Rethinking Concussion Treatment

If you or someone you love plays competitive sports, either with a few friends at the park or in the big leagues, concussions are probably high on your list of concerns. The Social Brain Blog, curated by The Ohio State University Wexner Medical Center Neurological Institute and The Stanley D. and Joan H. Ross Center for Brain Health and Performance, interviewed James Borchers, a physician specializing in sports medicine at The Ohio State University, and the Buckeyes’ team physician about concussions, how we’ve changed the way we think about and treat them, and what we still don’t know about head injuries and their effects.

Rethinking concussions

Source: Pixabay, used with permission.

Social Brain Blog (SBB): Dr. Borchers, as a former college football player and now a doctor of sports medicine, how were concussions treated differently when you were playing football at The Ohio State University in the early 1990s?

James Borchers (JB): Back when I played football, a concussion was to only have occurred if you showed a lot of neurological dysfunction—either you got knocked out or you were acting really unusual. Whereas, if you got hit in the head and you were dazed for a minute and felt like things weren't quite right but you continued to play—those were not necessarily considered concussions. Those were considered a head ding or a minor head injury. So I think we've changed the way we make the diagnosis and obviously the treatment and the evaluation is different as well. The evaluation back in those days wasn't nearly as significant as it is today. The return to activity was based on how you felt and there weren't good protocols to do that.

SBB: What are the latest ways to evaluate someone with a head injury and the treatment strategies for those recovering from concussions?

JB: I think probably the most important thing is that we have to recognize that a concussion is not a one-size-fits-all diagnosis. You really have to approach each individual with a diagnosis of concussion independently. And they can present in many different ways. So we can't just use one set of criteria to make the diagnosis of concussion. It really requires what we call a multi-modal approach to diagnosis where we don't just hang our hat on one area—symptoms, balance, tracking, or neurocognitive tests. All of those tools have to be assessed by a medical professional, preferably one who knows an athlete that's had a concussion, to arrive at the diagnosis.

As for recovering from a concussion, again I would say that we've come a long way. We don't lock people in dark rooms and wait for their symptoms to resolve. We know that there are important steps to take allowing the symptoms to resolve, but also in the recovery of those symptoms addressing things like light exercise as being helpful in the recovery. Looking at things like the vestibular and ocular rehab and emerging technologies that will reset our neurologic system from a concussion. And then certainly continue to focus on a graduated return to activity and not putting somebody right back into the sport or activity.

SBB: We hear a lot about CTE. What is its relationship to concussion and neurological function?

JB: It is important to understand that chronic traumatic encephalopathy, or CTE, is a completely separate entity from a concussion. CTE is a chronic neurodegenerative disorder, which goes through a number of phases and severity that can lead to a myriad of symptoms and behavioral issues. In someone who's had a previous history of head trauma, the difficulty is that we don't know the exact factors that caused the CTE. And certainly, we have to be careful not to draw as our only conclusion that concussion is the only variable that leads to the diagnosis of CTE. We don’t know if there are genetic factors at play or other issues that lead to that diagnosis. That being said, we know that CTE causes a change in function that can affect neurologic function, it can affect behavior, and lead to significant clinical symptoms that can affect the well-being and functioning of a person. It is something we need to be aware of, but not every individual that has a sport-related concussion is going to end up with CTE.

I think the most important thing with an athlete that has a concussion is making certain that they resolved that concussion and that we're doing the best that we can to protect them from further head trauma.

SBB: Are we able to identify signs of CTE in those who have or are suffering from brain trauma?

JB: There was just recently a study looking at PET scans and the ability to try to make a diagnosis of CTE in individuals that are living. The problem with CTE is that even with these emerging studies, you can still only make the diagnosis postmortem, or at the time of autopsy after death. And so, although there are a constellation of signs and symptoms and behaviors and other things that we will often attribute to CTE, those same signs, symptoms, and behaviors can be due to other issues as well—mental health issues or neurologic issues. And so attributing all of those things to either past concussion or to CTE is very difficult. We have not perfected a way to make that diagnosis.

