Wednesday, September 29


When 49ers quarterback Steve Young was knocked out in a game last year against Arizona, viewers, players and fans held their collective breath until he regained consciousness and walked off the field under his own power. But that doesn't mean that Young was as good as new. In fact, he was diagnosed with his fourth concussion since 1996 and missed the rest of the season, and his NFL future remains uncertain.

Concussions are not limited to the professional arena. The Centers for Disease Control and Prevention estimates that 1 million Americans with Traumatic Brain Injuries (TBIs) are treated and released each year from emergency rooms. Head trauma is a leading cause of disability in children, adolescents and young adults. And as athletes continue to get bigger and faster, simple mathematics and physics say that the numbers of these types of injuries probably will increase.

Getting a handle on the exact nature of concussions, however, is not that easy. "Any time you disrupt the function in someone's brain, that is a significant event. Yet there is not a lot known about concussions because it is very difficult to measure alteration in brain function," says Dr. Charles Burke III, team physician of the Pittsburgh Penguins and a member of the Association of Professional Team Physicians (PTP). "Something serious has occurred, but we can't measure it other than to look at the symptoms." We asked Dr. Burke to explain the basics of the injury and the steps that can be taken to prevent these potentially serious injuries.

What is a concussion?

Dr. Burke: Concussions, or what we're now calling mild traumatic brain injuries, by definition cause some change in brain function. Due to a trauma to the body, not necessarily the head, there is an alteration in mental status that is represented by symptoms -- confusion, "seeing stars', wooziness, short-term memory dysfunction, unconsciousness, or long-term memory loss. But because the brain is a very complicated organ, we don't presently have diagnostic tests or measurements other than looking at the symptoms.

What are the causes and symptoms of concussions?

Dr. Burke: Any time a body is in motion, the head obviously also moves, leading to two types of concussive injury. One is as a result of a direct blow to the head where the brain can collide with an area where the impact has occurred. Another is when the head quickly decelerates, even in the absence of a direct blow, and the brain continues to move until it hits the other side of the skull. It's called either a coup or contra coup injury, where the trauma occurs either at the point of impact or at the direct opposite area of impact.

There can be a wide array of symptoms. Short-term symptoms can be confusion, memory dysfunction, loss of consciousness, sensitivity to light and noise, ringing in the ears, blood pressure changes, numbing and tingling in certain areas. We also see such long-term effects as sleep disturbances, personality changes, headaches and memory loss.

Q: I suffered a sprain to my MCL while wrestling about five weeks ago. I don't have the major pain anymore, but it's still tender and hurts now and then if I bend it in certain ways. I wear my brace but still can't shoot takedowns without discomfort. Can you help me? What should I be doing to help make it even stronger? Will I always have this pain or will it fully heal? Thanks in advance.
-- Mike Ciesnolevicz, Williamsport, Pa.

A: From Dr. Bruce Moseley, PTP member physician and team physician for the Houston Rockets:
"MCL injuries take a long time to become pain-free. While it is possible to resume activities fairly soon after the injury, the pain gradually subsides over 2-4 months or even longer. Occasionally there is an associated meniscus tear that might require arthroscopic surgery, but this is unusual. If your knee isn't becoming pain-free after 3-4 months or so, you might want to have your orthopedic sports medicine physician take a look at it again to look for signs of a meniscus tear."

Do you have a question for a team physician? Click here to ask. And check out more "Ask the Pro Doc" answers to users' questions.

Are there levels of severity with concussions?

Dr. Burke: There is a grading system for concussions established by the American Academy of Neurology (see below) and it is important, especially for people unfamiliar with the symptoms of concussions. For example, the grading system can assist recreational athletes and coaches in recognizing the symptoms and guiding them as to when athletes who have suffered concussions can return to their activity. We fully support that. On a professional level, we have the ability in the NHL to collect data on every concussion that occurs. Our goal is to discover what the most important and consistent symptoms are and to see how we can translate these into diagnosing and treating the players.

What is the prognosis for concussions?

