Webner, David M.D.
With the ever-increasing worldwide popularity of amateur and professional contact and collision sports (primarily soccer and football), more attention has been given to concussions in sports (CIS). Categorized as mild traumatic brain injury (mTBI), a sports-related concussion is caused by either a direct or an indirect force transmitted to an athlete’s brain, which results in postincident neurological symptoms (9).
Sports-related head injuries have been mentioned in history since ancient Greece. A collection of Hippocratic works mentions concussion, referring to it as a “commotion of the brain,” resulting in neurological impairment (5). At the turn of the 20th century, 19 American football players died or were paralyzed because of brain- and spinal cord-related trauma in 1904. At that time, President Roosevelt threatened to ban American football, which led to the development of the National Collegiate Athletic Association as a watchdog group charged with making sports safer (3).
Although rule changes and protective equipment have improved throughout the decades since the early 1900s, a total of 819 deaths were attributed to American football from 1931 through 1986. The chances of a fatal head injury in American football are equivalent to those in gymnastics and ice hockey and not as frequent as sports such as horseback riding, skydiving, and motorcycle/auto racing (3).
Through the years, physicians caring for athletes have realized that mTBI can occur in less aggressive sports such as soccer, field hockey, basketball, and even volleyball (9). We have learned that CIS can occur any time an athlete sustains a “jarring” motion to the head — whether from an errant basketball pass or from a high-force head-to-head collision in tackle football (9). Although these athletes don’t sustain any “structural” damage to their skull and brain, symptoms from this type of injury can manifest for days, weeks, or even months after the injury (9). It is believed that, on the microscopic level, the neurons that are “shaken” during a concussion are injured, causing a chemical reaction at the cellular level that slows down normal brain functioning. CIS-related symptoms include a mild headache, sleep disturbance, inattention, sensitivity to light and sound, balance and visual disturbances, nausea and vomiting, loss of appetite, emotional lability, and depression. Loss of consciousness was once thought to be the most severe symptom; however, over time, studies have shown that amnesia is associated with the most long-term sequelae in sports concussion (10).
For years, as the monitoring of athletes from the sidelines increased, we began to see that the heretofor so-called “mild” or “ding” concussion possibly had potentially serious delayed neurocognitive effects (7). Neuropsychologists armed with paper and pencil testing were able to qualify the severity of the head injury and the possible residual deficits. This specialty spawned a litany of computerized neuropsychological tests (CogSport, Headminder, ANAM, and ImPact, to name a few) that could help assess an athlete’s cognitive function. Although history and physical examination are still the cornerstones of return to play, neuropsychological testing has become an important tool assisting in these decisions (4).
The conundrum for athletes, parents, coaches, and fitness personnel has become identifying concussions from other less serious injuries. In addition, as fitness professionals, we have been placed into the position where we may be asked to make recommendations to athletes who have sustained multiple CIS with respect to their future participation in collision/contact sports. Indeed, a fine line is being drawn between protecting our children from possible head injury and allowing them to participate in athletic activities that not only confer good physical health benefits but improve psychosocial demeanor and self-esteem as well.
THE HEADACHE DILEMMA
Most athletes who participate in collision and contact sports finish practices and games in a usual fashion; however, there are those athletes that sustain neurological symptoms either during practice/competition or after an event has occurred. Any athlete experiencing neurological symptoms or signs during or after an athletic event or practice is deemed to have a sports concussion until proven otherwise (9). Management of CIS has improved a great deal, to the point where we believe that proper recognition and removal of an athlete with a sports concussion could mean the difference between chronic neurological deficit and intact neurological health (9).
Fitness professionals should be most aware of the so-called devastating second impact syndrome (SIS). This rare event occurs if an athlete sustains a sports concussion but returns to play without complete symptom resolution and then suffers another mTBI. In rare cases, this second impact may cause neurocognitive devastation or even sudden death (3).
