In the wake of a sports-related brain injury causing a student-athlete’s death in New Jersey, Tua Tagovailoa’s on-field seizure activity, and the 2022 International Concussion in Sport Group meeting set to release updated guidelines from Amsterdam, it is a perfect time to think about the current state of concussion care. The brain, because of its complexity, is vulnerable to injury and disease processes that are not simple to diagnose. Catastrophic injuries such as bleeds and infarctions are visible on imaging, but a concussion is not. So, while we know from the work of Dr. Omalu since 2007, and Dr. McKee confirming thereafter, that football causes long-term damage to the brain, we do not yet have a way of knowing when this actually begins or when damage to the brain is severe enough to warrant the end of a career. What is worse, we have no way of predicting events such as the one that took the life of the high school football player.
Damage to the brain is not unique to football. It has been shown in other contact and collision sports, and it is not a new concept. Dr. Corsellis described chronic traumatic encephalopathy in 1973 in boxers, but Dr. Martland described dementia pugilistica as far back as 1928. These discoveries changed the rules of the game and made the arena safer for participants, but did not eliminate the risks. In football, helmets were originally worn due to the growing number of deaths from brain bleeds, and the spearing rule was implemented after an explosion of cervical spine injuries. The Zach Lystedt law is the framework for all 50 States concussion policies which require education and enforcement of rest after brain trauma. We have made progress in regulations, helmet technology, and education, but there is much work to do. Especially in the absence of a reliable biomarker.
Did you get your bell rung?
Getting your bell rung is a phrase that just about every collision sport athlete will recognize. What happens on the field and the common perceptions of concussions as visible injuries are warped. Less than 10% of concussions have outward signs that an observer such as a skilled sideline physician or athletic trainer can recognize. These observable signs (https://www.cdc.gov/headsup/pdfs/providers/ace-a.pdf) include loss of consciousness, shaking of the head, disorientation, or loss of balance (seen in the first Tua injury); and posturing (seen in the second Tua injury). In most instances of sport-related brain injury, athletes experience symptoms silently inside their own minds, wondering about the significance, and debating whether to report. Many brain injuries remain unreported.
Don’t say the “C” word.
Amongst themselves, athletes talk about a ding, getting laid out, pudding head, or having had their bell rung. But they don’t dare say the “C” word. And they know the lists of symptoms to avoid reporting for fear that doing so will leave them sidelined. There is also the history of the game and the notion that “back in the day” guys played through these things and were fine. Physical findings are limited and current testing including balance and computerized cognition testing is also only modestly reliable in the sense that variation can occur from test to test in the same person with or without injury. With the uncertainty of diagnosis and the risk of missed playing time, individuals are left to wonder whether there is any benefit at all in speaking up. After highly reported incidents there tends to be an uptick in concussion reporting, and then as the memory and fear fade the numbers of those choosing to report also declines. If we rely on self-reporting, the cycle of hyper-vigilance and cavalier neglect will likely continue.
Should I report?
As soon as an athlete comes to the attention of the medical staff the first question is, “when can I return to play?” Guidelines are based on consensus supported by averages of reported symptoms. There is wide variation. An athlete may have just moments of symptoms after brain trauma, or several weeks or even months. Studies using MRI and biomarkers suggest that there is a significant change over the course of a collision season with or without reporting symptoms. There is also evidence that the metabolic effects of a concussion can last even after symptoms resolve. This leaves us with an unspoken lie, “tell us everything, but we know you’re not.” Until we have a widely available biomarker, available imaging protocols for detecting change, or some other objective test for concussion, we must have a more honest conversation. Current protocols create a false sense of concussion as a single thing when it is really a mixed bag of injury types with various presentations and durations. If athletes, parents, and other stakeholders cannot be reassured that they will be part of a shared decision-making process, with autonomy, to help decide when they will return after reporting symptoms, we will not get an accurate representation in communities or in the elite arena of actual experiences of those playing the game. Requiring essentially arbitrary timelines interferes with the doctor-patient and athletic trainer-patient relationships that should dominate the reporting and decision-making needed. Expertise in concussion care really comes down to the relationship we have with our athletes.
When is it enough?
Our concussion retirement paper offers a framework for a decision-making algorithm for a complex conversation. The branch points use the best available evidence. This discussion takes place when the number, severity, or findings during evaluation suggest that the risks of repeated concussions are becoming too great. But even during routine consultations for concussion, when I ask my athletes if they ever had symptoms like the ones we are discussing for their current injury, I often get a yes. “Has that occurred once, twice, ten times, more than a hundred?” There is surely a research project there, but the answers never surprise me. It is clear that the exposure risk – the number of years in a sport, is as important if not more so than the number of recorded concussions. Organizations have done well in increasing the age at which collisions are part of the game at the youth level. Sometimes the answer to the challenging question about retirement is that we should take some more time to allow for further brain healing, and sometimes it is to change positions, and sometimes to change sports. The bottom line is that we do not currently have a way to measure this. So, for now, we lean on the bits of evidence we do have, then engage in honest conversations about these limitations.
