Concussions and teens athletes

Apr 07, 2011

Jon Almquist, athletic training coordinator for Fairfax County schools, will answer your questions about preventing, recognizing and treating teen athletes' concussions.

Read Lenny Bernstein's MisFits column on Why we should step up vigilance of concussions in teen girls.

At what age should concussions be considered injurious to boys who will later be playing college ball?

Concussions at any age should be taken very seriously, especially in the young devloping brain.  Whenever they occur, the important thing is that the athlete's brain has completely healed before risking another hit.  Each concussion should be evaluated by a licensed medical professional educated in concussion management using current best practices.

Does Fairfax County have a policy where any head injury to an athlete means the athlete is immediately taken out of the game? I have known of athletes who suffered head injuries, stayed in the game, and later discovered they had a concussion with long range problems. We need coaches to stop telling athletes to play through the pain and recognize that a head injury needs to be examined immediately.

Yes, when a concussion is suspected the athlete is to be removed from participation and referred for evaluation by the licensed athletic trainer.  Symptoms of a concussion do not always manifest immediately, so we also frequently see athletes the following day(s) indicating they "got hit" in the game or practice but did not realize any symptoms. Sometimes this may be due to the athlete minimizing the symptom immediately after, sometimes the symptoms do not appear until hours or even a day or two later.  This is one of the reasons concussion management is very complicated and never black and white.

I had approximately 8 concussions when growing up during youth from various sports (e.g., 2 from football, 1 from a head-on-head collision in soccer, 1 from BMX biking, 1 from wrestling, 1 from ice skating) and extracurricular activities. I don't have any long-term effects that I know of, like depression, memory problem, etc, but it definitely became easier and easier to get concussions for me as I accumulated more of them. FYI: After high school and not playing football anymore, I have not had any more concussions (thank God). I am guessing that I had minimal to mild types of transient traumatic brain injuries from my various accidents, but my question is why were my concussion symptoms more like a migraine headache (severe headache with photophobia, sonophobia, and positive visual phenomenon for 30 mins, followed by vertigo, nausea and vomiting for 30 minutes and then sometimes temporary short-term memory difficulties that lasted for 12 to 24 hours). I have seen lots of discussions and articles or papers about concussions being a subtype of mild traumatic brain injury and their possible long-term effects, esp. in relation to second-impact syndrome or accumulated more severe damage. However, none mention trauma as an inciting event for causing a migraine headache, which most of mine appeared to be, especially since my last few concussions occurred with minimal head impact. Anecdotally, I have seen several patients in the Emergency Room with trauma-induced migraines too as I am an ophthalmologist.

We have been reviewing literature that indicates a history of migraines appear to elicit a longer recovery period. I am not aware if there is one answer to the connection with migraines and concussions, but it is something we continue to monitor.  There are specific symptoms that are included in the "migraine cluster" that occur following head trauma. More research is needed in this area.

What is being done to educate athletes, parents, and coaches about sports concussion signs, symptoms, and protocols?

Information on concussions has been included in both parent meetings and athlete meetings as well as coaches meetings provided by FCPS schools over several years now.  The law that goes into effect July 1, 2011 will require all student athletes and their parent to complete a concussion education program prior to participation in sports. 

This past October, the Virginia High School League passed a rule that all coaches complete a concussion education course.

We continue to work on the education piece and feel it is essential to the overall concussion management policy.

For my soccer and baseball First Aid kit, how strong of a flashlight will I need to check for light sensitivity? I'm hoping for a penlight size, but most of the LED flashlights seem way too strong for checking a kid on a sideline.

Penlights are adequate, so is the sun (if outside) or indoor light (if inside).

How helpful is protective headgear in protecting against concussion, particularly in soccer?

At this point, it is safe to say that no headgear approved for sports (including helmets) can prevent concussion.  Concussions can occure with no contact to the head (whiplash type movement from hit to body).  More research needs to be completed to determine the true validity of how much a particular headgear may reduce the severity of a concussion, if at all.

A 17 y/o female family member was struck in the head (front lobe) by a golf club (an iron, not a wood). Although her skull was not fractured, she was unconscious for a few minutes and she suffered headaches, fatigue, etc., for several days afterward. Lack of insurance precluded follow-up care. In her early and mid-twenties, she suffered amnesia for certain current day events, amnesia that has stayed with her into middle adulthood. Although her later amnesia spells were never linked to the injury, I wonder: can such a head injury cause amnesia two, five, or more years after the fact?

The answer to this question would be best provided by a team of experts following an in-depth review of the history as well as a thorough clinical evaluation.

Often we talk in terms of days to return to play. Of course in some cases it can be months or years (or never). Often symptoms are subtle and easy to overlook. How do you decide that an athlete needs to quit the sport permanently?

As with all concussions, attempting to place them into a cookbook protocol is not advised.  There is no way to tell if an athlete will be out for 4 days with symptoms or 11 days with symptoms.  Same is true when attempting to determine how many is too many.  What is important is to confirm that there are no "bridges" between concussions.  Has the brain really healed completely before returning to stress.  Any athlete (non-athlete as well) suffering from multiple concussions should be evaluated extensively by experts in concussion management.   Case by case basis, too many variables to consider to offer a blanket statement.

Two kids on my son's football team (10-years-old) were breifly knocked unconcious during a game this year. The coach told the parents that he didn't believe in "this concussion nonsense" and sent the kids right back in (even though they'd both ended up throwing up on the sidelines). I removed my child from the team and reported him to the league, but they did nothing. Did I overreact?

Absolutely NOT, you did the right thing.  I would question having my son participate on any team in a league that allows a coach to make poor decisions such as that.  (trying to be polically correct here!!)

Are coaches of younger children receiving the same education about sports concussions as high school coaches? Do you ask your athletes if they have a history of concussions prior to their participation in high school sports?

I believe there is a significant effort to provide appropriate education on concussions to coaches at the youth level.  Some organizations are more aggressive at this than others.

Yes, there is a question on the VHSL Pre-participation Physical Evaluation form that addresses previous conucssions.  We are also reviewing our epidemiological data to look at the number of athletes who have suffered multiple concussions and the timeframe between cases.

Is there evidence that once you get a concussion that getting another one becomes easier, that is, does having one or multiple concussions lower the trauma threshold needed to cause a concussion?

I'm not sure anyone is certain of the answer, but that could be a possibility.  We do know that every kid responds differently and some will have symptoms with 15 g's of force, while others of the same body size will not have symptoms when hit with 25 g's of force.  What the difference is between the to kids?  Perhaps the answer is in the DNA.  More research is needed.

Thanks to everyone who has sent in a question.  I hope I've provided some useful information.  The science of concussions has changed drastically over the past years and continues to evolve quickly.  Remember these simple points, if there is trauma and concussion symptoms are a result, the action to take is REST the athlete, PREVENT further harm. REST both phyically and cognitively and have them evaluated by a medical professional.  When in doubt, Sit them out!

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Jon Almquist
Jon Almquist is the athletic training administrator for Fairfax County Public Schools. Almquist provides oversees a staff of more 50 certified athletic trainers who work with more than 25,000 student athletes annually.
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