Parents can be most helpful to the sports medicine team by communicating with their children and asking about potential symptoms of concussion; however, the onus is on the athletes themselves to not minimize symptoms and to alert the fitness professional, certified athletic trainer, or coach, who can promptly remove the athlete from the field of play.
Prolonged postconcussion syndrome and SIS occur much less frequently if children are removed from play when still symptomatic. Although CIS is difficult to prevent — helmets and other headgear are protective against skull fractures but have not been shown to decrease the incidence of sports-related concussion (13) — the keys to eliminating long-term sequelae are identification, management, and safe return to play (9).
MANAGEMENT OF SPORTS-RELATED CONCUSSIONS
Experience has shown us that the best way to resolve concussion symptoms is with complete academic and athletic rest (9). This means that children will not only be removed from all sports but also will be excused from all structured learning. Because the brain is in a state of acute injury, any physical, emotional, or cognitive stress may lengthen time to resolution of symptoms. Although it may be tempting to “just go to school for a few hours a day,” this apparently minimal educational stress may lead to a prolongation of concussion symptoms (11).
Whereas sports concussions take time to resolve, there are no known medications that hasten symptom resolution. Nonsteroidal anti-inflammatory drugs and other headache medications (abortive or preventive agents) may alleviate some of the symptoms — particularly if headache is the main complaint — but their use will not change the time course of CIS (12).
SAFE RETURN TO PLAY
A sports medicine practitioner with training in sports concussion management can return asymptomatic athletes to play. Under the watchful eye of a certified athletic trainer, the athlete will undergo a graded return. The cornerstone of this protocol is the ability of the athlete to remain asymptomatic throughout the stepwise progression. He or she may advance to the next stage of increased exercise intensity provided he or she has been asymptomatic for the previous 24 hours. Once the athlete has participated in full-contact sports-specific practices, he or she will be allowed to return to competition (9).
Parents should be careful to note that athletes may so miss their sport of choice that they may not be completely forthright in volunteering symptoms during the return to play period. It is imperative that the fitness professional, coach, and family emphasize that playing with postconcussion symptoms will potentially lead to increased morbidity and time lost from sports (2).
CONVERSATION ABOUT SPORTS CESSATION
Unfortunately, like many other facets of concussion, we, as sports medicine professionals, do not have an exact answer to this question; however, parents can be educated as to the likelihood of future concussions based on an athlete’s history of CIS. After three or four concussions, it may become evident that the athlete will sustain a concussion with far less provocation. When this occurs, it is incumbment on the sports medicine professional to reassess participation in contact/collision sports (8).
Unfortunately, with each subsequent concussion, the chances of sustaining further CIS increase. If proven cognitive decline is documented, then all collision and contact sports should be discontinued. At this point, certain athletes will be able to participate in alternative noncontact sports (running, baseball, softball, golf, tennis, etc.) provided that participation in these sports does not trigger symptomatology (6).
Whereas it is well known that no current equipment or rule change can completely eradicate concussion from the competitive sports realm, a paradigm shift in collision sports may be necessary. Less exposure to situations that can cause CIS may help decrease the number of overall concussions in collision athletics. This potentially could be accomplished by limiting collision and full-speed practicing, teaching evasive and protective maneuvers, and emphasizing neck strength and reaction time in the strength and conditioning arena (1). Finally, minimizing exposure during game play (e.g., substituting frequently and sharing player workload evenly among athletes) may reduce overall concussion numbers.
Sports concussion is a complex topic that we have yet to fully understand. Continued athlete and parent vigilance, coupled with fitness professional counseling and proper surveillance by the sports medicine team, will identify athletes at risk and return these athletes to play in a safe fashion. It is our responsibility as fitness professionals to keep looking for potential symptomatology in the athletes we work with and alert the athlete’s family and sports medicine team if we feel that further attention is warranted.
Special thanks to those certified athletic trainers and sports medicine physicians who patrol the sidelines at practices and games on a daily basis. They are on the frontlines, protecting our athletes from harm.
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