SportsDoc Update: Concussions 9/24/2013
1280 The Zone - September 24th, 2013
Jamaal Williams reportedly had both a "stinger" and a concussion - what is a stinger and how is a concussion managed?
What is a "stinger"?
A "stinger" is a temporary injury to a nerve that causes transient (short term) nerve dysfunction. It gets its name because it causes an electrical like shock in the distribution of the affected nerve and can be associated with some numbness and or weakness where that nerve goes. In football, the nerves most commonly affected are the nerves in the neck and can be scary at first because of the numbness and weakness. The injury can be from a stretch of the nerve or a pinching of the nerve. The key is that the symptoms are temporary lasting only a few minutes and then they resolve. If the numbness or weakness persists for longer than 5 minutes it can indicate more serious nerve injury which is why Williams was treated very carefully and taken off the field on a back board just in case there was something more serious. After testing at the hospital more serious nerve damage was ruled out and for that part of his injury, one can usually play if there is no residual weakness or numbness and structural damage has been cleared.
How about "concussion"?
Williams will more likely be held out for the concussion than the stinger. There is a significant amount of commentary in both the lay press and the medical community about how to manage concussion. There is still a lot of debate in the medical community because there seems to be a number of ways to "grade' seriousness of a given concussion and then what are the long term ramifications of playing after such an injury. Some groups want to eliminate football altogether to prevent them others would disqualify an athlete from participation after one concussion and lots of in-between recommendations. What I will put out there is my own personal management after 30 years of experience dealing with them. I know it will expose me for criticism from many different groups, but it has worked for me and the athletes I have cared for.
The first thing that needs to happen in managing a concussion is to grade the severity of it. A concussion is basically a bruise to the brain and just like any other structure it can be mild, moderate, or severe. My grading scheme is as follows:
Grade 1: Either no loss of concussion but some amnesia or memory loss for the event, or up to 60 seconds of loss of consciousness after the injury.
Grade 2: Loss of consciousness for greater than a minute but less than 5 minutes, along with amnesia or memory loss for the injury before and after contact. There is usually some dizziness, blurred vision, headache, or lightheadedness associated with the injury.
Grade 3: Extended loss of consciousness for greater than 5 minutes, along with significant confusion, headache, dizziness, lightheadedness, and no memory for what happened and disorientation for what is going on around the injured athlete. These are obviously very serious and require hospitalization and extended support and treatment.
Once a classification of severity has been made, treatment varies greatly. For me , with a Grade one concussion, if all symptoms disappear within 24 hours- no headache, dizziness. lightheadedness and memory up to the point of contact returns, I'll test the athlete by having them do some sprints to increase the blood flow to the brain and see if the symptoms remain absent. If the symptoms have cleared I will allow contact after one week.. With a Grade two, the length of time from potential repeat injury should increase. My rule of thumb is a least one week with no symptoms with heavy physical demand before being put at risk for a repeat. Grade three concussion, which are thankfully rare require a more prolonged course of observation and time for clearing of symptoms. Usually these severe injuries are hospitalizable. There are now some testing protocols that can be performed to see if symptoms have cleared before return to play.
The treatment of every athlete with concussion should be individualized according to severity, frequency and persistence of symptoms. There are no perfect protocols as yet because the recovery is so variable from individual to individual.
It appears that Williams had a Grade1 injury and could play this week if his symptoms have cleared.
Many could argue against my particular grading scale and treatment, but it has served me and the athletes I've cared for well with no adverse consequences. there is a lot of research currently being conducted that may clarify best treatments in the future.