Sports-Related Concussions: How Many Are Too Many?

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The challenges of moving past the “3 strikes and you’re out” rule.
The challenges of moving past the “3 strikes and you’re out” rule.

Concussions have received much media attention recently, with several professional athletes deciding to retire rather than risk the long-term effects of multiple events. The issue is not limited to professional sports; according to the Centers for Disease Control and Prevention (CDC), an estimated 3.8 million recreational or sports-related concussions occur in the US each year.1

In a review published in Physical Medicine and Rehabilitation Clinics of North America, Scott R. Laker, MD, and colleagues reviewed new guidelines for retirement and activity restrictions following concussion.

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Recommendations on when to retire originally followed the "3 strikes and you're out" rule, established in the 1950's when concussion required loss of consciousness. The current definition — an injury to the brain that causes temporary loss of normal brain function — is much more subjective and difficult to document, the authors write.

"Only a few concussions cause anatomical changes that are clear contraindications for return to play. Magnetic resonance imaging (MRI) is rarely helpful [and] guidelines must rely on expert opinion," Dr Laker, an assistant professor of physical medicine and rehabilitation at the University of Colorado School of Medicine in Denver, told Clinical Pain Advisor.

"In the past, concussions were probably underreported. Today we may be in danger of over-reporting. Many are self-reported and non-specific. What do we do with an athlete who reports more than 3 concussions?" Dr Laker questioned.

Defining the Problem

According to the CDC, football has the highest number of concussions as well as the highest rate of concussions. Other high-risk sports include ice hockey and wrestling. In 2014, 11.7% of Division 1 college athletes reported having 1 concussion, and 4.5% reported multiple concussions.1

Few would contest clear contraindications for return to play (RTP), such as documented moderate to severe traumatic brain injury (TBI), subarachnoid hemorrhage (SAH), structural brain abnormalities, or persistent clinical neurological deficits.

In the absence of these events, however, guidelines become much less reliable. Although multiple concussions and prolonged concussion recovery may indeed be contraindications, the evidence is limited and conflicting. Under such circumstances, neuropsychological testing is a critical component for post-concussion management, the authors write.

"Evaluation by a psychologist or neuropsychologist trained in neuropsychological testing for concussion is the most important and the best way to make clean, objective decisions regarding return to play or retirement," Dr Laker emphasized.

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