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Concussion Treatment: Clearing the Fog

It’s frightening to consider, but diagnosing and treating one of high school sports most potentially debilitating injuries – a concussion – is often little more than a guessing game.

Unlike other injuries, concussions leave few outwardly visible signs such as a bruise, blood, or a limp. For decades doctors, coaches, and athletic trainers have been forced to rely on how the athlete says he or she is feeling to diagnose and treat concussions and, ultimately, to determine when to return them to the playing field.

Fortunately for the 300,000 Americans who are diagnosed with such injuries annually, that’s beginning to change with the ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) test.

Greg Lucas is a licensed athletic trainer employed by Door County Memorial Hospital who works with area high schools. He described the test as a neuro-psychological test to evaluate different levels of cognitive functions such as memory, reaction time, and other skills related to brain function. The ImPACT Web site said it “measures the impact of the concussion on their attention span, working memory, response variability, non-verbal problem solving, impulse control, and reaction time.”

Ideally the online test would be administered to athletes before the season begins so any time an athlete suffers significant head trauma a doctor or trainer can go back to the test and measure them again to determine if something has changed. Even if the athlete was not tested, the doctor can refer to average data collected on similar athletes to deduce any effects.

DCMH is now partnering with Door County’s schools to administer the test to area high school athletes. The hospital is covering half the cost of the $500 software licensing fee, with the schools picking up the other half of the tab. Lucas said the ultimate goal is to have all athletes involved in collision sports tested in their freshman and sophomore years.

Mark Lovell is Director of the Sports Concussion Program at the University of Pittsburgh Medical Center. One of the country’s leading experts on diagnosing and treating concussions, his department created the ImPACT test in 1997 and he said it has improved concussion treatment immensely since becoming available nationwide in 2001.

“We know a great deal more about concussions today than five years ago,” Lovell said. “We have improved recognition among doctors, athletes and coaches about not only the risks associated with concussions, but just knowing what one is.”

Most people assume you must get knocked unconscious to suffer a concussion, but only 10 percent of concussions result in loss of consciousness. The other 90 percent can be more dangerous because they’re more likely to go unrecognized and the athlete will more likely remain on the playing field, where they’re more susceptible to another, more severe trauma.

“One of our major concerns is the repeat concussion,” Lovell said. “We all believe there is a period of vulnerability after a concussion, especially when an athlete hasn’t recognized something’s wrong. They’ll go back out there and it will happen again, maybe because they’re not as quick getting out of the way.”

They may not be as quick because a slowing or loss of reaction time is one of the common effects of a concussion. It’s also a symptom the ImPACT test can help detect. Other common indicators include headache, dizziness, nausea, blurred vision, and memory loss, among others.

With the test, doctors can more accurately determine what specific effects the athlete is feeling from the concussion.

“We use normative data to compare where he should be,” Lucas said. “We still use doctor visits and evaluation, but this is another tool. In the past, if an athlete said he was symptom free, it was standard practice to hold him out seven more days then return him to action.”

With the test an athlete can be evaluated more quickly and can possibly return to action sooner, or more importantly, return when he or she is symptom-free.

“It gives us objective data besides, ‘how are you feeling?’” Lucas said. “It’s especially important because a kid will often say he’s better because he wants to play.”

Both Lovell and Lucas said the test could become as standard in high school sports as the pre-season physical in years to come.

“People using it say to me ‘I don’t know what I’d do without this test,’” Lovell said. “It’s something objective you can sink your teeth into. You can go over the results with parents and players and coaches. In the past it was always so subjective. It’s all too easy to say ‘oh, I think you’re OK’ and send the kid back out there.

But treating brain trauma today isn’t just about deciding when an athlete can return to the playing field. Dr. Phil Arnold of DCMH said he recently sent a patient back to school with a note of a different sort.

“For the first time I sent him back with instructions not to participate in any intense brain activity,” he said. “We’re trying to limit the amount of intense school work when recovering from a concussion.”

Lovell said research has shown the importance of the new practice.

“We want to shut the brain down and let it rest,” he said. “When we do that we see the brain recover more quickly. That’s different than every other kind of sports injury, where you want to get them back out there and recondition the injured part of the body.”

Lovell said concussion treatment has come a long way from the days when football coaches taught players to use their helmets as a weapon. He recalled his days in youth football, when coaches routinely instructed players to keep their head down.

“Get low and stick your head in there!” he said his coach would yell. “Well, that’s probably the last thing they should be telling players.”

Now Door County athletes can be better treated if they do.

To download or request concussion information, visit the Web site for the Centers for Disease Control and Prevention at http://www.cdc.gov/ncipc/tbi/Coaches_Tool_Kit.htm.