What is a concussion?

A concussion is a traumatic brain injury, caused by either a direct blow to the head or a hit to some other part of the body that causes a whiplash-type motion of the neck and head. Imagine the brain as the yolk of an egg, nestled comfortably in its shell and protected by the egg white. When the yolk is moved quickly and violently, it smashes into the rigid shell – similar to the brain inside the skull.

A concussion is not a structural injury to the brain, but rather, it is a functional injury. That is why concussions do not show up on MRI or CT scans. The brain has to be in perfect balance or equilibrium in order to function at its fullest potential. A concussion results in disturbance to this equilibrium, which then results in impaired brain function, and causes symptoms and functional deficits.

Red Flags

If you experience or witness any of the following signs and symptoms SUDDENLY after sustaining a blow to the head, call 911 or go to the nearest emergency room:

  • Headache that worsens significantly
  • Slurred speech
  • Repeated vomiting
  • Seizure
  • Prolonged loss of consciousness (greater than 30 seconds)
  • Significant midline neck pain, associated with any weakness or numbness of arms or legs
  • Marked increased in irritability, confusion, or unusual behavior
  • Inability to recognize people or places
  • Looks drowsy and or cannot be awakened/aroused
  • Loss of vision

Common Signs and Symptoms

A concussion may result in a variety of symptoms, which can be loosely placed in four categories: physical, cognitive, emotional, and sleep-related.  A patient may likely experience symptoms across more than one category. Even if a patient has sustained previous concussions, he may experience a completely different set of symptoms with a new injury.

An athlete who demonstrates any of the following signs or symptoms following a direct or indirect blow to the head, should be removed from play and should not return to play until evaluated by a healthcare professional.

Physical symptoms include headache, dizziness, balance problems, nausea, vomiting, sensitivity to light or noise, numbness & tingling, and fatigue.

Cognitive symptoms include feeling mentally foggy, feeling slowed down, confusion, difficulty concentrating, and difficulty remembering events before or after the injury.

Emotional symptoms consist of irritability, sadness, feeling more emotional than usual, and nervousness.

Sleep-related symptoms are drowsiness, sleeping more or less than usual, and trouble falling asleep.

Care and Treatment

Concussions are TREATABLE.

After a new concussion, the initial care involves relative neurocognitive rest (both physical and cognitive).  The period of time and degree of rest recommended is individualized depending on severity of injury, though generally this period of ‘relative rest’ is 24-72 hours.

It is also critically important to ‘stay out of harm’s way’ – avoid activities with risk of repeat head trauma.  This generally includes staying out of PE class, athletic practices, competitions, fitness activities and other activities that pose a risk of head injury, until directed by your care team.

Relative cognitive rest involves eliminating or significantly decreasing time spent on electronic devices (phone, tablet, computer, etc), watching tv, playing video games, studying, or any other activity that stimulates the brain.

Each patient is unique and each injury is unique.  Our physicians and staff will make specific recommendations at each stage of the recovery process to ensure that your injury resolves completely and as quickly as possible.

Returning to sports after a concussion is a gradual process.  We want to make sure your body and brain are ready for the demands of high levels of activity.  In order for our doctors to make sound return to play decisions, we ask each concussion patient to complete a RETURN TO PLAY PROGRESSION.  Ideally, this is completed under the supervision of a certified athletic trainer.  This progression is a gradual increase in activity, broken down into stages.  At a certain point in your recovery, you will be instructed to start a return to play progression by your care team.

Resources for Healthcare Professionals

This page and all included information is intended for the use of healthcare professionals only.  It is not intended to serve as a substitute for a thorough medical evaluation done by a qualified healthcare provider, but to provide tools to allied healthcare professionals in assessing and managing sport-related concussions.

If you suspect a life-threatening injury, call 911 immediately.

For any further directions of clarification regarding our forms, please call the Carolina Sports Concussion Clinic Hotline at 919-238-2017 to speak with a Certified Athletic Trainer.

SCAT 5

Developed as part of the 5th Consensus Statement on Concussion in Sport, the SCAT5 is a tool, intended for use for healthcare professionals,  in sideline assessment of concussion.

Child Scat 3

Also a result of the most recent Zurich meeting, the Child-SCAT3 is intended for use by healthcare professionals.  It can be used as a tool to evaluate concussion in patients ages 5 – 12.

