TCB follow-up to Robert “Woodsgate” and this is not the first time the PAC-12 has been under the microscope here at TCB, if you recall “Lockergate” a few years back.
There are hundreds if not thousands of hits on any given weekend in football that will result in concussions across the football landscape, many go unnoticed, except by the trained medical staff (mainly athletic trainers); certainly we see a very limited number on national TV. However last week Robert Woods of USC was drilled in the head while blocking that resulted in OVERT signs of brain trauma. Before we go further we should define what a concussion is, in its simplest terms:
- A concussion, at the very base level, is a pathological event that results from forces to the brain that cause disruption of normal brain activity. These “disruptions” can occur immediately or in a delayed response. Regardless, any disruption of normal physical, cognitive or emotional behavior would fit this criteria.
The new standard of care for concussions across all levels is that if someone exhibits signs of a concussion they should be removed from play for a proper evaluation. If there is no one there to do a proper evaluation (see youth and HS levels) then that player may not be returned to the game and cannot return to sport without a medical clearance from a physician.
As I have stated many a time most evaluations on the sideline are either a case of detective work – weeding through the subjective nature of the injury – or not needed because of the overt signs and clinical presentation. I say this as an expert, one who deals with concussions in sport on almost a daily basis. Observation is the most trusted source for concussion detection; whether it be observation of overt signs like that of Robert Woods in the game last week, or observation of the demeanor of the player in question – knowing the personality of the person.
I surely do not enjoy “calling out” my professional peers but there are times we must all learn from situations that present themselves. I can tell you that if that happened on the football field I was covering a player with the similar reaction – it has happened to me – would not be allowed to return to the game, period.
To me what is more troubling is listening to Woods talk about the play in question and his reactions, watch the first 1:25 of the video;
Not only did Woods use the term “dazed” he also capitulated that he was not “OK” after the initial hit it, took him until he fell the second time before he had his wherewithal. The other concerning part of this interview is near the end of the 1:25 he discusses how he was being serial tested for concussion issues. Why would a team be testing a player for concussion issues if the player didn’t sustain a concussion? If I have a player go through the testing on the sidelines and passes and I am confident they did not sustain a concussion then I don’t test them; perhaps I may ask them how they are the next few hours or day, but not test them. Heck, when someone has been assessed with a concussion here they don’t even get follow-up computer and balance testing until they get through school, light aerobic activity and practice drills without symptoms, that is at best five days post injury.
If that is not enough of an indictment, how about his Woods’s quote in a piece on ESPN.com;
“First, I was like, ‘Wow,’ ” he said. “And then after, I was like, ‘Wait, I did all of that?’ I didn’t know I laid down on the ground that long.
“It’s fun to laugh at now, but it’s just a blessing that I’m all right.”
He stumbles and has zero balance after the hit, first sign (and enough in my book to remove him) then he tells the press he does not remember what happened immediately after the head injury, second red flag. Yet, the USC staff removed a player in the same game for “precaution” after he didn’t pass his sideline screen. So frustrating and head scratching.
I get the emotion of the game, I get that it could be your best player; that is all well and good if you are a coach, but if you are truly concerned about the brain health of any individual a case like this is why the legislative pieces are put into place. It removes all doubt and sits them out.
I had the opportunity to interview an athletic trainer from a FBS program about this situation the words were very important to share;
I work with my coaches, but I work FOR my athletes. My pressure is internal to do the best thing for my guys. I want the best for them. I want the best care to result in the best outcome. Situationally I think athletic trainers often times allow the environment drive their decision. For instance, if a player is “knocked out” in practice like Robert Woods was in the game, of course there would be plenty of time to properly evaluate and care for the young man. Right? The brakes would’ve been applied and there is no way he would have finished the practice because it is “just practice”. Game day seems to blur proper judgement. I just don’t see how it is any different from practice. Do the best at practice and games and your outcome will reflect the proper decision.
Football is violent and violent injuries occur each game. I marvel at what types of injuries some of these players are able to manage on a day-to-day basis. Sprains, strains, fractures are all treated and managed with the potential to return to play. ATF sprain can return to play. ACL should not return to play. Phalanx fracture might return to play. Tibia fracture should not return to play. Why would anyone consider concussion different? Current information tells us that concussion should not return.
I do think there is a perception of pressure other places that is completely misread by athletic trainers. Is the pressure felt directed from the coach or is it an internal belief that we have to fix/return all of our players to play as soon as possible? My feeling is no different from one injury to the next. Evaluate, assess, and make a plan of care to properly treat the injury directly in front of you. This certainly has evolved over time. I don’t treat a syndesmotic injury the same now as I did just five years ago. Same goes for concussion. Evolve and educate.
This athletic trainer is exactly right we all need to evolve and educate ourselves on concussions at EVERY level.
The Concussion Blog 
It is a even game at D1. Woods got a scholarship to play (hopefully he goes to class and takes real classes). He gets some face time on TV as he is big name in a big program. The only parties making money by putting the kid back on the field are the school, program and the coaches. He has less than a 6% chance of making it to the combine and far less of chance of vesting in the NFL. If these parties are so interested in having this kid risk his neck, then make them liable for any long-term neurological damage he may suffer (especially the coach and his multimillion dollar salary). He is putting this kid at risk for his personal gain.
He had a concussion; he should have been pulled from the game. He should have be sitting for the week. Sideline testing is a joke at these programs. Follow-up testing appears just as ridiculous.
No excuses and nothing more needs to be said.
It’s a joke at all levels. I believe the AT reference said it best…the judgement gets clouded from Practice to Game. Why? The fans, the music, and opponent different from the practice squad…I see why it does cloud judgement, but it shouldn’t. How do we fix it?
