Note: The information presented below is primarily for the benefit of athletic trainers. However, we hope that others interested in learning more about concussions in sports will also find this information useful.
George O’Neil, ATC
Certified Athletic Trainer, Princeton (N.J.) University
US Lacrosse Sports Science and Safety Committee
US Lacrosse Men’s Game Subcommittee on Sportsmanship and Safety
Dr. Margot Putukian, MD, FACSM
Director of Athletic Medicine, Head Team Physician, Princeton University
Chair, US Lacrosse Sports Science and Safety Committee
NFL Head, Neck and Spine Committee
Presenter at last two Zurich International Conference on Concussion in Sports
O’Neil: What is the prevalence of concussions in lacrosse?
Putukian: Concussion is an important injury in a lot of sports, including both boys’ and girls’ lacrosse. The estimates are that there are 3.8 million concussions per year in the United States during competitive sports and recreational activities, however as many as 50% of concussions may go unreported. For most sports in the U.S., the numbers are increasing, and why this is occurring is unclear. For college lacrosse, which in general has a low overall injury rate compared to other sports (men’s lacrosse 12.6 game injuries per 1000 athletic exposures vs. 18.8, 26.4 and 35.9 for men’s soccer, wrestling and football, respectively, and women’s lacrosse 7.2 game injuries per 1000 A-E vs. 7.7, 12.6, and 16.4 for women’s basketball, ice hockey and soccer respectively (Hootman JAT 2007)), concussion remains a significant issue and one of the top three most common injuries in both the men’s and women’s game. The rate for concussion in both games and practices in college lacrosse players is 0.26 and 0.25 per 1000 A-E’s for the men and women, respectively (compared with 0.37 and 0.54 for fall and spring football, respectively, 0.41 and 0.28 for women’s and men’s soccer, respectively).
At the high school level, the incidence in concussion for boys and girls is 0.28 and 0.21 in combined game and practice injuries per 1000 A-E (Lincoln AJSM ’07). At the college level, the same researchers found an incidence of concussion of 0.32 and 0.37 per 1000 A-E’s in women and men, respectively. Though the incidence of injury appears to be greater in older players, it’s important to note that in several evidence-based reviews, youth athletes may have a more prolonged recovery and are more susceptible to a concussion accompanied by a catastrophic injury, underscoring the importance of this injury in lacrosse.
O’Neil: What is the difference between mechanisms of concussion in boys’ vs. girls’ lacrosse?
Putukian: There are differences in the mechanisms of concussive injury that appear to be present in the girls and boys games at both the high school and college level. In the boys’ high school game, 51% of concussions are due to direct contact or impact (body-to-body), whereas in high school girls, 49% are from contact with the stick (Lincoln ’07). At the college level, 83% of concussions in the men’s game occur with contact with another player whereas in college women, 76% are from contact with the stick or ball, and only 14% are from contact with another player (Lincoln ‘07). More research is needed looking at the mechanism of injury at other levels of participation.
O’Neil: What are the “Best Practices” for concussion management?
Putukian: Best Practices for concussion management start with being prepared ahead of time for health and safety issues, and specifically having an emergency action plan that includes a concussion plan. It is ideal to provide education to athletes, coaches and parents as it relates to managing health related issues and being able to recognize the signs and symptoms of concussion. Concussion is a brain injury that occurs after a blow to the head or body. The hallmark of concussion is confusion, but a variety of symptoms, such as headache, dizziness, feeling “in a fog” or slowed down, or emotional irritability, can occur immediately and/or several minutes to hours later. Loss of consciousness (LOC) occurs in approximately 8-10% of sport-related concussion and does not indicate a more severe injury unless the LOC is prolonged.
Any athlete suspected of having a concussion should be stopped from playing and assessed by a licensed health care provider trained in the evaluation and management of concussions. If there is any doubt, it’s best to play it safe and err on the side of caution. For the health care provider on site, it’s useful to use a symptom checklist, cognitive evaluation (including orientation, past and immediate memory, new learning, and concentration), balance testing, and further neurological physical examination.
Athletes with a diagnosed concussion should not be allowed to return to play on the day of the injury. Once a concussion is diagnosed, the initial treatment is physical and cognitive rest. For the school-aged child, it is important to limit the stimulation that comes from using video games, the computer, texting, as well as weight lifting and other physical activities. There should be a plan for follow-up, and athletes should be monitored for the development of new symptoms as well as how they are doing in their schoolwork or other demands. In some situations, more comprehensive neurocognitive testing can be incorporated into concussion management, but this is ideally used with the integration of a neuropsychologist as part of the assessment and management team.
