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"This issue is clouded not only by the lack of data, but also by confusion in definition and terminology. "
During the Super Bowl it was reported that Brandin Cooks suffered a "head injury," but Patrick Cooks suffered a "concussion". Days prior, Gronk was released from “the protocol” and the NFL announced that it added on-site concussion spotters for the Super Bowl. You have a child in youth sports. What does this all mean?
Let’s look at the concussion issue from the perspective of the youth athlete, their parents and coaches, and youth sports organizations in which they play.
Two Overriding Premises
1. “SRC [sports related concussion] is considered to be among the most complex injuries in sports medicine to diagnose, assess and manage.” Ref
2. When in doubt, take them out!
Why the confusion? It’s all about the terminology and who is using it.
“Concussion is poorly understood by the general public who are regularly exposed to this type of injury via televised sports." Ref
Media tend to trivialise concussion and this may have an impact on the public’s knowledge of, and influence their response to, concussion.” Ref
Concussion terminology is not consistent. Certain terms have “medical” definitions. The media and sports organizations then use these terms improperly. To make matters worse, even the medical profession does not agree on the definition of these terms. And this starts with the definition of the word concussion. Ref
Definition of Concussion
The definition of the word concussion is not consistent in the medical literature. The most recent international concussion consensus statement (2016) basically says that sports concussion:
Is a brain injury
Is caused by direct blow to the head or other part of the body
Symptoms can occur quickly or be significantly delayed and may be short lived or last a while.
You don’t have to be knocked to have a concussion
You probably won’t “see” the damage either physically or via an MRI
Ding, Bell-Ringer, Head Injury, Blow to the head, Brain Injury, Hard Collision, He got popped or smoked, and Impact Event all indicate that a concussion has occurred.
The Signs and Symptoms of Concussion
The signs (what you as the observer see) and symptoms (what the athlete reports) are pretty consistent in both medical and lay reporting. They are:
Loss of Consciousness
Slow to Get Up
Falling to the Ground
Dazed or Confused
Blank or Vacant Look
Facial cut, bruise
Seizure (Fencing Response)
Change in behavior
Inability of athlete to stop crying
Answers questions slowly
Headache, head pressure
Feels like going to vomit
Radiating pain arms or legs
Numbness/tingling arms or legs
Sensitivity to light
Sensitivity to noise
“I don’t feel right”
"I can't think clearly"
"I feel sluggish, groggy"
"I feel very tired"
"I feel nervous"
"I feel sad“
As you can see by the definition, if you have “concussion symptoms” you have a concussion!
Impact Event or Collision
If there is an impact – either player to player/spectator, player to surface, player to equipment – and there are signs and/or symptoms, it is a concussion.
Grading of Concussion
In 1986, Dr. Robert Cantu formulated a grading scale which became widely accepted in the medical field. Several other grading scales were adopted and revised over the next few decades.
The public and and doctors were told that concussions were graded:
Grade 1 or mild
Grade 2 or moderate
Grade 3 or severe
The additional confusion surrounding loss of consciousness (LOC) and concussion comes from the fact that a Grade 1 concussion did not require LOC, but Grades 2 and 3 did.
And then, in a 2013 press release the American Academy of Neurology stated, "We’ve moved away from the concussion grading systems ...." So no more grading system for concussions.
What does “Mild” mean?
"If you tell me something is mild, then it's no big deal," says a parent. Well let's just wait a minute!
In the medical literature there is a term called Traumatic Brain Injury or TBI. There is again, inconsistency in the medical definition of the term. The most recent definition is, “a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head…”
Then we have Mild Traumatic Brain Injury or mTBI.
For 50+ years, the term mild TBI has been used interchangeably with sport-related concussion. These authors found 38 definitions of mTBI and “a continuing lack of unity regarding mTBI definitions.”
Their definition is “an acute brain injury resulting from mechanical energy to the head from external physical forces.” “Conceptually,” the difference between concussion and mTBI is that mTBI causes brain damage that can be documented. They state that concussion is the mildest form of mTBI. How is that for clarity?
So, if a concussion is the mildest form of mTBI, what is a mild concussion?
There is no medical definition for this! There is no mild concussion!
Post-concussive Syndrome (PCS)
PCS is simply a fancy way of saying that the signs and/or symptoms are not going away. Again, "there is no consensus with regards to the criteria for diagnosis” and an “unambiguous definition for PCS is missing.”
Second Impact Syndrome (SIS)
SIS is a second concussion that occurs before full recovery from the first concussion which may cause a catastrophic outcome, i.e. death. Again, definitions of the term vary in the medical literature.
Sub Concussive Hits
Sub concussive hits mean impacts that do not cause symptoms. The most recent paper on subconcussive head impacts states, "Evidence reviewed predominantly from studies of male athletes in contact and collision sports identifies that repetitive hits to the head are associated with microstructural and functional changes in the brain. Whether these changes represent injury is unclear. We determined the term ‘subconcussion’ to be inconsistently used, poorly defined, and misleading. Future research is needed to characterize the phenomenon in question."
Even the way subconcussive is spelled (vs. sub-concussive) differs in the literature.
This paper has received a lot of attention due to its statement, “These observations suggest that repeat head injuries, even in the absence of concussion, may induce TBI and CTE brain pathologies.”
The recent comment by Dr. Lee Goldstein only adds to the confusion. “It’s the hits to the head, not concussion, that trigger CTE.” Maybe a better way to have said this would have been that it is all hits to the head in total, not only hits which are diagnosed as concussions, that trigger CTE.
