Ask Dr. Pat · Health

Ask Dr. Allen: Football and the Defense Against Concussion

Dr. Patricia Yarberry Allen is a collaborative physician who writes a weekly “Medical Monday” column for Women’s Voices for Change.  (Search our health archives for her posts—calling on the expertise of medical specialists—on topics from angiography to vulvar melanoma.)

 

Dr. Baxter Allen. (Photo by Cheryl Fleming)This week, Dr. Pat turns for expertise to another Dr. Allen—her son Baxter, a resident in the Department of Neurology at Weill Cornell Medical College/New York–Presbyterian Hospital. Dr. Baxter Allen is a third-year neurology resident who has been involved in head trauma research for the last five years. This week’s subject: the concerns of a woman whose son’s two concussions, suffered during college football games, have derailed the young man’s life.
(Dr. Baxter Allen photo by Cheryl Fleming)

 

Dear Dr. Allen:

My son graduated from college last spring. He had been a running back on the football team there. I was somewhat anxious about his decision to play college football, but the coaches assured us that the latest helmets were used to prevent brain injury. My son had two concussions  during his college football career—one in his third season, one in his fourth. It took him a long time to recover from the second one. He became depressed, but we thought it was because he had to miss the rest of the football season. However, he then had trouble focusing, and reading was particularly difficult, since it brought on terrible headaches. He had fatigue and was really angry a lot. We had to finally take him home; he missed the last half of his senior fall semester. He returned for the final semester and did much better socially, though he does have unusual anger issues, which he’d never had before. His grade point average dropped from a 3.6 to a 3.0, in spite of hard work. He is now living at home and still looking for a job. He doesn’t seem like the boy who began college and had those two concussions.  

Are the “new” helmets that were available in 2010 to 2103 designed to minimize head injury? Obviously this did not prevent my son’s concussions, and now, one year later, I feel that he is still not right. How long does it take for someone who has had two hard head impacts and resulting concussions to get back to normal?  His CAT scans at the time of the concussions were normal, and the ER doctor told us that he needed rest and he would recover.

What happens in a concussion caused by head injury in football? What doctor should he see for evaluation, now that he is one year away from the last injury?  Does some kind of occupational therapy help?

Our internist simply tells us that some people with concussions take longer to return to normal.  

Beth

 

Dr. Baxter Allen Responds:

Dear Beth:

I’m sorry to hear about your son’s recent issues after his concussions. While the vast majority—80 to 90 percent—of patients do recover from their symptoms (see below) within 7 to 10 days, it is not uncommon for patients to have a prolonged post-concussive syndrome. When patients do not recover quickly, it is even more important for them to be evaluated by a physician trained in concussion management—usually a neurologist. In addition to ordering and evaluating imaging tests that are more sensitive at picking up small areas of damage that could be missed on a CAT scan (generally an MRI), a neurologist can help with strategies to manage symptoms that seem to persist longer than expected, and can work toward getting patients back to their pre-concussion functioning.

A concussion, as this video from the Centers for Disease Control explains, is a traumatic brain injury caused by a blow, jolt, or bump to the head or body that causes the head and brain to move rapidly back and forth. This can cause the brain to bounce around in the skull, stretching and damaging brain cells and causing chemical changes in the brain. Mild symptoms of a concussion can include headache, nausea, difficulty concentrating, behavioral changes, and many others; as explained above, they can clear quickly. But when behavioral and cognitive issues are interfering with school, work, or social life, it is common for a treating physician to refer a patient for neurocognitive testing and therapy with a neuropsychologist. Anxiety, depression, and other psychological symptoms are very common with prolonged recovery from a concussion, and their under-treatment can cause apparent cognitive or attention issues after a patient may otherwise be recovered from the initial head injury. The only proven treatment is rest: avoiding strenuous physical activity, strenuous mental activity,  and exposure to screens (e.g. TV, computer, phone) as much as possible until symptoms resolve, with a gradual reintroduction to these things as is tolerated.

 

What happens in a concussion. Source: Centers for Disease Control and Prevention.

Your question about the function of current football helmets is a good one. These helmets are mostly designed to prevent direct trauma to the head that could cause an immediate and life-threatening injury, such as a skull fracture with an epidural or subdural hemorrhage (when blood vessels between the skull and the brain burst and blood presses down on the brain, causing severe damage). Concussions are not generally caused by directly applied force, but are rather thought to be due to the consequences of a rotational force as the head and brain move around a fixed point at the neck. Since helmets do not prevent the head from moving around the neck, they cannot prevent these rotational forces from being applied to the brain.

There is much research and interest in the lasting impact of multiple concussions. In addition to the large hits that cause a concussion, lesser blows to the head—those that do not reach the level of impact that causes a concussion—are still important. These sub-concussive events (say, when a boxer is hit in the head with a jab, or when an offensive lineman is smacked across the side of the helmet by a defensive player trying to get by him) may have as great a role in long-term health outcomes. While football players, and boxers in particular, have a higher risk of early dementia and death than members of the general population do, it is unclear what threshold (or number of hits/concussions) it takes to impart this sort of risk. What is clear is that having a prior concussion puts you at risk for another, and each subsequent concussion is likely to take longer time for recovery.

The most important thing to recognize in preventing these severe injuries is that people who have suffered from a concussion are at a significantly greater risk of severe injury if they return to play before they have fully recovered from their symptoms. While a minor brain injury can cause small scarring or microscopic bleeding in the brain, most of the symptoms seem to be from alterations in brain chemistry and disruptions to the connections between cells. Exactly what happens when someone is fully “recovered” is unclear, but it likely involves the brain cells’ making new connections and adjusting to the insult. This makes it even more important to know what to look for during a game and imperative that players be removed from the field as soon as an injury is recognized.

The signs that someone may have had a concussion are sometimes subtle, but at other times (as was the case in the recently publicized injury occurring during a Michigan football game, seen below), everyone around the field can immediately see that something is wrong. If a player receives a blow directly to the head or body that might possibly cause a concussion, the athlete should be removed from play and evaluated. If a player is “wobbly” getting onto his feet or has a sort of “glazed over” look in the eyes, it should be obvious that he needs more attention. In the case of the video below, the athlete who was unnecessarily placed at risk did not get seriously injured. However, there was appropriate concern when this player was not immediately removed from the game.

 

As a neurologist in training, I am finding it hard to continue my love for football when it is increasingly obvious that the risks to players’ long-term health are high. While this sport continues to be played, it is imperative that we put more safeguards in place to prevent concussions from occurring.

References:

More Women’s Voices Articles on Concussion:

 

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  • Sally Bahner October 6, 2014 at 8:23 am

    I have never been able to watch more than a few minutes of football (or boxing or any such sport). The constant bashing of testosterone-fueled body parts over a little ball just stuns me. I could never understand the Super Bowl hype and more than more and more long-term problems are being pinned on the game, my only response is, “Do ya think?”
    There’s whole demographic of men turning into mental midgets by middle age, preceded by violence that seems to be carrying into their personal lives. And that’s accompanied by another demographic that financially supports the game. You know that Beth’s son is only one of thousands who have been affected.
    THAT is enough to make my head hurt.

    Reply