A concussion, or mild traumatic brain injury, can be defined as a transient disturbance of neurological function caused by head trauma. Common signs and symptoms include headache, nausea, dizziness, difficulty concentrating, visual disturbances, confusion, tinnitus, slurred speech, loss of balance, post-traumatic amnesia, and loss of consciousness. These symptoms are not generic, and vary between individuals. This variation in symptoms is due to the type of sport, position played, impact of the trauma, and other factors unique to the individual. Concussions are commonly graded on a scale of I, II, or III, depending on the pre-established guidelines used. The three most common guidelines used by Certified Athletic Trainers are the Cantu, AAN (American Academy of Neurology), and the CMS (Colorado Medical Society).The majority of concussions in high school and collegiate sports occur in Football, however other sports here at LSU where concussions are common are Gymnastics, Men’s and Women’s Basketball, and Women’s Soccer.
Here at LSU, our primary Sports Medicine physician, Dr. Jeff Burnham, M.D. has a specific protocol that he uses to diagnose concussions and determine when the athlete can return to play. His protocol is based on the athlete’s signs and symptoms, and their progress of recovery.
Question and Answer with Dr. Jeff Burnham:
1. When evaluating an athlete that you suspect has a concussion, what are the first steps you take?
“The very first step is to evaluate the athlete’s general demeanor. It is important to note any abnormal behavior that is not common to the athlete’s normal everyday demeanor. To recognize these differences, it is important for the Athletic Trainer to know their athletes’ normal behaviors. Examples of this abnormal behavior include a vacant stare like a “deer in head lights”, talking unintelligibly, mumbling, lack of coordination, unusual quietness, confusion, and so on.”
- See The Fencing Response to view a recent news report from ABC news on one sign that can occur from concussions.
2. What protocols do you use here at LSU to grade a concussion?
“I use a protocol called a Graded Symptom Checklist (GSC) with patients at Burnham Family & Sports Medicine Clinic, as well as with the athletic teams here at LSU. The GSC is a list of symptoms such as: blurred vision, concentration problems, confusion, dizziness, drowsiness, excessive fatigue, feeling foggy, headache, inappropriate emotions, irritability/nervousness, loss of consciousness, memory problems, nausea/vomiting, personality change, poor balance/coordination, seizures, sensitivity to light, sleep disturbances, and any others the patient may be experiencing. The athlete is instructed to grade the severity of the symptom they are experiencing at the following intervals: the time of the injury, 2-3 hours, 24 hours, 48 hours, and 72 hours post-injury. Grading of the severity of the symptoms is as follows: 0=not present, 1=mild, 2=moderate, and 3=most severe.”
“Following the GSC, I will perform a neurological exam, assessing cognitive function and cranial nerve assessment. If neurological exam is within normal limits, I will then perform balance/coordination tests, and lastly check the ability of the athlete to perform sport specific skills.”
- For more information on Neurological, Cognitive, and Coordination Tests and a sample of the Graded Symptom Checklist, visit the NATA Position Statement for Management of Sport-Related Concussion
3. Is there a pre-established Grading Scale that you prefer to use?
“A combination of CANTU and American Academy of Neurology, but it is important to note that no general scale applies to every athlete because of variation in symptoms.”
- Click here to view a table that compares the three guidelines. It is important to remember that if you suspect an athlete has a concussion, referral to a physician is necessary for further evaluation.
4. Since every athlete is different, and there are no generic signs and symptoms, how do you account for these differences when diagnosing and grading concussions?
“The most common SYMPTOMS are headache, dizziness, blurred vision, sensitivity to noise and light, fogginess, and excessive fatigue. The most common SIGNS are photophobia when performing visual tests with a light, blank stare, unusual speech, balance, and mood or personality change. Some people get less or more talkative than usual; anything out of the ordinary behavior for that individual should be noted.”
5. Can you explain the ImPACTTM and any advantages and disadvantages that you find associated with the test?
“The ImPACTTM test is used to determine the athlete’s brain function AFTER symptoms have concluded. It also helps determine if the patient is experiencing Post-Concussion Syndrome. An initial baseline test must be performed to asses normal cognitive function for that individual athlete.”
