concussion confusion

Sunday, July 21, 2013

“It is well settled in the scientific community that an athlete must never be returned to play on the same day after a concussion diagnosis.”  – Dr. Robert Cantu

Dr. Robert Cantu is the medical director of the National Center for Catastrophic Sports Injury Research and has been one of the leaders in developing guidelines for concussion diagnosis, assessment and return to play guidelines for 30 years. His 1986 concussion guidelines allowed athletes with grade 1 concussions to return to play within the same game if the symptoms on the sideline had resolved. These guidelines remained in force for a generation while technology and the understanding of traumatic brain injury evolved.

The grading of concussions went away and the focus was on the neurologic function of the concussed athlete. The ability to walk and talk was not good enough to return to play. The symptoms of concussion might take hours and days to be detected and the brain’s ability to heal might take days or weeks. Loss of consciousness was not a good enough indicator of the severity of functional damage. The initial diagnosis of concussion became difficult and perhaps impossible to make and the same could be said for determining the severity of the brain injury.

But what the medical world thought they knew was not translated into the guidelines that were published by major medical organizations. In June of this year, the American Academy of Neurology published an update of their sport concussion guidelines, the first since 1997. Unfortunately, the most recent guidelines were couched in the language of statistics and provided little guidance to the trainer or doctor caring for the athlete on the field or in the office.  “In order to diminish the risk of recurrent injury, individuals supervising athletes should prohibit an athlete with concussion from returning to play/practice (contact-risk activity) until a licensed health care professional has judged that the concussion has resolved.”

At least this a positive step compared to what the neurologists recommended beforehand. A player with a grade one concussion, where “the athlete is not rendered unconscious and suffers only momentary confusion (e.g., inattention, poor concentration, inability to process information or sequence tasks) or mental status alterations”, could return to play “if mental status abnormalities or post-concussive symptoms clear within 15 minutes.”

In the 16 years that it took the neurologists to reconsider their position, other organizations and researchers were blunter. The 2012 Zurich conference on sport concussion published this consensus statement: “A player with diagnosed concussion should not be allowed to RTP on the day of injury.”

This updated their stance from 2008 where they suggested that American football players might return to play in the same game if the team physicians had found them asymptomatic, without memory or thought problems. However, the 2008 stance also noted that high school and college football players might develop delayed symptoms and should be treated differently than professional players. Even elite adolescent athletes who sustained a head injury should not be allowed to return to play on the same day.

But the Zurich people might also have been a little late to the game. The National Athletic Trainers Association issued a position statement on concussion in 2004 that suggested that it took at least 7-10 days for the brain to properly heal after a concussion. They were aware that some doctors felt that a week was too conservative and that athletes could return sooner. Their review of data showed that 30%of high school and college athletes returned to play during the same game after concussion.

In 2010, the American Academy of Pediatrics updated their sports related concussion guidelines with the not so subtle declaration: “Under no circumstances should pediatric or adolescent athletes with concussion return to play the same day of their concussion.” The pediatricians noted that adolescent athlete brains took longer to recover that their college or pro counterparts. It would seem rather arbitrary to consider an 18 year old high school football player brain to be any different than the brain of an 18 year old college football player.

The problem with concussion, or minor traumatic brain injury, is that the diagnosis is made clinically. This is very frustrating to a public that has come to see technology as the be all and end all of medicine. We can look at the brain with CT or MRI and detect bleeding or swelling but the machines are not good enough to know what is happening at the cellular level. However, imaging the brain with CT or MRI is not indicated in most concussed athletes. Tests are being developed that might detect proteins, like S100B, that are released when the brain is injured, but it will take time until they are clinically useful on the sideline. Trainers and doctors are left with the bedside skills of taking a history and performing a physical examination to decide if a concussion has occurred.

News headlines makes all this relevant. The NFL is being sued by former players and now the NCAA is under fire for not issuing stronger ocncussion directives to its affiliated universities and colleges. Presumably, the organizations did not act in the best interest of the player, exposing them to risk of future brain dysfunction from psychiatric illnesses to dementia.

Unfortunately, the NFL and NCAA do not look after players; it is left to real people at the bedside, the doctors and trainers who evaluate the athlete on the field and on the sideline. The player should expect that the provider is well versed in the current standards of care, and would first and foremost be their advocate, providing advice and treatment that benefit the player. The provider, though perhaps paid by the team or school, should have first allegiance to the player and nobody else. The coach should not matter, the general manager should not matter and the athletic director should not matter. Hiding behind guidelines is perhaps legal but it is not ethical. Ultimately, there is a real person who is charged with caring for the athlete.

An elite athlete will do almost anything to compete, including hiding or covering up an injury. Taking one for the team is a time honored tradition and those who play with fractures, torn muscles and broken brains are celebrated as heroes. It is the responsibility of those who are entrusted with their care to sometimes say “no” and to stand in the way of bad decision making. Serving both the player and the team at the same time is a no win situation for a trainer or team doctor. But when the brain of a patient is on the line, they should appreciate to whom they owe their allegiance and do the right thing.







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