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 become known.

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 appear.
• 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 698-5544 or AnnEngellandMD.com