Add the following test:

VOMS

The VOMS (Vestibular Ocular Motor Screening) is a screening tool developed to detect signs and symptoms of a concussion. It looks at the systems responsible for integrating balance, vision, and movement. The equipment you need to conduct it is very simple. You only need a target with a newspaper size font, a tape measure, and a metronome.

Return to Play Progressions & Instructions

When an athlete is symptom-free with rest and school, consider starting him/her on a gradual return to play progression.  Click here for an example of one our custom return to play progressions.

Education

Education and awareness of sports-related concussion is imperative to those involved in youth sports.

If you are a certified athletic trainer or healthcare professional and wish to learn more or visit the Carolina Sports Concussion Clinic, please call the concussion hotline at 919-238-2017.

FAQ For Patients

What should I do if I think I have a concussion? 

Tell someone!  Tell your parent, coach, athletic trainer or teacher. DO NOT return to playing sports if you are showing any signs or symptoms of concussion.  A good guideline to go by is “when in doubt, sit them out.”  You will need to be evaluated by a healthcare professional.  Research has shown that by removing an athlete immediately following injury or as soon as concussion is expected could cut down on recovery time. In a study of 69 high school athletes, the group that continued to play following injury took an average of 22 days longer to recovery and were 8 times more likely to take more than three weeks to achieve full recovery (Elbin et al, 2016).

Do I need to go to the Emergency Room?

The vast majority of concussions do NOT need to be evaluated in the emergency.  This can lead to unnecessary costs and testing.  At the time of evaluation in the ER, an ER physician cannot tell you when your child will be able to return to play safely.  If your child is seen in the ER, an additional evaluation by a medical provider with training in concussion management will help better determine when it is safe for your child to return to sports.

However, an emergency referral is indicated in the following cases if you:

  • have sustained a high risk mechanism fall, such as falling from a height directly on to the head or neck
  • have sustained a suspected cervical spine injury
  • experience loss of consciousness, or level of consciousness deteriorates over time (can’t walk, can’t speak)
  • vomit repeatedly
  • are unable to recognize people or places
  • are profoundly confused
  • have any numbness or tingling in the arms / legs
  • have any symptoms that worsen dramatically in a short period of time (typically in a matter of minutes)

These are all signs of traumatic brain injury that is likely worse than a concussion, and should be addressed in an emergent manner.

I didn’t get hit that hard.  Can I still have a concussion? 

Yes.  While research is still being performed on the amount of force needed to sustain a concussion, many other factors apply: whether or not the athlete was braced / prepared for the hit, the presence of rotation, momentum. A fairly benign looking hit may result in a concussion, while a hit that that appears very forceful or even violent may not result in symptoms at all. Each hit and mechanism of injury is different and each injury is different.

Can I give my child any medication to help with the discomfort of a headache? 

After assessment for a more serious head injury has been performed and excluded, and a concussion is diagnosed or suspected, it is safe to treat a headache with ibuprofen (Motrin or Advil), acetaminophen (Tylenol), or naproxen (Aleve).  Any narcotics or other drugs which impact cognition and mentation should not be used.

I know I need to rest to get better, but is there anything else that can be done to help recover faster? 

Concussions ARE treatable. You have a great deal of control over your recovery and it is important to be an active participant in your own recovery.  At the Carolina Sports Concussion Clinic, we will instruct you regarding a variety of interventions to facilitate recovery.  The foundation of this treatment generally involves:   exquisite sleep hygiene, excellent nutrition and hydration, sub-symptom threshold exercise, and appropriate rehabilitation (vestibular, ocular, etc), along with appropriate adjustments and accommodations for school and work.

To schedule an appointment or speak with a certified athletic trainer about concussions, please call the Carolina Sports Concussion Clinic Hotline at 919-238-2017.

FAQ For Parents

Parents, you know your children better than anyone.  You know what is baseline (or normal) for your children and you know and recognize any subtle differences in their behavior or personalities.

As a parent, you already play an active role in your children’s development, both in the classroom and on the athletic field.  From tackling homework questions, to volunteering as a coach, to providing nutritious meals to fuel your children’s activity-filled days, you are a key member of your child’s development team. This includes your role in getting educated and recognizing concussions.

What should I do if I suspect my child has sustained a concussion

Remove your child from play. Do not let your child return if he / she is showing any signs or symptoms of concussion.  A good guideline to go by is “when in doubt, sit them out.”  Have your child evaluated by a healthcare professional.  Research has shown that by removing an athlete immediately following injury or as soon as concussion is suspected could cut down on recovery time. In a study of 69 high school athletes, the group that continued to play following injury took an average of 22 days longer to recovery and were 80 times more likely to take more than three weeks to achieve full recovery (Elbin et al, 2016).

