Making Headway – Perspectives on Treating Concussions Continue to Evolve

If the last 10 years have taught us anything, it’s that concussions are not a one-size-fits-all problem.

Still, for some, it was jarring to hear, after 10 years of ever-increasing caution in returning concussed athletes to the field, that trainers and doctors might be taking it too easy on them.

But that’s exactly the message of a 2014 study that, while reiterating the importance of a slow return to the gridiron — or baseball diamond, or lacrosse field, or wherever — for athletes who have sustained a head injury, recommended a more aggressive timetable for getting them back to a normal day outside of sports.

“What was done in the past was, they’d sit in a dark room until their symptoms went away,” said Tom Dodge, an athletic trainer at Springfield College.

But then a team led by Dr. Naomi Brown, pediatric sports medicine specialist at the Children’s Hospital of Philadelphia, published a report in the journal Pediatrics two years ago questioning the dark-room philosophy.

The study included 335 patients, ages 8 to 23, at a concussion clinic, who presented within the first three weeks following the initial injury. Each participant was asked to rate their cognitive activity — defined as anything that taxes the brain — on a scale ranging from minimal activity to full activity. Minimal activity implied they were out of school and not doing much reading or watching TV, while full activity implied they were back to school, fully engaged in activities, and acting as if they had never had a concussion.

After dividing the patients into quartiles based on their reported activity level, Brown said during a speech following the report’s publication, “we found that those participating in the most amount of activity, meaning the highest quartile, took 100 days to recover versus those in the other three quartiles, who took 20 to 50 days to recover.”

That wasn’t surprising, she went on; if anything, it reinforced the importance of at least some cognitive rest. But what did raise interest was that the other three quartiles took about the same amount of time to recover. “This would suggest that mild to moderate activity after the initial amount of rest that is recommended is not detrimental to patient recovery and that perhaps cognitive activity at some level may be beneficial.”

What that means may be different for every case, Dodge told HCN.

“Maybe you can listen to music — just a little, softly, not aggressive music. If you’re going to the college dining hall, maybe go at a time when the volume is lower, say 7 instead of 5:30 the first couple of days. You’ll want to avoid noise, avoid bright light. Maybe try to read 15 or 20 minutes, and if you have difficulty, put the book down, rest, hydrate, get a meal in, and try again a few hours later.”

He compared this new school of thought on concussion to other forms of rehabilitation. “You want to stay off the sprained ankle the first day or two, but then, after that, get motion back slowly. You want to get some of that function back. (With a concussion) try to go to a class, maybe don’t take notes, but try to listen. If it starts to bother you, put your head down for a few minutes. If it still bothers you, leave class. If it’s not bothering you, try to pay closer attention.”

In short, Dodge said, “everyone has their own tolerance, every patient is different, every athlete is different — and with concussions, those differences are tenfold.”

This recent focus on a quicker return to cognitive function comes at a time when sports programs across America, from the youngest levels to the pros, are increasingly vigilant about diagnosing concussions on the spot, taking the athlete out of the game, and launching days and even weeks of testing before even thinking about letting him or her back on the field.

The two trends may seem at odds at first, but in fact simply reflect a greater nuance in the way head injuries are handled — a far cry from, say, the ’70s and ’80s, when football players who ‘got their bell rung’ were shuttled right back on the field, risking a possibly catastrophic second trauma; countless athletes from that era, having absorbed thousands of collisions, eventually succumbed to brain damage, dementia, and even death, a risk they were not aware of then, but that now has a name: chronic traumatic encephalopathy, or CTE.

“Risk in sports always exists in some form,” Dodge said. “It’s the job of the people doing research and people like myself to keep them safe.”

Healthy Start

Particularly at younger levels, coaches that aren’t keenly interested in head injuries shouldn’t be coaching, said James Gutierrez, who coaches peewee (grades 3 and 4) football for the Chicopee Chargers program. All his players go through what’s known as a ‘heads-up clinic’ that teaches them how to tackle with their head to the side of an opponent’s body, instead of using the helmet as a weapon.

But coaches need training too. Once the game is underway and momentum kicks in, he said, players don’t want to come out even after a hard collision involving the head. “That’s where the coach has to use his knowledge to make sure they’re OK. A lot of kids, 95{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of the time, never want to admit they hit their head.”

