Concussions in Collegiate Recreation: Are we prepared?

September 15, 2014

Ann Wittkopp
Head Athletic Trainer
Central Washington University-Recreation

 This article is the first in an ongoing series about concussions and other relevant sports medicine topics in collegiate recreation.

Concussions have frequented the news in the last several years. The NFL and ESPN have made sure that anyone who watches professional football is well aware of the word” concussion.” But how much do we really know about concussions? What constitutes a concussion? What does the peer-reviewed literature say about concussions? Until recently, concussions were only referred to as ‘mild head injuries’; due to misconception of the severity of the injury, they are now referred to as ‘mild traumatic brain injuries.’

As an athletic trainer working in collegiate recreation, I have seen more than my fair share of concussions with varying degrees of symptoms and duration; what always concerns me, however, is the complete lack of concern (and sometimes disregard) most patients have for the injury itself and what it means for his/her health, and potential future.

The CDC estimates that between 1.6 and 3.8 million sports-related concussions occur in the US annually; how many of us as collegiate recreation professionals can say that we understand the injury, its implications, and proper management for the injury? How many of us can say we feel adequately prepared to manage the potential influx of head injuries in our events and programs?

Although the injury itself is not completely understood, the most recent research suggests that it “is a complex phenomenon, involving interconnected pathophysiological/neurophysiological (cellular and vascular) changes that occur as a multi-layered metabolic cascade. The primary mechanisms. . .include ionic shifts, abnormal energy metabolism, diminished cerebral blood flow and abnormal neurotransmission” (Comper, Hutchison, Magrys, Mainwaring, & Richards, 2010).

These changes will not appear anywhere on a CT or MRI (Comper, Hutchison, Magrys, Mainwaring, & Richards, 2010). Injuries sustained in sport-related activities usually do not include a loss in consciousness, and once an individual sustains a concussion, he or she is more likely to sustain them in the future, often with increasingly longer recovery times and prolonged symptoms. A concussion can result from a direct blow to the head, but can also occur without any direct contact at all.

There are no specific symptoms that always occur with a concussion; symptoms and their duration are very individualized. Symptoms can include (among others not listed):

• Headache
• Nausea/vomiting
• Confusion
• Dizziness
• Fatigue
• Sleeping problems
• Difficulty concentrating
• Anterograde(memory loss after the concussion ) or retrograde (memory loss before the concussion) amnesia
• Sensitivity to light or noise
• Irritability or over-emotionality

It is critical to keep in mind recovery time is very individualized; post-concussion syndrome can also develop, which means that the affected individual’s symptoms last for weeks or months longer than would normally be expected. Oftentimes, the fact that there are no actual visual symptoms like a bruise or a fracture can be misleading therefore more serious injuries such as second impact syndrome, epidural and subdural hematomas, skull fractures, and spinal injuries. It seems like the list of worries is never-ending, and unfortunately for some, these neurological and cognitive deficits in the brain can be permanent.

Dr. Wayne Gordon, a neuropsychologist at Mt. Sinai School of Medicine in New York City, has been studying and documenting the long term effects of concussions and repeated blows to the head since the late 1980s (Carroll & Rosner, 2011). According to Gordon;

A surprisingly large number of patients had suffered jolts to the head that weren’t anywhere on their medical records; they had come to him because they could see their lives unraveling and were having a more and more difficult time coping with relationships and job responsibilities. Some of them could trace this downhill slide to a particular event (car accident, fall, etc.) but none could understand what it was about the incident that had thrown their lives so out of whack.

Furthermore, according to Carrol and Rosner (2011), Gordon began to expand his research of concussions, studying various populations in New York City and the State of New York, including children, special education program participants, substance abuse program participants, and even homeless individuals in New York City. His results were astounding:

• Ten percent of children in a NYC school said they had sustained a significant head injury, and these children turned out to have cognitive impairments when later tested. Most of the injuries incurred were undiagnosed.
• Upon interviewing and testing children in special education classes, the results concluded more than 50% of the learning-disabled children had experienced a significant impact to their heads.
• Results conducted from 800 individuals indicated 54% had a history of head injury, 40% of whom still had post-concussion syndrome. Additionally, patients with head injury history were more prone to mental illness and substance abuse treatment failure.
• In 2006, Gordon tested 100 homeless individuals in NYC for signs of concussion. These tests indicated nearly 70% had memory, language, or attention deficits, while 82% reported a significant head injury before they became homeless, often the result of parental abuse.

Prevention of concussion is often as simple as wearing a helmet during certain activities, such as climbing, cycling, playing lacrosse, equestrian, etc., and wearing a seatbelt when driving. After prevention, education about concussions is the next most important component.

Fortunately, concussion awareness/education has rapidly accelerated in recent years; however, this growth needs to expand past the traditional collegiate varsity and professional athletic setting into the field of collegiate recreation. It is our responsibility to share the message that concussions are serious brain injuries and must be treated appropriately, and to be able to refer those individuals to the professionals they need.

How can we manage the number of concussions coming through our doors and protect our departments and universities? An athletic trainer is the best way to protect your department from litigation and to manage the risks associated with many collegiate recreation programs. An AT is trained specifically to manage concussions and other injuries.

However, many collegiate recreation programs do not have a full or even part-time AT on staff to provide evaluation and care for concussions. In my experience traveling with teams, I am usually the only AT on site for club sport games, and usually provide care for both teams. If there is another individual, it is usually an un-certified undergraduate student or an intern, which, legally, is not any better than a layperson certified in CPR and First Aid. This leaves a gaping hole of negligence in our risk management programs. To add to this conundrum, recreational athletes are also often less experienced and more untrained than the traditional varsity collegiate athlete, which means an increased risk for injury before they even begin an activity. We as recreational professionals have a duty to provide a level of safety and care for these individuals.

I have been asked more than once whether only providing coverage to some events and not others leaves us open for litigation. To those individuals, I always answer the same: it’s all about what program or event contains the most risk. What are the riskiest events your collegiate recreation program has?

An AT is able to easily determine this and provide coverage accordingly by gauging the nature of the event or sport, the amount of contact, playing surface, type of equipment used, and so on; this is why athletic trainers are invaluable. They are trained specifically to constantly think within this frame of mind.

Conversely, the question then becomes “Does NOT providing any emergency medical support at all show that we are concerned for our participants? Or does it show blatant negligence?”   If we can show that we are providing athletic training or EMT coverage for these at-risk events (lacrosse, rugby, soccer, equestrian, rodeo, wrestling, karate, etc.), it shows a concerted effort on our part to protect the participants from injuries and detrimental decisions made by themselves, coaches, or fellow participants, even if we can only cover, for example, only certain club events instead of all club events. This might not be ideal, but it will provide substantial support in our favor should any litigation arise later.

There are infinite resources available regarding the recognition and treatment of concussion. Some of those are listed here; in addition, I have listed my contact information below and welcome any and all questions and comments and would love to share resources and information.

http://www.cdc.gov/traumaticbraininjury/

http://www.brainline.org/index.html

http://www.nata.org/sites/default/files/Concussion_Management_Position_Statement.pdf

http://www.nata.org/sites/default/files/MgmtOfSportRelatedConcussion.pdf

Works Cited

Carroll, L., & Rosner, D. (2011). The Concussion Crisis: Anatomy of a Silent Epidemic. New York: Simon & Schuster.

Comper, P., Hutchison, M., Magrys, S., Mainwaring, L., & Richards, D. (2010). Evaluating the methodological quality of sports neuropsychology concussion research: A systematic review. Brain Injury, 1257-1271.