The Concussion Blog

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, Part V & VI) *All sources will be posted after last portion is up.

Helmets and Protective Gear

Gladiators used them to protect against fatal blows on the floor of the Coliseum and in battle, today helmets are used for the same purpose in the military and on the football field.  Helmets were not even mandated in the sport until a rash of skull fractures caused such alarm that President Theodore Roosevelt demanded changes to the game.  This eventually created the National Collegiate Athletic Association (NCAA), and mandates for helmets, which in turn reduced injuries by 31%[i].

One of the biggest myths about helmets and protective gear is that it will prevent concussions, wrong.  It will prevent what they were intended for, skull fractures and nothing more, the helmet sanctioning body; The National Operating Committee on Standards for Athletic Equipment (NOCSAE) makes sure of that with testing.  In fact you cannot play the game of football unless your helmet displays a NOCSAE sticker.  NOCSAE even states in a press release on February 4, 2011 that every player, parent, coach and anyone involved in the sport of football should know that helmets WILL NOT prevent concussions[ii].

Another piece of equipment has staked a claim into reduction and even prevention of concussion, mouth orthotics, which is also false due to the lack of current research and non-disputed journal article, backed by the Zurich statement[iii].  If you don’t believe the statement about mouth orthotics, take a quick look at boxing or MMA, they all wear mouth gear and they continually get knocked out or staggered (signs of concussion) during fights.

There is a simple reason as to why this is, physics.  As we have discussed you do not have to be hit in the head to develop a concussive episode, it only takes unnatural and traumatic forces distributed to the brain to do this.  Wearing a helmet will NEVER help the soccer player that gets hit hard running forward and whips his head back quickly.  The brain sitting inside of its case (skull) is jarred by the rapid movement causing the physiological response and concussion.  In the sport of football when the wide receiver is running a crossing pattern and is tackled by a linebacker going in the opposite direction in the midsection, essentially folding him in half, the receiver’s head is traumatically shifted once again in a whiplash motion.  The only thing that could prevent this from occurring is the HAANS device that motorsports athletes wear.

Even when blows to the head occur either via an opponent or the ground the helmet only absorbs a limited amount of force the rest of it has to go somewhere, Newton’s Laws of Physics.  The other aspect of helmets and physics is the rotational and shearing forces.  As in the examples above, whiplash is a movement that has “gross and traumatic” shifting at the neck joint in a forward and backward plane.  Most hits in the sport of football are a creation of varying vectors (direction of movement) of both bodies, as a result a lot of the time the head gets “twisted” or rotated, again creating a traumatic insult to the brain.  These factors are the most obvious as to why helmets and mouth gear would not protect against concussions.

What is less known is the condition of the helmet itself.  Although you cannot (should not) be allowed on the gridiron without a NOCSAE sticker, this sticker only guarantees that the helmet met specifications at the time of production/sale.  What about the helmet that has gone through a season of hard hitting?  Great question, that is completely up to the owner of the helmet as currently there are no “laws” demanding helmets get recertified and reconditioned on a regular basis.  Schools and professionals alike probably have a policy in place for each helmet, more importantly they have the resources (see money) to get the helmets taken care of on a regular, mainly yearly basis.  Most high schools that I know of attempt to get part of their stock taken care of every two years, but some just do not have the resources (see money again) to get it done in a fashion that would make the helmet safer.  Although there is not a study out there showing this, I would opine that every Friday night in America there are thousands of helmets that have imperfections and are not duly fit for play.  This would most likely extend, to a far less extent, to the college game as well.  Developing more on this subject is the age and model of the helmet, one would assume that driving a 2011 model Mercedes would be much safer than a 1999 model for the simple fact of safety technology evolution.  This also translates to helmets, the newer versions of helmets are technologically “better” than previous models, they will provide better “hardware and software” if you will.  The other aspect of this is; research and design concepts have been made upon much more information and case studies.  In college football the issue of newer technology is not as apparent as in professional football and high school football.  In the pro’s the athletes tend to wear helmets they are comfortable with and that “look good”, foregoing the newer designs.  In high school again the resources (see money, again) are not there to buy the more expensive models.  This can lead to more and more issues as it related to concussions.

