Concussion – PediaCast 177
- Concussions in Student Athletes
Dr. Thomas Pommering
Chief of Sports Medicine
Nationwide Children's Hospital
Nationwide Children's Hospital
- Sports Medicine at Nationwide Children's Hospital
- Concussion Information Page
- Sports Medicine Article Database
- STOP THE MADNESS – How to be a Good Fan
Announcer: This is PediaCast.
Announcer: Welcome to PediaCast: a pediatric podcast for parents. And now, direct from the campus of Nationwide Children’s, here is your host: Dr. Mike.
Dr. Mike: Hello everyone, and welcome once again to PediaCast. It is episode 177 for August 30, 2011. And we are joined today by Dr. Tom Pommering again. He is the sports medicine guru here at Nationwide Children’s Hospital. And we’re going to talk about concussion today, so we’re really excited about it as the fall sports season is right upon us. And with football, we certainly do see lots of concussion injuries. And so, we’re going to talk about concussion in student athletes. So that’s coming up.
I want to remind you if there’s a topic that you would like to talk about, it’s easy to get a hold of us at PediaCast. Just go to pediacast.org and click on the contact link. You can also email: firstname.lastname@example.org, or call the voice line at 347-404-KIDS. That’s 347-404-5437. I also want to remind you the information presented in PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals.
All right. So we are happy to have Dr. Tom Pommering with us again. And this is getting to be a regular occurrence isn’t it?
Dr. Thomas Pommering: That’s fine. We love coming in.
Dr. Mike: The last time you’re here, I said you are our first repeat guest. And now, you’re the first three-timer.
Dr. Thomas Pommering: Oh, how about that?
Dr. Mike: Yeah. Yeah. Isn’t that great? And actually, I have plans. I have evil plans for another show this winter. So here is my idea. We just have people write in, listener questions about sports medicine.
Dr. Thomas Pommering: That sounds great.
Dr. Mike: You know, and just get a collection of questions together from moms and dads and have you back, I’m thinking, you know, February, something like that. And just shoot through them.
Dr. Thomas Pommering: Sounds good.
Dr. Mike: Sounds good? All right. Those of you who have seen you like the way until I get you on the show before. You’re right.
Dr. Thomas Pommering: No pressure.
Dr. Mike: Exactly.
As a reminder, Dr. Pommering is an assistant professor of pediatrics and family medicine at the Ohio State University College of Medicine. He's the division chief for sports medicine here at Nationwide Children’s Hospital and the co-director of the sports related concussion clinic at Nationwide Children. And you brought company today. Steevie Carzoo, how are you doing?
Steevie Carzoo: Good. And how are you?
Dr. Mike: I’m doing well. And you are a certified athletic trainer here at Nationwide Children’s and an athletic trainer locally for Thomas Worthington High School. And, as I understand that you’re also an emergency technical technician. Is that right?
Steevie Carzoo: Yeah. That’s right.
Dr. Mike: So EMT, run squad, that sort of thing. And you have kind of an interesting history with this. So when you were 16 years old, tell us what happened that got you interested in paramedic EMT kind of stuff.
Steevie Carzoo: So basically, we had a car accident in our front yard. I was, kind of, on the phone with my friend, heard a big noise. And, you know, mom called 911. Parents ran out to see what we could do. And there are three people in the vehicle. We’re able to get two of them out safely. And they were days confused. And actually thinking about it, they probably had a concussion.
Dr. Mike: Right.
Steevie Carzoo: Now that I know more. But, you know, they were struggling a little bit with the shock of the whole incident. And the gentleman at the backseat had much more severe injuries. And they had to actually cut him out of the car. But we’re kind of there for the immediate management of the scene. And seeing how that all evolve is really interesting to me. So we actually have a family friend who taught EMT course and I was able to get in to that course and was certified…
Dr. Mike: Sure. That is really cool.
Steevie Carzoo: Along with my school stuff. So it’s something that actually led me to athletic training, to see portion of taking care of people.
Dr. Mike: That’s an interesting story. And you see if you hadn’t had that accident in your yard, you may not be doing what you’re doing today, you know?
