Sonoma County Medical Association
Robert Nied, MD
In May, Junior Seau--one of the greatest football players of his generation--took a gun and shot himself in the chest. He was just 43 years old. His friends and family blamed his suicide on the accumulated toll of repeated concussions.
Seven days a week, Google Alerts fills my smartphone with new concussion-related links and press releases. Most concern injuries to professional athletes, but there are also stories of high school careers derailed, new findings on the severity and long-term consequences of concussion, and reports on new or pending legislation. Indeed, nearly every state legislature in the country is racing to enact laws protecting kids from concussions; and for good reason. The Centers for Disease Control estimates that 1.6 to 3.8 million concussions occur annually in sports and recreational activities.
Up to 20% of high school football players will have symptoms of a concussion in a given season. This is not surprising, given that the average player gets over 1,000 subconcussive blows in excess of 20 Gs per season.[2,3] As many as 90% of concussions go undiagnosed and untreated, although this number is declining with increased awareness of the condition, along with growing acceptance among athletes that a concussion is a legitimate injury. In a sign of the times, pediatric ED visits for head injury increased almost 100% between 1995 and 2007.
Marisa is a 16-year-old club soccer player who collided with another player while attempting to head the ball and was knocked to the ground. She doesn’t remember the moments following the collision. Initially she had a headache, dizziness and a feeling she was “in a fog.” She did not vomit. By the time she presents to your office two days later, her symptoms have nearly resolved, although she still is having some trouble concentrating.
What grade of concussion did she have? What should you include in your initial evaluation? What are your initial treatment recommendations? When can she return to play?
What is a concussion?
Concussion is currently defined as a “complex pathophysiologic process affecting the brain” resulting from either a direct or transmitted blow to the head and a having a lack of abnormalities on standard structural neuroimaging. Recent advances in neuroimaging, such as fMRI, along with the identification of serum and CSF biomarkers of traumatic brain injury, have yielded insights into the cellular processes of concussion. At present, however, there is no reliable biochemical marker for traumatic brain injury, and advanced imaging technologies are mostly limited to the research setting. As such, a concussion remains primarily a clinical diagnosis based on typical symptoms in the context of a head injury.
For the front-line clinician, perhaps the most important change in the current definition of concussion is the abandonment of the traditional graded concussion paradigm because of the complex and variable nature of individual symptoms and outcomes. In other words, a patient simply either has a concussion or not.
What should your initial evaluation include?
Marisa’s initial evaluation should include a symptom inventory (see sidebar on concussive symptoms). More symptoms across more domains generally correlate with a more significant injury. A recent study looking at subtle injury patterns on DTI (an advanced MRI modality) has suggested a correlation between the location of brain injury and the symptom complex the athlete experiences. Loss of consciousness less than a few minutes, though dramatic, seems to have little predictive value for the severity of the concussion or long-term consequences.
Loss of Consciousness
• poor concentration
• inability to process new information
• sleepiness or fatigue
Your physical exam of Marisa should focus primarily on signs and symptoms of skull fracture and intra-cranial bleeding. If present, consider a head CT scan. You should assess her balance--loss of balance is an objective finding in some concussed athletes. In our office we use the Balance Error Scoring System (BESS), a simple and quick test which can be done by any physician. Finally, you should evaluate her cognitive function. The simplest option is using the Sideline Concussion Assessment Tool 2 (SCAT2). Both the BESS and SCAT2 can be found in the Zurich Guidelines.
More advanced testing can be done using neuropsychological testing (see below), but this may not be necessary. At Kaiser Permanente, we have adapted the SCAT2 to our electronic medical record and are evaluating best practices for its inclusion in the primary care office setting.
Marisa’s exam demonstrates no focal neurologic deficit. She has no increase in her symptoms with exertion or deficits to balance testing. Based on her history, symptoms and physical exam, we can conclude that Marisa had a concussion.
What is your initial treatment plan?
The mainstay of treatment for a concussion remains brain rest. Although exertion clearly increases concussion symptoms, there is little evidence that the injury actually resolves faster with rest, or what amount of rest is most beneficial. A recent observational study reported significant benefits, even months after the injury occurred, with a week of “total rest” (including no TV, computer or telephone use). Athletes and coaches usually understand the need for physical rest, but physicians should actively prescribe cognitive rest as well. There are standardized templates describing a “return to school” protocol available from the CDC and others.
