Dr. Decipher: The Danger of Head Injuries to Athletes

By Dr. John Janousek, M.D. Monday, September 06, 2010

Last May, Dylan Steigers was playing linebacker at the Eastern Oregon University annual Blue-Gold football scrimmage game.  On the second to last play, he was among a group of defensive players who dove at a running back.  He got up, walked to the sideline, then told his coach “I think I got hit in the head.” After being sent to the trainer, he vomited, and EMS was called for hospital transport. Dylan was initially taken to a Grande Ronde Hospital, and then emergently flown to a Saint Alphonsus Regional Medical Center where he died from a subdural hematoma, a collection of blood between the brain and its tough covering, leaving behind a 2-year-old daughter.

Brain injury is a danger of sports, especially football, where players collide each and every play. Even with the latest ultra-padded helmets, the brain, which is gelatinous in consistency in vivo, takes a beating due to the sudden movements and stops. Since head trauma occurs in many sports, especially football, difficult decisions must be made as to when an athlete should be taken out, when he should be taken to the hospital, and when he should return to play. There can be a lot of emphasis by the coaches, the athletes themselves, sometimes even the parents to keep playing because the majority of the time the injury is not serious.

The more common serious problem is long-term effects of concussions. Dr. Robert Cantu, co-director of Boston University’s Center for the Study of Traumatic Encephalopathy met with NFL commissioner Robert T. Goddall in 2009 to discuss further research support after an October 2009 hearing before the House Judiciary committee. Dr. Cantu and his colleagues perform pre- and post-mortem brain testing on athletes who have suffered repeated concussions. Many athletes such as Ted Johnson, a former linebacker for the Patriots, who suffered multiple concussions and has chronic emotional and memory problems, are participating with the center.

What is a concussion?
As stated in the Zurich Consensus Statement a concussion is a disturbance in brain function caused by a force to the head with symptoms. Also known as mild traumatic brain injury (MTBI), concussion results in the rapid onset of impaired neurologic function, such as confusion, which resolves. Loss of consciousness may or may not occur. No abnormality on radiologic testing such as CT scan occurs with concussion.

What are the symptoms and signs of a concussion?
Symptoms include headache, cognitive disturbance (feeling in a fog), vomiting, and emotional symptoms (mood lability). Signs may include loss of consciousness and amnesia. There may be behavioral changes such as irritability and slowed reaction times. Drowsiness and sleep disturbances may also occur.

What should occur immediately after a head injury?
Any athlete in whom a concussion is suspected should be removed from play, then evaluated medically. One tool is the SCAT2 (included at the end of the in the Zurich statement) which involves a series of questions and examinations that are scored and used as a tool to determine seriousness of injury. Repeat SCAT2 testing should be done to follow recovery and assess return to play. Another widely used test system is Impact. This is a computer-based neuropsychologic test that can be administered on-line by trainers or physicians but requires a subscription.

Basically, an evaluation of brain function needs to be performed with testing of memory, orientation, and coordination. Serial testing over the next few hours is essential. Other serious injuries such as subdural and epidural hematomas (blood clots around the brain) like the one that killed Dylan Steigers need to be ruled out (requires CT scanning) as well as cervical spine (neck) injury.

What about return to play?
After a concussion, children, collegiate and high school players should not return to play the same day. There should be an initial period of brain rest without sports or school, video games, even text messaging. A graduated program of return to play is recommended based upon being asymptomatic at rest and with exercise. The Zurich paper lists 6 rehabilitation stages: no activity, light aerobic exercise, sport-specific exercise, non-contact training drills, full contact practice, and return to play. Each step should take at least 24 hours based upon resolution of symptoms, so an athlete requires at least a week before full activity is allowed.

What are the modifiers indicating potential for prolonged symptoms?
Special attention should be given to athletes with severe symptoms or those lasting more than 10 days. Other worrisome modifiers include: prolonged loss of consciousness more than 1 minute, amnesia, convulsions, repeated concussions (frequency), recent concussion (recency), repeat concussion with less impact, slower recovery after repeat concussions, age < 18, history of migraines, depression, ADHD or other mental health disorders, anticoagulant or psychiatric medications, dangerous style of play, and high-risk sport activities.

There can be a lot of emphasis by coaches, players, even parents to keep playing because most injuries are not serious. The take home point is that head injuries which may be concussions or other brain injuries need prompt evaluation and coaches and trainers need to have a high “index of suspicion” for them. Awareness is becoming much greater now with less of a hard-line approach to coming out of a game and restricting practice and play afterwards with appreciation for the hard hits modern athletes are taking and the repercussions of the concussions (ha!).

Feel free to share personal experiences concerning sports-related head injuries, viewpoints and helpful suggestions.