Photo: Earl Gardner

Editors note: This guest column is by Matt Kirkpatrick, a licensed athletic trainer who has worked with high school soccer teams in Pennsylvania and New Jersey, as well as Sky Blue FC, Reading United AC, and Buxmont Torch FC. He wrote this column at PSP’s request after sharing some insightful comments about concussions after a Bethlehem Steel player suffered a head injury.

Concussions are a hot topic of conversation these days. Parents as well as athletes are concerned with the immediate and future outcomes of playing a sport they love. Proper recognition and management could mean the difference between a seamless return to sport and catastrophic consequences, not the least of which is death.

Licensed athletic trainers and some physicians are trained to manage these situations with the athlete’s best interest in mind.

I am a licensed athletic trainer currently working in a high school setting and have been fortunate enough to work with some of the local area soccer teams. In both settings, I have had to use my concussion evaluation skills multiple times to determine whether an athlete can return to the field of play safely.

The following is an overview of what I go through when I suspect there to be a concussion.

Evaluating potential concussions: Ask the right questions

With any head injury, you always want to rule out a fracture of the neck first, because any further movement could result in paralysis.

Once that has been ruled out, I begin my concussion evaluation.

Regardless of whether I saw the mechanism of injury or not, I always ask the player to describe to me what happened. This helps me determine the exact nature of the injury and the player’s ability to think clearly and remember recent events. Types of questions include:

• Where specifically were you hit on the head?
• How are you feeling?
• Have you had any previous treatment for headaches or migraines not related to concussions?
• Have you had prior concussions? If so, how many?
• Does the athlete have any diagnosed learning disabilities?

These questions help determine whether any findings that may arise as I continue with my evaluation are related to this incident or are a result of a preexisting condition.

I will then ask the player if they have any of the following symptoms:

• headache
• nausea
• numbness/tingling
• balance problems
• dizziness
• confusion
• blurred vision
• double vision
• fatigue
• sensitivity to light
• sensitivity to noise
• feeling mentally foggy
• feeling slowed down
• difficulty concentrating
• difficulty remembering
• irritability
• sadness
• more emotional and
• nervousness.

If the athlete is experiencing any one of these symptoms, then I would suspect a concussion, and their day is done.

After I ask about their symptoms, I begin asking orientation questions such as:

• What month is it
• What is the date today?
• What is the day of the week?
• What year is it?
• What time is it right now?
• Who are we playing today?
• What is the score of the game?

Another important set of questions at this juncture is to ask the athlete if they remember things that happened before the injury and things that happened since the injury. I like to ask the athlete to give me a play-by-play rundown from right before to the moment I asked this question. If the athlete claims to feel fine and is not experiencing any symptoms and correctly answer my orientation questions, I move on to vestibular ocular testing.

The eye test

Concussions can disrupt the body’s vestibular ocular system, which is responsible for integrating vision, balance and movement. It’s what helps us to keep our balance when we move.

I start with a simple eye tracking test by having the athlete keep their head still and follow the movement of my finger with their eyes only. I am looking for how well the athlete’s eyes track my finger. Are the eyes slow and delayed? Is the overall movement of eyes smooth, or is it choppy?

Along with basic eye tracking, I test horizontal and vertical saccades by holding up two fingers about 12 inches apart and asking the athlete to keep the head still and look back and forth between my fingers, first horizontally and then vertically.  Again, I am looking for choppy, delayed or skips in their eye movement. I then test the convergence, I tell the athlete to follow my finger as I move it closer to their nose. If they have double vision within four to six centimeters of their nose, that is considered normal. Double or blurry vision before that may be significant.

Evaluating cognition and balance

After checking the athlete’s eyes, I evaluate the athlete’s cognitive and balance capabilities. I start with immediate memory. I give the athlete five words and have the athlete repeat them back to me. For example I usually use the words: ankle, coin, tree, horse and puddle.

Then I move on to concentration and ask the athlete to repeat a set of digits back to me in reverse order. For example, if I give the athlete 1-2-3, the athlete has to respond 3-2-1 for a correct response. It starts with a set of three digits and goes up to five digits.

Following the digits, I ask the athlete to repeat the months of the year in reverse order.

To end the cognitive portion, I ask the athlete to give me the five words I gave them from the immediate memory portion.

The last thing I will evaluate is balance, using a modified version of the Balance Error Scoring System (BESS test). Basically, I am looking for the athlete’s ability to stand and maintain their balance. It involves three stances, single leg, double leg and tandem stances. Each stance will be tested in two conditions, eyes open and eyes closed, both for 20 seconds each with their hands on their hips.  For the single leg stance, I have the athlete stand on their “plant” foot, if they kick with their right I have them stand on their left. Double leg stance is both feet together touching and tandem stance is with their “plant” foot behind and the other foot in front touching heel to toe. An inability to perform these tests without staggering or any report of dizziness may be significant.

That is my personal concussion evaluation that I utilize when I come across a suspected concussion. There is a multitude of other tests that can be used that are just as effective.

It is important to note that knowing the athletes under my care at the time is extremely helpful because it becomes much easier to see if they are not acting like they normally would. It also helps to have coaches and athletes who understand the severity of concussions and how important it is to recognize symptoms early and remove the athlete from the field of play.

As a licensed athletic trainer, my job is to have the athlete’s best interest in mind. I will not allow the athlete, parents, coaches or winning to come before the health of my athlete. I will take as much time as I need to determine whether or not the athlete has a concussion or can safely return to the field of play. As one can imagine, this evaluation can take quite a bit of time. At the professional level of soccer, it would result in playing down a player for this period of time.