In February, a 12-year-old patient of mine sustained a concussion during a basketball game. His symptoms resolved, and he gradually returned to playing basketball and the other sports he loves. He did well until November, when he was hit in the head by a pitched baseball. Even though he was wearing a helmet, the force of the fastball caused another concussion.
Once again the boy’s symptoms resolved, and he eased back into play. He enjoyed being on his junior high school teams and hoped to continue with his chosen sports in high school and possibly beyond. But he remains anxious about getting hit in the head again, and what the long-term consequences would be if that happened.
Hitting theaters December 25, the movie “Concussion” is shining a spotlight on the possible medical consequences of repeated head trauma in sports. It also highlights the uncertainty surrounding multiple head injuries, with no direct cause-effect yet demonstrated between head trauma and long-term medical problems.
"While long-term neurological problems are possible with repeated head trauma, even without a history of concussion, medical science is just starting to try to better understand the link."
What We Do and Don't Know
While long-term neurological problems are possible with repeated head trauma, even without a history of concussion, medical science is just starting to try to better understand the link. These long-term problems occur most often in sports with repetitive, high-impact forces to the head, such as boxing and American football. At present, however, we have more questions than answers: Which athletes are at the greatest risk? Is the age at which head trauma is sustained significant? What amount of head trauma produces the changes that lead to CTE? Is tau protein a problem or just a finding on autopsy? Should sports with inherent high-impact forces to the head be changed or avoided by young athletes?
Right now, there are no controlled epidemiological data and no established clinical or pathological criteria to diagnose CTE. Further research involving prospective, longitudinal, population-based, blinded neuropathological studies evaluating concussed and non-concussed athletes involved in high- and low-impact sports--beyond the current anecdotal case reports and selection-bias limited studies--is essential to understand the pathophysiology leading to CTE and to define the cause-effect relationship. Interestingly, a recent study systematically reviewed detailed information from more than 3,000 retired National Football League (NFL) players’ seasons from 1959-1988 and found lower rates of mortality and suicide in former NFL players than the general population.
" We need to equip patients and families affected by sports-related head injuries with the most up-to-date and relevant information we have."
While there remains much the field of medicine doesn't yet know regarding head trauma in sports, here is some of what we do know:
Helmets are helpful to prevent serious head injury, such as fracture or bleeding in the brain, but do not prevent concussions.
Loss of consciousness does NOT occur in the majority of concussions.
Athletes with a suspected concussion must be removed from play or training. When in doubt, sit out!
Athletes should not return to play after a suspected concussion until evaluated by a medical professional experienced in the care of concussions.
Sleep is currently the best medicine to enable concussion recovery.
Appropriate cognitive rest and refraining from schoolwork and screen time, facilitates recovery after a concussion.
Return to school is important and must take priority over return to sport and return to screens.
Return to play prior to full recovery may put an athlete at greater risk for chronic symptoms or further injury to the brain.
Knowing when to go back to play with the help of medical professionals helps with full concussion recovery and prevention of re-injury.
Standard CT scans and MRIs will appear normal in isolated concussion injuries, as concussion is a functional rather than structural injury.
Baseline testing of balance, cognitive function and computer-based neurocognitive evaluations can be a helpful tool for comparison post-injury and to determine readiness to return to play after a head injury.
As the medical community seeks more conclusive evidence about the long-term effects of head injuries, we need to equip patients and families affected by sports-related head injuries with the most up-to-date and relevant information we have. And as we “coach” them through recovery, we need to counsel them with another proven fact: Physical activity promotes health, and exercise is a powerfully effective medicine for all ages. Any risk of injury must be weighed against the numerous benefits of sports participation.
Baron S, et al. Body Mass Index, Playing Position, Race, and the Cardiovascular Mortality of Retired Professional Football Players. Am J Cardiol 2012;109:889 – 896
Davis GA, Castellani RJ, McCrory P, Neurodegeneration and Sport, Neurosurgery 76:643–656, 2015.
Iverson GL. Chronic traumatic encephalopathy and risk of suicide in former athletes, Br J Sports Med 2013;0:1–4.
Kirkwood MW and Yeates KO, Chapter 17: Sports-related Concussion, From Mild Traumatic Brain Injury in Children and Adolescents: From Basic Science to Clinical Management: 2012.
McCrory P, Meeuwisse WH, Aubry M, et al., Consensus statement on concussion in sport: the 4th International Conferece on Concussion in Sport held in Zurich, November 2012 Br J Sports Med 2013;47:250–258.
Tracy Zaslow, MD, FAAP, is the director of the Sports Concussion Program and medical director of the Sports Medicine Program at Children's Hospital Los Angeles and a team physician for the L.A. Galaxy soccer team.