concussions and football

Tuesday, September 30, 2014

 

The latest concussion controversy involves Shane Morris, the University of Michigan quarterback  whose head injury was unrecognized by the coaching and medical staff on the sideline and therefore was allowed to continue to play. After a few public relation gaffs, the university admitted that an error was made and instituted new procedures to address the “communication processes”. Athletic director, Dave Brandon, said that Michigan would have an athletic medical professional in the press box or video booth with the ability to talk to the medical personnel on the field and would increase communication between medical and coaching staff as to player availability.

The NCAA has a recently revised policy on concussion that addresses the issues of diagnosis, treatment and return to play. Good for the NCAA and good for Michigan but it is just window dressing for the whole head injury issue. Here are but a few of the issues that make head injuries a significant public health issue.

There is no easy way to make the diagnosis: Depending upon the research you choose to read, somewhere between 30 and 50 percent of head injuries go unrecognized and therefore unreported. The NCAA guidelines suggest that players will hide their concussion because of the invincibility of youth to fear of losing their roster spot. Studies looking at concussion rates in high school and college athletes suggest that the player did not report concussions because they were unaware that their symptoms were associated with head injury. Headache was the most commonly non-reported initial symptom. Those who had an unreported concussion were more likely to be knocked unconscious with a subsequent concussion and also have more severe post-concussion symptoms.

The diagnosis on the field needs to rely on the players and referees on the field: It is nice that Michigan has the resources to place medical personnel in the press box and have communications equipment to talk to the medical and coaching staff on the field. For all the football played in the US, from freshman and JV high school games to the Division II and III college level, virtually none will have a neurologist or head trauma specialist on the field or in the press box. Most won’t have a press box. Coaches on the sideline are too often shielded from all the action and it’s incumbent upon those on the field to be their brother’s keepers. Watching the replay of Shane Morris laying on the field after being hit, slowly getting up, stumbling and having to be supported by another player, it is clear that something is wrong. Yet, after a few seconds, he waves off help and gets into the huddle for the next play. The lineman who helped steady him and the referees on the field need to feel empowered to stop the play and have him removed.

The diagnosis of concussion on the sideline, in the ER or the doctor’s office may be also difficult to make: While it is easy to make the diagnosis of head injury when a player is knocked unconscious, is vomiting on the field or is dazed and having light sensitivity, many of the symptoms can be subtle and take hours to manifest themselves. It could be that irritability, difficulty concentrating, changing sleep patterns or headaches lead to the diagnosis. While guidelines and scoring systems exist, the diagnosis of concussion is made clinically by symptoms alone. By definition, a minor head injury or concussion, may have a normal physical exam.

Treatment of concussion is brain rest, but for how long: The first order of business is to remove the player of the game to prevent further injury. In football, that starts by having the medical staff take away the player’s helmet. There is no missed communication between the athletic trainers and coaches when the player walks the sideline without a helmet on his head or in his hand. There is a six step program endorsed by the NCAA and the 2013 Zurich International Conference on Concussion in Sport that lays out the path for an athlete to return to play. It is interesting that while there is a presumed safe path to the football field, there is no such safe path to return to school or work.

From the NCAA: “There are no standardized guidelines for returning the athlete to school…Returning the student to school, even if the day is shortened, can be considered when the student can tolerate cognitive activity or stimulation for approximately 30 to 45 minutes. This arbitrary cutoff is based on the observation that a good amount of learning takes place in 30- to 45-minute increments… Given that most concussions resolve within three weeks of the injury, adjustments may often be made in the classroom setting without formal written plans.”

So it is with a heavy heart that we congratulate the University of Michigan, the NCAA and college football. Players will be watched from on high, yet between one third and one half of concussions will not be recognized. There will be no easy way to make the concussion diagnosis. Rest will be the only treatment available. Return to full play may occur within one week, yet return to the classroom may be limited to less than an hour a day.

With all this lack of clarity, what direction and information does this give to players and to their parents who want their kids to play ball. It’s a reminder that institutions of higher education, like the University of Michigan, have a hard time applying science to their everyday lives.

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