With recent examples of concussions in the national news, science writer David Orenstein checked in with Russell Fiore, Brown’s head athletic trainer, about how concussions are noticed and cared for on the field, the ice, or the court.
There are specific protocols and procedures followed every step of the way, Fiore said, to ensure that head impacts involving student-athletes are evaluated and to ensure that concussions are identified and tended to, both immediately and throughout the recovery process.
In a game, how is a potential concussion first noticed? What factors suggest a concussion may have occurred?
During an athletic contest, a concussion would initially be suspected after observing a collision or impact. Examples include two student-athletes colliding on the field, a student-athlete falling and striking his or her head on the ground or getting hit on the head with a stick, ball, elbow, knee, etc. Following the blow to the head, a certified athletic trainer — ATC — would notice if the student-athlete exhibited any unusual behavior, which may include not getting up from the ground in a timely manner, problems with balance, or disorientation. Even if the ATC may not have witnessed an impact but observes unusual behavior on the sideline or bench, he or she would begin to ask the student-athlete questions. Depending upon their answers, the ATC can determine if the student-athlete has a suspected concussion and if they should progress to further evaluation.
How is the potential concussion assessed and by whom?
In sports where there is a physician present during games (such as football, men’s ice hockey, men’s lacrosse), the physician will assess the student-athlete for a potential concussion. Otherwise, an ATC will make the assessment. Brown University Student Health Services and local hospital emergency rooms are also available to assess and treat concussions.
If a concussion is suspected, the person responsible uses a sport concussion assessment tool such as the SCAT3 to evaluate for concussion, beginning with basic questions for the student athlete, such as Where are we playing right now? What is the score of the game? Who did we play last week? What month is it? What is today’s date? What year is it?
If the student-athlete exhibits confusion during this questioning process and a concussion is suspected, the physician or ATC will continue with the concussion evaluation, which includes several components: a cranial nerve exam involving the eyes, hearing, smell, facial muscles and sensation, tongue and shoulder movement.; a concussion graded symptom checklist, including any loss of consciousness, dizziness, feeling mentally foggy, headache, visual problems, difficulty remembering, nausea, balancing problems, difficulty concentrating, or sensitivity to noise or light.
There is also a cognitive evaluation including several tasks such as counting backward by seven starting at 100 (i.e., 100, 93, 86); repeating back, in any order, words from a list of five words that are read to the student-athlete. They will repeat this two more times with the same set of five words. In another task, a group of numbers is read to the student-athlete for them to repeat in reverse order (e.g., 719 and 917). This process is repeated with a group of four numbers, five numbers, and six numbers. The student-athlete is asked to recite the months in reverse order.
There is also a balance examination, a delayed recall test in which the student-athlete is asked to repeat as many of the five words from the immediate memory test as he or she can remember and a strength and exertion assessment.
If a concussion is deemed likely or confirmed, what happens with the injured student-athlete at the game?
The ATC will follow the current National Athletic Trainer’s Association (NATA) position statement, “Management of Sport-Related Concussion.” The student-athlete is withheld from the competition or practice and will not return to activity for the remainder of the day. The ATC will examine the student-athlete on site immediately and at five-minute intervals for the development of mental status abnormalities or post-concussive symptoms at rest and with exertion, if appropriate. The ATC will use the graded symptom checklist protocol for the initial evaluation and for each subsequent follow-up assessment until all signs and symptoms have cleared for the student-athlete, both at rest and during physical exertion. The ATC has the unchallengeable authority to determine management and return to play. The ATC’s decision is final. Then the ATC calls or has the student-athlete call for an appointment at University Health Services as soon as possible that day.
What happens with the student-athlete after the game in terms of treatment and recovery and returning to play?
The student-athlete is not allowed to attend classes for 24 to 48 hours, during which time he or she does not attend practice, team meetings, or strength and conditioning sessions. Once the student-athlete is seen at University Health Services, the health service provider will determine when the student-athlete returns to classes. When he or she is symptom-free and is allowed to return to class, the student-athlete is permitted to watch practice and attend team meetings. This is all coordinated through University Health Services, the physicians, the head athletic trainer, the head coach, and the deans.
