It was almost twenty years ago. David Mocklin was playing defensive back for his high school football team against one of their main rivals. On one particular play, David zoned in on the ball carrier and delivered a jarring hit. It’s one of those hits that could be heard throughout the stadium. The crowd erupts, and his teammates crowd around him to congratulate him on a spectacular play. Everyone there knew it was a tremendous hit, except for David himself.

For him, the crowd eruption was muffled as he could only hear a ringing in his ear. He did not lose consciousness, but could not remember what happened for a few minutes after the hit. His fogginess led him to the other team’s huddle. Although he cleared up pretty quickly, David had a grade 1 concussion.

Fast-forward to today and David is a certified athletic trainer for East Jefferson General Hospital and Mount Carmel Academy. He sees injuries of varying degrees and each sport he monitors tends to have its own sports-specific injuries. All, however, carry some risk of head trauma that can result in a player suffering a concussion.

“The major sports that carry a higher risk of concussion injury are football, hockey, wrestling, soccer, basketball, baseball, and, of course, boxing,” says David. “As an athletic trainer on the high school level, I’m usually the first out there to provide medical care. I need to take concussions very seriously and be extremely conservative in assessing the athlete in terms of when or if they can re-enter the game or even if it is best to go to the hospital for testing.”

What is a concussion?

According to the American Academy of Neurology, a concussion is defined as a “trauma to the head which induces alteration in mental status that may or may not involve loss of consciousness.” Confusion and amnesia are the hallmarks of a concussion.

Concussions are essentially blows to the head that can occur in sports and in daily life. The major causes of concussions outside of the playing field are car accidents, falls, and cases of assault. Your brain is soft tissue encased in the hard bone structure of the head. As a person sustains a blow to the head, the brain sloshes inside the head. The jostling back and forth disrupts the neurons needed for normal function by interrupting the relay of impulses between the brain and the brain stem. This disturbance in neurological function is temporary, and the time it takes to return to normal function helps physicians gauge the severity of the concussion.

“A concussion is not the same as bruising of the brain,” says Dr. Wendy Jamison, Chief of Neurology at East Jefferson General Hospital. “Bruising or any bleeding of the brain is a much more serious and potentially life-threatening condition that needs to be looked for if symptoms do not improve or if symptoms occur which suggest focal injury to the brain such as seizure activity, loss of vision or weakness in any of the limbs.”

Concussions are usually graded on a severity scale accepted by the American Academy of Neurology and the National Athletic Trainer’s Association. A concussion can be rated a Grade 1, 2, or 3, with Grade 3 being the most serious.

Assigning a grade level to a concussion is not always clear-cut and is based on observing the individual for symptoms. Some common and immediate symptoms include dizziness, headaches, nausea or vomiting, memory loss on events before or after the trauma, and an unresponsive state. The days and weeks following the impact can cause an individual to have chronic headaches, fatigue, emotional or personality changes, trouble sleeping, depression and an inability to concentrate.

“The only treatment for a concussion is time and rest,” says Dr. Jamison. “You can treat the symptoms with medication but the concussion simply needs time to heal. Most people recover fine, but, until they do, they should be monitored closely to make sure symptoms are not worsening.”

Dr. Jamison went on to say that someone with a concussion should not go to sleep for a few hours after the concussion. The reason is that if they are asleep, those monitoring may not be able to recognize worsening symptoms. If the person complains of extreme sleepiness, it may be a sign of a more significant problem. Once they are asleep, it is best to wake them hourly for the first 24-hours to see if symptoms are getting worse.

Since diagnosing a concussion is primarily done through observation, it is a judgment call on when a concussion needs additional medical testing. The common guideline is that a Grade 3, and in many cases, a Grade 2, requires the person to be transported to the emergency room for diagnostic testing. The reason for a cat scan or an MRI is not to diagnosis the concussion necessarily, but to rule out something more serious.

“When looking at the cranial CT or MRI scans, I am trying to see if the injury has left a footprint on the brain,” says Dr. John Joslyn, EJGH Chief of Radiology. “I want to make sure there are no signs of bleeding, edema or abnormal fluid. Many times scans of patients with concussions show no abnormality.”

What does this mean for the athlete?

David Mocklin believes that the volume of research on concussions has led to more education on how to handle a concussed athlete, especially on the high school level. In the past, a player may have returned to the game as soon as the symptoms subsided. That is not the case in most instances now. Coaches, trainers, parents and the players themselves are much more aware of the seriousness of letting a player return to action and understand the risks of sustaining a second concussion.

The heightened awareness on concussions has led to improvements in sports equipment that has helped to reduce the number and severity of the concussion. Rule changes in sports have been made to better protect the athlete on every level. In football, spearing an athlete with the helmet or leading a tackle with the head is penalized; while in baseball, batters and coaches on the first and third base line are required to wear a protective helmet.

“We can’t just dismiss a hit to the head and say ‘oh, he just had his bell rung,’” says Mocklin. “Clear studies show that when you sustain a concussion, you are at greater risk of suffering from another one, especially if you are not healed from the first one. This Second Impact Syndrome can lead to permanent brain damage and can cause the brain to swell.”

With the risk of Second Impact Syndrome in mind, trainers are much more aware of the need to pull the athlete out of the game immediately and keep them on the sidelines. Trainers also will not let the athlete return to practice until they are symptom-free for at least two or three days and, possibly, a week or more depending on the severity of the concussion. Parents are given an educational checklist for symptoms and have detailed instructions on how to monitor at home. If there is any doubt at all, parents are told to seek an emergency room immediately.

At the professional level, major league umpires and players are required to take a baseline, neuropsychological exam. The test includes such areas as attention span, working memory, reaction time and non-verbal attention problem-solving. Umpires and catchers in particular are vulnerable to a baseball coming off the bat to strike them in the head. The post-concussion test can then be compared to the baseline results to determine cognitive function. This comparison is especially useful in determining when it is safe to return to the field.

“The baseline testing that Major League Baseball requires is a tremendous tool in the management of concussions,” says Mackie Shilstone, Executive Director of the Fitness Principle and advisor to Major League Baseball. “In fact, it may be a good idea for parents to have a baseline test for their children whether they are playing sports or not. This can be particularly useful in case they sustain head injury from a fall or in a car accident.”

As the concussed athlete recovers, limiting the amount of mental stressors after the concussion may help the healing process. According to guidelines published by international experts in The British Journal of Sports Medicine and reported by Science Daily, “children and teens must be strictly monitored until fully healed. These restrictions include no return to the field of play, no return to school, and no cognitive active.” These guidelines further report that children and adolescents may need a longer period of full rest and gradual return to normal activities than adults.

“Our job is to take care of injuries and to keep the athlete safe,” says Mocklin. “It doesn’t matter if you are in high school or on the professional level, the same principles for treating concussions should apply. It is just not worth it to let someone return too soon.”