Taking a Toll
Sport-related concussions not always an easy diagnosis
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, some Missouri 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 patient either has a concussion or doesn’t,” said William Feldner, DO, a sports medicine specialist at South County Family & Sports Medicine and St. Anthony’s Medical Center in St. Louis, pointing out the gold standard for medical providers’ information on concussion diagnosis: the consensus statement on concussion and sport, determined by international experts at the 3rd International Consensus Conference on Concussion in Sport in 2008.
Rush to Action
It’s even more vital to accurately diagnosis a sports-related concussion before it leads to a secondary concussion.
“Concussions may cause significant and sustained neuropsychological impairments in information-processing speed, problem solving, planning and memory,” said Feldner, also the team physician for Lindenwood University and 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 around St. Louis 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.”
With the vivid memory lingering of former NFL standout Dave Duerson committing suicide last year and donating his brain to science to be studied, it’s vital for football players to “fess up” to their coaches if they believe they may have a concussion. It’s no longer OK to just say, “I got my bell rung,” said Feldner.
“With concussions, it can affect your thinking,” he said. “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 – not 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,” he said. “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.
“I don’t know that concussions are occurring more often, but they’re being reported more often since the Missouri Legislature passed a law last year requiring a healthcare professional to authorize a student athlete’s return to play following a concussion,” he said. “It’s inevitable, though. Across the board, athletes are getting bigger, stronger and faster. And it’s simple physics: mass times acceleration is force. When you get a 6-foot-two, 250-pound kid running a 40 in seconds, that’s a lot of mass and velocity.”
RELATED STORY: One Year Post Passage, New State Law Helping Student Athletes
Former St. Louis Rams linebacker Mike Jones was pleased to see Missouri state lawmakers take a giant leap forward last year toward protecting concussion-prone student athletes with the passage of the Interscholastic Youth Sports Brain Injury Prevention Act.
Jones, who famously tackled a Tennessee Titans wide receiver at the 1-yard line to set up a Rams victory in the 2000 Super Bowl, and is now the head football coach at Lincoln University in Jefferson City, had testified before state lawmakers mulling legislation that would prevent high school athletes from returning to play if they appeared to suffer a concussion or brain injury.
|The Centers for Disease Control and Prevention estimates that nearly 4 million concussions related to sports and recreation occur nationwide annually.|
“Young athletes and their parents need to be educated on the symptoms and dangers of concussions and shouldn’t be allowed to return without medical clearance,” Jones told legislators. “That’s what the bill is about.”
State Rep. Chuck Gatschenberger (R-Lake St. Louis) introduced House Bill 300, modeled after a Washington state law that applies to all youth sports. The Missouri legislation required the state Department of Health and Senior Services to develop guidelines on the risk of concussion and brain injury.
The new law mandates benching student athletes suspected of sustaining a concussion or brain injury for at least 24 hours.
“Sometimes, we need people in our life to tell us what we need to hear, not what we want to hear,” Jones shared after the committee hearing. “This takes the decision out of the hands of the coaches and athletes and gives it to (healthcare professionals), and that’s the way it should be.”
Student athletes may not return to play (RTP) without written permission from a medical professional trained in the evaluation and management of concussions. However, the definition of “medical professional” is rather vague.
Non-Mandatory, Helpful Baseline Tests to Determine Concussion
ImPACT (Immediate Post-concussion Assessment and Cognitive Testing) is one of the first-developed and most widely-used computerized concussion evaluation systems.
Web-based, it’s given to student athletes before the start of a sports season. It provides a baseline evaluation that tracks verbal memory, visual memory and reaction time functions; the results help more accurately assess a child’s condition after a possible concussion or brain injury.
SCAT2 is another tool that’s of standard use in the NCAA (National Collegiate Athletic Association). The pre-season test calculates an athlete’s thinking ability, general well-being, and balance testing for a baseline score.
“Balance is a significant part of evaluating concussions,” said William Feldner, DO, a sports medicine specialist at South County Family & Sports Medicine and St. Anthony’s Medical Center in St. Louis, and also the team physician for Lindenwood University and USA Volleyball. “Combine both tests and if someone has a concussion, you retest them on IMPACT or SCAT2. Both are very important tests.”
“In Missouri, the wording allows the medical professional to be an athletic trainer, chiropractor, psychologist or other provider who says they have expertise,” pointed out Sarah Alander, MD, a pediatric emergency medicine doctor at Mercy Children’s Hospital who leads the new Mercy Clinic Post Concussion Service. “In other states, a physician’s or clinical neuropsychologist’s permission is required before the student athlete is allowed to return to play.”
Harvey Richards, associate executive director of Missouri State High School Activities Association (MSHSAA), helped write the legislation, which also requires mandatory pre-season concussion education for coaches, athletes and their parents, and a stipulation for schools to report concussions. The association also recommends benching athletes with three concussions in a single season until a comprehensive exam is performed.
Because the law is relatively new, the issue of enforcement and penalties remains to be seen.
“I don’t know what happens to people who don’t comply,” said Alander. “That’s a gray area. Because a concussion is a clinical diagnosis, and there’s no one particular test to diagnose a concussion, I think it’ll be a difficult law to enforce on an individual level. It’ll definitely be interesting to see what happens.”