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Concussions are a very hot topic right now between the legislatures passed in the state of New Jersey to the settlement reached in the NFL. More and more people are being injured and more and more athletes are missing playing time because of this serious brain injury. The best approach to managing a concussion involves the injured person and their family, coaches, athletic trainers, physicians, and physical therapists all on the same team to progress to a full return to sports, work, or whatever activity they were doing prior to the injury.

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What is a concussion?
Quite simply, a concussion is a brain injury. The brain "floats" in your skull bathed in cerebrospinal fluid. This fluid is typically enough cushion to absorb forces when you move your head throughout daily life. If an impact is hard enough, the brain can hit the wall of the skull, creating the direct blow injury of a concussion. To heal, the brain will bruise and could swell just like your body would respond to a kick to the shin. This increased bruising, tissue damage, and possible swelling creates the typical post concussive symptoms including difficulty concentrating, feeling foggy, dizziness, headaches, sensitivity to light, etc.

Baseline testing
The best way to diagnose a concussion is to have a baseline test to compare to. Every school athlete in New Jersey is required to have baseline IMPACT testing, which is a 20 minute computerized test that measures several variables that are commonly affected post-concussion. This gives physicians a good understanding of how well the athlete could focus, react, and think quickly prior to an injury. Different athletes and people have different reaction times, so it is important to compare the individual to themselves pre and post injury rather than just compare to normal measures.

On the field diagnosis
Athletic trainers and coaches are very critical pieces to recognizing the initial signs and symptoms of a concussion. When an athlete suffers a contact injury, whether it is contact with another player or with the ground, there could be a risk of injury. Initially, the symptoms may present as confusion, headache, and possibly loss of consciousness. Coaches and ATCs are trained in a series of questions and balance tests that an athlete must perform without symptoms or problems to return to the game. For instance, if the athlete cannot recall where they are playing, has difficulty counting backwards by 7s, has difficulty looking the eyes side to side, nodding the head up and down, or standing on one foot, then they will be held from additional competing until assessed by a physician.

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Physician office diagnosis
A possibly concussed individual presents to the physicians' office for IMPACT testing in addition to cognitive and physical testing. If there is a baseline IMPACT test to compare, this makes it very easy to diagnose a concussion based on slower reaction and a decline in score. If there is no baseline, then it is up to the expertise of the physician to look at the IMPACT testing as well as physical exam to make a determination.

Acute/subacute phase
Different people respond differently to concussions. Some have symptoms for only a day and then some others have symptoms that could last for years. The state of New Jersey has adopted legislation that requires any high school athlete who has a concussion to be out of participation for at least 7 days, which will be explained later in the return to play discussion. Initial management of concussions involves limiting the stimulation to the brain. Some students will be excused from school until symptoms are more manageable (which they usually don't mind), and some will be kept from TV, music, video games, and texting (which they all very much mind) to keep the stimulation at a minimum to promote healing. The physician will make the determination as to when to introduce school, texting, reading, and testing based on symptoms. (The American Physical Therapy Association writes that recent studies have shown that most people post-concussion will benefit from vision and vestibular rehabilitation.) This can be started in this phase as long as there is no increase in symptoms. The vestibular system and visual tracking system have a high correlation with duration of symptoms – the post-concussive symptoms last longer when there is an underlying visual and vestibular deficit. Physical therapists trained in working with these deficits can have a large impact on the healing of the injured person. There is also a correlation with neck pain and prolonged headaches that must be addressed. At this phase, it is important for the physical therapist, athletic trainer, concussed individual, their family, and the physician to maintain close communication to ensure proper progression and management in a team approach.

3dpt fbReturn to play phase
Before a high school athlete can return to play, they must be symptom free for 5 days, and then complete a 5 step return to play process. This return to play progression incorporates monitoring heart rate response, environmental stimulation, and exercise intensity to progress an individual to return to play. Any re-emergence of symptoms result in the athlete returning to the acute/subacute phase until symptoms subside again. This phase is typically managed by the high school ATC, and requires close communication between the athletic trainer and physician to progress and clear the injured athlete to return to play.

Second Impact syndrome
A severely debilitating condition known as second impact syndrome is being more studied. This involves people who have been recently concussed and suffer a second concussion before the first fully heals. Second impact syndrome results in a cascade of events that leads to brain degeneration and significant loss of function. Many professional athletes, such as Keith Primeau, Eric Lindros, Scott Stevens, and more recently (possibly) Kevin Kolb, were forced to alter the length of their career due to multiple concussions.

Can concussions be prevented?
The short answer to this is no. While companies continue to make better and better helmets with more padding and new and improved mouth guards, studies show limited ability of these protective devices to decrease the risk of a concussion. One of the best analogies that is used to summarize equipment is that of an egg toss. If you and another person were throwing an egg back and forth, you could catch it without letting it break. If you back up to a greater distance, you can cushion the impact of catching it with a pad or wrap the egg in bubble wrap, but eventually you will be at a great enough distance and there will be great enough force that the egg will break. As football and lacrosse players are getting bigger and bigger, the best way to prevent a concussion is to avoid getting hit in the head.

Team approach
A concussion could be a devastating injury that could last days, weeks, or even years. Proper management initially, as well as a comprehensive rehab program is essential to a faster and more complete recovery. Once symptoms are identified, the injured person must find a physician trained in managing concussions, as well as find a trained physical therapist who is knowledgeable about post concussive symptoms as well as vestibular rehabilitation. It is up to the injured person, physician, physical therapist, athletic trainer, and coach to all work together to achieve the ultimate goal of full recovery.

Ken Guzzardo, PT, DPT, OCS, SCS
Jeff Sallade, PT, DPT, OCS, SCS, CSCS
Ryan McDevitt, DPT

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