Concussions: An Overview for Football Coaches

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The full text of “Concussions: An Overview for Football Coaches” by Dr. Jack Hughes, from the Vol 3 — Winter 2018 issue.

John H. Hughes M.D., F.A.C.S. C oaches, players and parents need to understand concussions in context of blunt force injury to the brain. The Center for Disease Control and other agencies (1) consider that concussion usually fall into four categories: 1) difficulty thinking clearly 2) feeling slowed down, 3) difficulty concentrating, and 4) difficulty Remembering new information.

Symptoms may include 1) fuzzy or blurry vision 2) nausea or vomiting 3) sensitivity to noise or light 4) balance prob - lems 5) difficulty concentrating, 6) feeling tired, having no energy 7) trouble falling asleep 8)nervousness or anxiety 9) headache, irritability, and 10) sleep disturbances. The American Academy of Neurology defines concussion as a “clinical syndrome of biomechanically induced altera - tion of brain function, typically affecting memory and orientation, which may involve loss of consciousness.

This can result from direct or indirect forces to the head.” (3) There can be considerable variability in time of onset, intensity of symptoms, and the degree in which symptoms disturb usual daily patterns of living. The degree of difficulty may be perceived differently by the player, the trainer, coach, parents, friends, and medical professionals.

In regard to relative incidence, a recent study (2) reported “Adolescents who participated in baseball, basketball, football, gymnastics, ice hockey, lacrosse, soccer, track, weightlifting, and ‘other sports’ had greater odds of reporting multiple diagnosed concussions compared with peers not participating in these sports. Adolescents who participated in tennis had lower odds of reporting any diagnosed concussion or multiple concussions.

Females who participated in gymnastics, soccer, and swimming showed a stronger association in reporting a diagnosed concussion when com - pared with males who participated in these same types of sports.” One authoritative study of head injury (3) pointed out that “Studies of football athletes have implicated repetitive head impact exposure in the onset of cognitive and brain structural changes, even in the absence of diagnosed Concussions: An Overview for Football Coaches

43 concussion. Those studies imply accumulating damage from successive head impacts reduces tolerance and in - creases risk for concussion.

Support for this premise is that biomechanics of head impacts resulting in concussion are often not remarkable when compared to impacts sustained by athletes without diagnosed concussion.” Dealing with the dynamics of adolescent development that include both cognitive and social development, the thought processes of winning and losing, and the concurrent process of brain change where dendrites (neural connections) are trimmed and neuroplasticity (development of fresh pathways of brain information transmission) all complicate the monitoring changes of both concussion and post-concussive injury.

Advances in the manufacture of football helmets have added to the protection of the brain from injury reduc - ing the kinetic force of impact. As reported by Collins et al (5), that “Despite differences in interior padding and exterior shells, all football helmets should provide comparable protection against concussions.

Yet, debate continues on whether differences in the rates or severity of concussions exist based on helmet age/recondition status, manufacturer, or model” They examined “ Characteristics of concussed football players (ie, mean number of symptoms, specific concussion symptoms, symptom resolution time, and time until return to play) were simi - lar among players wearing new helmets when compared with reconditioned helmets.” They noted that “Fewer players wearing an old/not reconditioned helmet had concussion symptoms resolve within 1 day compared with players wearing a new helmet.” They found that “Despite differences in the manufacturers and models of helmets worn by all high school football players compared with players who sustained a concussion, the mean number of concussion symptoms, specific concussion symptoms, symptom resolution time, and time until return to play were similar for concussions sustained by football players wearing the most common helmet manufacturers and models.” They concluded that “Overall, for new and reconditioned football helmets, the most common helmet manufacturers and models on the market today appear to provide high school football players with similar protec - tion against concussions.” A thorough and comprehensive review with an excellent bibliography addressing sports concussion laws are reviewed by Bell, Master, and Lionbarger.(6) These authors point out that 90% of student athletes who have concussions will recover within weeks.

Statistically, between the years 2001 to 2012 emergency department visits for brain injury of student athletes increased from 73.1 in 2001 to 152.0 in 2012 per hundred thousand popula - tion. Similar trends were seen in visits to primary care pediatricians. Since 2007, all 50 states and the District of Columbia have enacted various youth sport concussion laws designed to improve the recognition and manage - ment of concussions.

These authors also call attention to the” second impact syndrome in which diffuse brain edema develops after a second head impact is sustained but prior to symptom resolution of an initial head impact.” They point out” that youth sports concussion laws generally include three core requirements.