Steevie Carzoo: That’s very true. That’s very true.
Dr. Mike: It’s crazy how things like that work out. All right. So we are talking about concussion today. And why don’t we start, Dr. Pommering, if you could just define for our audience, what’s a concussion? What is that?
Dr. Thomas Pommering: Yeah. That’s a good place to start because I think that we need to think about concussions as a head injury. And I think the term gets used so loosely now that it loses some of its importance and its potential seriousness. So it really is a brain injury that occurs not just in sports, but anytime the head gets turn into another direction quicker makes impact with something hard that stops direction.
Dr. Mike: So really just any injury to the brain is what causes concussions so to speak.
Dr. Thomas Pommering: Exactly.
Dr. Mike: Now, other than a concussion, what other problems can arise from a head injury? So we hear about concussion and talk about it, but head injury can lead to other things. What other things are possible?
Dr. Thomas Pommering: Well, you know, obviously, concussions are the things we see most often but, you know, significant head injuries can cause the brain to bleed or leak. You can fracture the skull. You can lose consciousness. And that makes it hard for you to protect your airway.
Dr. Mike: Yeah. Absolutely. And this is going a little bit, I guess, as we sort of step through this. And I know you typically see the kids after they’ve had the concussive injury and you’re trying to get them back onto the playing field. But if one of you could just comment a little bit on, sort of, the initial stabilization and what sort of things might be done to tell if it’s a concussion or if there’s a skull fracture or bleed in the brain or the cervical spine injury, you know, that would be associated with it, just sort of how, from the doctor’s standpoint.
And then in terms of its importance for moms and dads, what can they expect when they have an encounter with the emergency medical system or the emergency department on urgent care, you know, in terms of trying to figure out if it’s just a concussion or there’s something more to it?
Steevie Carzoo: So if we have a student, say, were at the high school and we have an injury on the field that’s football. They got hit and they go down. Well, one of the important things we need to make sure is do they have other injuries aside from the concussion, for instance, a neck fracture. Any cervical spine fracture could be potentially dangerous as well as life threatening and can cause things like paralysis. So if you get hit in the head, the chances are neck is also involved since they are attached. So we got to make sure that there’s nothing wrong with the neck first.
So and that’s something that they’ll even ask once they get to the physician’s office even if it’s just a minor head injury is you have any neck pain and make sure that that’s all OK. But to actually figure out if they have a concussion, loss of consciousness is something that we can use but there’s a big myth around loss of consciousness. Everybody used to think well you have to be knocked down to have a concussion. And actually, you only lose consciousness about 10% of the concussions that we see. How’s that?
So just because they haven’t lost consciousness doesn’t fairly mean they don’t have a concussion. So that’s one thing that we kind of look at. And another thing we look at is symptoms. That’s probably one the biggest ways to kind of tell, you know, does this athlete have a concussion. And those are things like headache, dizziness, sensitivity to light and the ways, balance problems.
They can even have some nausea and some vomiting, as well as some confusion about either what happen or where they are or are they having trouble remembering things or making new memories. So we ask some questions to kind of figure out are they having any of those problems. And then there’s couple of other things we can do. We can actually require them to do some sort of tasks to see how their brain’s functioning. So, for instance, we can ask them, you know, “Can you count backwards through 100 by 3.”
And it tests their balance. Things we can actually use to measure, you know, how well are they functioning, as to what we think that they should be normally and kind of all of that together gives us an indication of what’s going on. And that’s what we used on the sidelines. Once we get to physician office, I’ll let Dr. Pommering take that down from there. It’s a little bit different, but…
Dr. Thomas Pommering: Yeah. And another thing I’d mention just for parents to know that a lot of times these symptoms will evolve. So after the football game, the adrenaline starts to wear off. And sometimes, the kids then start to have symptoms that are more obvious. And sometimes, they’re not.
I think parents have a good internal barometer about whether the kids seem like they’re right or not. I think if parents feel something is not right with my child, you know? So the things that Steevie just mentioned are just, you know, they’re more sleepy. They’re more agitated. They seem not themselves. And you know that they were in a contact situation, you should always suspect a concussion.
