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When to Quit Contact Sports Due to Concussion

The answer may be the least popular, most difficult, but smartest decision.

When is a hit to the head one too many? For sports fans, athletes, coaches and parents, this question regarding the consequences of possible brain damage from mild traumatic brain injury is becoming a daily debate.

Wide receiver Wes Welker has sustained three reported concussions in the last nine months, but he’s staying in the sport. Catcher Alex Avila says his three concussions this season won’t prevent him from continuing to play. Yet David Ash, former football standout at Texas, and Casey Cochran of Connecticut, both gave up their NFL hopes due to concussion.

Thousands of former NFL and NHL players are suing their respective leagues because of potential brain damage sustained during their tenure in the game. Yet, hundreds more are still playing.

There are two sides of the coin: One side says it’s just a part of the game. The other says it’s just not worth it anymore.

While it is possible to rehabilitate a damaged brain to some degree, there are several risks to consider:

Concussion Repercussion Risks

  • The younger the athlete, the more vulnerable the brain is to concussion, requiring longer recovery periods. The brain continues developing through the age of 25. Therefore, concussions in our youth and collegiate athletes can result in greater damage and potential risk to cognitive impairment.
  • A concussed athlete is more likely to sustain a repeat concussion, with the greatest risk in the first seven days.
  • Sustaining a repeat concussion before recovering completely from a concussion is associated with a risk for Second Impact Syndrome. This condition of acute cerebral swelling is fatal in 50 percent of sufferers and associated with serious long term neurological deficits in 100 percent of the survivors. Fortunately, this condition is rare and preventable with proper concussion management protocols.
  • Repeat concussions are slower to recover.
  • Athletes who have sustained three or more concussions are more likely to have long-term cognitive impairment and emotional struggles.
  • Concussions can accelerate the onset of dementia and an Alzheimer’s disease-like condition known as chronic traumatic encephalopathy.
  • People with a history of migraines are more vulnerable to concussion injury.
  • Females are more vulnerable to concussion injury than males.

When the brain meets enough force to cause it to bump against the inside of the skull, a variety of short-term symptoms can arise. And unfortunately, long-term and dangerous consequences can develop as well. A concussion, considered to be a mild traumatic brain injury (mTBI), can either: Heal quickly (about half recover within 10 days, over 90 percent within 30 days); or be the starting point of future problems; as well as complicate existing brain-health issues that accelerate the onset of more serious conditions, neurological disorders, and other brain drama.

Recently, there has been increasing concern about repetitive "sub-concussive" hits. These hits to the head are strong enough to be considered "abnormal" in the sense that they exceed the forces that occur during normal activity during sport.

Through review of scientific study of accelerometer data, the Sports Legacy Institute has adopted 20G or more force as the threshold for such a hit. The main concern is that although each of these hits are not in and of themselves associated with symptoms of concussion injury, over time they may cumulatively contribute to sustained brain injury. Further studies will be needed to define how many and over what period of time these sub-concussive hits are associated with neurological consequences.

Other than dying or paralysis from complications suffered from brain trauma, the most serious concussion repercussion is a decrease in overall quality of life due to a variety of cognitive and emotional impairments that may develop as the post-concussion syndrome. Memory loss, attention span, poor decision-making are warning signs of brain-related trouble.

An estimated 50 million Americans suffer from disorders of the brain or nervous system, which is a pretty good-sized chunk of the 317 million population. Some brain disorders are influenced by genetics, some are environmental, others from spinal cord or brain injury, and some result from a combination of any or all of these factors.

When you play a contact sport, you may be trading cognitive function for the thrill of the game, playing Russian Roulette with your future. From a medical perspective, playing contact sports is not a healthy or wise risk. Although I enjoy sport and realize there are many benefits from the game and being on a team, I caution you with the following conditions that can result if the gamble goes wrong.

In my practice, I avoid using “labels” for various conditions, preferring to understand the physiological issue causing the symptoms. Nevertheless, I’ve grouped a number of cognitive and emotional impairments that may occur should a concussion, or repeated sub-concussive hits lead to degenerative brain or neurological damage (in alphabetical order):

  • Anxiety
  • Attention problems
  • Balance/disequilibrium
  • Behavioral problems
  • Brain fog
  • Chronic fatigue
  • Cognitive decline
  • Depression
  • Language and speech difficulties
  • Memory and learning problems
  • Movement disorders
  • Sleep disturbances

So when should an athlete call it quits?

It’s a very personal issue and one that should be made along with a healthcare provider who has gathered necessary information to evaluate the risk-versus-benefit scenario. Then, with “informed consent,” the decision can be made.

The primary litmus test is determining if there is evidence of experiencing persistent or progressive concussion symptoms over time, which demonstrates possible progressive cognitive impairment.

These symptoms can include ongoing headaches, mood and sleep abnormalities, memory loss, brain fog, sensitivity to light and sound as well as attention deficits. If any of these are persistent or progressive, additional investigation would be recommended.

The number of concussions an athlete suffers starts to play a role in the decision making when considering retirement from the sport. Three concussions carry with them a higher risk of long term neuro-cognitive deficit. More importantly, there is heightened concern if these repeat concussions display a progressive pattern, such as worse symptoms or prolonged recovery with each successive concussion. Often in these cases there is also a pattern of less force of collision resulting in each concussion. These issues increase the player's risk for long term neurological consequences in continuing to play.

The decision to continue to play the game after repeated concussions is a risk-benefit analysis. The risks of long-term brain dysfunction must be weighed against the benefits of the sport including the physical, psychological and potential monetary (professional) gains associated with athletic participation.

Here are additional considerations:

  1. Has your sports team has implemented a concussion management protocol, such as XLNTbrain Sport to provide appropriate education, baseline measurements, sideline assessments and return-to-play guidelines to minimize the risk of future concussions?
  2. Are you familiar with established guidelines such as those provided by the American Academy of Neurology, the American Association of Sports Medicine, the American Academy of Pediatrics and the National Athletic Trainers Association, to help guide athletes in prevention and care of concussion injury in sports?
  3. The sooner we can start tracking “Hit Counts,” the better. With new accelerometer technology, we can add a device to helmets to count and measure the severity of hits taken to the head. Then, after every game, month, or season, we can review the number of possible sub-concussive hits to help measure the risk moving forward. The concept of the "Hit Count" is similar to the concept of the Pitch Count in baseball. Exposure to sub-concussive hits is limited by pulling the athlete from practice and gameplay when the Hit Count threshold is reached.

The real challenge with this topic is being able to look at the long-term implications as compared to the short-term opportunities. Ultimately, more research is needed to provide clear guidelines. But in the meantime, you can either read my advice now or see me as a patient later.