Should I take my child to the Emergency Room?

The vast majority of concussions do NOT need to be evaluated in the emergency.  This can lead to unnecessary costs and testing.  At the time of evaluation in the ER, an ER physician cannot tell you when your child will be able to return to play safely.  If your child is seen in the ER, an additional evaluation by a medical provider with training in concussion management will help better determine when it is safe for your child to return to sports.

However, an emergency referral is indicated in the following cases if your child:

  • has sustained a high risk mechanism fall, such as falling from a height directly on to the head or neck
  • has sustained a suspected cervical spine injury
  • experiences loss of consciousness, or level of consciousness deteriorates over time (can’t walk, can’t speak)
  • vomits repeatedly
  • is unable to recognize people or places
  • is profoundly confused
  • complains of any numbness or tingling in the arms / legs
  • complains of symptoms that worsen dramatically in a short period of time (typically in a matter of minutes)

These are all signs of traumatic brain injury that is likely worse than a concussion, and should be addressed in an emergent manner.

It didn’t appear that my child got hit that hard.  Can he still have a concussion? 

Yes.  While research is still being performed on the amount of force needed to sustain a concussion, many other factors apply: whether or not the athlete was braced / prepared for the hit, the presence of rotation, momentum, etc.  A fairly benign looking hit may result in a concussion, while a hit that that appears very forceful or even violent may not result in symptoms at all. Each hit and mechanism of injury is different and each injury is different.

My child was diagnosed with a concussion.  Should I wake him up every hour to make sure he is okay?

Once a more serious injury is ruled out, or if your child is NOT exhibiting the red flags outline above, it is fine to let your child sleep through the night.  It fact, this is a good opportunity for the brain to truly “rest.”

Check on your child by feeling for a pulse and listening / feeling for breathing.

Can I give my child any medication to help with the discomfort of a headache? 

After assessment for a more serious head injury has been performed and a concussion is diagnosed or suspected, it is safe to treat a headache with ibuprofen (Motrin or Advil), acetominophen (Tylenol), or naproxen (Aleve).  Any narcotics or other drugs which impact cognition and mentation should not be used.

The doctor has cleared my child to return to sports, but he doesn’t seem to be acting like himself yet.  Should I go ahead and let him play? 

If you suspect that your child’s injury has not fully resolved, do not hesitate to keep him out of play!  Communicate your concerns with your child’s coach, athletic trainer and / or physician.

A phrase to remember is “when in doubt, sit them out.”  This can apply immediately after witnessing a suspicious mechanism of injury that may lead to concussion, or when instinct tells you that your child is not ready to return to play.

I know my child needs rest to get better, but is there anything else that can be done to help him recover faster? 

Much research needs to be done to show whether or not some novel interventions such as DHA supplementation, hyperbaric oxygen treatment therapy, or other unique modalities can help these injuries recover sooner.

However, concussion is treatable. At the Carolina Sports Concussion Clinic, we have seen concussion resolve with the use of sleep hygiene, excellent nutrition and hydration, compliance with low cognitive activities, cardiovascular exercise below the threshold of symptoms, as well as vestibulo-ocular exercise programs.

Contact your healthcare provider or the Carolina Sports Concussion Clinic for further information.

For more information, visit the CDC’s website for Youth Concussions: http://www.cdc.gov/concussion/HeadsUp/youth.html.

To schedule an appointment or speak with a certified athletic trainer about concussions, please call the Carolina Sports Concussion Clinic Hotline at 919-238-2017.

FAQ For Coaches

Coaches are presented with the unique opportunity to nurture the development and growth of young athletes.  While on the playing field, coaches are often ultimately responsible for the health and safety of their players.  While practice and game preparation is key, so is having a plan in place for how acute injuries will be handled.

The National Federation of State High School Association has posted a free online course for coaches.  Click here to view “Concussion in Sports – What You Need to Know.”

Head’s Up: Concussion in Youth Sports is a program that was established by the Centers for Disease Control to help educate athletes, parents, coaches, and clinicians.  Visit the CDC website for free materials!