SBB: Since not everyone reacts the same way to concussions, what role do genetics and other individual factors play in concussion—from susceptibility to recovery and treatment? Are there biomarkers that you're able to use in the treatment and recovery process?

JB: The difficulty with concussion is it's a really multifactorial problem. It’s got some intrinsic issues that are pertinent to the individual themselves. And then extrinsic factors that are either pertinent to the activity, the individual and the number of head traumas they've had, and the number of the subconcussive or concussive injuries that they've had. There are also so many things that go into determining a concussion. It’s not an easy diagnosis at this point to make and certainly not necessarily an easy condition to treat.

You mentioned biomarkers: The hope is that we could identify a test, and some people are focused on either a scan or a biomarker or something in the blood that we could test that would alert us to the fact that someone has had a concussion or a head trauma and that they need to be withheld and monitored. And then, with that same biomarker testing, be able to use it to tell us when that concussion has been resolved and if it is safe to return to activity. In normal clinical practice, we don't have that biomarker, although there's a great deal of research going on to identify a biomarker or series of biomarkers to help us do those things. I think that that's an area of research that’s going to continue to expand and something of interest to try to help us make the critical diagnosis using something objective rather than a lot of subjective data.

SBB: So it sounds like there is a lot that we still don't know. Is it worse to have a concussion versus repeated light brain trauma? Is that still something that is to be determined and does it affect different people in different ways?

JB: I think it's fair to say that subconcussive injury, or mild traumatic brain injury, however you want to define these things, exist on a continuum and we don't have great data and answers for what the outcomes are of the potential issues on that continuum. We are more aware of the severity of that today than 30 years ago and we have better protocols in place and better ways to make diagnoses, but we don't have all the answers and it's not a diagnosis that fits into a clean criterion that makes the diagnosis 100 percent of the time. And whenever you're counting on subjective data from an individual to make a diagnosis, how that individual reports in response to those symptoms can affect that. So looking for objective ways to make the diagnosis will help us maximize our treatment.

SBB: Is there any guidance you can provide parents on concussion?

JB: I think the number-one thing for parents is to educate themselves about the risk of concussion for an activity that your child's in. And then evaluate that risk versus the benefit. We know today from the epidemic of childhood obesity that it is much more harmful to not participate in activities. Exercise is really important. That being said, I think we have to concern ourselves as parents about the risk of young kids playing a contact sport like football or lacrosse or ice hockey, or even the risk of heading a soccer ball. I think the best a parent can do is to educate themselves and understand those risks and then be an active participant in their child's health care. And understand that if your child has signs and symptoms of a concussion to certainly hold them out of activity until they're evaluated by someone with appropriate background and expertise.

SBB: Where do you see us 10 years down the road in our understanding of concussions and treatment protocols?

JB: Looking into a crystal ball is always difficult. I'd hope that we would be able to make diagnoses through more objective criteria. And I think we'll continue to see the advent of biomarkers that will be able to help us in that diagnosis and the resolution of symptoms. Imaging will continue to advance in concussion, in sub-concussive injury, and in the diagnosis of long-term sequelae. And I think we will continue to advance our treatment protocols to reduce the risk of long-term sequelae and help recovery.

I think a lot of times what gets lost in this is the athlete's ability to assimilate the information about themselves, to help make decisions about their own health care. Hopefully, all these steps will continue to allow athletes to be active participants in their healthcare and making those decisions moving forward. I think we're seeing more of that today, but I think that's going to continue to evolve as we advance the diagnosis and treatment of concussive injury.

James Borchers, MD, is in his eighth season as a team physician in The Ohio State University football program. He also provides medical treatment for student-athletes from the soccer, lacrosse, tennis, field hockey, and softball programs at OSU.