Concussions in the NFL: a Willful Disregard for Evidence
By Barbara Lock, MDNovember 29, 2009
About a year ago, I saw a 15 year-old girl in the Emergency Department who had suffered head trauma while playing rugby. She had taken a hit, had passed out briefly on the field, but had returned to full consciousness within about a minute, albeit with a moderate headache. The physician assistant, who had performed the work-up including a CT scan (which was normal) was concerned because the parents were asking for a note to clear the patient to play in next week's playoff game. I went to see them.
They looked at me expectantly.
"So, did she have a concussion?" the parents asked.
"Well, yes, but let's use the term minor head injury instead," I said, examining her head and neck. "She looks good. Just watch her for signs of trouble like vomiting, worsening headache, change in behavior or personality. Bring her in right away if anything seems funny to you."
"Like if she starts cleaning her room?" asked the mother with a half smile.
"Exactly," I said, smiling back.
Then I addressed the girl. "You've got to protect that head of yours. It's not good to get too many head injuries. You could end up being depressed and stupid, you know. People can die from head injuries. Seriously. Do you wear a helmet?"
The girl rolled her eyes at me, as if to say this doctor must have had too much head trauma already.
"You don't have to wear helmets in Rugby," she said.
"Ok, well, maybe you should find another sport," I said, "One that's not so bad for your brain." They all stared at me as if I was from another planet. "In the meantime," I said, "You'll have to take it easy for a couple of weeks. No contact sports."
"Well, next week is the playoff game," said the father. "She needs to play."
"You can let her do whatever you want," I said. "I can't prevent you from making bad medical choices."
"Then, can you write a note to her trainer saying that she can play in next week's game?" asked the mother.
All of a sudden, it was my turn to stare at them in disbelief. What part of depressed, stupid, no contact sports, protect your head and bad medical choices did they not understand? I caught the eye of the physician assistant across the room, who gave me an I told you so nod. I felt like time was standing still, I felt like I was speaking in slow motion.
"No," I said. "I cannot do that. It would be dangerous, even life-threatening, for your daughter to get a second concussion so soon after a first one. It is not worth the risk. I advise her to avoid contact sports including rugby for at least two weeks. I can't stop you from ingoring my advice, but that's what I'll be writing in the note."
The all stared daggers at me, and left angry.
But this family's response to medical advice is not unusual. In fact, their response mirrored that of the entire sports-entertainment industry's response to medical advice about head trauma: willful disregard.
So, I was not at all surprised to read that professional NFL players are routinely played after multiple head injuries, and I was curious to read that NFL Doctors Ira Casson and David Viano, the doctors who had lead the league's committee on concussions, resigned after their evaluation of the medical evidence finding no link between concussions and brain sequelae was challenged. In a congressional hearing in October, California democrat Rep. Linda Sanchez played a T. V. clip of Casson denying any link between head injuries in players and brain disorders. Sanchez likened the denial to the way tobacco companies used to deny the link between smoking and cancer.
What is a concussion?
A concussion, also sometimes called mild traumatic brain injury or minor head injury, is an injury to the brain from an impact, frequently from a fall, sports injury, or bicycle or motor vehicle injury. The brain is bathed in cerebrospinal fluid inside the skull. This fluid cushions the brain to some extent, but a significant impact to the head can cause the brain to hit right up against the inside of the skull. A second, rebound, impact can occur as the brain sloshes back and hits up against the opposite side of the skull. This is called a contrecoup injury.
What are symptoms of a concussion?
People who suffer minor traumatic brain injury may lose consciousness for a few seconds to a few minutes, but loss of consciousness is not a necessary diagnostic criterion. Headache, confusion, and mental fogging frequently occur. Initial vomiting is also common, but repeated or delayed vomiting can also signal more serious brain injury, and along with severe headache and loss of consciousness is frequently considered a serious sign that may point to the need for medical evaluation and/or brain imaging.
Why is a concussion dangerous?
A concussion, or mild traumatic brain injury, can lead to depression and dementia later in life, especially if a person racks up many concussions. In some cases, mild traumatic brain injury can even lead directly to death, as can occur when one concussion rapidly follows a previous concussion, in so-called second impact syndrome.
