Protecting Our Players
As football players crisscross down the turf, ducking and weaving to avoid their opponents, shoulder pads mesh together and helmets collide. Propelling themselves across the soccer field and competing over the ball at high velocity, elbows come into contact with faces and players’ heads strike the ground. In hockey, athletes glide across the ice before abruptly plowing into the boards, courtesy of a check from an opposing player.
For many competitive sports, at every level from elementary school to professional leagues, the inherent danger of collision and, subsequently, concussion, is always present. Driven by an exponential increase in concussion awareness, education and prevention, many physicians, athletic trainers, coaches and players are banding together to battle the looming threat of sports related head injuries.
“There was a fumble, and I was chasing the tackler, and I just got blindsided and my head hit back on the turf,” recalled Andrew Reue, an offensive lineman for the Rice Owls men’s football team who sustained a concussion during game time. “I blacked out for probably five seconds or so, and I got up when they scored the next play.”
It was not obvious at first that Reue had sustained a concussion, but when he began to show signs of confusion, a teammate immediately alerted Rice University’s athletic trainer. They attribute the training team’s quick response, and his teammate’s concern, to ongoing educational efforts surrounding concussion awareness. Unlike other injuries sustained on the football field, signs of a concussion can be subtle, and symptoms easy to miss.
“I actually went in for another series before we realized I had a concussion—I don’t remember any of that series, and still don’t to this day,” he added. “I looked up at the scoreboard and asked how the other team had scored…I didn’t even know where I was. Our center told the coach and they got the athletic trainer over, who started the concussion protocol. I was pretty much done for the season.”
A concussion is the term used to describe mild traumatic brain injury—it is characterized as any type of blow to the head or body that causes the disruption of brain functioning. “Really, a concussion is a physiological dysfunction that occurs in the brain,” explained Kenneth Podell, Ph.D., FACPN, neuropsychologist and co-director of the Houston Methodist Concussion Center. “If two players are running at full speed and they collide, both their helmets and the skull stop, but their brain will continue to move. It’s the same as if you were in the car and slammed on the brakes, where you would lurch forward as the car stops. In a car, you have a seatbelt, but unfortunately, we haven’t designed that for the brain yet.”
“The brain is the softest tissue in the body, pretty much like cold Jell-O,” he added. “Imagine the brain were to hit something, it would compress like a spring and then bounce back and hit the other side of the skull—that causes the shape of the brain to change. When that happens, you’re changing the shape of the cell membranes, and the normal balance of chemicals inside and outside the brain is disrupted. That imbalance that develops inside the cells of the brain causes this whole chain reaction, which manifests as the initial signs and symptoms of a concussion.”
Backed by a multispecialty team that incorporates a wealth of disciplines from neurosurgery to athletic training, experts from the Houston Methodist Concussion Center serve as team consultants for an equally broad range of professional athletes, including the Houston Texans, Houston Astros, Houston Dynamo and Houston Rodeo, as well as Rice University, collegiate, high school and youth teams. Embracing education and community outreach, Houston Methodist Sports Medicine’s athletic trainers work in conjunction with the Houston Methodist Concussion Center to provide an arsenal of weaponry in efforts to combat concussions.
Visiting over 300 schools in the greater Houston area, they provide information about the concussion center, administer ImPACT baseline testing, which serves as a neurocognitive assessment tool, and deliver presentations on concussion education. The latter, reflects Podell, is essential in addressing sports injuries to the brain.
“There are a good number of myths about concussions,” noted Podell. “The important thing to understand is the distinction between what is myth and what we simply don’t understand yet, because the data just hasn’t been collected. More and more data is coming out, and at some point, enough correlational data is the same as causation. As of right now it still hasn’t been definitely proven that the development of degenerative brain diseases, like chronic traumatic encephalopathy, is due to repeated trauma to the head. We still need more information.” According to Podell, the average college football player sustains up to 3,000 hits a season.
“What we do know is that if a player is acutely concussed, meaning that they’re showing symptoms, cognitive deficits, impaired balance, or a combination of those three, that the brain is considered much more vulnerable to being re-concussed,” he added. “In those instances, the effect is potentially exponential—that second concussion could be much more severe and much more detrimental to the individual, long term.”
While the cumulative impact of repeated concussive blows to the head is still being studied, the necessity of preventing additional concussions prior to a player’s symptoms resolving, especially at the high school level when their brain is still developing, is paramount.
“When the brain has already been concussed, it’s in a state of stress,” explained M. Cullen Gibbs, Ph.D., clinical neuropsychologist at TIRR Memorial Hermann (The Institute for Rehabilitation and Research). “There are a variety of things that occur in terms of metabolic changes happening in the brain, from changes in the amount of blood flow to the ability to metabolize glucose. If another concussion occurs in that state of heightened vulnerability, there can often be longer lasting symptoms and the level of severity of those symptoms may increase. A person in a previously damaged state is being put at increased risk for further loss of function.”
Fortunately, in cases of acute concussions where symptoms are recognized and treated appropriately, players are able to return to their sport and their lives without issue. “What we tend to do, initially, is reduce physical and cognitive activity,” said Podell. “We might say, ‘Hey, you might not want to go to school for a couple of days and we’re going to monitor your symptoms throughout that process.’ Once those symptoms start to drop, and it doesn’t have to be zero, but once they’re low enough, we will start some low level physical activity.”
“Once the symptoms have cleared up sufficiently, then we start phasing them in gradually, over a period of a few days or more,” added Houston Methodist physician David Braunreiter, M.D.,team physician for the Houston Dynamo and physician member for the Major League Soccer Concussion Committee. “It’s never wise to return an athlete to the sport with this injury without testing gradually up the ladder of intensity in game-like circumstances before getting them back in the actual game.”
