Ask Doctor Hockey — Concussions

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Question

My son was checked into the boards during yesterday’s game and couldn’t play the rest of the game. This morning he has a headache and feels dizzy. How do I know if he has a concussion and when can he play again? I have read online about NHL players with CTE (chronic traumatic encephalopathy), should I be concerned with the long-term effects of this injury?

Answer

Ice hockey is a physical game that continues to grow in popularity. In all contact sports, there is an inherent risk of trauma. Most injuries affecting the musculoskeletal system are visibly notable and readily diagnosed. Concussion, however, can be missed and is often difficult to recognize from physical signs, making symptoms reporting the most important tool we have. Fortunately, education programs regarding the symptoms of concussion have become widely available. Any player complaining of headache, dizziness, fogginess, blurred vision, feeling slowed down, ringing in ears, light sensitivity, nausea, among others, should prompt removal from play and formal evaluation. If an athletic trainer or physician is available at the hockey game, a SCAT-5 can be performed to establish the diagnosis.

Jonathan Toews #19 of the Chicago Blackhawks is welcomed back to NHL action after missing six games due to a concussion with a stick to his upper body from Sean O’Donnell #6 of the Los Angeles Kings. (Photo by Jonathan Daniel/Getty Images)

No player suspected of having a concussion should be allowed to return to play until an evaluation by a physician establishes resolution of the injury. This means that any of these symptoms noted at the time of practice or games should be taken seriously.

Typically, all symptoms will resolve in 7-10 days at which time a progression of activity can begin. That being said there is significant variation in the length of time symptoms can be present. Sometimes injuries that seem severe can resolve in less than 24 hours, but in other cases seemingly mild symptoms can progress and evolve over 1-2 days.

Initial rest from physical and cognitive activity, such as school work, tests and computers and smart phone use is recommended immediately following the injury and until symptoms begin to improve. Physical findings of concussion can be subtle. A physician with experience in the diagnosis and management of sports related traumatic brain injury will note coordination deficits, ocular changes and vestibular function as part of the evaluation of your injury. Your physician may also perform testing to measure reaction time, balance and cognitive function, which can show objective changes that can be tracked through recovery.

Players with concussion symptoms that have resolved can also have recurrence of symptoms upon return to play, which make following a return to play progression with step wise increase from light exertion to more physically demanding activity, such as calisthenics and then weight lifting, and finally sports specific activity very important. During this time a symptoms journal before, during and after activity will help to establish safety of moving on to the next step. Steps are separated by 24 hours as symptoms can sometimes become apparent several minutes or hours after exertion ends. Your physician will likely want to see you back once you have completed return to academics and activities to repeat the physical exam and other tests to insure complete resolution and establish a baseline of normal function.

The brain is particularly susceptible to injury in youth hockey because of the metabolic demands of the developing brain, demands of schoolwork, and longer recovery times. Beyond these concerns, younger players may not have acquired all the skills necessary to protect themselves from injury. Elimination of checking at younger levels of participation has had an impact on the incidence of injury that has increased safety for participants in youth hockey. In addition, the elimination of checking allows participants to focus on their developing skating, stick handling, and ice awareness skills at the youth level, which can translate to reduced injury rates at higher levels.

While chronic traumatic encephalopathy (CTE) has received a lot of attention in the media due to the work of Bennet Omalu and Ann McKee, there is still much to learn about the timing of onset of these conditions. At our center, we are working on identifying the findings that indicate a player may have had an injury or series of injuries that make continued participation unsafe. There are currently no available markers to make the diagnosis of CTE. Players should be aware of the total number of injuries they have had and should not ignore symptoms such as headache or getting your bell rung. These benign events can point to brain injury.

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From the encouraging side of things, the brain does have some ability to heal after these types of injuries. But healing is slow and requires avoidance of further contact so as to not insult the healing process. It has been well established that the rate of injury and severity of injury increase dramatically during the immediately following traumatic brain injury. This means that a player that rests appropriately and allows the brain time to heal may more safely return to hockey, decreasing the risk of more severe brain injury. It is the repeated trauma to the brain that likely causes CTE.

Brady Bender of Steamboat Springs explains what he remembers from a hit to Karen McAvoy PsyD at the Center for Concussion at Rocky Mountain Hospital as she evaluates his condition while being treated for a concussion. (Joe Amon/Getty Images)

In hockey, rule changes limiting checking until 13 years of age, instilling the “Look up line” or adding no-touch icing enforcement by officials, elimination of fighting and stricter penalties for “dirty play” and checking from behind are all important considerations to help diminish head injury while maintaining the spirit of the game.

USA hockey has programmatically addressed these concern through rules changes, coaching education and instructional videos for coaches and players alike.

Take home points for players: If you have symptoms, report them. Sit out until evaluated by a doctor trained in the recognition and management of concussion. Never return to play on the same day you notice symptoms. You cannot always see the signs of concussion and reporting remains the most important way to protect your brain. There is no such thing as getting your bell rung. If you have symptoms, your brain is telling you that you have a brain injury.

 

Thomas S. Bottiglieri, DO – Sports Medicine Specialist. Assistant Professor of Orthopedic Surgery, Columbia University Medical Center; New York-Presbyterian Hospital. Dr. Bottiglieri specializes in the non-operative management of complex medical conditions affecting athletes, including chronic and acute injuries affecting the bones, joints, and muscles of pediatric and adult patients. Additionally, he is an expert in the field of concussion care and management, and focuses on a patient-centered approach to patient care that stresses shared decision making with his patients and their families.

 

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Here at HockeyClan we pride ourselves on understanding what hockey families want and need. Now we have assembled a team of world class physicians, our founder included, that allows you access to their medical and hockey expertise. Our physicians all have a unique passion for ice hockey and dedication to their field of expertise. Now you can email your hockey related medical questions to us at: doctorhockey@hockeyclan.com.

We will choose select topics to cover based on these questions. Please forgive us as we will not be able to answer all questions nor provide individual medical advice. Please note that this is not medical advice and is for informational purposes only. Please consult your own physicians as your symptoms and problems may not relate to the information provided. Please call 911 or your local emergency services in case of emergency.

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