Having an emergency action plan (EAP) in place for your practices and competitions is important.  If you haven’t already, consider developing a venue-specific emergency action plan for your sports organization.  It is the best interest of your participants’ safety to put this plan in writing, post it in a conspicuous location, and rehearse the plan annually to ensure that everyone involved knows his/her role in executing the plan.

Visit the Gfeller-Waller Concussion Awareness Act  site to get more information on EAPs and to view a sample emergency action plan.

What are some of the common signs and symptoms of a concussion?

Signs and symptoms of concussion can, and will, vary from athlete to athlete. They may develop immediately or after a few minutes / hours.

Common signs and symptoms include:

  • Headache
  • Dizziness
  • Nausea or vomiting
  • Balance problems
  • Blurred vision
  • Sensitivity to light or noise
  • Drowsiness
  • Fatigue
  • Irritability
  • Dazed, confused appearance
  • Slow to answer questions or follow directions

When should I suspect a concussion?

If your athlete demonstrates any of the signs and symptoms listed above after a blow to the head or elsewhere on the body, be suspicious that a concussion has occurred.  “When in doubt, sit them out.”

What should I do if a suspect a concussion?

Remove that player from activity and do not let them return until they have been evaluated by a healthcare provider with training in concussion management. Research has shown that by removing an athlete immediately following injury or as soon as concussion is suspected could cut down on recovery time. In a study of 69 high school athletes, the group that continued to play following injury took an average of 22 days longer to recovery and were 80 times more likely to take more than three weeks to achieve full recovery (Elbin et al, 2016).

My player didn’t take a direct blow to the head.  Is it still possible for him to have a concussion? 

Yes!  Even a blow to somewhere else on the body, such as the chest or back, can transmit enough force to cause the brain to move within the skull.

FAQ For Educators

Information for Educators

‘Relative’ cognitive rest is an important component recovery from concussion.  Implementing a plan for return to school is paramount in setting the tone for recovery.  Prior to resuming formal athletic activity, a student – athlete must be symptom free at rest and with cognitive exertion.

This information from the CDC gives some important things for school administrators to look for, as their observations of a student’s behavior and performance are invaluable to the recovery process.

Returning to School After Concussion

In North Carolina, the Department of Public Instruction has created a policy to better delineate responsibility among educators / administrators to assist students recovering from concussion.

The TBI – Return to Learn Policy has been created to assist LEAs and Charters in the development of a plan that address the needs of student’s preschool through twelfth grade suffering concussions. The plan must include:

  1. guidelines for removal of a student from physical and mental activity when there is suspicion of concussion;
  2. a notification procedure to educate staff regarding removal from learn or play;
  3. expectations regarding annual medical care update from parents, medical care plan/school accommodations in the event of concussion; and
  4. delineation of requirements for safe return-to-learn or play following concussion.

Return to Learn Concussion Policy HRS-E-001

Implementation Guide

Gfeller Waller Concussion Awareness Act

The Gfeller-Waller Concussion Awareness Act was signed into law on June 16, 2011 by NC Governor Bev Purdue.  As a tribute to two young men who lost their lives as a result of traumatic brain injuries in the summer of 2008, North Carolina became the latest of 32 states to implement legislation for sports-related concussions.

ImPACT Testing

The Carolina Sports Concussion Clinic has used ImPACT (Immediate Post-Injury Assessment and Cognitive Testing) as part of our management program since March 2009.  ImPACT has become a very helpful clinical tool is assessing the severity of concussion as well as helping our physicians make sound return to school and return to play decisions for our patients.

ImPACT is made up of three parts: sport & health history, current symptoms & conditions, and the neurocognitive test portion.  Six subtests make up the neurocognitive portion, and raw scores from those six sections contribute to four composite scores (verbal memory composite, visual memory composite, visual motor speed, and reaction time).  These four composite scores are statistically determined clinical scales that help determine level of impairment following an injury.  If an athlete has a valid baseline test (done when no injury is present), then the post-injury scores can be compared to that baseline to indicate changes in cognitive function following concussion.

Effective Spring 2017, ImPACT Pediatric is available for patients as young as age 5.

Baseline testing should be performed when an athlete is uninjured.  The goal of baseline testing is establish a valid set of scores to be used in the case of an injury. It is recommended that baseline testing be performed every year for patients ages 5-11, and every other year for patients age 12 – 18.

For more details about ImPACT, visit www.impacttest.com.

If you are interested in providing your team or child with baseline ImPACT testing, please call the Carolina Sports Concussion Clinic hotline at 919-238-2017.