Traumatic Brain Injury: Safe Play On and Off the Field

Neurology Now
Fall 2005
Volume 1(3)
p 44–48,50
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It was a Friday night in November 2002, early in the final round of the Ebensburg, Pa., high school district football playoffs. Bishop Carroll High School's Huskies were losing 7 to 6. More than 5,000 fans — more people than the population of Ebensburg — had crammed into a stadium designed for 4,000.

The fans were hopped up on adrenaline, emotion and noise. Then it happened — football coach Craig Sponsky's star quarterback hit the ground headfirst. He had not been hit hard, but he got up slowly. He yelled to Sponsky that he was okay. But Sponsky knew something was wrong. “Looking at him, you could tell something was different,” Sponsky recalls. “He just looked different. It was almost like he was trying to hide something.”

Sponsky took him out of the game. After halftime, the quarterback pressed Sponsky and the medical staff to let him play. “The dilemma is, you see 52 other kids who want to win so badly,” Sponsky says. “You've worked so hard to get to that competition. Then you have all the fans yelling. It seemed to me like there was so much weight on my shoulders, and so many differing opinions. It was awful.”

Finally the doctors relented. The quarterback begged Sponsky to let him return. Sponsky refused. And then another player scored a touchdown, securing Bishop Carroll's victory. The quarterback sat out the remainder of the game. After the game, they learned that he had suffered a mild concussion.

Fall Brings Football — and “Seeing Stars”

Fall is football season, and along with football's thrills and pageantry come injuries. Among them, thousands of young players will experience the brain-jarring injury that took Craig Sponsky's quarterback out of that playoff game three years ago.

Indeed, the language of football hints both at how ubiquitous concussions are and how lightly they're sometimes taken — players speak of “dings,” of “having your bell rung,” of “seeing stars.”

An estimated 62,816 cases of mild traumatic brain injury, such as concussions, occur annually among high school varsity athletes, with football accounting for about 63 percent of the cases, according to a study reported in 1999 in the Journal of the American Medical Association. But football players are not alone. Wrestlers, soccer players, basketball players and other athletes will suffer a similar fate, albeit in smaller numbers. Children will have concussions on playgrounds or when falling off a bicycle. For parents and coaches alike, knowing how to handle a young person who has had a concussion, both on the field and at home, is crucial.

The American Academy of Neurology (AAN) defines concussion as “a trauma-induced alteration in mental status that may or may not involve loss of consciousness.” Most cases are minor; noticeable symptoms last no more than 15 minutes, according to the AAN's Practice Guidelines for the treatment of concussion.

But minor does not mean harmless. Research increasingly demonstrates that even minor concussions alter brain function for days, usually impairing memory, reaction time, concentration and other neurological functions.

“There is still a perception that if you didn't lose consciousness you didn't have a concussion. That's wrong,” says Deborah L. Warden, M.D., a neurologist and psychiatrist who is director of the Defense and Veterans Brain Injury Center at Walter Reed Army Medical Center in Washington, D.C. Even an injury that causes a bit of fuzzy thinking is a mild traumatic brain injury.

“Even what we call a ‘ding,’” she adds, “causes changes in the brain. Kids really need a couple of days to recover.”

Recognizing Concussion

Common signs of concussion include a vacant stare, delayed responses to questions, disorientation, slurred speech, lack of coordination and poor short-term memory. Any loss of consciousness, no matter how brief, signals a severe concussion, according to the AAN.

Some symptoms of concussion, however, may appear hours or even days later; others, such as memory loss, might persist even after an individual's reported symptoms have disappeared. For example, Dr. Warden conducted a study of West Point cadets who had suffered a concussion while boxing in physical education class. She and her colleagues reported that reaction times suffered four days after the concussion, even though the cadets reported no physical symptoms.

Figure. High School Sports-Related Injuries

Click here to enlarge

Similarly, it's not uncommon for someone who has had a concussion to feel listless and inexplicably sad for several days, or to experience mood swings. “Let the child rest,” Dr. Warden advises. “Let the brain recover. Also keep them out of situations that could be dangerous.”

Advice for Parents and Coaches

* Anyone who might have suffered a concussion should never return to a game before being evaluated by a physician or certified trainer, says James P. Kelly, M.D., a neurologist in the Neurosurgery department at the University of Colorado School of Medicine in Denver. “The parent or coach should find a qualified health care professional to intervene and make that decision,” Dr. Kelly says.

* Never rely on the youngster's perception of whether he or she feels well enough to play. As Coach Sponsky notes, “Kids never want to admit they're hurt.”

* Observe the youngster closely in the days afterward. One extremely common symptom is the inability to sleep well. “In my experience, it's uncommon for someone to sleep normally for the next few days and even weeks,” Dr. Kelly says.

* Talk to teachers. Dr. Kelly calls school “a type of neuropsychological test.” “It's a stressor,” he explains. “The child may do okay in an unstructured setting, like home. But when time limits are set, when noise and bright lights come into the picture, he or she might have trouble. A teacher might recognize a problem more quickly.”

* Anyone who loses consciousness as a result of trauma should have a neurological exam, which would include examining their eyes, hearing, smell, ability to move and other functions.

* Anyone who has a concussion, but does not lose consciousness should see a physician if symptoms worsen or last longer than a week, or if he or she experiences a physical abnormality, such as weakness on one side of the body.

Most importantly, bear in mind that someone who has had one concussion is more likely to have another. And the symptoms of subsequent concussions are often more severe than the first. In rare cases, so-called “second-impact” syndrome — when someone suffers a second concussion before the brain has fully healed from the first — can have catastrophic consequences: coma or even death. Repeated concussions also seem to have a cumulative effect on the brain, affecting memory and other neurological functions.

Table. Symptoms of Concussion.

Click here to enlarge

Preventing Concussion

* Kids should wear a helmet, not just in high-contact sports like football or hockey, but also when bicycling, rollerblading and skiing.

* Young athletes should learn proper techniques. Football players, for example, should learn not to use their heads to block and tackle. Soccer players should learn to head the ball with the forehead.

* Teach young people to walk away from a fight. Fighting can be more dangerous than most people realize. Last spring, for example, it made newspaper headlines when a teenager in St. Paul, Minn., died after a single punch — he fell and hit his head on a curb.

For More Information in Patient Pages:

For the article “It's Just a Ding, Coach; I Can Play” — But Should He,” go to the American Academy of Neurology's journal Neurology at www.neurology.org , click on “Patient Pages” and scroll down to October 2004.

FOR MORE INFORMATION

On Brain Injury:

The American Academy of Neurology Foundation

The Brain Matters

www.thebrainmatters.org

Brain Injury Association of America

(703) 761-0750; (800) 444-6443 (Helpline)

www.biausa.org

National Institute of Neurological Disorders and Stroke

(800) 352-9424

TTY: (301) 468-5981

www.ninds.nih.gov/disorders/tbi/tbi.htm

Brain Trauma Foundation

(212) 772-0608

www.braintrauma.org

National Rehabilitation Information Center

(301) 459-5900; (800) 346-2742

www.naric.com

National Institute on Disability and Rehabilitation Research

(202) 245-7460

TTY: (202) 245-7316

www.ed.gov/about/offices/list/osers/nidrr/index.html

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