Concussion Concerns

By Staff

Athletic Management, 15.6, October/November 2003,

A series of recent articles warn that the dangers of concussions may be even more serious than previously thought. The articles, published in the past year by researchers at the University of Pittsburgh Medical Center, reveal that high school athletes are affected differently than their college peers, suggest rewriting the rules on how concussions should be graded, and provide new guidelines on how long athletes should be held out of action.

One of the studies was actually the first to ever look at how high school athletes—who suffer the most concussions—are affected by the injury. Published in the May 2003 issue of the Journal of Pediatrics, the study shows that, on the whole, these younger players take longer to recover from concussions than college athletes.

The researchers found that seven days after suffering a concussion, high school athletes reported significant symptoms, such as headaches and nausea, and performed worse on cognitive tests than their uninjured counterparts. College athletes who had suffered concussions typically returned to near-normal levels within three days, despite suffering more serious injuries.

“Our finding that high school athletes did not recover from concussions as quickly as college athletes is a cause for concern because the largest majority of at-risk athletes are at the high school level or below,” according to principal investigator Dr. Melvin Field, Chief Resident in the Department of Neurological Surgery at UPMC. “Furthermore, existing return-to-play guidelines assume a standard use for all age groups and levels of play, from school-age to professional. Our study is the first to suggest that there may be differing vulnerabilities to concussion at different ages and that current guidelines may not be appropriate for all age groups.”

“This study suggests that further studies are needed in children of all ages before current adult-based return-to-play management guidelines are maintained or implemented in high schools,” says Dr. Mark Lovell, study co-investigator and Director of the UPMC Sports Medicine Concussion Program.

Their studies also call into question concussion evaluation for athletes of all ages. Traditionally, the main criterion for judging the severity of a concussion has been whether or not the athlete loses consciousness. However, in a study published in the July 2003 issue of the Clinical Journal of Sports Medicine, Lovell and his colleagues determined that amnesia—defined as any period of memory loss occurring either before or after sustaining the injury—was the most important symptom for measuring severity.

The researchers used a computer program called ImPACT (Immediate Post-concussion Assessment and Cognitive Testing) that compared athletes’ responses at the beginning of the season to post-injury. They found that many athletes who did not seem significantly affected under the current concussion-grading criteria showed marked neurological deficits through their ImPACT scores.

“There is no such thing as ‘just a bell ringer,’” says Dr. Michael Collins, Assistant Director of the UPMC Sports Medicine Concussion Program, and principal investigator on many of the studies. “Our study showed that many athletes with mild concussions whose symptoms disappeared within 15 minutes still showed significant decline in memory processing and other symptoms within one week post-injury, which means they weren’t healed.”

Based on this research, Lovell and his colleagues suggest that athletic trainers and coaches revisit the way they judge the severity of a concussion. If an athlete is suspected of suffering a concussion, he or she should be tested for retrograde amnesia (loss of memory for things that happened just before the injury), and antegrade amnesia (memory loss for events that take place after the injury).

“You want to find out if the player remembers what happened for the first five or 10 minutes before and after the injury,” says Lovell. “Ask the athlete to remember three words. Ask them to recount details of what happened to them. We think it’s very very important to evaluate that on the field, at the time of the injury.”

Another common symptom that can be used to judge whether someone has received a concussion is headache, according to the researchers. “It’s usually described as a pressure headache,” Lovell says. “A lot of times, athletes will complain of pressure behind the eyes. And it’s also often described as a pulsing headache, like a migraine.

“Most of the time, if you do an evaluation on the sidelines, you can tell when there’s something wrong with them,” he continues. “If we can detect any amnesia on the field, if there’s any detectable mental status change, if they have a significant headache, or if their balance is off, then we hold them out for the rest of the contest.”

The researchers strongly warn against going by the 15-minute rule that some people now follow—which allows athletes who seem to have recovered after 15 minutes to be sent back in the game—warning that concussions can take much longer to resolve. Returning an athlete too soon can increase his or her chances of receiving another, more serious, concussion.

“I’d say a week is a pretty good average time for a concussion to fully go away,” says Lovell. “You get kids who bounce back quicker and others who have longer recovery times as well, but a week is about average.”

To assess an athlete’s recovery, Lovell suggests using the ImPACT program. “The test itself takes 20 minutes to do,” Lovell says. “It evaluates a number of symptoms of concussion, like headache, balance problems, nausea, and so on. It also includes seven two-minute tests that measure things like reaction time, mental speed, and various aspects of memory.”

General information on concussions, along with information on ImPACT, can be found at

What Is A Concussion?
Concussions occur when the brain is jostled inside the skull as a result of a blow to the head, neck, upper body, or even the end of the spine, if the force is great enough. Basically, it’s a brain injury, usually temporary, that results in a change in mental status. That could mean loss of consciousness, but less severe symptoms are just as important. These include amnesia, confusion, disorientation, headache, nausea and vomiting, uncoordinated hand-eye movements, numbness or tingling, poor balance, drowsiness or fatigue, poor concentration, ringing in the ears, sensitivity to light or noise, irritability, memory problems, and nervousness.

Experts urge that all concussions be taken seriously. Even mild concussions can have serious negative effects. Athletes need to recover fully before being allowed to return to their sport.