By Dr. Christopher Couture, Wentworth Health Partners Seacoast Orthopedics & Sports Medicine

If you have been participating in sports for a significant length of time, or if you are a parent of an athlete, it might seem like the most common medical topic that you hear about is concussion. As a sports medicine physician for over 20 years, it certainly feels to me like the topic that I discuss the most. In fact, the first instructional lecture that I gave as a “sports doc” was about concussion. And yet, for as much as we may have talked about concussions over the last 20 years, there has been a real evolution on how we manage these injuries. Therefore, it is worthwhile to take a moment to bring yourself up to date, especially if you or your child are entering a new sports season.

When I gave that first talk 20 years ago, we as sports physicians were entering an era where we were trying to raise awareness of the importance of recognizing sports-related concussion as a brain injury. For the most part, we have been very successful at doing this: Athletes, coaches, parents and medical personnel are much more attuned to the necessity to take concussions seriously and to treat them accordingly. That much hasn’t changed - and neither has the definition of a concussion, which is:

• …”a traumatic brain injury brought about by biomechanical forces”
• May be caused either by a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head
• Typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously
• Results in a range of clinical signs and symptoms that may or may not involve loss of consciousness
• Resolution of the clinical and cognitive features typically follows a sequential course. However, in some cases symptoms may be prolonged.

As much as our awareness of sports-related concussion has improved over the years, it can still be very difficult to recognize it when it happens to you. That is for a number of reasons, but primarily because concussions affect different athletes in different ways. The symptoms of a concussion are not necessarily very specific - meaning that those symptoms can be attributable to a wide range of other causes. Moreover, there’s no objective test for a concussion; rather, a medical provider makes the diagnosis primarily based on the athlete’s history of injury and symptoms, as well as a physical exam. The list of possible concussion symptoms is long and varied:

• Headache/migraine; “pressure in head”
• Neck pain
• Sensitivity to noise and/or light
• Blurred vision
• Dizziness; loss of balance
• Nausea or vomiting
• Feeling “in a fog”
• Difficulty remembering or concentrating
• Feeling irritable; sadness; anxiety
• Feeling slowed down or low energy
• Fatigue, and/or trouble falling asleep

Once a concussion is recognized or suspected, it is important to take it seriously and take appropriate precautions. Another concept that hasn’t changed over the last 20 years is the urgency to remove the athlete from activity; even if there is only a suspicion of a concussion, “when it doubt, sit it out”! However, one thing that has changed is our expectation of the athlete once he or she has been removed from sport. It used to be that the strategy was essentially to have the athlete “do nothing” until the concussion symptoms resolved - even for a week or more! We have since learned that it is far more beneficial to take a more proactive approach to recovery and rehabilitating the injury. 

Therefore, we no longer expect the concussed athlete to spend days on end in a darkened room doing essentially no activity; that level of strict rest is now recommended for no more than 24-48 hours, as staying inactive for longer can be counterproductive. Most young athletes will start to see at least a slight improvement in their symptoms within the first few days, and so can begin to engage in some light physical and cognitive activity as tolerated (for example, going for short walks, reading for brief periods of time, etc.) as long as such activity does not significantly worsen symptoms.

Another area where our management of concussions has improved is in our recognition of how long it can take a normal athlete to fully recover. While most concussions will completely resolve in 7-10 days, it is now recognized as normal for full recovery to take up to 28 days, especially in adolescents. As such, we do encourage a patient but active approach to recovery. We use light, non-contact exercise as “medicine”, while being careful not to return athletes to more risky levels of participation until it is clear that a full recovery has been made.

Lastly, our ability to intervene in very specific ways has significantly improved. We now recognize that concussions can manifest over a number of different clinical areas or “trajectories”, and we can target our treatment strategies along those trajectories. Those areas can include:

• Headache/migraine
• Vestibular (in other words, the balance system)
• Ocular (the visual system)
• Cognitive (thinking, remembering, concentrating)
• Fatigue (including energy and sleep)
• Mental health

We can therefore use a multidisciplinary approach to rehabilitation, utilizing different professionals such as athletic trainers well as physical, occupational and speech therapists and mental health specialists to guide different aspects of recovery. We also incorporate the results of computerized neurocognitive testing (such as ImPACT) to help determine that an athlete’s recovery is complete.

Obviously, no athlete wants to sustain a concussion, and no parent wants to see it happen to their child. But being aware not only of how these injuries can occur and present, but also of how we manage them once they do occur, can help you feel more confident going into a new sports season.