Is second impact syndrome real?
Yes, second impact syndrome is real. Second impact syndrome can cause death in persons who have suffered two episodes of minor head injury in quick succession, usually hours to 10 days apart. Each injury in isolation could very well be considered minor by onlookers; victims may have had no loss of consciousness with either impact, and may hide symptoms of a headache from parents or coaches. While there are multiple case reports of second impact syndrome causing death in the medical literature, there is no good data to inform us how often this syndrome actually happens.
There is controversy over how second impact syndrome occurs. What is it about two episodes of minor head injury that can cause death? Two theories, both of which may be correct, exist. The first is that after an initial episode of minor head injury, the regulation of blood flow to the brain is changed so that the brain does not swell excessively. While most areas of the body swell after injury, including the brain, excessive swelling in the brain can cause death because the brain is trapped inside the bony skull, with nowhere for the swelling to expand. To regulate this phenomenon, the brain may experience reduced blood flow (perfusion), and altered processing (metabolism) of chemicals. This altered metabolism and perfusion may predispose the brain to worse injury and worse swelling after a second seemingly minor impact.
The second theory is that a first impact may cause or predispose someone to a subdural hematoma, which develops from slow bleeding next to the brain, and is frequently undetectable on initial evaluation. A second impact may cause or worsen a subdural and lead to worse swelling.
How many concussions predisposes someone to dementia?
For a study out of the University of North Carolina by Guskiewicz et al surveyed retired professional football players, and found that of their sample, 61% had reported at least one concussion during their career, while 24% reported three or more concussions. Former players who had suffered three or more concussions were five times more likely to have symptoms of mild cognitive impairment and three times more likely to have significant memory loss than those who had had no concussions. The retired football players as a group were more likely to develop early Alzheimer's disease than the general American male population.
How many concussions predisposes someone to depression?
In a separate study of the same design, Guskiewicz et al found that 11% of retired professional football players in their sample had symtpoms of depression. Players reporting three or more previous concussions were three times as likely to suffer from depression as those who had never had a concussion.
What will happen if the NFL imposes a Lifetime limit on concussions before retirement?
This is just speculation, of course, but informed speculation: if the N.F.L. imposes a lifetime limit on concussions, over which a player must retire, players and teams will immediately start to become secretive about concussions. If a player is knocked out briefly, for maybe 10-20 seconds, the player and any teammates who have witnessed the event will deny that it happened, instead saying that the player just had the wind knocked out of him. Players at college and high school levels may try to hide their concussion history so that it can't be counted against their lifetime limit. Parents will conveniently forget about their daughter's concussion that happened when she fell ice skating at age 6. There will be a push to redefine concussion to include only findings that a person cannot disguise, like imaging findings or results of neuropsychological testing. Epidemiologists will wonder why reports of concussions are mysteriously declining.
So what should we do?
Parents should be aware of the signs of concussion, which may be as subtle as a headache after practice, and carefully question their children about impacts. Parents and coaches should strictly limit play for at least two weeks after a concussion, longer if there are still symptoms. The American Academy of Neurology recommends that athletes stay out of play for at least one month following a second concussion that is associated with loss of consciousness. Parents should keep a tally of concussions and should seriously consider the risks of additional injury to their child compared to the benefits of continued participation (for there are benefits, of course, to exercise), after an initial concussion.
Colleges and the N.F.L. may consider a limit on concussions, but should limit the tally to concussions suffered within their college career or professional career only, and not before, so that young athletes are not tempted to hide concussions for fear that it will affect their chances for college or professional play.
Parents of young athletes and athletes of majority age in sports at high risk for head injury should be required to review the known risks of head injury at regular intervals, say before each season.
And professional athletes who suffer minor head injury should be evaluated by doctors who are not on the payroll of the team.
Please read our legal disclaimer.
Write a comment
- Required fields are marked with *.
Posts: 1
Reply #3 on : Mon August 30, 2010, 12:32:50
Posts: 2
Reply #2 on : Wed December 02, 2009, 21:14:03
Posts: 2
Reply #1 on : Tue December 01, 2009, 07:20:59
Bookmark with:
What are these?