All parties have varying interests when it comes to concussions. Education and “when in doubt, sit ‘em out” campaigns aim to reduce the risk of missing brain injuries. A coach’s job includes motivating athletes to be their best, coordinating the success of the team, and in fairness to coaches, (I have dabbled in some youth coaching with my children and have the utmost respect for the mentorship and role a coach has in an individual’s development) diagnosing injuries is not part of that job. Parents and even officials have been engaged in education efforts. Here too, we cannot expect diagnoses. Any program running contact or collision sports practices and games without athletic trainers is doing their players a disservice. Adherence to recommendations is not possible without a skilled medical professional to tease out the “real injuries” from those that can continue with some sideline care. “Are you hurt or are you injured?” This phrase burns in my brain as if I first heard it yesterday. But it was during my own playing days that I debated this very question often, and often answered it incorrectly as a player. The successes of sports medicine in achieving athlete safety are not possible without the care of athletic trainers. In fact, an athletic trainer saved my life in college. Their presence is even more necessary when it comes to concussions. Knowing the athlete and when that individual is “off” is sometimes all it takes to prevent missing the injuries we really need to not miss. Those that can turn chronic, or worse, deadly.
Why not just make it flag football?
I write this piece as the game plays in the background. Over the years, disillusioned by so much of what is wrong in athletics, but somehow the sounds of football in the background, while the Sunday sauce aromas fill the house, brings the family together. I played football on the street, in high school, and in college. My son played football. My father, my son, and I have bonded over this grueling game. Friends, and teammates, that to this day I would love to line up next to again. Relationships are forged in the wake of the gridiron’s violence and elegant athletic design and achievement. Why do we allow or embrace violence in sports? Is it baked into our mammalian DNA, like grizzly dominance rituals in preparation for hunting or in the protection of their families? The awe inspired by athletics, the early morning workouts, the dedication, the bravery of taking on the opponent with everything you’ve got. The rules of the game originally attempted to resemble the skirmish of colonial battle lines. Fathers of Ivy league sons encouraging this game to develop toughness and readiness during peacetime. The rules have changed. Safety is a priority. But there is a core to the game, that if changed, seems to take away the very heart of what it is supposed to represent.
Take a sip, get off the field
When in the heat of battle if neurological symptoms arise (headache, dizziness, lightheadedness, etc.) my recommendation is to take a moment. Get off the field (sub out), do a personal inventory, and if you have symptoms of concussion, talk to your trusted athletic trainer or team physician. I was asked once by an elite college coach if we ever let an athlete back in the game after they have reported symptoms. We know that this happens, constantly. We know that athletes are playing through symptoms. So why, if the player is honest, is there a “penalty” for that honesty? I do not pretend to be able to singlehandedly change the guidelines to something other than the current recommendation of absolute removal from play for any concussion symptoms, but we must find better ways of studying actual experiences and delineating what is, and what is not a brain injury requiring absolute refrain from play. Because whether we like it or not, it is happening. In every collision sport. So, for my athletes, I again remind them that their brains are vulnerable. That we, as medical professionals, cannot easily make decisions regarding your safety. And we know that safety is not your highest priority while playing a game that requires suspending sense of vulnerability. That is when your relationship with your trusted medical partner comes into play. You let them make that decision with you. Don’t enter the “am I hurt, or am I injured?” dialogue in your own mind.
Are we getting better?
As the culture in sports changes, awareness increases, and technology improves, we have seen adaptations. High-profile scenarios where athletes have chosen rest after brain injury, rules changes, improved helmet technology, improved practice schedules, restrictions, and techniques. Where my generation was taught to put their face masks in the numbers, players are now taught to get their head away from contact. Although coaches and officials should not be asked to make diagnoses, their awareness has allowed the recognition of countless injuries and acceptance of the needed recovery for brain injury. All of this seems to have diminished the number of exposures, concussions, and hopefully long-term risks. Treatments are improving as well. Simple measures including modification of activity and exercise prescriptions can expedite healing. Medications and rehabilitation protocols can also help in recovery. We have also seen high-profile retirements in the recognition that longer careers, and repeated injuries will increase the likelihood of chronic brain disease.
Experience dictates how we “see” concussions.
My playing days in high school and collegiate football during the 1990s, and martial arts for about 20 years thereafter, make it clear to me that no matter what we know about risk, some human beings have a need to compete, sometimes in aggressive sports. Collision experiences can be difficult to describe and vary in presentation and severity. As difficult as these are to explain, it can be even more difficult to report and accept treatment. The motivation to continue to train, play, and be part of a team consistently leads to underreporting. My hope is that athletes and those that care for them will recognize this more clearly and have more honest discussions about their symptoms, and their need for autonomy, and we can capture events more consistently before catastrophic outcomes and untimely deaths occur. We can never get to zero risk. But I do think we can be more honest about the relative risks of concussion acutely and in the lifespan, allowing for guidelines to be just that – a framework for shared discussion and autonomous decision-making.
Currently brain injury in sports relies on symptom reporting. There are no usable biomarkers to more clearly define epidemiology and risks. That being said, there is solid evidence about the harms of repeated head trauma, and we must continue to pursue safety in competition. Second impact syndrome should be a never event. It seems that survivors of this catastrophic brain injury all have one thing in common; they continued to play through symptoms despite neurologic symptoms. Having trusted athletic trainers, and skilled medical professionals, at all practices and games in which collision sports occur is essential and doable. In many parts of the country, ATCs double as educators and have had great success in not only protecting student-athletes but also in educating the next generation of medical professionals. I have been part of creating these relationships and have watched these programs grow into self-sustaining and prosperous endeavors for all involved. Continued recognition that youth sport is not a time to “use up” one’s lifetime head impact exposures through rules changes to introduce collisions later in development has helped. Practice and technique rules have also had a positive impact. Enforcement of those rules, especially at the community level, is sometimes lacking and needs to improve. Autonomy is essential and guidelines need to reflect this. “All or none” (reported symptoms lead to absolute restrictions) concussion diagnosis and recovery pathways are not a one size fits all and must be amended to allow shared decision-making.