For the majority of concussed athletes, rest is all that is required. For prolonged symptoms lasting more than 3-6 weeks, other treatments may be considered. Vestibular rehabilitation may help persistent balance and vertigo symptoms. Tricyclic antidepressants and amantadine are often employed for prolonged headache and sleep disturbance. High dose (2-4 grams a day) Omega 3 essential fatty acid supplements have been suggested as an active treatment for axonal healing. Clinical outcome studies in humans, however, are lacking. There is a significant overlap between the symptoms of a prolonged concussion and common mood disorders such as depression. The use of SSRI antidepressants may be helpful, but coordination with a behavioral medicine specialist is recommended.
What about neuropsychological testing?
Neuropsychological (NP) testing has long been used both in research and clinical treatment of concussion and other traumatic brain injury. The advent of computer-based testing has made it available for routine use in the training room and office (see sidebar on ImPACT testing). Although not universally accepted or shown to actually improve outcomes, NP testing can help identify a subset of athletes with demonstrable cognitive defects even after self-reported symptomatic recovery. Aside from cost, the primary limitation of NP testing is the need for baseline measurements.
How long should Marisa rest?
The typical concussion in an adult lasts about a week, with physical symptoms lasting a few days and NP testing returning to baseline in about a week. Recent studies using NP testing have shown that teens take about twice as long, with younger and female athletes taking the longest to return to baseline status.[10,11] Changes on MR spectroscopy take months to resolve. Diffusion tensor imaging (an advanced MRI technique which detects subtle brain injury by measuring the direction of water diffusion in white matter) has demonstrated injury pattern changes years after injury, although the clinical significance of this is unknown.
Individual recovery, however, is highly variable and unpredictable. Sidney Crosby, despite the pressure of being the most recognizable hockey player in the world, sat out of competition for nearly a year. Prolonged symptoms of post-concussion syndrome are fairly common, affecting up to 20% of athletes. There is also a correlation with pre-existing mood disorder, migraines and learning disability. Some evidence suggests that initial anterograde amnesia and balance impairment are the symptoms most closely associated with a longer recovery.
For Marisa, absent a baseline NP test, we’ll prescribe complete physical rest until asymptomatic and then a graded return to school and play while monitoring for the return of symptoms.
Is Marisa at risk for another concussion?
There is a generally recognized period of increased vulnerability for a repeat concussion. The second concussion tends to be more symptomatic, longer lasting, and to result from a lesser impact than the initial injury. Retrospective and animal model studies suggest a “window of vulnerability” lasting less than a week, but with a four- to six-fold increase in likelihood of concussion. It is unknown if the resolution of reported symptoms or deficits on NP testing predict the closing of this window of vulnerability.
Although the NFL has begun to take concussion history into account in evaluating draft prospects, it is unknown if there is a genetically determined “concussion threshold” or predisposition. We have known for decades that the APOe4 allele is associated with boxers developing dementia pugilistica (punch drunk syndrome). Recent studies have suggested that it may also identify a subset of individuals at risk for more severe consequences of sports-related concussion injury.[5,14]
What about the bad stuff?
The much publicized and feared “second impact syndrome,” in which a repeated concussion during the recovery process results in sudden death, is actually an exceedingly rare event. It is estimated to occur once per every 5,000 team seasons in American football. It is most likely a subset of malignant brain edema, a previously recognized entity with a genetic predisposition, and not truly a consequence of a repeat concussion. Even if NP testing could prevent second impact syndrome by stopping premature return to play, it would take an estimated 18 million baseline tests to prevent one case.
Much attention has been given recently to chronic traumatic encephalopathy (CTE), following the discovery of large abnormal accumulations of Tau protein in the autopsied brains of former football players. As with many other medical conditions, however, there is a difference between association and cause and effect. Why repeated trauma might lead to CTE and whether and how those changes lead to clinical symptoms remain unanswered questions. Indeed, earlier this year a CDC study looking at death rates of almost 3,500 retired NFL players found lower than expected death rates and suicides. Others have pointed to the known associations between chronic pain, depression and substance abuse in former athletes as confounding variables.
What about the effects of heading on our soccer-playing patient?
