My FOOTBALL INJURIES blog last December, briefly mentioned Cerebral Concussions as one of those colloquially-described disorders commonly referred to as “having your bell rung.” As I alluded, concussions have taken on significant importance in the long-term well-being of college and professional athletes. The emergence of information from the research of forensic pathologist, Dr. Bennett Omalu, has resulted in a completely restructured approach to head injuries, and an attitude of precaution and prevention. After a head injury, a player is no longer allowed to return to a game as soon as he says he’s OK or when the “cobwebs” have cleared. He must enter a prescribed, structured concussion protocol, conducted by a professional, and prove that he has recovered.
When a player is suspected of having a concussion before re-entering the field of competition he must be thoroughly examined in a private tent on the sideline. What do they do inside that blue tent on the sideline, anyway? Why is it so secretive? What is a “concussion protocol?”
Cerebral concussions, or concussion, for short, can occur in any sport. But because of the high frequency of violent collisions that occur in football, it is the game most associated with their occurrence. They seem to be more common now than ever before, but some of that is due to greater awareness of the dangers of concussion and the serious emphasis on preventing long term brain effects. Traumatic brain injury (TBI) is the name given to the result of a bump, blow, or jolt to the head or body that causes the brain to move back and forth in its confined space. The brain actually bounces inside the skull.
Needless to say, the brain responds negatively to this trauma. The result is memory loss, confusion, clumsiness, slow mental response, a dazed or stunned look, and at worst, loss of consciousness. Symptoms also occur: headache, head pressure, nausea and/or vomiting, dizziness, poor balance, blurred or double vision, confusion, and a sluggish, foggy feeling.
Any combination or degree of these signs and symptoms can occur and defines a concussion.
Prior to the beginning of the sport’s season, athletes, today, are given a complete baseline neurologic and psychological exam to evaluate their “concentration, memory, and reaction time.” These tests are done by a “trained healthcare professional” to establish each player’s baseline status and detect any potential concussion symptoms that pre-exist. The baseline exam is used for comparison to the athlete’s status, later, after an injury that results in concussion symptoms. It’s important to know if the athlete has pre-existing migraines, ADHD, depression, anxiety, learning disabilities, or mood disorders which can affect recovery after a concussion.
What happens, then, when a player doesn’t get up after a violent collision on the field?
Signs and symptoms of concussion usually are apparent soon after injury. The sideline training and medical staff immediately do an on-field assessment of a down player. They determine his level of consciousness, check his memory (ask him to recall events prior to the hit, what day is it?, where are you?), see if he appears stunned or dazed, or if he is slow mentally. Any indication or suspicion of concussion demands removal from the game and complete evaluation by trained professionals.
That’s when the big blue tent on the sideline comes into play. Inside the tent, the player is assessed thoroughly. A “focused neurological exam is performed that includes: (i) asking what happened; (ii) reviewing the ‘Go/No-Go’ signs and symptoms; (iii) asking the Maddock’s questions on the sideline.” They also review a video replay of the hit to help remove any doubt if a concussion has occurred.
Maddock’s Questions were the work of an Australian neurologist and are part of every concussion protocol used today. Administered by trained professionals both on-field and in the blue tent, the questions are:
1. What venue are we at today?
2. Which half (of the game) is it now?
3. Who scored last in this game?
4. What team did you play last week?
5. Did your team win the last game?
This protocol detects concussions “32-75% of the time,” is highly specific “86-100% of the time,” and has a very low (“0-11%”) false negative (concussion was missed) rate. If the athlete fails to answer these questions correctly, he is not allowed to re-enter the game, and is taken to the locker room for more testing. Anyone can ask these questions so when certified professionals are unavailable this is a good assessment tool for trainers and coaches to use.
Should the athlete exhibit “Concussion Danger Signs,” he must be sent to the emergency room for evaluation and hospitalized for observation and further testing. These “danger signs” are as follow:
1. One pupil is larger than the other
2. Drowsy, unable to fully awaken
3. Worsening headache
4. Slurred speech, weakness, numbness, decreased coordination
5. Unusual behavior, restlessness, agitation
6. Nausea, vomiting
7. Seizure
8. Complete loss of consciousness
On April 26, 2017, the British Journal of Sports Medicine (BJSM) published SCAT5. A group of five athletic sanctioning organizations came together to create a “Sport Concussion Assessment Tool-5th Edition (SCAT5).” This is an 8-page step-by-step protocol/check-list for evaluating concussions. It’s far too complicated and lengthy to include here, but it covers every aspect of concussion diagnosis, treatment, and recovery. Highlights are as follow:
Immediate or On-field Assessment:
1. Observe for “Red Flags”— concussion danger signs
2. Look for “observable signs”
3. Memory Assessment— MADDOCK’S QUESTIONS
4. Examination —Glasgow Coma Scale
5. Cervical Spine Assessment
Off-field (Blue Tent) Assessment:
1. Athlete Background — review of history and baseline assessment done before season
2. Symptom Evaluation
3. Cognitive Screening — orientation, immediate memory, concentration (digits, months order)
4. Neurological Screen —balance exam
5. Delayed Recall —recall three objects at five minutes
6. Decision
Recovery Program:
1. Observe for danger signs up to 48 hours post injury
2. Rest and Rehabilitation — after a “few days” of rest, gradually increase daily activity
3. Gradual Activity—increase as long as symptoms do not worsen
4. Return to Usual Daily Activities—if symptoms cease may begin return to sport
5. Graduated Return to Sport—six steps are listed
6. Graduated Return to School—four steps should be completed before return to sport
Dr. G’s Opinion: This complete re-evaluation and renewed emphasis on the seriousness of athletic head injuries is a good thing. Too many high-profile athletes had symptoms and signs that were just passed off as part of the game until tragic deaths or suicides brought to realization that traumatic brain injuries had very serious consequences. Thank goodness Dr. Bennet Omalu had the kahunas to “fight city hall” so to speak. He fought an uphill battle to do what’s right for athletes who were victims of a game they loved, but were unaware of how negatively it was affecting their brain function. Those big blue tents on the sidelines at football games are there because he saw a problem that was being ignored. Thank goodness he followed through on his efforts.
Will concussion protocols prevent Mike Webster, Dave Duerson, Junior Seau-like incidents in the future? I don’t know, but I do think athletes will be better off neurologically in later life because of them.
References: Davis GA, et al. SCAT5, Br J Sports Med 2017;0:1-8.
CDC.gov/heads up/basics/baseline-testing
CDC.gov/heads up/policy
CDC.gov/heads up/basics/return-to-Sports
CDC.gov/heads up/basics/concussion-danger-signs
CDC.gov/heads up/basics/concussion-recovery
momsteam.com/Maddocks-questions
SCAT5–Sport Concussion Assessment Tool-5th Edition copyright Concussion in Sport Group 2017
National Football League “Concussion Checklist”
