By Capt. Christine L. Wolfe, Keller Army Community HospitalMarch 28, 2013
WEST POINT, N.Y. (March 28, 2013) --March is Brain Injury Awareness month. Both the greater Army and the leadership at West Point have worked to increase awareness of brain injury, with focus on prevention, early recognition, and treatment.
In June 2011, the Army instituted traumatic brain injury, known as TBI, training for all service members -- Soldiers, leaders and commanders, medics, and providers alike.
Gen. Raymond T. Odierno, U.S. Army chief of staff, and Roger Goodell, NFL commissioner, met Aug. 30, 2012, at West Point to discuss the issue of brain injury and signed a letter of agreement to continue to work together to combat it. Though different than the larger Army's approach, West Point has instituted extensive measures to combat brain injury.
The Army and much of the current American medical literature take the position that the terms concussion and mild traumatic brain injury, also known as mTBI, are interchangeable. Heath care providers and Certified Athletic Trainers at West Point follow the consensus statements from the International Consensus Conferences in Sport, seeing concussion as a subset of TBI, but meant specifically to describe relatively "low velocity injuries that cause brain 'shaking,' -- resulting in clinical symptoms that are not necessarily related to pathological injury."
Concussion typically results in the rapid onset of mental status changes or other symptoms that most often resolve spontaneously in a sequential course, though may, in some cases, be prolonged. A concussion may or may not involve loss of consciousness. Acute symptoms reflect a functional disturbance rather than a structural injury; no abnormality is seen on standard imaging studies.
Activities at West Point historically yielding the highest numbers of concussions have included boxing, combatives, football, rugby, and the not-necessarily-sports-related free time. As one would expect, given that about 90 percent of concussions resolve completely in seven-10 days, and a total of approximately 97 percent resolving sometime thereafter, very few of the head injuries at West Point have resulted in a protracted course requiring more intensive treatment. The majority of all of the concussion-related symptoms have resolved within 24 hours. In a relatively small subset of cases, symptoms persisted, requiring more than one or two days of limited duty.
While prognosis after a concussion is generally very good, with full recovery expected in a relatively short amount of time, rapid identification and appropriate treatment is necessary to prevent more serious injury and allow this full recovery. If a concussion is suspected, the athlete should be immediately removed from play and assessed for cognitive symptoms , such as dizziness, slowed reaction time, feeling like being "in a fog."
Physical or somatic signs or symptoms of a concussion include headache, nausea, loss of consciousness, or amnesia, or emotional or behavioral changes such as mood lability and irritability. It should also be noted that it is possible for the appearance of cognitive deficits or other symptoms, such as sleep difficulty, to be delayed.
The fundamental management approach with concussion is physical and cognitive rest until the acute symptoms resolve. Though ostensibly in contrast to the warrior ethos, to which Odierno alluded, a concussed player should not return to play for the remainder of the game or sports event from which he or she is pulled, and ideally not for at least the next 24 hours. This is primarily to prevent "Second Impact Syndrome," known as SIS, which is a condition in which the brain is injured a second time before inflammation and swelling from the first concussion has resolved.
SIS can have serious consequences. Additionally, once a player is concussed, he or she is at greater risk for another injury if he or she immediately re-enters athletic activity; she may be cognitively or physically slowed, and may not recognize it. After the physical and cognitive rest period with resolution of acute symptoms, the athlete should follow a graded program of exertion prior to medical clearance and return to play.
West Point has made strides in recent years to keep its active and motivated student population safe. In efforts to prevent as many concussions as possible, West Point has replaced intramural football with flag football, and has benched intramural rugby. The health care providers in Sports Medicine, Certified Athletic Trainers, known as ATCs, are knowledgeable in concussion recognition and care, and use the Sports Concussion Assessment Tool to obtain baseline measures of cognition prior to the beginning the season in all contact sports, as well as immediately after a head injury is suspected.
Corp squad athletes now take the ImPACT, which is a computerized neurocognitive assessment tool, before beginning play in any given season for later comparison to "baseline" should cognitive injury occur. ATCs recognize when to send a player to the Cadet Health Clinic to see a physician, or directly to the Emergency Room. A player is given an information sheet for his or her roommate to help monitor him or her following a head injury. No duty and limited duty orders, known in the Army as quarters slips and profiles, are provided to cadets whose treatment requires a period of full physical and cognitive rest, to include extension of academic requirements, if necessary.
Company Tactical Officers are instructed on recognition and the appropriate management after a concussion. Sports Medicine plans to brief the academic instructors this summer on concussion care, as well. As per the International Consensus Conferences in Sport guidelines, all ATCs currently implement the Return to Play program, which is a a gradual reintroduction to physical activity, following a concussion.
Brain injury awareness can help recognize signs and symptoms of a concussion. As Odierno and Goodell agreed last August, some of the best traits in Soldiers and NFL players -- "mental and physical toughness, discipline, team over self and stressing the importance of resilience" -- can actually hinder them from seeking help. Sometimes a player may not realize he or she is concussed, in which case recognition is entirely up to his team. Screening is necessary for head injuries incurred in "free time" activities, as well.