Concussion Detection, Management Varies Widely
Hard hits like this one often forces quick on-the-field decisions about concussions.
The bone-jarring collision heard throughout a football stadium sends shivers down the spines of both athletes and the audience. When a player lays limp, there are gasps of shock and penetrating silence. It's an eerie feeling to observe a hit that causes a concussion or worse, could cost a life.
In the minutes that follow such a hit, the most serious decision in sports is made: Is the athlete okay to play?
During this period, a number of neurological, physiological, financial, and perhaps philosophical issues start bubbling to the surface. The fallen athlete immediately begins self-assessing their ability to return to play, tasking the potentially-injured brain and body to cooperate instantly and generate a concussion pass or fail score.
Unfortunately, the athlete is not the best judge in this decision — and neither are the coaches, as conflicts of interest abound. One can only hope that someone intervenes and carries out a series of tests to help identify the severity of the concussion risk.
Concussion detection is complicated by the following issues:
- Most times, the athlete tries to “shake it off,” avoiding the sideline. Even if they do signal for a substitute, the sports culture that breeds “toughness” pushes the athlete back in the game.
- Most symptoms of concussion take several minutes, hours, or even days to materialize. Therefore, an immediate assessment may not reveal the concussion.
- Every athlete's brain has a different threshold for absorbing hits. Brain health varies based on heredity, genetic factors, gender differences, prenatal health, history of prior brain trauma, nutrition, exercise, sleep, toxicity from alcohol use and abuse, tobacco use, and presence of environmental toxins from drinking water, air, and chemicals from foods.
Medical professionals then must decide how best to identify the possible risk of concussion. Holding up a finger and watching for visual disturbance is common but not always accurate. More obvious tell-tale symptoms, like loss of consciousness, wobbly walking, and vacant stares are easy to identify. But without the simple signs, the medical professional must turn to one of a myriad of concussion detection tools to help guide the decision about returning the athlete back to game play, including:
- Vision testing
- Helmet impact or hit sensors
- Sports Concussion Assessment Test-3 (SCAT3)
- Mouth guards
- Voice-Analyzing app
- Blood testing
- Saliva testing
- Mobile app sideline assessments
“Best practices” for concussion detection are still a moving target. While “when in doubt, pull them out” isn't the most clinical conclusion, it's better than rushing the sideline assessment, returning the player to the game, and him or her suffering a second concussion before the first one heals. That's called Second Impact Syndrome, and it has a scary 50% fatality rate.
How Are We Doing?
The NFL has come a long way in recent years, and while it may be leading the way, it still has a way to go — largely due to possible conflict of interest within the organization. Most teams at the professional level can afford to have full-time team doctors on staff. They determine whether an athlete has a concussion or not, and when the athlete is ready to return to game play. But, too often conflict of interest arises, because the doctor, player, and organization have a vested interest in winning. Instead, they all should have a vested interest in proper care, prioritizing brain health and safety above wins and losses.
At the collegiate, high school, and youth levels, concussion detection and management vary greatly. From having no protocol to embracing the latest technology and everything in between, sports programs are trying to implement whatever they can get their hands on. Many states now mandate education, certain protocol, and medical clearance, but they have yet to embrace baseline testing. I believe a complete concussion protocol should include:
- Education: compliant with statewide laws
- Baseline testing: measuring cognitive and emotional scores
- Sideline assessment
- Recovery: 5 step progressive exertion
- Symptom tracker
- Reporting tool
Ultimately, the sports world is starving to benefit from neurological and technological advances that create a seamless, thorough, and practical sports concussion management solution that any sports program can implement — and it all centers around detection.
Clinicians need to get in the game, have clearly laid out protocol and put their knowledge into practice. We can save the game, and help athletes benefit from all that sports can offer.
Harry G. Kerasidis, MD, is a cognitive neurologist specializing in sports concussion management. He is the founder of XLNTbrain LLC, a mobile sports concussion management program, and author of "Concussionology: Redefining Sports Concussion Management" coming in April 2015.