Dr. Burke: One of the things we do know is that multiple concussions usually produce more problems than single ones. Generally, it's worse to have had five concussions than one although we don't know why someone with one concussion may end up with post-concussive syndrome and someone who has had five may not. The only way to find answers to these and other questions is through further study and the development of more precise tests to measure how the brain functions

Are athletes today more at risk for concussions than ever?

Dr. Burke: As an orthopedic surgeon, I look at forces exerted on the muscloskeletal system. Force equals mass times acceleration. So as athletes get bigger, stronger and faster, the forces increase. As the forces increase, especially in contact sports, the potential for all injuries increases, including head injuries. It's a standard principle of physics, with a little statistics thrown in.

Can you offer any prevention advice?

Dr. Burke: People should always wear helmets when playing contact sports or riding their bicycles and motorcycles. Another vital element is educating the general public. So if someone is faced with a situation where a head injury occurs, he or she can know how and where to seek appropriate advice as to diagnosis and treatment. Decisions on returning to play after a concussion should be made by experienced professionals. If someone is allowed to compete with a concussion whose symptoms have not cleared, they're risking a potential catastrophic situation called second-impact syndrome, which can be fatal.


Here's the American Academy of Neurology's guide to management of concussion in sports:

Grades of concussion

    Grade 1
    Transient confusion
    No loss of consciousness
    Concussion symptoms or mental status abnormalities on examination resolve in less than 15 minutes
    Grade 2
    Transient confusion
    No loss of consciousness
    Concussion symptoms or mental status abnormalities on examination last more than 15 minutes

    Grade 3
    Any loss of consciousness

Management recommendations

    Grade 1
    1. Remove from contest
    2. Examine immediately and at five minute intervals for the development of mental status abnormalities or post-concussive symptoms at rest and with exertion
    3. May return to contest if mental status abnormalities or post-concussive symptoms clear within 15 minutes

    Grade 2
    1. Remove from contest and disallow return that day
    2. Examine on-site frequently for signs of evolving intercranial pathology
    3. A trained person should reexamine the athlete on the following day
    4. A physician should perform a neurological examination to clear the athlete for return to play after one full asymptomatic week at rest and with exertion

    Grade 3
    1. Transport the athlete to the nearest emergency department by ambulance if still unconscious or if worrisome signs are detected (with cervical spine immobilization, if indicated)
    2. A thorough neurologic evaluation should be performed when consciousness is regained, including the appropriate neuroimaging procedures when indicated
    3. Hospital admission is indicated if any signs of pathology are detected, or if the mental status of the athlete remains abnormal.

When to return to play

Grade of concussionAn athlete may return to play only after being asymptomatic with normal neurologic assessment at rest and with exercise
Grade 1 ConcussionReturn in 15 minutes or less
Multiple Grade 1 ConcussionsReturn in one week
Grade 2 ConcussionReturn in one week
Multiple Grade 2 ConcussionsReturn in two weeks
Grade 3 - Brief Loss of Consciousness (seconds)Return in one week
Grade 3 - Prolonged Loss of Consciousness (minutes) Return in two weeks
Multiple Grade 3 Concussions Return in one month or longer, based on decision of evaluating physician

To receive more information on recognizing, treating and managing concussions, call the American Academy of Neurology at 800-879-1960.

Dr. Charles J. Burke III, a member of the Association of Professional Team Physicians (PTP), serves as team physician for the Pittsburgh Penguins and is also vice president of the NHL Team Physician Society. He is a member of the Sports Medicine Committee at Allegheny General Hospital and is a staff physician at The Children's Hospital, both in Pittsburgh, Pa. Dr. Burke received his undergraduate degree from Harvard University and his medical degree from the University of Cincinnati College of Medicine, and hecompleted his orthopedic surgical residency at the Hospitals of the University Health Center in Pittsburgh.

The information, including opinions and recommendations, contained in this website is for educational purposes only. Such information is not intended to be a substitute for professional medical advice, diagnosis or treatment. No one should act upon any information provided in this website without first seeking medical advice from a qualified medical physician.

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