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Recognize sports concussions to minimize long-term damage

Monday March 25, 2013
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After former National Football League star Junior Seau shot and killed himself in May 2012, his family requested an analysis of his brain. In January, researchers from the National Institutes of Health determined the 43-year-old retired linebacker had chronic traumatic encephalopathy, a degenerative brain disease associated with frequent blows to the head. Symptoms include irritability, forgetfulness, inability to concentrate and depression.

At least two other former football players with CTE have killed themselves in recent years. Dozens of professional players have been diagnosed with CTE, and thousands have joined a class-action lawsuit against the NFL, claiming the league withheld information about the harmful effect of concussions. The Centers for Disease Control and Preventionís Heads Up campaign defines concussion as an injury resulting from a blow to the head or body that causes the brain to move rapidly inside the skull, and that changes how brain cells function.

Though their stories are tragic, players and families make an impact by speaking out, say school nurses and those in sports medicine interviewed for this story. Suddenly parents, teachers, coaches, athletic trainers, care providers and young athletes are taking the identification, treatment and prevention of concussions very seriously. School nurses, pediatric nurse practitioners and nurses working in sports medicine say the visibility of the NFL cases have made it easier to explain to young athletes and their families why resting and careful monitoring of symptoms after a concussion is so important.

"Thereís been a lot of public recognition of this injury in the last four years," said Ariana Moccia, RN, BSN, a pediatric neuroscience nurse who works at Boston Childrenís Hospitalís Sports Concussion Clinic. More schools are developing rules for returning to study and play after the injury. Coaches and trainers are making careful assessments after a player receives a blow to the head, and referring them for medical care if there is evidence of a concussion. In fact, Mocciaís clinic sees about 350 concussion cases a month, a 50% increase since it opened four years ago, she said. "I tell them, 'This is the only brain you get for your entire life. Youíre not going to get another one,í" said Amy Perusek, RN, MSN, CNP, pediatric nurse practitioner at the Center for Orthopedics and Sports Medicine at Akron Childrenís Hospital in Ohio.

Play it safe

The Centers for Disease Control and Prevention estimates 1.6 million to 3.8 million sports concussions occur each year. Ten to 15 years ago, athletes who got hit in the head often were sent back into the game unless they had lost consciousness. Those who saw a physician were diagnosed according to their symptoms at the time of the injury, Perusek said. If the patient had not lost consciousness and wasnít vomiting or confused, the blow might be designated a grade-one, or mild, concussion, which meant the person could return to play within 24 hours without being seen again, she said. Recurrent or later symptoms, such as headaches, irritability or difficulty concentrating on the field or at school, were not taken into consideration.

But a body of more recent research has shown the danger of such practices. Most people who get concussions donít lose consciousness, and symptoms may not appear for hours or days after the injury. Those who suffer a concussion are at greater risk of getting another. A second concussion that occurs before the first has healed may slow recovery or increase the risk of long-term problems. Young people, once thought to recover more quickly, actually take longer — sometimes weeks or months — to heal. All concussions should be considered severe until symptoms are gone, according to the CDC and nurses who see those with concussions.

"The student can seem absolutely normal [after the injury], but then be really struggling for a month or two after the concussion," said Anne L. Diaz, RN, PhD, NCSN, a school nurse in Nevada and co-author of a position statement on concussions for the National Association of School Nurses.

Lights out for recovery

Anyone who suffers a blow to the head or a hit to the body that causes rapid movement of the head and exhibits symptoms including confusion, memory problems, dizziness, balance problems and sensitivity to light or noise should be seen by a healthcare provider experienced in evaluating concussions, according to CDC guidelines. Many healthcare providers, especially those in sports medicine and concussion clinics, diagnose concussions using a description and observation of symptoms and a 20- to 30-minute computerized neuropsychological test of memory, problem-solving and attention skills. Some school teams require a baseline assessment during a preseason sports physical, with results compared to an athleteís results from a repeat assessment after a suspected concussion.

The primary treatment for a concussion is rest, nurses said. "It takes a lot longer for a young personís brain to heal than it does an adultís," said Colleen Norton, RN, PhD, CCRN, associate professor of nursing at the Georgetown University School of Nursing and Health Studies in Washington, D.C.

Many schools have developed specific protocols for returning to both physical and academic activity after a concussion. Students may start off by staying home for a week, sleeping when they are tired, treating headaches with pain relievers and staying away from electronics, reading or noises that cause them dizziness or a headache. As symptoms decrease, they may return to school, at first going for half-days or attending classes and listening to lectures but not taking notes or tests requiring intense concentration, and avoiding stimuli such as bright lights and loud noises. "[All of] that stresses the brain more, as if you were running on a broken leg," said Leah J. Wyckoff, RN, BSN, MS, a school nurse in the Denver area and co-author of the NASN position statement.

After being cleared by a healthcare professional, students who have had concussions may start light exercise, and eventually return to practice and their sport, but they require monitoring from school nurses, primary care providers, coaches, parents, teachers and even teammates.

Education reduces risk

Eliminating the risk of head injuries from sports is almost impossible, nurses said. Football is the leading sport for concussions among people under 18, but any sport, including swimming and track, has a risk of head injury, nurses said. Using proper protective equipment is important, but "thereís been no helmet thatís been proven to reduce the risk of concussion," Moccia said.

Proposed rules such as prohibiting contact play until high school could reduce injuries among younger children, but these have received mixed public reception. Many nurses see education as the best answer to reducing risk of permanent harm from concussions

Despite growing awareness, many people still believe concussions arenít serious, nurses said.

Even in primary care providersí offices and EDs, there is sometimes miscommunication regarding concussions. Perusek said parents have told her their child was diagnosed with a "stage-one" or "stage-three" concussion, terminology thatís more than 10 years out of date. Though the CDCís Heads Up program and districtwide protocols for monitoring students who have had concussions have been helpful, school nurses said they still need to explain to some teachers why a student with a concussion cannot take a test or do regular classwork.

Thatís where stories from the pros prove useful, nurses said. "People are talking about it, they are concerned about it, theyíre aware of it," Wyckoff said.

Norton and Margaret Harvey Granitto, RN, MSN, CRNP, an instructor at Georgetown University School of Nursing and Health Studies, and a nurse practitioner at Suburban Hospital, part of Johns Hopkins Medicine in Maryland, recently co-authored an article in the January issue of Nursing2013 called, "Tackling Long-Term Consequences of Concussion," describing nursesí roles in assessing and caring for patients with concussions, and in educating all involved about the injury.

The two researchers support national regulations for responding to traumatic brain injuries, including preconcussion neurocognitive testing; education for coaches, trainers, teachers and families; and protocols for return to athletic and academic activities. School nurses said theyíd like to see better communication among school officials, coaches, primary care providers and the school nurse, who often serves as a liaison between teachers and parents.

Though they support more research, regulations such as limiting contact sports to older players, and better protective equipment, nurses said they donít want children and parents to be afraid of organized sports.

Norton, an avid football fan, said the message to young athletes is that they will play better and longer if they follow rules, use proper equipment and take care of themselves after an injury. "Itís just a matter of doing what you like — safely." •


Cathryn Domrose is a staff writer.Write to editor@nurse.com or post a comment below