Girls’ soccer is second only to football in the risk of suffering a concussive head injury. Eighty-six percent of soccer-related concussions are related to the act of heading, but most of these are collisions in the course of play, e.g., head-to-head, head-to-ground. A widely publicized recent study reported that heading the ball more than 1,000-1,500 x/year was associated with changes on fMRI resembling minor traumatic brain injury, as well as lower scores on NP testing vs. age-matched peers. But the number was small (n=38), and other retrospective studies of the long-term effects of heading the ball are conflicting. For now, a reasonable approach may be to delay heading until skeletal maturity, to limit unnecessary heading in practice, and to teach excellent fundamental technique.
Can concussions be prevented?
Helmets, which are designed for and do a remarkably good job of preventing skull fractures, do not prevent concussions. Indeed they may be part of the problem. The late Joe Paterno famously said that the way to prevent concussions was to take away helmets--then players would not hit with their heads. Similarly, mouth guards only prevent dental injury. There is no current evidence that soccer headgear products can reduce the incidence or severity of concussions.
Lesser neck strength relative to head size has been postulated as the reason for increased incidence in younger and female athletes. Several small studies, however, have failed to show that neck-strengthening exercises result in fewer head injuries.
The most effective systemic way to prevent concussions is through rules changes. In the early 1900s, President Theodore Roosevelt threatened to ban college football after a rash of deaths due to head injuries. Instead, the flying wedge was banned and the NCAA was born. More recently, outlawing spear tackling dramatically reduced the risk of spinal-cord injury in football. “No hitting” leagues have been established in youth hockey, and I expect we will see further rules changes in other contact sports.
What does this mean for Sonoma County?
Earlier this year, California became the 42nd state to enact concussion legislation for high school athletes. The new law requires high school athletes suspected of having a concussion be removed from play and not returned to competition until they are cleared by a medical professional trained in the management of concussion. (Interestingly, this is a broader statement than existing California Interscholastic Federation regulations, which specifically require that athletes be cleared by a physician.) Additional pending state legislation stipulates the specifics of mandatory annual training for coaches and athletes. Clearly we will be seeing more patients.
Local communities are beginning to assemble the patchwork of health resources so that all young athletes have access to concussion education and care. For example, the mission of the Northern California Concussion Coalition (NCCC) is “to work in partnership to provide student athletes in the community with the best-in-class resources available to protect them from concussions in sports.” Physicians from UC Davis, Sutter Health, Mercy, and Kaiser Permanente have already formed a similar concussion coalition in partnership with the Play It Safe program in the Sacramento area, and we hope to develop a similar program here.
What will NCCC, Play It Safe and similar programs mean for an athlete like Marisa? The hope is that Marisa can play on a team in which her coach is aware of and watching out for concussions. That Marisa’s parents and teachers understand and respect her need for brain rest following an injury. That her teammates support her recovery even though it is a silent injury. That Marisa herself understands the importance of not “playing through” her injury, and that she receives care from a physician who makes an informed diagnosis and initial treatment plan. And perhaps most important--that she has access to a network of sports medicine specialists and others in the community as needed regardless of her health plan or insurance status.
Dr. Nied is a family physician and sports medicine specialist at Kaiser Santa Rosa.
ImPACT is a computer-based neurocognitive test that can be administered by doctors, psychologists, school nurses, athletic trainers or other qualified personnel who complete the necessary training. Among other functions, the 30-40 minute ImPACT test measures attention span, working memory, sustained and selective attention time, response variability, non-verbal problem solving, and reaction time.
Ideally, ImPACT should be administered to establish a baseline screen for athletes before the season begins, but it can be used regardless of baseline to help evaluate cognitive deficits after a concussion. Whenever an athlete appears to sustain a concussion during the season, he or she is pulled from play, evaluated, and if necessary sent to a physician or other professional certified by ImPACT for clinical assessment and specialty care. The ImPACT test is then readministered, and the results are used to determine the extent of the concussion and to help with the treatment plan.
Locally, ImPACT testing has been implemented at both Santa Rosa Junior College and Sonoma State University. Dr. Ty Affleck, a certified ImPACT concussion specialist and team physician for both schools, hopes to implement the testing in local high schools in the near future. Discussions with Santa Rosa City Schools are ongoing.
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