Yes, helmets themselves do not prevent against concussions, but when they are at optimal performance they can limit the forces applied to the brain case, which can in some cases of lower force hits reduce the effects.  It would be proper to say that helmets can protect against concussions, but they DO NOT prevent concussions.

This brings us to the debate that some have begun about removing helmets to alleviate this epidemic of concussions.  Clearly, as you can see above the Laws of Physics will not allow this to happen.  Add to that the removal of helmets would gravely increase the incidence of the most serious injury; skull fracture.  Taking the helmet out of the game has no place or validity in this authors mind.

Athletic Training

Athletic training is practiced by athletic trainers, health care professionals who collaborate with physicians to optimize activity and participation of patients and clients. Athletic training encompasses the prevention, diagnosis, and intervention of emergency, acute, and chronic medical conditions involving impairment, functional limitations, and disabilities. Students who want to become certified athletic trainers must earn a degree from an accredited athletic training curriculum. Accredited programs include formal instruction in areas such as injury/illness prevention, first aid and emergency care, assessment of injury/illness, human anatomy and physiology, therapeutic modalities, and nutrition. Classroom learning is enhanced through clinical education experiences. More than 70 percent of certified athletic trainers hold at least a master’s degree[iv].

 

Athletic trainers are also recognized by the American Medical Association (AMA) as a health care profession.

I like to tell people I get paid to watch sports, in the best seats in the house; on the sideline, bench or dugout.  However there is much more to what we do, often behind the scenes; preparing athletes or rehabilitating them or even checking the field that is being played on for issues including weather.  I could go on with the courses we take and the continuing education needed to keep certification, but that would bore you.  What you need to know is that this profession and its professionals are the ones that have the health and safety of the athlete on the foremost of our mind.

Prevention is our number one domain, meaning we want no injuries to occur.  If you see me doing nothing I have done my job to perfection, this however is a VERY rare sight.  Part of prevention is taping and making sure athletes are conditioned properly for their activity.  It can entail doing a “walkthrough” on a playing surface to look for possible dangers and injury risks, like snake holes on a football field.  Prevention is also in watching the weather; whether it is heat, lightning or freezing temperatures our background allows us to provide information about safe playing conditions.

Our second domain is clinical evaluation and diagnosis; using all the education we have, a lot of athletic trainers can tell you what the injury is even before laying hands on the athlete.  We use our eyes and information from the mechanism of injury to narrow down all the possibilities as we arrive to the patient.  We then perform a skilled evaluation using techniques that one would have performed on them in a doctor’s office.  At times the evaluation we perform is more in-depth than most general or family physicians.  In terms of orthopedic care and evaluation the hands on evaluation and techniques are on par with orthopedic surgeons.  The information gathered doing this give us the ability to route the athlete to the proper care in a timely fashion.  A simple case of a sprained ankle would not warrant a trip to the hospital (in most cases, some extenuating circumstances not withstanding), therefore saving a trip and money, while getting them pointed in the right direction of a doctor that can help with the issue.

Our third domain is immediate care in the cases where life threatening situations arise.  We have been trained to provide necessary care, triage, and gather information for advanced care arrival.  Now we cannot perform a tracheotomy but we do have training to be sure vessels are not compromised when fractures occur, not unlike an EMT.

The fourth domain is treatment, rehabilitation and reconditioning, allowing us to get the injured back to previous levels of performance.  Many of the athletic trainers in the workforce split time between physical therapy clinics and high schools, utilizing this domain on the general population as well as the athletic population.

The fifth domain is organization and administration, not high on the list our training gives us the necessary information to run a fully functional athletic training room.  Purchasing, policies, cleaning and regulations are all things one must consider when working in a training room.

The last domain is also an area athletic trainer excel at in the health care field, education.  It is also our job to make sure everyone has the knowledge of what is going on with their body and possible outcomes of an injury.  The strong science background naturally pushes athletic trainers into teaching degrees in this area, when they are employed in a school district (of course we have to have a teaching certificate).  This domain also is meant for the education of the general public about injuries and the profession, kind of like we are doing now.

Athletic trainers are very valuable to any sports team and the general public, we as health care professionals are often misunderstood, mainly about what we actually do and can do.  In the area of concussions the health care profession of athletic training may only be behind sub-specialties of medical doctors; neurosurgeons and neurologists and PhD’s in the field; neuropsychologists.