Concussions have been a hot topic in sports medicine over the past few years, fueled mainly by the attention they have received in the NFL. Since football season is now getting into full swing, I have asked a local concussion expert and head of the Norton Sports Health concussion program, Dr. Tad Seifert, to answer some questions about concussions.
“Dr. Seifert, how does an athlete know if they have sustained a concussion?”
There are many classic symptoms typically associated with sports-related concussion, the most common of which being headache. Other symptoms of acute concussion are very similar to those seen in alcohol intoxication, including balance difficulty, confusion, and sometimes (although not always) loss of consciousness.
“How do you treat an athlete who comes in to see you after a first time concussion?”
The hallmark of present day sports concussion treatment is rest for the injured athlete until all symptoms have cleared. This rest period also includes cognitive rest for approximately 48 – 72 hours (i.e. no texting, video games, reading, television, driving, etc). The majority of sport concussions and their associated symptoms clear in approximately 7 to 10 days. For symptoms persisting beyond that time period, a brief trial of prescription medication may ultimately be needed.
“When would you let them return to their sport after a first concussion? Does it matter what sport they are playing?”
I will allow a player to return to contact and/or collision play after they have returned to their normal baseline (off medications) and have successfully completed the Graduated Return to Play Protocol. This protocol was designed at the Zurich 2008 International Conference for Concussion in Sport, and outlines a stepwise procedure for gauging an athlete’s readiness for return to competition.
“Are your treatment or return to play decisions different for a second, third, or fourth concussion?”
The initial treatment of cognitive and physical rest are very similar for all concussions, no matter the first or fourth lifetime event. However in an athlete suffering repeated concussions, I will often progress them more slowly through the Graduated Return to Play Protocol. This ensures me they can indeed tolerate all forms of physical activity without recurrence of symptoms.
“How many concussions are too many?”
There is no “set number” as to when an athlete should retire from a particular sport and transition to an alternative activity involving less risk for contact/collision. I have sometimes recommended this after a single event in which the athlete required an unusually prolonged time period to return to their normal baseline. Conversely, I’ve seen athletes having just sustained their 3rd event, yet rapidly returned to their normal baseline without evidence of long-term effects. In that setting, I typically will allow continued play in their respective sport.
Specific factors I take into account regarding this type of decision making include the following:
- Did the athlete recovery in the expected time frame, or was this an unusually prolonged course?
- Are recurrent concussions occurring with less forceful impacts than the previous injuries?
- Does the athlete show evidence of subtle cognitive dysfunction on a formal neuropsychological evaluation, despite a “normal” appearance otherwise?
These factors are all potential red flags in allowing an athlete continued participation in their sport of choice. Each case of course, is unique and treated with individual care.
“Do all athletes that sustain a concussion need to see a neurologist?”
Since a concussion by definition is a form of brain injury, I would indeed recommend formal evaluation by a neurologist after the event.
“What is second-impact syndrome?”
This is a very serious syndrome where an athlete takes a second hit to the head prior to recovering from a first concussion. It is quite rare, but when it does occur results in death in approximately 50% of individuals and significant permanent disability in the other 50% that survive.
“Are some people genetically predisposed to getting a concussion?”
There is still debate within the medical community on this question. We do know some athletes react differently than their teammates when sustaining a head impact of similar force. We know without question however, that an athlete is at higher risk of sustaining a recurrent concussion after they have suffered an initial event.
“I know that many of the Jefferson County schools have implemented ImPACT testing. What exactly is that?”
ImPACT testing is a brief computerized neuropsychological test administered to help clinicians detect subtle cognitive problems. Some of the items tested include visual memory, verbal memory, and reaction time. The ImPACT test, although quite useful, is just one tool used by physicians in determining if a player is ready for safe return to play.
“Are there special football helmets that are better at preventing concussions?”
To date, the 2011 and 2012 Virginia Tech helmet studies are the only research available directly comparing various makes/models. They assigned a 1 to 5 star rating for each tested helmet — 5 being the best. Only three helmets currently carry Virginia Tech’s 5 star rating: the Riddell 360, the Riddell Revolution Speed, and the Rawlings Quantum Plus. See here for the complete ratings: http://www.sbes.vt.edu/pdf/STARRatings2012.pdf
A key point to remember is that NO helmet is concussion preventative. The primary role of football helmets is to prevent skull fractures. Do they decrease the likelihood of concussions? Likely to some degree, but it certainly does not eliminate all risk.
“At one time, special mouth guards for football were thought to help prevent concussions. Has this proven to be true?”
This is a big misconception in the general public. There have been many clever marketing ploys by various companies touting mouthguards that help to “prevent concussion.” There simply is no evidence-based medicine or research to support these claims. Bottom line: mouthguards prevent dental injury only.
“Is there anything that players can do to help prevent concussions?”
In addition to the standard recommendations (appropriate sport-specific technique, equipment, etc) there have been some recent suggestions regarding the importance of neck and shoulder musculature. I am now counseling my athletes on the importance of developing a strength & conditioning program with special attention to neck/shoulder training. The theory is a stronger neck region helps to dissipate forces applied to the head & neck region. Lower force absorbed results in less movement of the brain inside the skull. Studies are underway on this theory and more definitive information should be available in the next 1-2 years.
Dr. Seifert is a part of the Norton Sports Health Sports Injury Clinic that we will host on Saturday mornings during football season. Follow him on Twitter @neurodoctad
Questions or concerns about concussions? Please comment below or on Twitter @samcartermd