concussion rears its ugly head…again

Monday, January 5, 2015

For all the attention given to head injury in sport, for all the NFL protocols to screen players who have been suspected of being concussed, for all the research being done to help decide when it is safe to return to play, a dark secret exists in the scientific literature that rarely sees the light of day. When a player has been hit in the head and is visibly shaken, confused or knocked unconscious, the diagnosis of concussion is relatively easy to make. But when there is no direct blow or if it is deemed to be minor and the symptom onset is delayed, the diagnosis on the field may be impossible to make.

Monday morning quarterbacking is no longer limited to questioning a third down pass call or whether to go for it or punt on fourth and short. The latest episode that questioned the judgment of an NFL team’s medical staff occurred in the Baltimore-Pittsburgh playoff game, when Heath Miller was sent off the field by the officials after a hit to the head left him momentarily limp. He was back in the huddle in just a couple of minutes. His quarterback, Ben Roethlisberger was also hit hard, bounced his head on the ground and lay dazed for a few moments, but he, too, was allowed to return.

And here is the dark secret of concussion evaluation and management: there is no easy way to make an immediate diagnosis, there is no way to predict how long it will take for symptoms to subside and there is no way to know when it is safe to return to play. While consensus statements and guidelines have been published, they are couched in disclaimers and research continues that confuses the understanding of brain injury and recovery.

The Zurich consensus on concussion in sport has a five point statement on the on-field or sideline evaluation of acute concussion. Summarizing their mandates should a player show ANY (their emphasis) features of a concussion:

  • The player should be generally evaluated onsite by a physician or other licensed health care provider, with particular attention given to make certain no neck injury has occurred.
  • The health care provider has the responsibility to determine whether the player has been injured. If there is no provider available, the player needs to be removed from play and arrangements made for urgent evaluation.
  • Sideline concussion screening tests should be performed.
  • The player should not be left alone and should be monitored with repeated exams to make certain that brain function is not worsening.
  • A player with the diagnosis of a concussion should not return to play on the day of injury

Then come the caveats:

A majority of concussions in sport occur without loss of consciousness or frank neurological signs. At present, there is no perfect diagnostic test or marker that clinicians can rely on for an immediate diagnosis of concussion in the sporting environment

A standardized assessment of concussion is useful in the assessment of the athlete with suspected concussion but should not take the place of the clinician’s judgment.

The current published evidence evaluating the effect of rest following a sports-related concussion is sparse. An initial period of rest in the acute symptomatic period following injury (24–48 h) may be of benefit. Further research to evaluate the long-term outcome of rest, and the optimal amount and type of rest, is needed.

The bottom line on head injury is more than a little murky. Concussions may occur without visible initial symptoms. Tools do not exist to make the diagnosis, except for clinical judgment, and that may be hampered because the injured athlete may not exhibit immediate symptoms. Rest may be helpful but there is no scientific evidence to prove how much or how little is needed. Perhaps the only way to help the doc on the sideline is the way the NFL helps its referees…instant replay, and we all know how perfect that has turned out.

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