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Head cases


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  Spring 2011 issue (pdf)

A hot topic nationally, sports-related concussions are
always on the minds of the doctors who treat and study them

Athletes at all levels tend to have a competitive urge to play through, or in other words disregard the symptoms of, an injury sustained in the course of a contest. Sometimes, this is simply a matter of pain tolerance, but in certain cases, like concussions, an immediate return to action can have unpredictable and potentially devastating consequences.

Michael J. Brennan, MD ’79, was team physician for the Arizona Cardinals of the National Football League when the organization played in Super Bowl XLIII in Tampa in 2009. At that time, concerns and conversations about concussions were starting to become more pronounced around the league and in the media.
Michael J. Brennan, MD ’79, was team physician for the Arizona Cardinals of the National Football League when the organization played in Super Bowl XLIII in Tampa in 2009. At that time, concerns and conversations about concussions were starting to become more pronounced around the league and in the media.

Michael J. Brennan, MD ’79, was a team physician for the Arizona Cardinals of the National Football League (NFL) for four years and accompanied the team to its 2009 Super Bowl appearance. He said convincing professional football players to stay out of a game after a blow to the head can be a difficult task, even if it is in their best health interests.
“A lot of times, you had to hide their helmet so they couldn’t go back out on the field,” he said.

Recent policy changes in the NFL combined with heightened media coverage have shone a more intense spotlight than ever before on sports-related concussions. Although as a health issue, awareness and change have begun to trickle down to amateur and youth ranks in multiple sports, Medical College of Wisconsin alumni familiar with concussions suggest the room for improvement is greater than the distance already covered.

Because identifying concussion depends greatly on self-reporting, there has been a need to change the culture in locker rooms in which ignoring injury is analogous to toughness, and doing otherwise lets down the team.

“I think there is a better appreciation for the health consequences, long and short term,” said Dr. Brennan, an orthopaedic surgeon who remains team physician for the Arizona Diamondbacks Major League Baseball team. “It’s been a fluid change that includes having someone more specialized in brain injuries assess the players.”

In recent years, the NFL made two specific “return to play” rule changes. A player who shows any symptoms of concussion is not allowed to return to a game or a practice. That player is also required to be evaluated by an independent neurologist and can only return to activity after being cleared by both that consultant and the team medical staff. Additionally, the league announced in February that it had created a standardized protocol for sideline concussion assessment.

Unique diagnostic challenge

The National Collegiate Athletic Association mandates its member institutions have a concussion management plan in place for activities ranging from football to pole vaulting, cheerleading to equestrian. Requirements typically include recording of baseline neuropsychological assessments for each participant and removal from competition for display of any behaviors or symptoms associated with concussion.

Casey G. Batten, MD ’03 (center), Head Team Physician for University of California-Berkeley, tends to an injured football player. Treating concussions is a significant part of Dr. Batten’s practice.
Casey G. Batten, MD ’03 (center), Head Team Physician for University of California-Berkeley, tends to an injured football player. Treating concussions is a significant part of Dr. Batten’s practice.

Casey G. Batten, MD ’03, developed the management plan for University of California athletics. Dr. Batten is Head Team Physician for University of California-Berkeley and coordinates the work of all clinicians in the Cal Sports Medicine Program. Policy for concussions is one thing. As Dr. Batten suggests, diagnosing concussions is a challenge of its own.
“There is no one test that can give you a yes or no answer as to whether or not an athlete sustained a concussion,” he said. “By definition, a concussion does not cause structural damage – it manifests as a disturbance in cognition. In light of this, you need to rely heavily on subjective information from the athlete.”

The need for an athlete’s honest participation to arrive at an accurate diagnosis has driven efforts by medical staffs and organizations to educate players about the warning signs of concussions and the importance of truthful reporting. Dr. Batten believes a transformation in mindset has begun in collegiate sports.