Dr. Mike: Sure. A lot of parents, you know, show up in an emergency department or in an urgent care facility after their child has head injury and they want a CAT scan. I mean they think that that’s what’s needed. Is a CAT scan needed for every kid with a head injury?
Dr. Thomas Pommering: Yeah. It’s another great question. And the answer is absolutely not. And luckily, in just a minority of the situations, and the best place to have that determined is going to be at the urgent care or the emergency department where those physicians know what the difference in a more serious injury such as a head bleed that I mentioned earlier versus a concussion. So I certainly don’t want parents to think that they’ve been cheated out or got substandard care if they don’t get CT scan because it really isn’t necessary most of the time.
Dr. Mike: Right. And we should also mention there’s actually a risk with head CTs in that your overall lifetime exposure of ionizing radiation certainly leads to cancer risk. And so, when you don’t want, you know, to be getting too much radiation over the course of your lifetime because that can cause consequences down the road. That’s not I say parents should be afraid of either if it’s needed. But you just want to make sure it’s needed before you do it.
Dr. Thomas Pommering: Yeah. And I think we’re very cognizant of that here at Children’s.
Dr. Mike: Now, so let’s say there’s not a brain bleed. There’s not a skull fracture. It’s just a concussion. If you were to do a CAT scan on those kids, it would be normal. Correct?
Dr. Thomas Pommering: Correct.
Dr. Mike: So what is it that really happens, I guess, at the tissue or cellular level with the concussion? Obviously, it’s not something that you can see on imaging. But obviously, there’s something going on there to make folks have the symptoms that Steevie had pointed out. But what is it that’s happening?
Dr. Thomas Pommering: Yeah. So it’s actually pretty interesting from what we understand so far. And again, we’re really in our infancy in understanding concussion both at the, sort of, the basic scientific level and also just at the clinical level. But what happens is the brain takes an impact of some type. And the neurons or the nerve cells in the brain start firing out of control. And that uses up the energy sources for the bridge such as glucose very rapidly.
And that causes some changes in the physiology so that blood can’t get into the brain as fast as it should, so there’s a giant energy deficit that gets created. So that really explains the symptoms that the kids experience or the symptoms that Steevie mentioned. And they can last for several days, often, you know, a week to 10 days or longer depending on the situation.
Dr. Mike: We had talked a little bit about the short-term symptoms of concussions. So when the brain gets charred, and you have this disruption of the chemical processes in the brain and she had mentioned, you know, brief loss of consciousness is really not, I mean, about 10% or so have that. The more common, you know, with the moderate headache, feeling of nausea or brief vomiting, dizziness, confusion, you know, sleepiness, fatigue, that kind of thing.
Steevie, what about the long-term effects of concussion? So, I mean, you know, like the next day and a few days later and sometimes even a few weeks later, what kind of things can parents expect?
Steevie Carzoo: Well, the interesting thing about concussions is that everybody is different. So especially with kids, their brains are still growing and developing. So everybody is going to have different symptoms at different times. And there’s really no necessarily pattern to them. So they might be dealing a lot with the physical symptoms, the headache, the dizziness, those type of things immediately afterward.
But as they began to heal, they might start having more complaints of having difficulty remembering things in school or difficulty focusing and concentrating on things in school. Parents might notice emotional changes. They seem very irritable, more irritable than normal. So they might notice that they’re a little bit down or reserve. They’re a little sad. And so, those are normal things to a certain extent because of the way the chemicals are kind of go in haywire in the brain.
It’s going to cause some of those changes. But from day to day, things might differ. They may have a good day where they feel pretty good and only have a little headache. And then the next day, they might feel pretty crappy again and be struggling. So it really varies as they go through the healing process. Eventually, we hope it all goes away, but it’ll change.
Dr. Mike: And each kid as you mentioned is really different in terms of which set of symptoms they’re going to have. I mean some kids, it may be more of a depression fatigue kind of stuff. Another kid, it may be more attention issues. Another kid may be sort of chronic headaches and really there’s no necessarily rhyme or reason for each individual kid which one you’re going to get.
