I have been asked to write about concussions from time to time. I attempted a chapter on concussions for a book at some point, over the next few weeks I will post this chapter, as I wrote it, no matter how horrible it is. After all I am not an author, but at least you can take a look. This particular chapter deals with concussions in the sport of football. We all should know this injury can be sustained in any sport. Because football is the biggest draw of sporting eyes I felt it was best to present it in this way. (Part I, Part II & III, Part IV) *All sources will be posted after last portion is up.
Classification of Concussions
Often we hear of “minor” injuries or sometimes they are referred to in degrees; 1st, 2nd, 3rd to give a sense of how bad it is or prognosis of recovery. These classifications not only serve to give the audience a perspective, but they are also necessary for the medical diagnosis and rehabilitation. Over years and years of injury surveillance, record keeping, surgeries, and rehabilitation on injuries of joints and muscles we can clearly define orthopedic injuries with these connotations. Concussion, not so much.
Concussions initially began with a similar “grading” of severity authored by Robert Cantu, MD in 1986[i] adopted by the American College of Sports Medicine and further defined by various other organizations; Colorado Medical Society Guidelines – 1991[ii] (adopted by the NCAA), American Academy of Neurology – 1997[iii]. The issue as time went on was there was not a consensus of which grading system was the appropriate practice of care, the problem existed until three years ago when most health care providers began to accept and conform to The 3rd International Conference on concussion in sport, held in Zurich, Switzerland[iv]. The key word being “most” as this information, widely accepted and worked on by the leaders in this issue, has not been seen or adhered to by physicians.
The consensus statement[v] was built upon the two previous meetings in Vienna (2001) and Prague (2004) as the exclusive panel began the process of trying to obtain a common ground on the concussion epidemic. The take home message from this in terms of classification is that a concussion is a concussion. Due to the varying factors and injury evolution differing from individual to individual the experts determined that “mild”, “moderate”, “severe”, “simpe”, and “complex” should not be used to diagnose or classify the actual injury. To this day doctors, players, athletic trainers continue to use those terms when describing the injury, which is improper.
There is nothing mild or simple about a concussion, this injury is a significant insult to the brain and its function; therefore a concussion is a concussion.
Those qualifying tags could be used to express the symptoms and signs occurring at the time of injury, but not to define the concussion. However, it must be noted that ANY symptom and ALL signs are as a result of misfiring in the brain, the complex network of signals the brain uses to function has been impaired. Along with the distancing of the qualifying terms the group in Zurich also made it clear that the grading (1st, 2nd, 3rd) was not warranted as each concussion should be treated the same (as you will see in the return to play section). Next time you hear an analyst or player say they “just have a mild concussion” take time to remember those words would be akin to saying someone is “mildly pregnant.”
Return to Play
It is not like a broken bone has healed enough in order for one to return to play from a concussion. It is much, much more complicated than that, after all we are considering the brain. The issue of concussions is not so much the injury, rather how we have and are currently handling the return to play. As we have seen, SIS can be a major issue as well as new and budding research suggesting a link between repetitive head trauma and diseases like; Alzheimer’s[vi], dementia[vii], depression[viii], amyotrophic lateral sclerosis (ALS also known as Lou Gehrig’s Disease)[ix] [x], chronic traumatic encephalopathy (CTE)[xi], and a host of other systemic brain dysfunctions.
With Cantu’s work in 1986[xii] the exact time someone was to be held from play was a problem that every person associated with the injury was struggling with; coaches wanted their players back, players wanted back on the field and doctors wanted to protect their patients. As of 1999 a compilation was published to give general guidelines figure 2[xiii].
Compilation of Concussion Guidelines
As the consensus statement from Zurich[xiv] spelled out in 2008 returning from concussion on the same day or 24 hour period following the injury is utterly discouraged and even life-threatening to youth and adolescents. This effectively threw out the grade I or 1st degree classification and not allowing an athlete to return after concussion in the same day*.
*An exception was made for professional American football players, ONLY, they have studies that suggest they could return on the same day[xv].
Through the Conference all athletes should be treated the exactly alike in terms of return-to-play (RTP)[xvi];
The panel unanimously agreed that all athletes regardless of level of participation should be managed using the same treatment and RTP paradigm. A more useful construct was agreed whereby the available resources and expertise in concussion evaluation were of more importance in determining management than a separation between elite and non-elite athlete management.