Unlike visible orthopedic injuries that come with the territory of competitive sports, concussions have a greater potential to go unnoticed. Vigilance from athletic trainers, coaches and fellow teammates in recognizing observable signs (appearing dazed, problems with memory, or personality changes) and transparency from the athletes themselves in discussing their symptoms (headache, nausea and problems with memory, among others) are both crucial.
“In our education process, we emphasize to our athletes to watch out for each other,” said Scott McGonagle, MS, ATC, LAT, head athletic trainer for Rice University. “These things happen throughout the course of a football game where nobody sees the impact and the kid continues play until, all of a sudden, somebody realizes that he’s not acting quite right. If a player keeps jumping on the snap count, or goes left instead of right, his teammates might catch on. They check on each other during the huddle—it’s really amazing, and our coaches tend to know when something’s wrong with one of their players. ”
As concussion awareness continues to evolve, the efforts to protect our athletes are manifesting in everything from research to equipment. David M. Eagleman, Ph.D., neuroscientist and director of Baylor College of Medicine’s Laboratory for Perception and Action, recently launched a new company, BrainCheck, which uses mobile tablets to assess concussions on the sidelines. “In six minutes we can harvest 12 measures of brain function that have the sensitivity and specificity for detecting concussion,” he said. “With this technology, we can provide coaches and clinicians with the critical information they need to optimize return-to-play decisions.”
Supported by a grant from General Electric and the National Football League, the Houston Methodist Concussion Center is working to develop biomarkers for concussion that can be identified through magnetic resonance imaging (MRI). While sensors that can be attached to helmets currently exist, they only measure pure force without acknowledging the influence of rotation on concussive blows. If they’re adapted with the capacity to measure rotation, physicians and athletic trainers will have to consider the ramifications of pulling athletes from play based on strictly mechanical data. As it stands, furthering education and fostering a climate of awareness are the two strongest assets that we have.
“I think that the attitude towards concussions has changed over the years, especially at the collegiate level,” said Reue. “In high school, unless you were unconscious or had some serious memory loss, the attitude was that you just got your bell rung and kind of shook it off. It’s a lot different now—it used to not be a respectable injury, but now that people are understanding the severity of it, it’s much more understandable. People are appropriately worried about the symptoms.”
“At the end of the day, being aware of concussions and getting to the point where the athletes are volunteering to take themselves out if they think they might have sustained a concussion is just remarkable,” concluded Podell. “The culture has changed, and we’ve arrived at a point where people are acknowledging that this is a real injury. That mentality of playing through pain and injuries is gone—the fact that we’re treating players differently than we were 10 years ago will make a big difference for their long-term health.”
What Is a Concussion?
A concussion is a mild traumatic brain injury. When an athlete hits an object or is hit, the brain moves around inside the skull, stretching and twisting the cells and fibers and changing the way that the brain normally works. Less than 10 percent of concussions result in any loss of consciousness.
What Happens During a Concussion?
During a concussion, the shape of the brain’s cell membranes are distorted, causing a chemi- cal imbalance. This sets off a cascade of effects leading to a disruption in blood flow and the brain’s ability to get oxygen and glucose that are necessary for recovery. This mismatch between decreased supply and increased demand leads to an “energy crisis” in the brain and results in con- cussion symptoms. If severe enough, permanent damage can occur.
Epidemiology of Sports Concussion
While several factors determine the rate of con- cussions in a given sport, football has the highest rate in males and soccer in females, with other sports like ice hockey, soccer, lacrosse, basketball and field hockey not far behind. Gender and age are also key factors, with younger athletes being more vulnerable and taking longer to recover. Women are more prone to suffer concussions compared to men.
Also, concussions are much more common in competition than in practice. Concussion fre- quency has increased over the past decade (most likely due to better detection and awareness), and the Centers for Disease Control and Prevention estimates upwards of 3.8 million concussions annually in the United States. However, many go unreported, so the exact number is unclear.
When Is an Athlete Ready to Return?
A gradual, incremental approach is essential. An athlete must be symptom-free, cognitively intact and demonstrate good balance before a return to play exercise protocol can begin. This is when an athlete is slowly reintroduced to competitive ath- letics with gradually increasing physical activity, followed by non-contact practice, contact practice, and finally game play. All 50 states have laws regarding concussion education and care.
Signs and Symptoms
- Appears dazed or stunned
- Confused about assignment or position
- Forgets an instruction
- Unsure of game, score, opponent
- Balance problems or clumsy movements
- Answers questions slowly
- Loses consciousness (even briefly)
- Can’t recall events before or after impact
- Loses balance or is unsteady walking
- Shows mood, behavior and personality changes
Symptoms Reported by Athlete
- Headache or “pressure” in head
- Double or blurry vision
- Sensitivity to light or sound
- Feeling sluggish, hazy, foggy or groggy
- Concentration or memory problems
- Just not “feeling right” or “feeling down”
It’s essential to be alert for symptoms that worsen over time. The student/athlete should be seen in the emergency department right away if he or she has:
- One pupil (the black part in the middle of the eye) that is larger than the other or loss of vision
- Drowsiness or cannot be awakened
- A headache that gets worse and does not go away
- Weakness, numbness, or decreased coordination
- Repeated vomiting
- Slurred speech
- Convulsions or seizures
- Difficulty recognizing people or places
- Increasing confusion, restlessness, or agitation
- Loss of consciousness (even a brief loss of consciousness should be taken seriously)
- Moderate or severe neck pain or rigidity