Steevie Carzoo: No. And that’s what makes it hard to sometimes diagnose and work with them because people sometimes don’t recognize the smaller symptoms like the irritability or the personality changes. You know, with the teenager, that could mean anything. So if you’re really not paying attention to your child and you really can’t put two on two together. When they have a football game and all of a sudden all weekend they’ve been a little off, well, that can be a normal teenage behavior or that actually could be a concussion that may be they don’t realize that they have or they’re hesitant to tell anybody about.
Dr. Mike: Absolutely. Now, how long have you seen concussion symptoms last? I mean are we really just talking a couple of weeks utmost or is it something that could go on for months?
Dr. Thomas Pommering: Yeah. For younger athletes, the athletes that we typically see, actually, their symptoms usually last a little longer than your typical adult athlete, but most of the time it’s seeing anywhere between 10 days and 2 to 3 weeks before they’re back to full go doing their sport again. And that’s sort of the best case scenario. Obviously, the more often you concuss or the closer together your concussions occur, sometimes more complicated your recovery is.
So, as Steevie mentioned, while there’s not one set way to expect them to heal, you know, everyone is not going to be the same. In general, most kids likely to respond pretty well if they follow instructions, rest. And we’ll talk about that a little bit more within a few weeks.
Dr. Mike: We will kind of get onto recurrent concussion and sort of concussion on top of concussion and the problems that can cause but, sort of, jumping ahead a little bit. Do you think, for teachers and coaches that are out there listening right now, kids who have a concussion, do you think they should see their primary doctor or concussion clinic like you guys run before they go back? I mean should they have to have a note saying, “Hey, I can return to sports now.”
Dr. Thomas Pommering: Yeah. That’s a great question because I think you have to think about, you know, when our young athletes experience a concussion, it really affects three realms of life in a very rapid and significant way. One is their family life. Two is their athletic or social life, other social situations, their social fun that they have related to sports and then the third is their school life.
And so, it’s really nice that they can get in to see their private care doctor or sports medicine specialists so that we can start advocating for them and getting things in place, accommodations, things like that that will make it easier for them to get through this period when they’re in concussion and they’re just not performing the way they would need to.
Dr. Mike: The schools really have to be geared into this. I mean, obviously, we’re learning more about concussions and the medical community. Do you find, as your dealing with schools and coaches, that they’re starting to get more onboard with understanding, you know, what entails a concussion, what kind of treatment, you know, the rest and when you can get back or is there more education that needs to be done?
Steevie Carzoo: There’s definitely ton of more awareness than were it used to be from coaches, parents, kids, everybody down the line and the teachers. But we still have a lot of work to do especially with the literature involving so quickly about what we know and how things have changed. We need to continue to educate. And the teachers and the coaches are now more knowledgeable about what’s going on, but that’s one of the missions of children’s sports medicine is that we are advocates for the patients.
So we want to make sure that these two groups, especially the parents, the coaches as well as the teachers understand what a concussion is, how to protect the kids and how to help them heal and continue everyday life especially in the classroom. And we have a concussion in the classroom program that we deliver to schools to educate the teachers about how concussion affect kids in school and what they can help the kids with while they’re healing until they get back to 100%.
Dr. Mike: Yeah. That’s great. Is there any way to hasten the effects of the concussion to go away faster? I mean is there any way to treat a concussion?
Dr. Thomas Pommering: Yeah. There are definitely some things that we would want people to know about and that we tell them in our clinic. The brain needs to rest. And we need to actually rest the brain and the body, so we talk about physical cognitive rest. And if you remember that the brain is, sort of, an energy deficit. It needs to heal again.
You need to do things to not stimulate the brain more than you need to. So, unfortunately, I was kidding my patients. I tell them I’m going to make their lives really boring for about a week or 10 days or until they’re feeling better. And by that, I mean we take them away from the TV, the video games.
Dr. Mike: Oh. See, that’s the killer.
Dr. Thomas Pommering: That’s the killer. Texting and even computer time unless it’s related to school. And we take them away from loud situations like band rooms and bright situations. There’s no reason a football player with terrible a headache and light sensitivity should be standing on the sidelines, you know, feeling even worse when they’re not really practicing or playing. So those are a couple of examples. And that actually will help them heal quicker if they can do that.
