Changes in the Care of Head and Neck Injuries in Helmeted Student Athletes
Lead author B. Kent Diduch, MD FAAFP and SpineUniverse Editorial Board Member Ali A. Baaj, MD comment
The care of helmeted student athletes following a concussion and possible spine injury has changed over the past decade with new research and revised protocols included in this evolution, according to a review article in the Journal of Bone and Joint Injury.
“This review should encourage sports medicine teams (athletic trainers and team physicians and EMS) to revise their emergency action plans to reflect current recommendations for the potentially spine injured athlete,” said lead author B. Kent Diduch, MD FAAFP, who is Associate Professor, Department of Health Sciences and Primary Care Team Physician at James Madison University in Harrisonburg, VA. “This should also provide an impetus for the sports medicine teams to practice pre-season training and to become better coordinated in their emergency response.”
Dr. Diduch highlighted three take-away messages from this review. The first is that spine-boarding recommendations have changed from the following organizations: the American College of Emergency Physicians (ACEP), the National Association of EMS Physicians (NAEMSP), and the National Athletic Trainers’ Association (NATA).
Specific Indications for Spine Boarding Outlined
“These changes include both a decreased use of spinal immobilization and a recommendation to remove the helmet and shoulder pads prior to securing the athlete to the board when sufficient numbers of trained providers are present,” Dr. Diduch said.
The NATA and ACEP suggest that spinal board immobilization should be reserved for student athletes with spinal pain or tenderness, focal neurological complaints or deficits, or who have undergone blunt trauma with an altered level of consciousness. This aligns with the evolving policies of many EMS councils.
“The review confirms that use of spinal boards is recommended for certain injuries only, and not needed in all cases,” commented Ali A. Baaj, MD, Spinal Neurosurgeon and Assistant Professor of Neurological Surgery at Weill Cornell Medical College, Cornell University, in New York, NY. “Side-line physicians and athletic trainers should be familiar with these guidelines.”
Preseason/Pregame Medical Time Outs are Needed
The second take-away message is that “Preseason training and pregame meetings or “medical time-outs” should become standard practice for the sidelines medical team (ie, the certified athletic trainer, team physician, emergency response personnel, and possibly others),” Dr. Diduch explained.
The 2015 NATA statement recommends use of these medical time-outs for the medical team to discuss emergency protocols and procedures, as well as each members’ specific duties during an emergency.
Elements of Concussion Evaluation Delineated
The third conclusion highlighted by Dr. Diduch is that “Each concussion evaluation, whether at the time of injury or during follow up, should contain similar elements: assessment of symptoms, assessment of cognitive ability, and assessment of coordination (of the eyes, upper extremities and lower extremities). It is important for the clinician to remember that the sidelines' evaluation has two purposes: is a concussion probable and is there an additional injury present that might warrant urgent management? The clinician should err on the side of caution when determining if a concussion is probable or not because the signs and symptoms can change and present over time.”
Loss of consciousness occurs in a minority of concussion cases (10%-20%), while more commonly reported symptoms can be classified as:
- Somatic: headache, nausea, phonophobia/photophobia, and balance disturbances
- Cognitive: confusion, memory loss, difficulty concentrating, slowed processing speed, and feeling “in a fog”
- Behavioral: irritability, anxiety, sadness, emotional lability
- Sleep: drowsiness, fatigue, and altered sleep cycles
In terms of assessment, signs of concussion include coordination changes in the eyes (eg, end position nystagmus, jerky pursuits during full eye range of motion, and saccadic dysmetria), upper extremities (eg, deficits in rapid alternating hand movements or finger-to-nose testing, and lower extremities (as shown using the Balance Error Scoring System). Cognitive assessments include the Standardized Assessment of Concussion and the Sports Concussion Assessment Tool, 3rd Edition.
Once a probable concussion is identified, a student should not be allowed to practice/compete that day and should be monitored for signs of a closed head injury. Signs of increasing intracranial pressure include worsening headache, seizures, deteriorating level of consciousness, repeated vomiting, and focal neurological signs.
“Guidelines for the initial evaluation and treatment of the injured helmeted athlete continue to evolve as both mechanisms and pathophysiology of injuries are better understood,” Dr. Baaj noted.
A Prepared and Coordinated Intervention May Improve Outcomes
“Care of the head/neck injured athlete begins before the first practice or game,” Dr. Diduch concluded. “It begins with pre-season staff training. It begins with coordination between the different care providers: the athletic trainer, team physician, EMS, emergency department providers and even the referral specialists. Being prepared and coordinated hopefully will improve the outcomes for these athletes.”
“Sports-related traumatic brain and neck injuries are all too common,” Dr. Baaj said. “Awareness among not only athletic trainers and physicians, but also athletes and their families is essential to ensure the proper treatment protocols are followed throughout the entire treatment process.”