concussions; what we don’t know

Thursday, October 13, 2016

Carson Palmer: concussion

Cam Newton- concussion

Sydney Crosby: concussion

NHL: new concussion screening policy.

Donald Trump- NFL need to toughen up; concussions around so bad.

And then there’s the knowledge gap.

“I don’t know.” Not the best thing to hear from your doctor after you’ve been examined. The expectation is that you go to the doc, get examined, you’re told what’s wrong, how you’re going to be fixed and when you’ll get better. That drill breaks down when the doc says “I don’t know”. Welcome to world of concussion.

Players and fans appreciate a potential head injury may occur with every play, but nothing is worse for the fan when the commentator announces that your favorite player is being evaluated for a concussion or in the concussion protocol. Those words are probably worse for the player. Whether it’s the NFL, NHL, MLB, NBA or MLS, the concussion protocol usually means that the player is gone for the game and perhaps, at least another week. The good news is that it may protect athletes after a concussion (regardless of Trump’s medical expertise), but the bad news is that nobody knows exactly how long to protect an athlete. Carson Palmer, Cam Newton, Sydney Crosby and the many other players who get hit in the head every week need to be protected, sometimes even from themselves, but how that’s done is up for debate.

Diagnosis

Concussion diagnosis is defined as brain injury and it’s easy to diagnose easy if the athlete is knocked unconscious, has visible signs of confusion or behavior changes. But the Zurich consensus on concussion in sports doesn’t require head trauma to make the diagnosis. Instead, the diagnosis only requires the head to be shaken, and just one symptom. That symptom might be as non-specific as not feeling right, being tired and fatigued, or becoming more emotional or irritable. There is no finding on physical exam, brain imaging (CT/MRI) or psychologic testing that can confirm or rule out the diagnosis. It is all based on self-reported symptoms.

Treatment

Concussion treatment is not necessarily evidence based. We don’t know how long it takes for the brain to heal after being concussed and the assessment decisions to allow sport participation often depend upon the athlete self-reporting symptoms and healing. And since many elite athletes are motivated to play, there are no tests available to confirm that the athlete is telling the truth and the brain is actually better. Anecdotes exist that suggest some athletes try to do poorly on preseason brain testing, so that if a concussion occurs, they can “pass” a test that compare brain performance before and after the injury. They set the bar low early to be able to clear it later.

Return to Play

The protocols that allow return to play protocol are arbitrary and while most concussion may resolve within 7-10 days, there is no objective test to know whether complete healing of the brain has occurred. According to the Zurich consensus, after a concussion, the athlete moves from one activity level to the next, as long as they are symptom free. If symptoms occur, then the progression through the protocol is delayed:

  • Day 1     No activity
  • Day 2     Walking, swimming or stat8ionary bike to increase the heart rate but no too much (just 70% of max)
  • Day 3     Sport specific exercise but no head impact activities, like heading a ball in soccer, or leading with the head or tackle in football
  • Day 4     Noncontact training drills that require increase information processing of the brian like passing drills in football or hockey
  • Day 5     If medically cleared, full contact practice
  • Day 6     Return to play

The long term effects of a concussion are still unknown. Does it take just one? Are lots of “small” concussions as ominous as one “big’ concussion? Can the effects of concussion be reversed?

In the real world of concussion, there is a lot of “I don’t know”. While the NFL and the NHL have empowered referees to pull players out of the game and have independent spotters monitoring replay video, it’s important to remember that concussion symptoms can be delayed. The Zurich consensus states it plainly, “…that the appearance of symptoms or cognitive deficit might be delayed several hours following a concussive episode and that concussion should be seen as an evolving injury in the acute stage.”

The logical application should be that if a player is pulled out of a game for fear of concussion, regardless of the sideline testing result, that player should be done for the day, since the sideline medical crew “won’t know” if symptoms will progress over time and in medicine, erring on the side of caution is never a bad thing.

But logic and pro sports don’t always go hand in hand. What we see on any given Sunday tends to filter down to the college, high school and even middle school levels. Pro athletes get paid to abuse their body and should know the inherent risks of their profession. Amateurs are trying to grab the brass ring to compete at the highest level of their sport. Most won’t get there and it’s the medical and coaching communities’ responsibility to protect younger, more fragile brains from long term damage. The problem is that we don’t just don’t know how.

 

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