“In the past, people may have had more of the mentality that they need to play through any and all injuries,” said Dr. Batten, for whom managing sports-related concussions is a significant part of his practice. “Athletes also may have been a bit reticent to report a possible head injury for fear they would automatically be held out of competition. Through education, I think we have been able to change this culture. Athletes have begun to understand that with prompt identification and appropriate treatment, there is actually less time lost from play than if they ignored a possible head injury, in addition to the possibility of minimizing risk for long-term complications.”

Integrity vs. pride

Kevin D. Walter, MD, GME ’01, conducts a balance test with a patient at the Children’s Hospital of Wisconsin Concussion Clinic.
Kevin D. Walter, MD, GME ’01, conducts a balance test with a patient at the Children’s Hospital of Wisconsin Concussion Clinic. An Assistant Professor of Pediatric Orthopaedic Surgery at The Medical College of Wisconsin, Dr. Walter says that girls are more likely to get concussions than boys in similar sports, and adolescents take longer than adults to heal from concussion.

The predisposition to downplay or dismiss injuries is equally common in youth sports. Every week, Kevin D. Walter, MD, GME ’01, sees patients who hide their concussion symptoms so they are not removed from participation or lie about their symptoms in an attempt to return prematurely. Dr. Walter is Assistant Professor of Pediatric Orthopaedic Surgery at The Medical College of Wisconsin. He practices in the Children’s Hospital of Wisconsin Concussion Clinic, the only clinic in the state dedicated exclusively to pediatric and adolescent concussion care. Diagnosis of a young person’s concussion can be like detective work.

“The biggest challenges are that young athletes may not recognize the symptoms of a concussion and continue to play,” Dr. Walter said. “Many teens are not honest about symptoms as well, so it can be a difficult task to figure out whether they are telling the truth or not. Young athletes cannot be expected to understand the consequences of inappropriately treating their concussion. It is difficult for them to comprehend problems like chronic traumatic encephalopathy, chronic headaches, depression and mental health problems that can affect them in adulthood.”

Dr. Walter visited in January with a teen patient whom he had previously warned not to play soccer the next season after the boy had suffered his second concussion, which took four months to heal. The patient did not heed that advice and, following a third concussion, is experiencing consistent daily headaches. Concussions are, of course, brain injuries, so the stakes are high for everyone, but youth athletes have particular susceptibility to damaging effects and take longer to heal.


Thomas A. Hammeke, PhD,
Fel ’79

“Young brains that are still developing, e.g., brain myelination continues through the teens and perhaps early 20s, may be especially vulnerable to traumatic injury,” said Thomas A. Hammeke, PhD, Fel ’79, Professor of Psychiatry and Behavioral Medicine and Lead Neuropsychologist for the Polytrauma Team at The Medical College of Wisconsin and Zablocki VA Medical Center. “Additionally, disability that arises in youth from traumatic injuries is lifelong for the individual and society.”

Under the magnifying glass

Dr. Hammeke has researched sports-related concussions for years, including a study of high school athletes funded by NFL Charities. That line of research revealed that most individuals clinically recover from sports-related concussions within a few days of injury and more than 90 percent within a week of injury. However, simply because the athlete is no longer reporting symptoms and performs normally on neurocognitive tests does not mean his brain functioning is fully normalized, he said.

That discovery may be contributing to the emphasis now being placed on understanding the consequences of multiple concussions or repeated subclinical head injuries (as can occur from the frequent impacts sustained in a typical football practice). To date, research has produced mixed findings, but at least some athletes have shown adverse outcomes, Dr. Hammeke said.

“More research on developing and understanding economical biomarkers of brain concussion and brain functioning is needed to better document the severity of brain concussion and track recovery of normal brain function or lack thereof,” he said. “This information will be especially useful for developing public health policies for determining if and when to let athletes return to play, based on scientific data.”