The Concussion Protocol
This is a huge area of confusion and we are very concerned about the ramifications of what people read and listen to every week and the decisions they make on our youth fields of play. There is no formal definition of “the protocol”. It is typically the period of time from when the player is removed from play to when he/she is returned to play.
Let’s look at the Gronk situation. Here are the headlines just prior to the Super Bowl:
So, how can you be “in the protocol,” yet participate in a practice?
Remove From Play
The first part of the Protocol is the remove from play (RFP) decision making process. The NFL completely disregards their own guidelines which state:
"Player receives impact to the head AND player exhibits or reports symptoms or signs suggestive of a concussion or stinger OR ATC [athletic trainer], booth ATC, team physician, NFL official, coach, teammate, or UNC [Unaffiliated Neurological Consultant] initiates protocol >> Player is immediately removed to sideline or stabilized on field, as needed."
So, IMPACT + SIGN and/or SYMPTOM (only one is required) = RFP!
BUT, how do you actually remove the player? If you think it is safe to simply get the player up and walk them off, you may wish to read this:
Did the player get up on their own and walk off? If not and there is any doubt whatsoever, you must stabilize their head/neck and call 9-1-1. Do NOT let them move and do NOT remove the helmet/facemask (do you have the proper tools?) unless they are not responsive, and you must perform CPR.
Next part. After the player is stabilized and removed from the field, the SIDELINE SURVEY is performed.
"Removed helmet. Team Physician and UNC perform Sideline Survey.
No-Go (Loss of Consciousness, Confusion, Amnesia - automatic no return to play)
History of Event
Concussion Signs & Symptoms
Read the next line!
"If any elements are positive, inconclusive or suspicious of a concussion, player is escorted to locker room."
Let's regroup here. In order to start the process someone observed an IMPACT + a SIGN/SYMPTOM. The player is "stabilized" and the Sideline Exam is performed. And part of the exam is what: CONCUSSION SIGNS & SYMPTOMS! So why is this player not "escorted to the locker room?"
OH MY! PARENTS - ARE YOU PAYING ATTENTION! REMOVE YOUR ATHLETE AND DO NOT LET THEM RETURN TO THE GAME OR PRACTICE. SEEK MEDICAL ATTENTION. LOOK FOR THE DANGER SIGNS.
Incredibly, the NFL guidelines state if the Locker Room examination is normal, the player can return. How can the exam be normal if there was Impact + Signs/Symptoms? It cannot be normal!
Just as bad is the fact that the sideline examination is NOT the "full" examination performed in the Locker Room. So decisions are made without a "full" examination. Gee, any medical student (or any health profession) will tell you that that if you do not perform a "full" examination during your practicals, you FAIL!
Could this mess happen to your child - well, yes! Read:
Finally, there is no magic same day or sideline return to play "test." Please remember that signs and symptoms can be delayed, so why would you risk letting your child return?
Return To Play
Next we have to look at the definition of return to play (RTP)? The recent medical literature defines RTP (sport) and for youth athletes, the term return to learn (RTL).
In the NFL protocol, the teams are basically free to return the player at the discretion of the team doctor with certain guidelines. For youth athletes, if they play in school, there are state high school sports association guidelines as well as state concussion laws. If they play in leagues/clubs, only half of these concussion laws protect non-school based sports programs.
The basic requirements as defined in concussion laws for return to play in youth sports are:
The athlete must be removed for a suspected concussion
The athlete cannot return that day and must stay out for at least 24 hours
The athlete must have a doctor’s note to return to play
What does the date on the note mean?
Is the doctor familiar with the most recent guidelines?
Why do all the state high school sports associations have a different doctor's note? Here is the TeamSafe™Sports physicians note.
Can the athlete return to the sport, meaning all practices and games?
Or does it mean the athlete must start the RTP protocol?
RTP is well-defined protocol with multiple stages that should be overseen by a health care professional. On top of this is the RTL protocol, a separate protocol that the consensus statement recommends the athlete complete BEFORE starting the RTP protocol.
Hah! Clear enough for you? Does your doctor even understand this? Your child’s coach? Now YOU do!
The Short and Long-Term Implications of Brain Injuries
Finally, let’s close by looking at what the recent research says about the far-reaching implications of hits and concussions.
1. Age of first exposure: This study stated, “those who began playing football before age 12 had >2 × increased odds of impairments in behavior regulation and >3 x increased odds for clinically elevated depression scores.”
This study stated, “incurring repeated head impacts during a critical neurodevelopmental period [tackle football before age 12] may increase the risk of later-life cognitive impairment.”
2. Concussion and Short Term Outcomes: This study stated, “that NFL players who sustain a concussion face a higher overall franchise release rate and shorter career span.”
3. Concussion and Long Term Outcomes: This study stated, “Multiple concussions appear to be a risk factor for cognitive impairment and mental health problems in some individuals.”
4. Predictors of Recovery: This study stated, “The most consistent predictor of slower recovery from concussion is the severity of a person's acute and subacute symptoms.”
This study stated that predictors of slower recovery include “female gender, previous history of concussion(s), previously diagnosed ADHD, a lower initial total SCAT2 score, a higher presenting SSSS [symptoms], and participation in a non-helmeted sport.”
Does your child’s league have a system of documentation, education, communication, and oversight? If not, why not?
TAKE HOME MESSAGE - Here is your plan.
IMPACT + even 1 SIGN and/or SYMPTOM = REMOVE!
WHEN IN DOUBT, TAKE THEM OUT! DO NOT LET THEM RETURN SAME DAY!