Youth and Concussions: Insight on Prevention and Protocol from Athletic Trainer Amanda Khor

Fall is in the air, and that means football season is here. Along with the tailgates and touchdowns come concussions. A form of a traumatic brain injury (TBI), concussions are common in many sports and have received more attention lately as former professional athletes have come forward with their stories about long-term struggles that resulted from multiple concussions. The Centers for Disease Control and Prevention estimates that between 1.6 million and 3.8 million sports- and recreation-related concussions happen annually in the United States. People who have concussions can experience headaches, personality changes, motor control problems, depression, and insomnia, to name a few symptoms.

I had the opportunity to talk with Amanda Khor, MA, LAT, ATC, who has been an athletic trainer for five years. Khor works with high school athletes and specializes in sport psychology. She shared her knowledge about concussions and encourages athletes, coaches, and parents to understand the signs, symptoms, and treatment recommendations.

What is a concussion and how do they happen?

A concussion results from any trauma or contact to the head that results in the head snapping backwards or forwards, or rotating. Although a concussion can result from direct contact to the head, a whiplash mechanism may also cause a concussion to occur. For example, an athlete taking a direct blow to the chest may cause the head to whip backwards, causing the brain to shift within the skull, resulting in a concussion. Other examples include athletes hitting their heads off the ground or a stationary object, being hit by an object directly, or from coming into contact with an opponent or teammate.

I typically explain the process to my athletes by having them visualize their brain inside their skull. The brain is not strapped down. Therefore when an athlete is hit or whiplash happens, their brain shifts within their skull. As the brain shifts it can come in contact with the skull, causing bruising or damage. The area of the brain that has sustained the damage can affect the amount and type of symptoms the athlete can experience. I tell my athletes just as they must allow any bruise they get on their body to heal, they need time to allow the bruise on the brain to rest and heal. As with any bruise, if you continue to bump it or hit it, it will cause more damage. Therefore, if they were to continue to play, they could have the potential to cause more damage to their brain, resulting in a longer recovery time. Each athlete is going to experience their injury in their own unique way. My goal is always to help them better understand the injury, how it happened, and how to heal it.

How common are concussions?

Due to the fact that athletes under-report concussions, I believe they are more common than we think. It is no longer just about the helmet-to-helmet or large contact hits, it includes the repetitive hits on an athlete that take place over and over again. Athletes may think that the consistent headaches they get after practice are normal, and they do not want to be benched, so they do not report their headaches. Athletes hear coaches complain that concussion numbers are up and that they are more common now than when they played sports. Concussions have been around for as long as we have been playing sports, we are just able to better identify the injury today and athletes are reporting symptoms more often. Concussions can happen playing any sport or participating in everyday activities.

Why have we become so concerned about the effects of concussions over the last few years?

I think due to the increased awareness of the long-term effects. Over the last few years research has proven that a concussion is more than just getting your “bell rung;” there are long-term side effects of multiple concussions. The biggest sport in the news over the last few years is football. The movie “Concussion” came out last winter, which was based on the NFL concussion crisis. Now that football has been placed under the limelight for so many years, athletes from other sports are coming out about their long-term complications with head injuries. For example, numerous women’s soccer players have decided to donate their brains to research due to their belief that they have suffered some long-term damage from their years of playing.

This increase in awareness that the brain damage can be lifelong, and is no longer just temporary, is the reason why we have become concerned about the effects of concussions. I always tell my athletes their ligaments, bones, and the majority of their organs can all be replaceable, but they only get one brain and that brain has to last them a lifetime. Their brain is who they are, and any damage to their brain can effect who they become. The research on concussions is prevalent today, and that allows for us to increase our awareness of the lifelong effects of this injury.

Who is at risk for a concussion?

I believe anyone can be at risk for a concussion. If you think about it, you can be walking down the street in the middle of winter, slip on ice, fall, and hit your head. You do not have to be participating in a high-contact sport to be at risk for a concussion. Obviously, the higher the contact of the sport you play, the greater the risk. But low-contact sports have a risk factor for concussions as well. 

How do we lower risk for concussions?

The best way to lower the risk of concussions is increasing the prevention of concussions. With football, for example, there are more teams doing less hitting during practice to decrease the amount of impact on the head. There is a higher chance of an athlete sustaining a concussion during football practice than in games. Practice takes place four to five days a week, a game occurs one day a week. Decreasing the amount of hitting that occurs during practice decreases the chances of an athlete sustaining a concussion. 

Another preventive method is the new tackling techniques teams are beginning to utilize. The high school where I am the athletic trainer has adopted the rugby style tackling technique, which is supposed to decrease impact on the head. Making sure coaches are well educated in the proper techniques will help decrease the risk of an athlete sustaining a concussion. This should be applied to all sports; coaches should be educated in the techniques they are teaching their athletes. It will benefit the athlete in the long run and prevent not just head injuries, but injuries overall. 

How do you know if you have a concussion? 

Concussions are subjective. This is what makes them a unique injury—because no two are exactly alike. You will know if you have a concussion based upon the symptoms that occur. The most common symptoms are a headache, dizziness, nausea, light and noise sensitivity, memory problems, difficulty concentrating, balance problems, and feeling mentally foggy. Athletes may report feeling “out of it” or not feeling like themselves. Symptoms may not always occur directly after contact and can take minutes to hours to occur. Symptoms can vary depending on the area of the brain that has sustained damage. That is what makes each concussion different from the next. 

Who is able to diagnosis a concussion on the field?

Any athlete who is displaying concussion-like symptoms should be immediately removed from play. This will typically be done by the athletic trainer or team doctor on site. After athletes are removed from play, they are evaluated by a medical professional and diagnosed. I will send any athlete with concussion symptoms to a third-party doctor—typically you want a concussion specialist. This takes out biased opinions and allows the athlete to receive optimum care.

What should athletes do if they have a concussion?

If you are experiencing any concussion-like symptoms after an incident, you should immediately report the symptoms to an athletic trainer. If no athletic trainer is present, you should report the symptoms to the coach and parents.

Once athletes have reported symptoms, they should be evaluated by a health care professional to be diagnosed. Typically, I will provide parents with referrals to doctors who specialize in concussions and who have had success treating other athletes. Another option is for athletes to see their primary care physician or pediatrician. It is vital that athletes report their symptoms immediately to prevent a secondary hit, which could result in a worsening injury.

When can athletes return to play and to regular activities after a concussion? Who can determine when athletes are ready to return to regular activity? 

There is a gradual return-to-play process that all my athletes go through. This process begins after the athlete has been symptoms-free, re-evaluated by a health care professional, and cleared to return to play. With my high school athletes, they are required to go through a return-to-learn process before they are allowed to begin the return-to-play protocol. This involves athletes being able return to their normal academic load without symptoms present.

Once they are able to go through a normal school day, they are allowed to begin the return-to-play process. This involves athletes slowly acclimating back into their sport. Just because they have no symptoms present without activity does not mean they are completely symptom-free. An athlete may begin to experience symptoms with activity, which can indicate the athlete is not ready to return to play. This is why they go through a gradual process. They are to complete each day symptom-free in order to continue onto the next day of progression.

When athletes are symptom-free and ready to return to play, they are to be cleared by the health care professional who removed them from play. Typically, they will have to go through a concussion testing process and reach their already established baseline. For example, my high school athletes are required to have an ImPACT baseline conducted prior to participating in activity. Along with clearance from their doctor, they are required to reach their baseline before they can return to play.

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