As a result, he went on, “we all take classes in concussions. So many symptoms are really hard to notice. When you have experience with youth football, you notice little changes — they slur a little bit, speak differently, even the light of the sun bothers them. These are all symptoms.”

Any suspicion of a concussion gets a child removed from the game, he went on. “The first issue is to get them off the field. Most of these players don’t even know if they have a concussion, so you take them off the field, ask a couple of questions, have them follow your finger, see if they’re responsive. If the response is a little slow, they sit down and get looked over by the trainer or head coach.”

But that’s just the start. Programs at all levels across the U.S. now employ a multi-step, gradual return to physical activity that can take weeks, depending on the severity of the injury and the lingering symptoms. Many use some sort of neurological testing at the start of the season to establish a baseline score for each player for memory, reaction time, impulse control, ability to follow directions, and other behaviors.

“That’s cycled down into youth and high-school sports, and they’re doing a good job with that, making sure symptoms are gone, then returning to play,” Dodge said. “Maybe they can bike one day, lift one day, maybe try to run one day, do non-contact practice, then contact practice, then a full game. That’s been in place for some years.”

Dr. Julio Martinez-Silvestrini, who runs the concussion clinic for Baystate Health, said his team is pleased that the school professionals they work with, including trainers, coaches, and teachers, are more aware of what concussions entail, and are more responsive than ever before to recommendations from medical providers.

“Initially, we were working with a lot of teachers who maybe didn’t understand the implications and refused to follow our recommendations,” he explained. “We still see that here and there, but it’s not the norm. Schools now are a lot more responsive and cooperative, and they actually play an important part in the recovery of the athletes.”

In fact, he said, even teachers who don’t coach sports often undergo training to identify concussion symptoms, and will flag students who don’t seem quite ‘right’ in class.

The 2014 Pediatrics article caused some confusion at first, Martinez-Silvestrini said, among teachers and coaches who misread it as recommending a quick return to normal activity for all concussion sufferers. “The problem with that is not every person can go back to school in two days. Patients who couldn’t walk without vomiting were being sent back to school.”

Clearly, he went on, the recovery schedule needs to be judged on a case-by-case basis. But the heart of the article wasn’t off base.

“It brought into the discussion that social isolation may exacerbate some concussion symptoms and cause other symptoms. We want to engage athletes and have them return to school with some modifications and according to their symptoms. If they’re suffering, if the fluorescent lights in the school hallways are killing them, we may be overprotective and hold them back.”

Martinez-Silvestrini agrees that holding back athletes too much — the dark-room theory — was causing some detrimental effects. “Now we’re being a little more aggressive on the rehabilitation process. Athletes still require clearance from physicians to participate in sports, and they must still be symptom-free to be cleared to return to play; the protocol to play sports is one thing that has not changed. Athletes can’t simply get a note from their primary-care provider.”

A League’s Shame

Much of this progress, it should be noted, was ongoing long before the NFL was dragged, kicking and screaming, so to speak, into the fray, a story given widespread attention in the 2015 film Concussion, which focuses on the work of forensic pathologist Dr. Bennet Omalu.

Starting in the early 2000s, he studied the brains of several former Pittsburgh Steelers and, later, other players who died young after struggling with early-onset dementia and other neurological problems.

While his contributions to understanding CTE were especially significant, Omalu was just one of a growing cadre of doctors and scientists who clashed for years with the NFL, which adamantly refused, at its highest levels, to acknowledge a problem. Instead, it deflected the issue through its Mild Traumatic Brain Injury (MTBI) Committee, established in 1994 and first headed by New York Jets team doctor Dr. Elliot Pellman, a rheumatologist with no background in brain health.

As recently as 2005, in fact, in one of many articles it wrote for the journal Neurosurgery, the MTBI Committee argued that “players who are concussed and return to the same game have fewer initial signs and symptoms than those removed from play. Return to play does not involve a significant risk of a second injury either in the same game or during the season.”

That’s right — as recently as a decade ago, it was considered OK for NFL players to return to the same game in which they sustained a brain injury.

“Under the right circumstances,” the article went on, “specifically with regard to final decision-making on return to play being solely at the clinical discretion of a knowledgeable team physician, it might be safe for college and high-school football players to be cleared to return to play on the same day as their injury. The authors suggest that, rather than blindly adhering to arbitrary, rigid guidelines, physicians keep an open mind.”