The current model of RTP that was developed by the experts at the Conference (table 1) gives a stepwise progression that will allow the athlete achieve certain “bench marks” and “check points” allowing for continual evaluation through the process. Each step is basically a 24 hour period, where if no symptoms return they can move along until they have been stressed enough a physician can clear them to play. If symptoms “explode” with increased activity the individual will wait 24 hours and try at the step below where they had the increase in symptoms.
|Rehabilitation Stage||Functional exercise at each stage||Objective of each stage|
|1. No activity||Complete physical and cognitive rest||Recovery|
|2. Light aerobic exercise||Walking, swimming or stationary bicycle keeping intensity <70% of max heart rate. No resistance training||Increase heart rate|
|3. Sport-specific exercise||Skating drills in hockey, running drills in soccer. No head impact activities||Add movement|
|4. Non-contact training drills||Progression to more complex training drills (e.g. passing drills in football and ice hockey). May start progressive resistance training.||Exercise, coordination, cognitive load|
|5. Full-contact practice||Following medical clearance, participate in normal training activities.||Restore confidence, assessment of functional skills by coaching staff|
|6. Return to play||Normal game play|
The consensus statement made it clear that a vast majority (80%-90%) of all concussions will resolve within a 7-10 day time frame; however it may take longer in children and adolescents[xviii]. As you will note in table 1, if a player was to sustain a concussion on Saturday and was symptom free after Sunday and stayed that way through the process he/she would be back to full practice on Thursday and conceivably be cleared to play on the Saturday following the initial injury.
This of course is a best case scenario and the athlete would have to be trustworthy in disseminating information about his/her symptoms along the way. This is the problem with concussions, as mentioned before it is mainly a subjective injury, and the pressure to return to play is overwhelming for some leading to misleading information and a dangerous situation for the athlete.
The general guidelines are that rest is the key, as the only true way to resolve this injury is spontaneously, nothing we have in our arsenal of technology will speed it along. What can happen though is an early stress on the brain can impede recovery and even result in further injury/debilitation.
Think of your brain and its chemicals like a snow globe, when things are fine and no injury is present that would be the globe at rest, all the floating particles at the bottom. When you get a concussion you shake the globe, thus sending all the chemicals, hormones and electrolytes into flux. During this time the brain is not functioning correctly and will not return to normal capacity until all the flakes are at rest once again. We can all grasp the concept that running and being hit will jostle the globe keeping all the “flakes” from coming to rest. What is less known is things like; reading, studying, playing video games, texting, basically anything that requires brain function will also continue the shaking of the globe. Hence the importance of the first step in the RTP progression from Zurich. After the brain has returned to normal (flakes at rest) it is time to slowly and cautiously add physical and cognitive stresses to see if the “flakes” will start to fly again in the globe. While the “flakes” are excited it is much easier for them to continue moving about, rest and return to normal is the MOST IMPORTANT FACTOR in recovery. Rest must include avoidance of ANYTHING that will use the function of the brain, in other words just sitting a dark room and attempting to sleep is the best course of action after the individual has been properly evaluated by a medical professional.
[i] (Robert Cantu 1986)
[ii] (Colorado Medical Society 1990)
[iii] (Subcommittee 1997)
[iv] (P McCrory 2009)
[v] (P McCrory 2009)
[vi] (Centre For Neuro Skills – TBI Guide 2011)
[vii] (Patrick Sullivan 1987)
[viii] (Daniel G. Amen MD 2011)
[ix] (Silke Schmidt 2010)
[x] (H Chen 2007)
[xi] (Ann McKee MD 2009)
[xii] (Robert Cantu 1986)
[xiii] (Harmon 1999)
[xiv] (P McCrory 2009)
[xv] (P McCrory 2009)
[xvi] (P McCrory 2009)
[xvii] (P McCrory 2009)
[xviii] (P. J. P McCrory 2005)
Interesting post. Got a concussion playing soccer hehe. Not as manly as fotball 🙂
Just a side note concerning RTP guidelines. Many state AT societies have recommended that physician clearance be obtained to go from step 1 to step 2. This has mostly been in response to many of the concussion laws that have been passed recently. They feel it is much more prudent to have the medical clearance to begin any activity rather than wait until an athlete was already 75% active.
I believe this is a much safer interpretation than the Zurich guidelines of not requiring medical clearance until 2/3’s of the way through the rehabilitation process. Beginning activity too early can have a huge impact on the recovery process. Imagine an athlete bouncing back and forth between steps 2-4 for a week or two before finally making it to step 5 and medical clearance. There could be some underlying cognitive impairment still, but is only now being discovered once evaluated by an appropriate physician. That time spent at a moderate activity level for over a week will be a huge detriment to the overall healing process for that individual.
I by far think it is much more prudent to have an athlete completely asymptomatic, neurocognitively normal and medically evaluated and cleared by the proper physician before beginning any activity. Even just slightly shaking that snow globe too early can have a detrimental effect on recovery, why not take every precaution that it doesn’t happen that way?
Great comment Bryan…