Dr. Mike: Now, we talked about, as I mentioned, seeing a doctor, seeing a concussion clinic before you go back. Can you speak, why is that important? I mean, what happens if they get another concussion on top of one that they already have.
Dr. Thomas Pommering: Yeah, that’s another great question. There are a lot of things in medicine that are controversial, but this is the one thing that whether you’re an NHL, a National Football League or National Hockey League player or player at OSU or a player for your local high school, we all agree on the same protocol right now on how to treat these athletes. There’s a specific way that we want them to go back into play.
First is they have to, you know, get out of that contest that they’re in if there’s a suspicion of concussion, we need to protect them. And the reason is, and this especially true for the young athlete whose brain is different as Steevie mentioned, is something called second impact syndrome. And what happens is it can cause brain that’s still going through these physiologic changes, these chemical changes that we talked about, if it gets traumatized or injured again while it’s still healing, in some kids, the problem is we don’t know how to identify who is really at risk, but any young patient is at risk for this. If they get hit again, their brains can swell very rapidly.
And then half of them, it’ll be lethal condition and die from that. The other half that survived usually aren’t normal again. And that’s called second impact syndrome, very rare, very tragic obviously, but only has been identified in young patients. So ultimately, that’s what we’re trying to prevent when about concussions.
Dr. Mike: What about, you hear now some NFL players who are retired and have dementia and seems like there’s a higher degree of Alzheimer’s in that population. Obviously, we think that there are long-term sequelae to recurrent concussion.
Dr. Thomas Pommering: Yeah. And that’s, again, one of those mysteries we’re trying to understand. And we definitely think that repeated head injuries put you at risk for long-term problems. I mean, the problem is we don’t know how to identify who is at greater risk and what is the, you know, the numbers that’s acceptable for concussion versus which we stop beyond that activity. And that’s what makes it tough.
Dr. Mike: Sure. So we’ve talked about, sort of, what happens with concussion in the brain, the symptoms that that causes, sort of, looking at how you get better and what kind of timeframe that takes. I guess even better than treating a concussion or waiting one out is preventing a concussion. So, Steevie, if you can talk a little bit about what’s the best way that students can prevent having this happen at all.
Steevie Carzoo: Well, there are a couple of different things they can do. One, if they’re playing in equipment contact sport, they need to make sure their equipment fits properly and then it’s maintained properly. For instance, a lot of football helmets today have air blotters in them. Well, when the temperature changes, the pressure and the amount of air in those air blotters are also going to change.
If they don’t continuously check and make sure their helmet fits properly, they go into a situation when they’re playing in a game or even practice and they get hit, having an improperly fitting helmet is thought maybe to contribute to the incidence of injury. So making sure — and this goes for hockey as well. The helmets are a little bit different or lacrosse, but making sure that their equipment fits properly and they’re wearing it properly and then it’s well-maintained.
The other thing is proper technique, especially again in contact sports, you know, especially football, the kids are hit head up, see what you hit. If they dropped their hat and they go in with the crown of their head, number one, they’re putting themselves at risk for either a concussion or a potentially devastating neck injury. And, two, they’re putting the other player at risk. And, three, I think the big thing is sportsmanship, making sure that they are playing by the rules of the game.
They’re not cheap shutting. They’re not blind side hitting somebody because nobody can defend themselves if they can’t see a hit coming or if they can’t see a ball or stick coming at them. So those types of things are totally, completely preventable. So we want to encourage the kids to make sure that they’re playing with the highest integrity that they can in their sport and that they’re competitive and they’re having fun, but ultimately they’re going to be safe while they’re doing it.
Dr. Mike: Absolutely. So we want the right protection and we want the right technique. And then I guess, too, we want parents and kids to recognize what a concussion is. And hopefully, we stressed the importance of not, you know, waiting until the concussion symptoms are over, seeing your doctor and getting the note before you go back to play and really trying to drive home to folks that recurrent concussions or concussion on top concussion is really dangerous thing, so just recognizing what that is.