These include the education of coaches in regard to recognizing the signs and symptoms of concussion, guidance for removal of participants from the game when a concussion is suspected, and rules requiring athletes to be cleared by a healthcare professional prior to returning to the game.

Furthermore they point to the “lack of specificity in youth sports concussion laws and evidence-based clinical guidelines.” They note that “First, state laws vary in their specification of who is qualified to provide clearance for student-athletes attempting to return to play. Second, concussion signs and symptoms are nonspecific in the absence of an objective diagnostic test makes diagnosis challenging.

Third the scientific evidence-base for clinical management is relatively early in its development and recommendations (which) continue to evolve.” In terms of rehabilitation, the teamwork between coaches, teachers, physicians, and mental health professionals can enhance recovery. According to Gagnon et al.

(7) “ rehabilitation program includes gradual, closely moni - tored light aerobic exercise, general coordination exercises, mental imagery, as well as reassurance, normalization of recovery, and stress/anxiety reduction strategies. The program continued until complete symptom resolution and readiness to begin stepwise return to activities.” They stated that “the primary outcome of the study was evolution of post‐concussion symptoms.

Secondary out - comes included mood, energy, balance, and cognition” and “After the intervention, post‐concussion symptoms significantly decreased for the group of participants.

They also had decreased fatigue and improved mood after 6 weeks of initiating the rehabilitation intervention.” References: (1) Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention (2) J Adolesc Health. 2018 Oct 25. pii: S1054-139X(18)30407-5. doi: 10.1016/j.jadohealth.2018.08.023. Lifetime Prevalence of Self-Reported Concussion Among Adolescents Involved in Competitive Sports: A National U.S. Study.

Veliz P, Eckner JT, Zdroik J, Schulenberg JE. (3) Neurology. 2013 Jun 11;80(24):2250-7. doi: 10.1212/WNL.0b013e31828d57dd. Epub 2013 Mar 18.Summary of evidence-based guideline update: evaluation and management of concussion in sports: report of the Guideline De - velopment Subcommittee of the American Academy of Neurology.Giza CC1, Kutcher JS, Ashwal S, Barth J, Getchius TS, Gioia GA, Gronseth GS, Guskiewicz K, Mandel S, Manley G, McKeag DB, Thurman DJ, Zafonte R.

Division of Pediatric Neurology, Mattel Children’s Hospital, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.

(4) Ann Biomed Eng. 2018 Oct 22. doi: 10.1007/s10439-018-02136-6. [Epub ahead of print] Comparison of Head Impact Exposure Between Concussed Football Athletes and Matched Controls: Evidence for a Possible Second Mechanism of Sport-Related Concussion.Stemper BD1,2,3, Shah AS4,5, Harezlak J6, Rowson S7, Mihalik JP8, Duma SM7, Riggen LD6, Brooks A9, Cameron KL10, Campbell D11, DiFiori JP12, Giza CC13, Guskiewicz KM8, Jackson J11, McGinty GT11, Svoboda SJ10, McAllister TW14, Broglio SP15, McCrea M4,5; CARE Consortium Investigators.

(5) Concussion Characteristics in High School Football by Helmet Age/Recondition Status, Manufacturer, and Model: 2008-2009 Through 2012-2013 Academic Years in the United States February 2016The American Journal of Sports Medicine 44(6) DOI: 10.1177/0363546516629626 Christy L Collins Lara B McKenzie Lara B McKenzie Amy K Fer - ketich Dawn Comstock (6) The Clinical Implications of Youth Sports Concussion Laws: A Review, Jeneita M. Bell, MD, MPH, Christina L. Master, MD, Michael R.

Lionbarger, MPH, January 20, 2017 https://doi.org/10.1177/1559827616688883 (7) Scandinavian Journal of Medicine &; Science in Sports A pilot study of active rehabilitation for adolescents who are slow to recover from sport‐related concussionI. Gagnon L. Grilli D. Friedman G. L. Iverson First published: 03 March 2015 https://doi.org/10.1111/sms.12441

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Adjusting your defense at halftime and during the game can pay big dividends. All coaches know that tweaking a defensive scheme during a game or at halftime can often make the difference between winning and losing. But how do some of the game’s best defensive minds approach in-game defensive adjustments? Is it better to com - pletely revamp a defensive game plan or is it better to make minor adjustments based on what you’ve seen from an offense?

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