Pellman resigned from the committee in 2007, replaced by two co-chairs, one of whom, Dr. Ira Casson, was a neurologist. But still the NFL publicly denied the effects of CTE. Only in December 2009 did the league begin publicly admitting the long-term effects of repeated blows to the head and begin recommending that concussed players don’t return to the field the same day.

The following summer, having thoroughly lost the public-relations battle, the NFL produced a poster to be hung in locker rooms, warning that concussions “may lead to problems with memory and communication, personality changes, as well as depression and the early onset of dementia. Concussions and conditions resulting from repeated brain injury can change your life and your family’s life forever.”

Today, concussions in the NFL are to be diagnosed on the field by a doctor, not a coach, and players must enter a multi-step protocol to return to play through a series of carefully monitored steps — something other leagues, from peewee to college, had been instituting in increasing numbers since the mid-2000s.

A small-scale study Martinez-Silvestrini was involved in with two Tufts Medical Center doctors, the results of which were presented earlier this year to the American Medical Society of Sports Medicine in Dallas, demonstrates the need for such protocols.

Twenty-nine semipro football players in new England — who don’t play under strict concussion protocols — were referred to an online survey. A definition of concussion as well as associated symptoms were provided to survey participants, and the players were asked if they had experienced symptoms consistent with concussion.

The results were poignant; 10 of the 29 had experienced at least one concussion, for a total of 21 concussions in all — but nine of the 10 never reported these symptoms, and instead kept playing. They gave several reasons for not reporting: seven said they did not want to be pulled from the game or practice, four did not want to let their teammates down, and four didn’t think the symptoms were serious enough. Prior to the season, only 11 of the players received concussion education from a medical professional.

“That’s scary. If they don’t tell us they’re concussed, they are possibly at risk of developing a chronic disorder,” Martinez-Silvestrini said, noting again how important it is for coaches to understand the symptoms and be willing to sit a player down, no matter how badly he wants to play.

Getting Better

Gutierrez was quick to note that children can sustain concussions simply from landing on the floor the wrong way or bumping into an object. But high-contact sports pose greater risks, and he drills home the importance of protecting one’s head while tackling.

“We’re trying to reach them with the idea that the head is the most important part of the human body. The brain tells your fingers how to move, your toes how to wiggle. The brain controls your entire existence.

“A concussion is something you don’t want to live through, but it happens,” he went on. “It could happen in any sport — you could get a baseball to the back of the helmet when your head moves one way and your whole body leans the other way — but football is such a contact sport, you have to make sure you’re stressing caution at every level. Your brain is too important.”

Meanwhile, many parents — observers say it’s hard to pinpoint how many right now — are thinking twice about introducing their children to football, concerned by stories, highlighted in the movie Concussion and elsewhere, about how even small ‘microtraumas,’ caused by constant acceleration and deceleration of the brain and accumulating over time, can cause permanent damage.

But other parents seem pleased that sports programs are taking this risk seriously and trying, as much as possible, to minimize it, Dodge said.

“Overall, I’m pleased with what I’m hearing. I know of a number of youth football programs that are constantly reassessing the rules and ways they’re teaching certain tactics of hitting and tackling,” he explained. “Even with soccer, it’s opening up conversations — when do you teach soccer players to do headers? How many times should they do that? While the guidelines are not set in stone, conversations have started, and that’s incredibly important.”

As for parents discouraging their children from playing football altogether, “that’s their prerogative,” Dodge said. “I think the key thing is, we are starting to identify what the dangers are, and we’re well on the way to identify some of the rules changes and best practices for keeping kids safe. We’re not there yet, though, and there are always some parents who are very conservative, and others who think we’re blowing this up too much.”

Gutierrez told HCN he wants the parents, especially at the peewee level, to come to the concussion clinic with their kids, and share in that conversation with them. “To me, the concern of the parents is appropriate. It’s their child. And for me, as a coach, I look at all the peewees as if that were my child.”

Unfortunately, Martinez-Silvestrini said, no one can say how many concussions are too many.

“The jury is still out, but I don’t think there will be a magic number,” he went on. “For some patients, one concussion is severe enough that they may not be able to participate in sports. Others may have more than one. Like everything in medicine, no two patients are the same, and no two concussions are the same. But we are getting wiser and more savvy in reading them, and we’re doing all we can to return them to play safely.”