This piece was originally written for RulingSports.com on July 30, 2012
Several lawsuits have been filed recently by former NFL players against the NFL regarding concussion. The issue at the forefront is whether or not the NFL knew about the long-term effects of concussion and withheld this information from its players. This post is not intended to address the legal issues at hand, but to introduce the reader to the current guidelines on assessment and management of concussions, as well as the potential repercussions of sustaining multiple concussions.
First, it’s important to understand exactly what a concussion is. It is a complex, functional disturbance of the brain that results from a traumatic force. It can be caused by a direct blow, rotational injuries, or impulses transmitted to the brain from another part of the body. One does not have to lose consciousness to sustain a concussion. It is not an anatomical injury, meaning conventional imaging such as CT or MRI will not reveal any abnormality. Concussion results in a constellation of reported symptoms as well as outward signs. Symptoms include headache, nausea, dizziness, photophobia (sensitivity to light) sleep disturbance, feeling “foggy” or “slow”, and difficulty with concentration. It is not uncommon to see emotional lability, irritability, loss of focus, and decreased reaction times as well. In about 85% of people, symptoms will resolve in 7-10 days (frequently longer in children and adolescents). However, for reasons still not completely clear, some will go on to experience post-concussion syndrome (PCS), which is diagnosed when symptoms persist, sometimes for months or even years. There is no correlation between severity of symptoms or the force of trauma and PCS.
When a player is suspected of having a concussion, he or she must be held out of competition and cannot return to play that day. The player is evaluated by a physician or other healthcare provider with training in concussion. The evaluation includes assessment of mental status, balance, vision, neurologic and cognitive function. Imaging is rarely indicated, for reasons previously mentioned, although newer modalities are currently being researched. The evaluation also includes neurocognitive or neuropsychological testing, which is a more objective means of evaluating a player for a concussion. This testing assesses an athlete’s reaction time, visual memory, verbal memory, and processing speed. It can be given in paper and pencil format, or more commonly, via computerized testing. In most instances, especially recently, athletes have undergone baseline testing to assess their “normal” scores. After sustaining a concussion, an athlete retakes the test, which reveals any deviation from their baseline. This portion of the evaluation is critical, because athletes often fail to report or underreport their symptoms. In fact, Troy Polamalu just recently admitted to lying about head injuries in order to keep playing.
While the athlete still has symptoms and/or the neurocognitive testing has not returned to baseline, rest is the primary treatment. The athlete must rest until symptoms resolve. This includes rest from both mental and physical activity. Players are encouraged to avoid excessive computer use, texting, and video games. Workouts are not allowed. When symptoms resolve and testing returns to baseline, a graduated exercise program is begun. This begins with light exercise and gradually increases in intensity over 5-7 days. The athlete must remain symptom free during all phases of the program in order to be cleared to return to play. If symptoms return during the program, he or she must return to the previous phase. When considering the time needed for symptoms to resolve, in addition to time required for the graduated exercise challenge, it is interesting and disturbing that we see many NFL athletes return to play the Sunday after sustaining a concussion. It is known that if an athlete sustains another head injury before the first resolves, the risk of long-term sequelae is greatly increased. Unfortunately, many former athletes still battle chronic symptoms such as headaches, vision problems, anxiety, depression, and insomnia.
With each passing year, we as healthcare providers know more and more about concussions – signs, symptoms, evaluation, management, etc. Unfortunately, many years passed in which concussions were not diagnosed and managed as they are today. In fact, the first international symposium on concussion in sport was held in Vienna in 2001. This symposium brought together several experts to “address specific issues of epidemiology, basic and clinical science, injury grading systems, cognitive assessment, new research methods, protective equipment, management, prevention and long-term outcome,” resulting in a consensus statement with recommendations and guidelines for assessment, management, and return to play. Two additional symposia have been held in 2004 and 2008, each resulting in updates to the previous recommendations. An important take-home point from the first symposium was that each athlete must be treated individually. Each and every athlete is different when it comes to head injury. Concussion grading systems, which were commonly used in the 1980s and 1990s, are widely disregarded today. Symptoms vary among athletes, as do recovery times. There is no way to predict how an individual will respond.
Unfortunately, there is still no consensus regarding how many concussions in a given season or over a lifetime are “too many.” However, there is evidence to suggest a correlation between multiple concussions and long-term sequelae. The issue of chronic traumatic encephalopathy (CTE) has been widely publicized recently in sports media, although it was described in the 1960s. CTE shares features of other neurodegenerative disorders (Alzheimer’s, Parkinson’s), but it is distinct in that it has a clear environmental cause. In short, repetitive trauma to the brain causes progressive degeneration, which unfortunately does not cease after the trauma stops. It is different from the chronic symptoms from concussion and PCS. Signs and symptoms occur later in life (but earlier than the onset of other types of dementia) and include memory loss, irritability, cognitive decline, headaches, language difficulties and aggressive behavior. Microscopic evaluation finds certain proteins that are not found in healthy brain; they are similar to those found in the brains of patients with Alzheimer’s dementia. This disease has been found on autopsy of the brains of several former professional athletes, including NFL players. However, not all athletes with a history of head injuries develop CTE. Research is ongoing to determine possible risk factors, such as age, gender, and genetic predisposition.
In summary, there’s good news and there’s bad news. The bad news is that many former athletes are suffering, thought to be secondary to multiple head injuries sustained during their careers. The good news is that this matter is receiving more attention and research. Moving forward, we need to exercise extreme caution when it comes to head injuries. Helmets or mouthpieces that decrease the risk of concussion? Don’t buy it. Using the phrases “getting dinged” or “getting your bell rung?” No more. Concussions should be taken seriously. Did the NFL take them seriously 10 to 20 years ago? That’s not for me to decide. In the meantime, I’ll keep watching (and judging) on Sundays.