Staying Smart after Concussion
by Dr. Ann L. Engelland
(February 14, 2008) For a person who generally
does not consider herself a football fan, the past two weeks
have been somewhat of an immersion in the sport. Of course,
I refer to my short-lived and mini obsession with the Giants.
But, in addition, I spent a day in Pittsburgh at the University
of Pittsburgh Medical Center’s sports medicine complex
learning about concussions. The Sports Medicine department
shares its campus with the Pittsburgh Steelers, and it was
a walk down their enormous indoor field that helped me to
appreciate just how far and fast the Giants were throwing
and running at the Super Bowl. It also made me even more aware
than before of the potential for injury from the aggressive
pile-ups that we take for granted and even revel in.
The football season may be over, but concussion season is
not. Hockey, lacrosse, and basketball are all high risk sports.
And then there is summer, when kids do dumb things and bump
their heads. Let me share what I have learned with you.
The definition, management, and treatment of concussion have
all changed over the past ten years. These changes are beginning
to be reflected in the way coaches, players, clinicians, and
psychologists respond to head injury. Professional teams like
the NFL have been in the forefront of this new thinking. As
the Mamaroneck School District physician, I have seen how
local districts are adjusting to this new information. I have
learned that other schools in our neighborhood have become
pro-active in educating, identifying, managing, and treating
concussions. We are not far behind.
So what is different?
1. For starters, the very definition of concussion has changed.
It is now defined as a trauma-induced “brain injury.”
From advanced research, we know that metabolic changes in
the brain’s vasculature and chemistry are taking place
following a blow to the head.
2. We now know that even mild or seemingly minor bumps and
blows to the head (or body) can result in brain injury. “Dings”
and “bellringers”, long thought a sine qua non
of a football season, are no longer thought of as minor.
3. We now recognize the wide variability in immediate signs
and symptoms following head trauma. We also recognize that
many will experience “post concussion syndrome”
for far longer - some as many as a year - than we used to
realize. Even mild brain injury can be associated with marked
changes in ability to think, retain information, and concentrate
and with ongoing profound headache, fatigue, sluggishness,
depression and academic difficulties.
4. Some good news! We know that complications of concussions
can be avoided by proper early management of the injured.
The potentially lethal ”second impact syndrome”-
where an athlete sustains head injury before healing has fully
taken place from a previous one - can now be minimized by
current standards of treatment.
5. Current recommendations for “return to play”
policies are increasingly based on objective neuropsychological
testing in combination with an assessment of a patient’s
signs and symptoms by a qualified professional. Increasingly,
this judgment is being made by professionals with specific
training in concussion, whether they be pediatricians, athletic
trainers or psychologists.
Because the trajectory of healing can be variable and depends
on a number of factors (age, gender, previous concussion history,
learning disabilities, attention deficit disorder, other neurologic
conditions), but is not always proportional to the apparent
size of the blow, categorizing concussions as “mild”
or “severe” is somewhat falling out of favor.
“Severity” may not become obvious until weeks
later when persistent headaches or poor school performance
How can we improve outcomes for our children?
The UPMC has developed and researched a neuropsychological
test that is being used internationally (with clients such
as USLacrosse, the NFL, US Soccer, Cirque du soleil, and the
New Zealand Rugby team in addition to over 1800 high schools
and colleges in the US) to help make intelligent decisions
about returning to activity, play and ultimately competition.
No such test can substitute for an accurate appraisal of a
patient’s signs and symptoms. But, trials have shown
that even when athletes feel “fine” and “good
to go” their neurocognitive tests (like memory) are
below their personal baselines. In addition, with pressure
from coaches, parents, teammates and themselves, many athletes
may not be completely honest about their symptoms.
The new neuropsychological tests are taken at a computer
terminal at an approved location and require about 20 minutes
to complete. Ideally every at-risk athlete should have a baseline
test before the season. This would include not only the helmeted
sports but also cheerleading, soccer, women’s lacrosse,
basketball and others. Athletes with prior concussions, or
risk factors for “post concussion syndrome” should
be baseline tested to help in measuring the impact of any
head injury in the future. In the absence of baseline testing,
athletes can be compared to published norms or to their own
sequential tests following the blow.
UPMC has taken the lead in creating a huge database and conducting
ongoing research to increase knowledge and improve management.
Their test allows athletes, families, coaches, doctors, and
trainers to work together and make safer decisions with some
objective data to back up the plans.
Many schools, athletic trainers, and coaches who have used
neuropsychological testing claim they will never go back and
that such testing will become the gold standard for managing
concussions. In our litigious and achievement-oriented society,
it’s only a matter of time before the rejection letter
from Harvard is blamed on the coach’s decision to put
Johnnie back in the game after that tackle last fall.
What can we expect to see around this area?
• More articles and information about head injury will
• Schools are likely to publish new guidelines on defining
and managing concussions.
• Coaches, athletes and parents will become better informed
about new information on concussions.
• Testing will become more widely utilized in decision-making.
My hope is that physical therapists, athletic trainers, schools
and pediatricians will work together to help coordinate improved
post-concussive treatment so that as a community we can say
we are Staying Smart after Concussion.
Dr. Engelland has a practice in Mamaroneck devoted
to Adolescent Primary Care. She now accepts Aetna and
Hudson Health Plan. Dr. Engelland can be reached at