A gradual return to activity progression can start once the athlete is symptom-free at rest and with exertion, and can progress slowly back to full activity. Ideally this is under the supervision of a physician and his or her designee (often an athletic trainer, school nurse or parent). It is important to take into consideration the prior history of individual issues such as the athlete’s history of prior injury, their age, their sport, as well as whether there is a pre-existing history of migraine, depression or anxiety, and/or learning disabilities/attention deficit hyperactivity disorder. It is important to recognize that there is no “cookie cutter” treatment for concussion and that each concussion is unique for each individual. It’s also important to understand that for the majority of sport-related concussions, recovery typically occurs in 7-12 days for college age athletes, with a longer recovery in high school and younger athletes. Infrequently, symptoms can persist whereupon different treatment options are considered.
O’Neil: What tools and resources should be used in concussion management?
Putukian: Several tools are available for health care providers that can help in the assessment and management of concussion. The SCAT3 is a standardized sideline concussion assessment tool developed by the International Concussion in Sport Consensus (CIS) Group in 2013 which includes a symptom checklist, a standardized cognitive exam and a modified balance assessment. In addition, the Child-SCAT3 was developed by this group specifically for the use in children.
For the non-health care provider, the Concussion Recognition Tool was developed by the CIS group and is particularly useful for coaches, parents, officials and others. This tool is designed to provide keys to recognizing concussive injuries. These resources are available online free of charge through the British Journal of Sports Medicine.
Other resources specific to concussive injury in lacrosse can be found on the US Lacrosse website, including a video as well as links to the educational information that US Lacrosse developed in collaboration with the CDC, NFHS and NCAA.
O’Neil: Many states have concussion laws, how does that help with concussion management?
Putukian: The first concussion law was passed in Washington State in 2009. Known as the Zackary Lystedt Law, it is named after the young boy who sustained a second blow after having a concussion and being allowed to return to play without being evaluated by a healthcare provider. After this law was successfully passed, laws in other states were pushed forth and passed. Each of these is different and it’s important to make sure that you’re aware of the law in your particular state. At a minimum, these laws provide for an increased awareness on the part of coaches, parents and players as well as for sports organizations regarding the importance of concussion assessment whenever there is any concern for injury.
O’Neil: Is there any equipment that can prevent concussions?
Putukian: There is a lot of controversy regarding the role of protective equipment in preventing or minimizing concussive injury. At the current time, there is no evidence that helmets or mouth guards prevent or minimize concussion. This protective equipment is useful in preventing or minimizing skull injury or bleed as well as dental injury, respectively. The use of soft headgear in women’s lacrosse is currently allowable, though no formal standard exists for this headgear. The issue of helmets in women’s lacrosse remains a controversial one, with a concern that if helmets are worn, the players may be more reckless in their play and possibly increase the risk for injury. On the other hand, there has been concern that with the mechanism of injury being stick and ball to head, that helmets might mitigate the forces and thus provide some protection. Further research is needed to help provide insight into this issue.
An area of injury prevention that is often overlooked and can’t be stressed enough is the importance of enforcement of the rules, continuing to look for rule modifications to make the sport safer, and ensuring that proper technique is provided to coaches, players and parents to keep the game safe. This is particularly important in the rules that relate to hits to the head or intentional use of the helmet. It is also important to consider limiting contact exposures. The youth rules developed by US Lacrosse that prohibit checking in the boys’ game among those 13 and younger and the new NCAA rules penalizing any blow to the head or blow to the body that follows through to the head, are examples of rule changes that can help keep lacrosse safe.
O’Neil: What’s the future in concussion management?
Putukian: There are many questions that remain in terms of concussion assessment and management. There are biomarkers, genetic markers and additional advanced neuroimaging techniques that allow us to potentially assess injury as well as track recovery in a more comprehensive fashion that are, at this time, still in development. The use of functional MRI, diffusion tensor imaging, magnetic resonance spectroscopy, and quantitative EEG are all examples of the emerging tools that may provide us with additional information.
In the most recent Zurich Statement, the routine use of baseline testing was abandoned, with caveats being that baseline testing is useful if the baseline is done correctly and knowing the limitations of NP testing. Concern has been raised related to the different motivation that’s present in baseline vs. post-injury and the method of testing (group versus individual). The motivation is often very low in the baseline evaluation and if several athletes are tested all at once, the value of the test may not be ideal. In addition, it’s important to understand the variability of neurocognitive testing in and of itself. The motivation of an athlete post-injury is often quite high as they are often very anxious to return to play. It is very useful to work with a neuropsychologist who is trained specifically in the interpretation of these tests, and to remember that NP testing is just “one tool in the toolbox” and not to be used to make the diagnosis or clear an athlete to play.
Interested in learning more about head injuries in lacrosse? Join our panel of medical experts in a free webcast on May 21.