Athletes who participate while they have still symptoms usually have a longer duration of symptoms and are at much higher risk for repeat concussion, Dr. Walter said. Because concussion affects every person differently, however, it is impossible to predict how long a concussion will last, and there is no standard for how many concussions it takes before developing post concussion syndrome or another complication. Symptoms can be delayed, and part of concussion is memory loss, so patients often have amnesia around the time of the injury.

Time out

“The cornerstone of treatment is cognitive and physical rest,” Dr. Walter said. “That’s easy to say, but tough to do.”

For teens, treatment involves restrictions at school, sometimes even absences. It includes allowing extra time to complete assignments or tests and providing tutoring. It also means no physical activity and minimizing TV, computer, video games and texting exposure. All of these things are difficult and stressful for the student and for the school to accomplish, he said.

Through research, Dr. Walter is examining whether some degree of subsymptom, low-intensity exercise might help an athlete recover from the sometimes debilitating long-term effects of concussion. The work is still in its earliest stages, but there is a sense of urgency in helping these patients.

Dr. Walter has anywhere from 20-25 visits each week for concussion, of which about 10-15 are new cases. He has followed patients experiencing symptoms for more than six months and others with persistent post concussion syndrome lasting even longer. Making progress against that high volume will require far-reaching education efforts.

“Continuing to improve awareness is imperative. This can only be done through education,” said Dr. Walter, a sports medicine advisory committee member for the Wisconsin Interscholastic Athletic Association and the National Federation of State High School Associations. “Public awareness is primarily achieved through the media, so I feel it is important for physicians to be available to the media. Major changes in NFL and NCAA policy have been very helpful. Football is the most popular sport in America. When the NFL talks, the media listens. However, I still believe the most important people to educate are the coaches and the athletes.”

Dr. Brennan observed that the NFL is currently encouraging state governments to pass laws akin to the state of Washington’s “Zackery Lystedt Law,” designed to protect young athletes from returning to play too soon after suffering a concussion.

Dr. Batten agrees that despite the publicity surrounding sports-related concussions, further engagement of all stakeholders in the athletes’ health is needed to improve protocols and outcomes.

“It all comes down to quality education – education on prevention, identification, treatment and return to play,” he said. “This education needs to be aimed not just at the athletes, but also at administrators, coaches, families and other health care workers who may treat the athlete.”

 

Protective stance

Medical College of Wisconsin alumni with expertise in sports-related concussion have varied suggestions for best protecting athletes from brain injury.

Kevin D. Walter, MD, GME ’01

“Young athletes need to follow the rules of the game and use proper technique for contact. For example, in football, athletes should never lead with the head or use the head as a weapon. Athletes always need to have the appropriate safety equipment and make sure it fits appropriately. However, it is important to recognize that helmets and mouthguards do not prevent concussion.

The key is that athletes recognize and report their symptoms, then stop activity immediately. This will prevent prolonged symptoms and complication.”

Thomas A. Hammeke, PhD, Fel ’79

“Key challenges are educating athletes and trainers to recognize concussions; managing the strong motivation from athletes, and often coaches and parents, for the athletes to return to play prematurely; and getting the sports community to accept a mandatory two-week wait prior to return to play after all concussions.”

Michael J. Brennan, MD ’79

“In the NFL, protection of the helmet and advancing science into making the helmet better can lessen injury. It is important to try to prevent recurrent injury caused by returning to play before the brain tissue is healed. This means restricting players not only from games but practice situations, too.”

Casey G. Batten, MD ’03

“At this time, the best protection is proper education about the identification and treatment of concussion coupled with individualized, graded return-to-play protocols. The bottom line is that you want to make sure to the best of your ability that an athlete has fully recovered from a concussion, and that you have taken into account all other pertinent clinical information before consideration for return to play is given.”

 

Comments

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Comments / Ratings

Title:
Educational talk
By:
thomas wood md
Date:
09-8-11  10:50 AM
Comment:

Great and timely article. As president of Racine Co Medical Society, I would love to have one of the MCW experts give an evening lecture to our group.

Thanks.

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