If you get on the ImPACT website you can find a list of programs (college and HS) that have ImPACT… USC is one of them!
How does it make any sense?
ImPact has been successful as it has always sold a nod and wink and not science.
It played the game and helped cover-up these shortcomings. It was always about money never the athlete. Of course, USC would us it. Plenty of wiggle room to get a player back on the field.
Why is there a rush to evaluate and return to play the same day if the athlete’s brain health may be at risk?
Given the below overlapping, yet non inclusive, lists of potential adverse symptoms that may occur from sustaining a concussion – a brief sideline screening CANNOT THOROUGHLY evaluate for the possible presence of ALL these and other symptoms.
Furthermore, some of these symptoms cannot be accurately detected by the presently developed instrumentation nor are they being addressed during a brief sideline screening.
In addition…if some symptoms may later evolve and thus be delayed…shouldn’t a SUSPECTED concussed player ALWAYS be removed for the remainder of the game / practice and correspondingly observed over a period of days to ascertain:
1- if evolving or additional symptoms manifest themselves; and
2- to avoid the possibility of the second impact syndrome from occurring ?…
since the primary role of the health care professional is to:
a) protect the health & safety of the athlete and
b) do no harm to the athlete.
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Possible persistent emotional, cognitive, behavioral and physical symptoms of a concussion / brain injury
A mild traumatic brain injury committee reported that patients who sustained a mild brain injury may display “persistent emotional, cognitive, behavioral and physical symptoms” (Gerstenbrand & Stepan, 2001).
Table 1
Physical, Cognitive and Social-emotional Impairments of a Concussion
A. Physical impairments:
speech, vision, hearing another sensory impairments, headaches
lack of coordination
muscle spasticity
paralysis
seizure disorders
problems with sleep
dysphagia — a disorder of swallowing
dysargthgia — a disorder of articulation in the muscular motor control of speech
B. Cognitive impairments
short and long-term memory deficits
slowness of thinking
problems with reading and writing skills
difficulty maintaining attention and concentration
impairments of perception, communication, reasoning, problem solving, planning,
sequencing and judgment
C. Behavioral impairments: [social-emotional]
mood swings
denial
depression and/or anxiety
lowered self-esteem
sexual dysfunction
restlessness and/or impatience
lack of motivation
inability to self monitor, inappropriate social responses
difficulty with emotional control in the anger management
inability to cope
excessive laughing or crying
difficulty relating to others
irritability and/or anger
agitation
abrupt and unexpected acts of violence
delusions, paranoia, mania
(BIA of America, 2003, Heading 4)
The mild traumatic brain injury committee reported that patients who sustained a mild brain injury may display “persistent emotional, cognitive, behavioral and physical symptoms” (Gerstenbrand & Stepan, 2001).
Specific symptoms of these various categories include:
physical symptoms such as nausea, vomiting, dizziness, headache, poor vision, sleep disturbance, sensitivity to light, or other neurosensory loss; cognitive delays in attention, concentration, perception, memory, speech/language, or executive functions; and behavioral changes and/or alterations in degree of emotional responsivity such as irritability, quickness to anger, disintegration or emotional ability (p. 96).
Evans (1987, 1994) outlined descriptions of frequently observed symptoms of mild brain injury. According to Evans, symptoms attributed to the effects of a concussion may also be called postconcussion syndrome. The symptoms listed by the author are: “headaches, dizziness, vertigo, tinnitus, blurry vision, double vision, memory dysfunction, impaired concentration, personality changes, anxiety, depression, sleep disturbances, decreased libido, irritability, noise and light sensitivity, fatigue, and slow information processing” (1987, p. 49).
King, Crawford, Wenden, Moss, and Wade (1995), along with Evans (1987), provided excellent overviews of the various symptoms a person may experience after sustaining a concussion. The authors’ respective lists are found in Table 2.
Table 2
Postconcussion Symptoms
Headaches:
Muscle contraction type
Migraine
Occipital neuralgia
Secondary to neck injury
Secondary to temporomandibular joint syndrome
Due to scalp lacerations or local trauma
Mixed
Dizziness
Vertigo
Tinnitus
Blurry vision
Diplopia
Memory dysfunction
Impaired concentration
Personality change
Anxiety
Depression
Sleep disturbance
Decreased libido
Irritability
Noise and light sensitivity
Fatigue
Slowed information processing
(R. W. Evans, 1987)
Headaches
Feelings of dizziness
Nausea
Noise sensitivity
Sleep disturbance
Fatigue
Being irritable
Feeling depressed
Feeling frustrated
Forgetfulness
Poor concentration
Taking longer to think
Blurred vision
Light sensitivity
Double vision
Restlessness
(King et al., 1995)
In addition to frequently observed acute symptoms of TBI, numerous long-term effects of a concussion have also been acknowledged.
Long-term effects of concussion include: physical damage to the brain, physical damage to the body, cellular biochemical effects and general physical changes, and cognitive decline and psychosocial /behavioral/emotional changes.
Inferential evidence that the brain has been permanently compromised becomes evident in the general physical changes that are sustained.
These include: decline or loss of vision, hearing, smell, or taste; headaches; speech and language impairments; reduced endurance; cognitive decline in short- and long- term memory; difficulties with concentration, judgment communication, and planning; and psychosocial/behavioral changes such as anxiety, depression, mood swings and emotional liability (Scientific American, 1999; NYS Education Dept., 1997).
Furthermore, children who sustain TBI’s may experience delayed effects that become more apparent at a later stage of cognitive development (NYS Education Dept, 1997).
(Brady, D., 2004 – Dissertation