptoms or signs of a concussion
beyond one hour, get a medical evaluation immediately.
- If a concussion occurs, it is very important to inform a player's primary care physician as soon as possible. In addition, it is strongly recommended that some type of standardized neurological and cognitive assessment be performed by a clinician with specific experience and expertise in concussion management.
The Centers For Disease Control (CDC) has developed a set of downloadable fact sheets entitled Heads Up: Concussion in Youth Sports. They contain advice and information about concussion specifically for use by coaches, parents and players.
Dr. Reardon earned his medical degree at the University of Colorado Health Sciences Center in Denver. He then completed a residency in Neurology at the University of Iowa, serving as Chief Resident during his final year. He continued at the University of Iowa to complete training in Pediatrics and Child Neurology.
Dr. Reardon earned his board certification from the American Board of Psychiatry and Neurology in June of 2004.
Research and scholarly activities have included studying the cognitive and behavioral effects of Traumatic Brain Injury and focal brain lesions, cognitive impairment associated with movement disorders, functional brain imaging associated with face recognition, and studying causes and outcomes related to stroke in children and adolescents.
Dr. Reardon currently practices general Pediatric Neurology, with special interests in concussion and traumatic brain injury. Dr. Reardon is co-director of the concussion clinic at Dell Children's Medical Center of Central Texas, and serves as co-director of the Pediatric Muscular Dystrophy Association clinic in Austin.