Following a concussion, an email is sent to the student-athlete with the following instructions:
- Call Brown Health Services to make an appointment for a consultation with a medical provider as soon as possible.
- See an ATC in the athletic training room daily. The ATC will help with your care by following your concussion treatment protocol, charting your progress, communicating with your coaches, and helping to make return-to-play decisions.
- Arrange for an appointment with a student support services dean. They will also help connect you with resources and provide you with support should any post concussive symptoms or other related problems interfere with your academics or daily function.
Once the student-athlete is asymptomatic, the ImPACT Test will be administered to assess cognitive function. However, for return-to-play consideration, the test is administered once the patient is free of symptoms for one day of normal school activities. We have two physicians — Dr. Peter Kriz and Dr. Neha Raukar — who interpret the results of the ImPACT Test and give medical clearance to begin exertion. A medical provider at University Health Services has the final authority for return-to-play clearance. When exertional exercise is recommended, the ATC will follow the Graduated Exertional Return to Play Protocol:
- On day one, if the symptom-free post-injury ImPACT Test compares favorably with the baseline, the student-athlete engages in mild exertion for 20-25 minutes – like biking, walking, or swimming to see if symptoms recur. No further activity is done that day and no resistance training is allowed. The student-athlete will also be monitored for recurrence of symptoms from mental exertion, such as reading, phone texting, computer games, or classwork.
- On day two, if symptoms do not recur with light aerobic exercise, the student-athlete begins to add movement by performing sport-specific exercise. For example, skating drills in ice hockey, running drills in soccer, etc. No head impact activities are allowed.
- The next day if symptoms do not recur with sport-specific exercise, the patient progresses to non-contact and more complex training drills, for example passing drills in football and hockey. The student-athlete may now start progressive resistance training.
- On the fourth day, if no symptoms develop during and/or after sports-specific non-contact activities, the student-athlete is allowed to return to full activity if given final clearance by a medical provider at University Health Services.
What are Brown and the Ivy League doing to minimize concussions?
In June of 2012, the Ivy League and the Big Ten partnered to form the Traumatic Brain Injury Research Collaboration. The group meets once per year for two days to discuss the latest research about concussions, including treatment and care, their cause and effect, and ways to improve education.
In recent years Brown and Dartmouth have also worked with Professor Trey Crisco to measure head impacts in sports like football and hockey by embedding acceleration sensors in helmets.
At Brown, each student-athlete is required to complete an athletics health questionnaire every year, which asks specific questions about concussions. The ATCs review all of the health questionnaires. If there are any red flags, such as history of previous concussion, the ATC will consult with the student-athlete to assess the need for further action.
Brown’s ATC’s attend annual conferences, hosted by the Eastern Athletic Trainers Association and NATA. These conferences include topics related to concussions.
Brown’s student-athletes and coaches are educated through a variety of avenues.
ATCs provide an overview of concussion symptoms, treatment, and recovery process to student-athletes and coaches at team meetings, stressing the importance of proper treatment for long-term health. The NCAA concussion fact sheet is linked to the athletics health questionnaire, which is filled out each year by every student-athlete. Student athletes watch concussion videos and see flyers that review what a concussion is, how to prevent a concussion, symptoms of a concussion, and what to do in the event of a suspected concussion.
Additionally, the email regarding next steps that is sent to student-athletes who have a concussion is also sent to me, Christopher Dennis, deputy dean of the College; Lynn Dupont (associate director, Health Services; Robert Kenneally, executive associate director of athletics; Dr. Peter Kriz, University Orthopaedics physician; Monica Kunkel, nursing coordinator, Health Services; Carolan Norris, associate director of athletics for student-athlete services; Dr. Neha Raukar, Lifespan emergency room physician; Maria Suarez, associate dean and director of student support services; and Dr. Unab Khan, medical director, Brown Health Services. This ensures that this whole team is aware of a new concussion and that the injured student-athlete will need medical consultation and academic support. Christopher Dennis, Carolan Norris, Maria Suarez, Dr. Khan and I convene monthly to meet about every student-athlete who has not fully returned to play. We discuss how student-athletes are progressing and if they will need any further medical and/or academic support.