“There are many advantages for this particular test because it assesses reaction time and concentration. It is OBJECTIVE. Other than the physical exam, we rely on the athlete to be truthful about signs and symptoms, but the ImPACTTM provides us with a more objective evaluation of the patient’s brain function. A disadvantage is that sometimes the concussed athletes do better on the repeat test than they do on the baseline test, because they take it more seriously, and really try hard to concentrate and pass the test. Also, there can be a learning curve associated with taking the ImPACTTM test multiple times for individuals having multiple concussions.”
- For more information on the ImPACTTM, click here.
6. What is Post-Concussion Syndrome?
“Post-Concussion Syndrome is when the athlete’s symptoms last for weeks, months, and even years after the initial concussion.”
- To read a recent article on Post-Concussion Syndrome from the New York Times, see Ex-N.F.L. Executive Sounds Alarm on Head Injury
7. Briefly describe your Return to Play (RTP) criteria.
“Most important, there should be absolutely no return to activity as long as symptoms are still present. If the athlete had a Grade I concussion and signs and symptoms resolve within 20 minutes and stay resolved, the athlete may be able to RTP the same day if symptoms do not return with sideline exertion tests. A Grade II concussion, with or without Loss of Consciousness (LOC), will result in being held from activity that day. They need to be re-checked every few hours the first day and then periodically until symptoms resolve. Symptoms could last 48 hours to months. A Grade III concussion would include LOC, immobilization, and transportation. The same progression below would be used, but the time to start the progression would be substantially longer than with a Grade II concussion.”
“To assess ability to return to activity we follow this general guideline: once symptoms completely resolve, this graded activity progression can begin. At any time, if ANY symptoms return, activity is stopped and possibly resumed the next day with possible modifications.
- Day 1, post symptoms: Ride bike (Level 1 or 2)
- Day 2, if no symptoms return: Light jog for 5-10 minutes
- Day 3, if no symptoms return: Non- Contact Sport-Specific Drills
- Day 4, if no symptoms return: Return to sport with modifications and limited contact
- Day 5, if no symptoms return: Full contact
Exceptions to this would include high school athletes (because of their still developing brain and high risk for further damage) and athletes with previous history of concussions. They will go through a slower progression plan in order to prevent further damage. In some situations cognitive as well as physical rest may be prescribed (e.g. no studying, video games, excessive texting, etc.).”
8. What are some ways to prevent concussions in contact sports like football?
“Remember, once an athlete experiences a concussion, the chances of sustaining another one increases 3-9x. As far as equipment, a good helmet fit is important. However, no specific helmet willtotally prevent a concussion. Your Equipment or Athletic Training Staff must be trained in the proper fit and use of helmets. It is important that the coaches and athletes are educated on good hitting techniques and rules such as no helmet-to-helmet contact or spearing.”
- For more information on proper helmet fit, visit the National Operating Committee on Standards for Athletic Equipment (NOCSAE).
9. Is there any other important evaluation information to know?
- “Most importantly, evaluate thoroughly, no return to play until symptoms cleared, and gradual progression checklist is performed after symptoms have resolved.”
- “While recovering from concussion, do not give strong pain medications or NSAIDs (such as Advil), because these will thin the athlete’s blood, and cause further bleeding and damage to the brain or mask severity of the concussion. Tylenol in small doses is the medication of choice.”
- “Athletes often think that no competition means they cannot participate in games or practices, and they think it is okay to lift weights. However, this is NOT okay. Lifting weights puts increased pressure on the brain, putting the brain at risk for further damage.”
- “There is new research being conducted on the effects of a concussion and a student-athlete’s ability to attend class regularly while recovering. This research indicates that, in certain instances, the athlete may need to be removed from classes and all concentration activities that engage the brain.”
A special thanks to Dr. Burnham for taking the time and allowing us to interview him for this month’s Tiger Talk!