Sport-related concussions not always an easy diagnosis
Dr. Jeffrey Tedder
Most athletic teams have defined protocols that coaches routinely follow in the event of a player suffering a head injury.
The first: to remove the athlete from play and check for signs of a concussion.
Second: to keep the athlete out of play the day of the injury and until he’s evaluated by a healthcare professional and released to return to play.
Also as a precaution, many high schools require team sports participants to take up to two online benchmark tests before they’re allowed to play.
However, sports-related concussions remain controversial, primarily because they’re sometimes difficult to diagnose in a way to best protect young athletes.
For starters, physicians no longer classify concussions by scale, such as 1-2-3 or mild-moderate-severe. A concussion is a clinical diagnosis, and therefore subject to debate on the sidelines during a game.
“As a doctor, you’re obligated not to let a student athlete return to play after a concussive event,” said orthopedic surgeon Jeffrey L. Tedder, MD, FACS, a solo practitioner and sports medicine specialist at St. Petersburg General Hospital in St. Petersburg, Fla. “Even though the NFL is taking it more seriously, there’s still room for improvement. For example, last year, when the Cleveland Browns’ Colt McCoy was hit by a Pittsburg Steelers’ linebacker, he went back in the game groggy. That’s unconscionable! You don’t return that game, and if you still have concussive-type symptoms on exertion throughout the week, you definitely won’t play the next game.”
Tedder pointed to the benchmark of sports medicine practice for concussive treatment: the consensus statement on concussion and sport, determined by international experts at the 3rd International Consensus Conference on Concussion in Sport in 2008. (The conference at press time is scheduled to be held Nov. 1-2 in Zurich, Switzerland, and will possibly produce a revised consensus statement.)
“They pretty much lay down the law of the gold standard for concussive treatment,” he said. “It’s incumbent on the doctor to err on the side of caution. If you have a second event, you’re out a month. A third event, you’re out for the season. The days of ‘getting your bell rung’ are over.”
Rush to Action
It’s even more vital to accurately diagnosis a sports-related concussion before it leads to a secondary concussive event.
“Concussions may cause significant and sustained neuropsychological impairments in information-processing speed, problem solving, planning and memory,” said William Feldner, DO, a sports medicine specialist at South County Family & Sports Medicine and St. Anthony’s Medical Center in St. Louis, Mo., and the team physician for USA Volleyball. “These impairments worsen with multiple concussions. Sustaining a second concussion while still having symptoms from the first – the second impact syndrome – can cause the brain to swell. If a school or university athlete suffers a third concussion, his sports career is over.”
Even though it’s rare, successive concussions can be fatal.
“There have maybe been a dozen such cases nationwide, and I don’t know of anyone who’s had a concussion-related death from a sports injury,” said Feldner, quickly adding that regardless of the statistics, “fatal is fatal.”
One reason hampering a concussion diagnosis: symptoms may not occur or be reported by the athlete for hours or days after the injury. Even though most people with a concussion recover quickly and completely, some symptoms linger for days, weeks or longer. Warning signs of a more significant injury, such as vomiting or weakness in the extremities, could indicate subdural hematoma. Even though no imaging test may show a concussion has occurred, a CT scan can identify a brain bleed.
“Some athletes are afraid to report a possible concussion for fear they’re not going to be able to play,” said Feldner. “Our goal is to have them playing their sport, but safely. It might be worth missing a handful of practices and maybe even a game rather than missing the whole season because you’re struggling through such an injury.”
Tedder pointed to NFL quarterbacks Ben Roethlisberger and Peyton Manning as players who seem able to endure successive hard hits.
“Ben Roethlisberger is a workhorse,” he said, of the Pittsburgh Steeler who endured a significant brain injury from an off-season motorcycle accident several years ago, and takes repetitive licks on the field. “One week last year, he had a sprained ankle and played anyway. Look at Peyton. He’s been playing for 16 years, and has had three neck surgeries. He was like his old self in the first (Denver Broncos) game of the season. That’s pretty amazing.”
However, with the vivid memory lingering of former NFL standout Dave Duerson committing suicide last year in South Florida and donating his brain to science to be studied, and former Super Bowl quarterback for the Chicago Bears Jim McMahon recently admitting he has early stage dementia at the age of 53, much remains to be learned about the impact of concussions.
“It’s amazing to see the study results of post-concussive brains of football players,” said Tedder. “Look at ‘Iron Mike’ Webster, who lived under a bridge. Who knows what happened to Junior Seau? Chronic depression with no will to live … where does that come from?” (Once considered football’s strongest man, Webster played 245 NFL games and died in 2002 at the age of 50.)
That’s why it’s vital for football players to “fess up” to their coaches if they believe they may have a concussion.
“With concussions, it can affect your thinking,” said Feldner. “If you can’t remember what you’re supposed to do, chances are someone’s going to take your spot anyway.”
Pressure to win may very well impact students, their coaches and others affiliated with the sport to have a student athlete – particularly a star player – step forward about a possible concussion.
“Everybody wants to win, and society has a want-to-win attitude, which isn’t all that bad,” he said. “Maybe there aren’t enough student athletes playing sports just to have fun.”
High Risk Positions
Linemen and linebackers who are constantly making contact during a game are at the highest risk for concussion on a football squad.
“Some of the risk is dependent on blocking technique,” said Tedder, who played defensive linebacker and fullback in high school, and center at Wofford College in South Carolina, emerging unscathed. “For example, it’s never a good technique to lead with your head. However, contact is inevitable.”
Another medical puzzler: why one of two players with the same position, experience, height and weight is more likely to get a concussion.
“We really don’t have a handle on that,” said Feldner.
For now, the best treatment for a concussion is to prescribe inactivity in a dark room until the symptoms disappear.
“That’s the ideal solution,” said Feldner. “Logistically, does that happen? Probably not. People sense that sitting on a couch watching TV, playing video games, or texting friends is resting. In terms of a concussion, it’s not.”
Increased awareness in the medical community will help prompt more accurate reporting of concussions by schools and universities.
“Across the board, athletes are getting bigger, stronger and faster,” said Feldner. “And it’s simple physics: mass times acceleration is force. When you get a 6-foot-2, 250-pound kid running 40 in seconds, that’s a lot of mass and velocity.”