Before beginning the final installment of our series on concussions we wanted to take a moment to acknowledge the death of NFL great Dave Duerson who shot himself in the chest last month. The former Chicago Bears safety had left a written note and sent a text message to his family requesting that his brain be donated to research.
Chicago Bears Great Dave Duerson
Yesterday, at the request of his family, Boston University researchers announced that Duerson’s brain had in fact developed chronic traumatic encephalopathy. This is the same trauma-induced disease recently found in more than 20 deceased NFL players. In the months leading up to his death, Duerson had complained of headaches, blurred vision and a deteriorating memory – all symptoms of C.T.E.
DeMaurice Smith, the executive director of the NFLPA, said that Duerson’s having C.T.E. “makes it abundantly clear what the cost of football is for the men who played and their families.”
At the press conference Duerson’s son Tregg said, “It is our hope that through this research questions that go beyond our interest may be answered — questions that lead to a safer game of football from professionals to Pop Warner.”
That is our hope as well. And now . . .
Concussions A Primer, Pt 3
In the first two installments of our series on concussions we explained the complex web of events within a concussion and how it is detected. In this final installment, we will explore post-concussion treatment and how decisions are made regarding when an athlete is ready to return-to-play.
The treatments of concussions are complex and each case is unique. The process of treatment, recovery, and management of concussions is a balancing act that depends upon the history of the athlete (including their overall health at the time of incident, prior concussions, etc.), the severity of the incident, the initial response, and long term monitoring. It requires a day-by-day assessment of the athlete’s abilities and disabilities to enable a team of providers to put together a personal treatment plan. Appropriate management is essential in order to reduce the risk of long-term symptoms and complications such as Second Impact Syndrome (SIS), which we will touch on later.
The treatment team (physician, athletic trainer, clinical sport psychologist, neuropsychologist, etc.) must maintain a high level of monitoring of cognitive, physical, and balance changes to understand the concussion and to plan a course of treatment, and eventually make the return-to-play decision. The mainstay of concussion management after diagnosis is self-reporting by the athlete, and the use of objective information that is measured from aspects of brain functioning (types of subjective and objective data were discussed in the prior column, see Concussion Primer Part 2).
The use of multiple baselines prior to an incident of concussion (e.g. symptoms reported from the athlete, computer-based cognitive testing, and balance assessment) provides the treatment team with tremendous advantages when assessing if a concussion has occurred. Having prior scores on tests (both subjective and objective tests) can provide valuable information highlighting the differences between an athlete’s state of abilities post-concussion and their normal, healthy performance.
Without established baselines, a much more complex process emerges for the question of return-to-play, and ongoing neuropsychological testing is a helpful tool during management of this type. Many levels of athletes (youth, high school, college, and professional) require some standard of comparison if there is suspicion of a concussion.
AUTHOR’S NOTE: While I believe baseline testing is a good first step, it does not constitute best practice nor do I believe it is sufficient by itself. My belief is that in the very near future, we will start to see the process of assessment and treatment of concussions become as complex as the treatment of cancer. If a loved one is given the “preliminary” diagnosis of cancer after one test, we ask for more information. The brain is such a complex organ that to assume we can take one assessment (computer based or not) and say we have an answer about well-being, return-to-play, and prognosis is not best practice, nor sufficient for the athlete.
For more complete protection, it is important to get multiple readings on cognitive functioning prior to athletic competition. Just as elite athletes measure their baseline strength, speed, aerobic/anaerobic, metabolic, and endocrine levels to track progress, I encourage all athletes to get these additional points of reference.
The American Academy of Pediatrics report (
http://www.aap.org/) notes that a return to sports and physical activity should not occur the same day as a concussion. This is an especially important warning for youth, as well as professional athletes, due to the risk of Second Impact Syndrome (SIS). Return to sports and physical activity requires a progressive exercise program, a complete absence of symptoms, successful completion of a standardized neuropsychological test, and continuing evaluation for any recurring signs or symptoms. An important aspect to note is that the recovery for pediatric and adolescent athletes is generally longer than for older athletes; however, recovery time always varies from case to case.
The growing awareness of the importance of detection and treatment of concussion is highlighted by Second Impact Syndrome (SIS). SIS is rare; however, unmanaged and undetected concussions are at the heart of this fatal set of symptoms. SIS involves an athlete who has been concussed and returned to play too early and then suffers another concussion, triggering a chain of reactions in the body including diffuse cerebral swelling and possible death.
Although this is a rare occurrence, we have only begun to shine the light on the issues of concussion in sports, and the occurrence of SIS may be underreported due to a lack of understanding of these incidents and how they have been researched and categorized. National Center for Catastrophic Sports Injury Research in Chapel Hill, NC, identified 35 probable cases among American football players spanning a time period of 1980 through 1993. Since SIS is acute in nature, it stresses the importance of detection and management from the first indications that a concussion may have occurred, however this should not lead us to believe that concussions in other forms do not require this same level of diligence.
AUTHOR’S NOTE: FUTURE DIRECTIONS
It is fair to say the treatment of concussions is still in its infancy. Comparing where we are with regards to detection and assessment, treatment is lagging behind. This is not surprising and follows patterns seen with heart disease, cancer, and other forms of illnesses; detection and assessment technology evolved first, and treatment options improved later.
It is my hope that in the future we will see clearer protocols that produce positive outcomes on brain health. With more research, I believe we will find that producing targeted stress on the brain we will create targeted growth in the surrounding injured area, or directed to injured areas. We hope to find that this targeting, along with calibrated rest, may produce healthy growth in the brain. We may not be that far off, as several technology companies are working on these questions of recovery and direct treatment; however, we will have to wait to see the science.
Thanks for following this series with us, as I think it is a critically important topic for athletes at all levels. Our next column will focus on the new helmets and their impact, and their effectiveness at reducing impact on the players.
Concussion Recovery-Mayo Clinic
Traumatic Brain Injury Recovery/Michigan Department of Community Health
National Athletic Trainers Association Position Statement on the Management of Sport-Related Concussion
ESPN E:60 Second Impact
ESPN Outside the Lines: Second Impact Syndrome
Acute Effects and Recovery Time Following Concussion in Collegiate Football Players – The NCAA Concussion Study
Second Impact Syndrome
Tareg Bey, MD
* and Brian Ostick, MD
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2672291/ Dr. John P. Sullivan, is a Clinical Sport Psychologist and facilitates both clinical and performance enhancement services for Providence College, the University of Rhode Island, and within the elite ranks of the Olympics, NFL, NBA, WNBA, and MLS. He works with a variety of performers emphasizing scientific based interventions focused on performance and increasing overall well-being. His passion has been engaging in activities that range from consultation, serving on scientific committees to direct service to organizations and individuals to facilitate excellence. He also brings his knowledge and experience to his own consulting practice Clinical & Sports Consulting Services
http://www.performancedocs.com and www.linkedin.com/in/sportpsychologist.
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