Brain Trauma

Unpacking cognitive behavioral neurology.

Navigating The Most Serious Decision in Sports

"I'm OK to play" could be deadly words if a concussed athlete returns too soon.

The moment a jarring hit sloshes the brain against the inner table of the skull, the clock starts ticking. The next few minutes that follow lead to the most serious decision in sports. Because during this period, a number of neurological, physiological, financial and perhaps philosophical, issues start bubbling to the surface, perhaps with life or death hanging in the balance. 

Onlookers may be gasping or cheering with the sound of collision. Amidst opponent’s trash-talking, teammates and coaches may be eagerly helping the player to their feet. The crowd roars with applause as the player walks off the field assisted by the athletic trainers. Is the cheering because the athlete is ok? Or is it because the player “took a hit for the team” and got back up? The athlete who sustained the hit immediately begins self-assessing their ability to return to play, tasking the potentially-injured brain and body to cooperate almost instantly and signal a concussion pass or fail score.

Unfortunately, the athlete is not the best judge in this decision. Nor are the coaches. Conflicts of interest abound. Hopefully, an athletic trainer or team doctor intervenes and carries out a series of tests to help identify the severity of a concussion risk.

Then, typically the decision is made: Play or sit.

It’s this period of time, from the hit to the return-to-play decision, where I fear sports may be risking too much. Too often, the post-hit evaluation process is rushed. With all eyes on the scoreboard, not enough emphasis is on the future well-being of the athlete. 

Complicating matters further, signs of a concussion often take several minutes, hours or even days, to materialize.

A concussion is considered to be a mild traumatic brain injury (mTBI). While science continues to discover ways of assessing concussions, numerous other studies show a connection between brain trauma and problematic futures. Consider these:

Perhaps an even louder wake-up call is that most concussions are not reported, and overt concussions are not required to cause brain damage. A 2012 study by the American Association of Neurological Surgeons looked at 45 high school varsity football players, none of whom experienced a clinical concussion during the season. The researchers concluded a single season of football play can produce measurable brain changes that have been previously associated with mTBI -- “adding to the increasing amounts of literature demonstrating that a season of participation in a contact sport can show changes in the brain in the absence of concussion or clinical findings.” 

Another grave concern is the condition known as Second Impact Syndrome, or sudden cerebral swelling that may occur when a second concussion occurs while the brain is recovering from injury. Most people don’t realize the 50 percent fatality rate among individuals who suffer this fortunately rare event. Of the survivors, 100 percent will have permanent neurological impairments. 

Then there is the more common Post-Concussion Syndrome (PCS). This constellation of symptoms, which includes migraine-like headaches, cognitive impairment, balance problems, sleep dysregulation and mood disorders can last days, weeks, months or even years.

Is this brain damage avoidable? In theory, yes. Realistically, no. But risk can be mitigated. Some of us are trying to educate and implement interventions designed to make better post-hit decisions.

Here are a few pointers to help navigate the most serious decision in sports:

1. Don’t move the unconscious person.

In the event of loss of consciousness, don’t attempt to move the unresponsive individual and risk exacerbating the problem of a neck and spinal cord injury. During a loss of consciousness, the brain and body are experiencing a forced re-boot, but the person’s pulse and breathing should continue. Should the individual stay unconscious for longer than a minute, call for help.

2. Better to wait, than be sorry.

A loss of consciousness may be the most obvious symptom, but also not likely to occur. Only one in 10 concussions result in a loss of consciousness. Therefore, onlookers have to be highly tuned into possible signs of a concussion. Symptoms can vary depending on the individual and where the brain suffers trauma. But generally, be aware of a glazed-over look in the eyes and perhaps signs of confusion within a few seconds.

If there is any hint of this, I recommend asking the athlete if they can stand and walk/skate to the sideline unassisted. Now, the waiting game begins. Give it at least two minutes before conducting any concussion assessments. Record and report the results and wait again. Don’t let the athlete, or coach, try to talk themselves back into action. 

I’ve created a protocol to help with the on-the-field concussion assessment. It involves cognitive, emotional and balance measures using a mobile app, called the XLNTbrain Sideline Assessment Tool. This tool, a companion to the comprehensive XLNTbrain Sport™ concussion management program, guides the responsible person on the sideline through a step-by-step process of assessing memory, orientation, and balance for a potentially injured athlete and instantly documents and reports the results.

3. Wait some more.

The least popular decision is to wait, perhaps another 30 minutes and conduct another concussion assessment. During this period of time, the brain is rapidly trying to heal itself, flooding blood and oxygen to the injury. Other functions may be compromised. Decision-making could be influenced. And further injury to the brain is the enemy, not the opponent on the field. Sometimes, concussion symptoms show up the next day. So, even if the athlete passes the sideline assessment, unless a trained medical professional has determined that there was no concussion, just the suspicion that a concussion may have occurred warrants that the player must sit out for the rest of the day.

4. Allow for recovery.

A recovery protocol needs to be set into motion. It begins with rest, minimizing mental and physical stimulation until the athlete is symptom free. The concept is “relative rest,” meaning the avoidance of any mental or physical activity that provokes the the athlete’s concussion-related symptoms. Once the injured player is free of symptoms at rest, I have included a 5-step progressive exertion recovery guide built into XLNTbrain Sport™ that monitors symptoms, and guides the timeline for a return to practice, or even classroom activities.

5. Decide.

Notice how careful I’m recommending a hard hit should be treated? A decision to allow a player to return to the game too soon, has too many risks. Give it time. Give it rest. Follow a recovery protocol, monitor symptoms and then decide when to return.

The Public Broadcasting Service television program “Frontline” has been tracking concussions during the last two seasons of the National Football League (NFL). Among the alarming discoveries, 49.5 percent of players never missed a game after sustaining a concussion. Given that the average concussion injury taeks 10-14 days of recovery, I feel many of these players may be returning to the game too soon. 

While there is no standard recovery time from a concussion, guidelines from the American Academy of Neurology and endorsed by the NFL Players Association, find that athletes are at greatest risk of repeat injury in the first 10 days post-concussion. And research suggests that the more head injuries a person suffers, the more likely they are to suffer from chronic traumatic encephalopathy (CTE) and face complications later in life.

The bottom line is that awareness and patience helps the athlete avoid becoming an unfortunate statistic. 

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Harry Kerasidis, M.D is the founder and medical director for XLNTbrain, LLC, based in Maryland, specializing in cognitive neurology. Through his practice treating hundreds of concussions, he created the, first and only, fully-integrated complete concussion management program that includes baseline measures, mobile assessments, reporting tools and a 5-step recovery care plan called XLNTbrain Sport™.

Harry Kerasidis, M.D., researches the impairment of cognitive and emotional performance resulting from brain trauma.

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