Dr. Thomas Pommering: absolutely. We don’t want to take an unfortunate situation and turn it into a tragic situation.
Dr. Mike: Yup. We do have some links for you at the website at pediacast.org. We’ll have a link over to the sports medicine page at Nationwide Children’s Hospital. We also have a link to the concussion information page from Nationwide Children’s and the sports medicine article database. We talked about that the last time that you were here, and I went and took a peak at it. I hadn’t seen that for myself. That is amazing. I mean that is really an incredible resource that you guys have.
Dr. Thomas Pommering: Super. We hope everyone will take advantage of it.
Dr. Mike: And an article there that caught my eye, “Stop the Madness, How to be a Good Fan.” That one is fantastic, aim the parents, you know, in terms of good sportsmanship and really puts into perspective what the real importance of student athletics is.
Dr. Thomas Pommering: Yeah. I think especially in recent events this weekend at a preseason football game with the Raiders versus the Redskins.
Dr. Mike: Yeah. And parents can be just as crazy, right, as fans.
Dr. Thomas Pommering: Absolutely.
Dr. Mike: All right. Well, each of our guests that comes by the PediaCast studio this year, we’re asking, you know, their favorite board games. And the last time you’re here you talked about monopoly that monopoly is your favorite board game.
And, Steevie, the reason that we’re doing this is we’re really try to encourage parents to spend time with their kids outside of technology so to speak, so you know, away from the computer screens and video games and just doing something fun as a family. And board games are one way they can do that. So if you remember from your childhood or even now today, what’s your favorite board game?
Steevie Carzoo: Well, I have one that actually just came out recently. I got it from my birthday a couple of years ago. And it’s called The Game of Things. It’s not so much nutritional board game because there’s no board involved. But basically what happens is that you have a card that says something like things you shouldn’t do while golfing. And everybody has a slip of paper gets to write down whatever they feel like you shouldn’t do while golfing.
All of those papers go into the hat. And then the reader who doesn’t play that round gets to read them all out and you go around the circle and try to guess who said what. And it’s a very, very fun game because you can write outrageously funny things on there. So it’s a good group game, but you can even play it with a small number of people. And it’s a newer version. So I would have loved it if I had it when I was younger.
Dr. Mike: We have that game. And we love, although it’s more fun when you have a larger group of people as you say. Have you heard of this?
Dr. Thomas Pommering: I haven’t, so I’m interested.
Dr. Mike: No, it was really cool. It comes in like in a little wooden box. And it’s a sweet game. It’s very nice. Although my son always writes the same thing so you can always tell. He does it for the laugh. He doesn’t care if he wins. So if it says gluing two ostriches together, that’s how he says it. I don’t know.
Steevie Carzoo: It’s really funny when the person who’s a reader reads the paper incorrectly.
Dr. Mike: Yeah. Yeah.
Steevie Carzoo: So you have an entry but they can’t read the writing while nobody else can look at the paper as you know, I don’t know their handwriting.
Dr. Mike: Right. Right.
Steevie Carzoo: So if you have the reader who has no idea what it says, well, that makes even harder to guess if doesn’t make any sense. We have that situation with my 10-year old cousin and ended up being absolutely hysterical.
Dr. Mike: Yeah. Yeah. It’s a good one. So Things. That’s one to write down. Check out. Put it on a Christmas list, right? OK. All right. Well, I want to thank Dr. Tom Pommering, the chief of sports medicine here at Nationwide Children’s Hospital for stopping by. And also one of their athletic trainers, Steevie Carzoo, thank you also for stopping by. And again, I want to remind you that Dr. Tom Pommering is going to, hopefully, be back by this winter. And we’ll take some of your questions.
So if you have a sports medicine related question, let us know. Actually, if you have any question, just go to pediacast.org and you can click on the contact link and you can get hold of us that way. And you can also email: email@example.com, or call the voice line at 347-404-KIDS. That’s 347-404-5437. All right. Until next time. This is Dr. Mike, saying stay safe, stay healthy and stay involved with your kids. So long everybody
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