Part IV – Concussions in Football: From a Medical Perspective

As the hits keep on coming, the worries and concerns about head trauma has taken over the spotlight among professional, college, high school, and youth football.

In ESPN 99.1's series on concussions in football, and sports, in general, there's been several topics discussed. First, youth football in South Dakota is growing despite the concern of player safety and health. Second, high school and college coaches talked about what their teams do to avoid concussions, and how they treat concussions. Third, parents said why they let their children play football because of the benefits the game offers. The fourth part of this study will look at concussions from a medical perspective.

What is a concussion?

"Every time you get hit in the head, there's a micro-trauma," says University of Sioux Falls athletic trainer Zach Mathers. "It's one of the most frustrating injuries, and there's not a lot of rehab. You completely shut down the brain so it has time to rest. It's hard for athletes to stay involved and coaches have to treat them with the utmost care."

Shanna Kindt, a concussion specialist at Sanford Hospital, defines concussion to begin to understand the underlying effects of head trauma.

"A concussion is an injury to the brain that happens more at a functional level. 'Concussion' is from the word that means to shake violently. Some people will have an actual hit to the head, a direct blow, or will have more of a whiplash type of injury that they don't even have to hit their head that has caused more of the functional issues where we see ongoing issues whether short or long-term."

To note, concussions can occur without a loss of consciousness. 

How are concussions found?

Sanford Hospital has an outreach program for area high schools with athletic trainers at most home games. When a concussion is spotted by the outreach athletic trainers, they will take the player out of the game, and begin their evaluation. Patients will typically be evaluated for memory, balance or physical symptoms such as a headache, nausea, dizziness, sensitivity to light or noise, or loss of memory or focus. Patients can have emotional-related issues such as irritability, sadness, nervousness, anxiety, or sleep-related issues. An athlete could have all the symptoms, some of the symptoms, or none of the symptoms.

Possible questions when concussions have been found?

• What were their first symptoms?
• What symptoms are they now still dealing with?
• Have they tried any physical or cognitive activity such as school, reading, computers?
• Are physical or cognitive activities increasing their symptoms?

How are concussions evaluated?

• The impact baseline test, which is a neurocognitive test on the computer is one way of evaluating concussions. Some schools compare baseline testing before an athlete's season, so they can compare tests from earlier or current concussions. For example, at USF, all athletes take a baseline test even before they can begin practice specific to their sport.
• Doctors and trainers also look at a thorough history of systems.
• A oculomotor test is a way to see how brain and the eyes are communicating.
• Other ways to check concussions is balance testing, eye-tracking tests, or pupil reaction time tests

Activities to avoid if concussed? 

• Contact.
• With mild symptoms, athletes can take part in light to moderate activity.
• In an academic setting, avoid computers, reading, bright lights, smart boards, cell phones (texting, internet).

What is the typical timetable for concussions? 

There isn't a timetable set for concussions. Kindt says each player has an individual plan. "Most concussions, 75 to 80% do get better within 7 to 10 days. However, it's that other 25% that lasts a bit longer. It could 2 weeks or 2 months."

For instance, USF's football program had a player with a concussion last for four weeks, and others who were out with concussions for just a week.

One concussion vs. multiple concussions 

Treat every concussion differently, whether a player has one or multiple concussions. Kindt has seen athletes with multiple concussions continue to play sports and athletes with one concussion never play sports again. She says it's really about all the factors. "It depends on nature of injury, the extent of injury, how old they are, how many they've had earlier, or any underlying effects such as ADD, dyslexia, autism, and chronic headaches. We individualize the plan for what's good for the athlete. Not about a number, but about the extent of the effects for when they can get back to play." She wanted to make sure that if there is any doubt about a possible concussion, sit a player out.

While treating every concussion differently, Mathers says that for athletes with more than one concussion, take more precaution. He said that he would have his athletes see a concussion specialist like Kindt, or Dr. Verle Valentine at Sanford Hospital.

What's the price of head trauma? 

A blow to the head is a structural issue that is like a brain bleed or bruise.  Brain cells aren't working, and basically, as Kindt says, it's like shutting down part of a big city. "The cells of brain aren't communicating correctly and it's like if you would take New York City and close three-fourths of the streets for road construction. Yes, you may still get where need to go, but it's going to take you a lot longer. We do cognitive and physical to open those 'streets' so communication among the brain cells can get back to what they should be."

Head trauma can also cause stress on a football player's life, as a concussion makes a player "shut" down their daily lifestyle until their brain is fully healed. Mathers adds that he thinks players get more stressed after they get a concussion when they cannot practice, or go to meetings. "I don't think they stress about it until they get one. We change their daily lifestyle, take them out and have to take them out of everything that is going to make their brain fire. We communicate and want them to sleep and they check in with us. We try to educate and talk to them., especially one's that are new to program."

Why care about raising awareness for head trauma?

“The bottom line is the concern is warranted. The brain is critical, and it takes time to recover. There’s no do-overs when you mess up your brain,” says Michael Bergeron, Ph.D., Executive Director of the National Institute for Athletic Health and Performance.

Bergeron hits the bullseye on the target. All the media hype and new medical studies surrounding head trauma is serving as a 'wake-up call' for the game of football, and sports, in general. In any sport, or recreational activity, a concussion can occur, and it's important to understand its effects.

Kindt says she sees people at Sanford with continual problems such as chronic headaches, concussion-induced ADD, emotional, sleep-related, or cognitive related issues. "We see people who cannot focus or concentrate in everyday life. It depends on the injury, and not only can it affect their playing career, but it can affect their every day life and academic career."

As stated earlier in Part III of this study, football and sports has an inherent risk. Likewise, there are benefits, and they bring together a lot of people, and teach life lessons, such as hard work, teamwork, and preparation. Munce shares that we should look at the role of sports in culture. "People get to form a relationship with their players, whether they know them or not. They have that affiliation, and when those people get hurt, they are affected. It feels like it's a friend or a part of them is being affected or being damaged. There are life lessons you learn, like responsibility, accountability, and discipline. It goes back to the risk-benefit. When people start to get more concerned about potential for injury and start casting aside all the potential benefits, then I think we run a greater risk of cultural aspect of losing out the great things that sports bring to us as people, communities and great nation."

Lastly, Munce wants to encourage families of athletes to ask themselves why they play sports, or let their children play sports. As a former football player at Augustana College, he hopes to give a balanced perspective and objective facts to guide those decisions. "I want to tell or remind people of the benefits of playing the game. In the current environment, there is so much on emphasis on injury and the potential long-term consequences, we don't fully know or understand. What often gets lost is all the positive reasons people play sports. I think it has to be a risk-reward risk-benefit analysis that parents and kids have to go through."

Present studies to look at head trauma?

Sanford Hospital and South Dakota Junior Football have recorded a study in seventh and eighth graders over the last three years. Sanford and SD Junior Football tested seventh and eighth graders in their first year before and after their seasons assessing their neurological functions. No deficits were found.

The last two years, Sanford and SD Junior Football experiment again with seventh and eighth graders. This time, a Head Impact Telemetry System (HITS) was used to place censors in the helmets of these players. The censors are called accelerometers to measure a players number of head impacts, the size of head impacts, and the location of the head impacts. In 2 years, the study tests twenty helmets. The results were not yet published, and Sanford will likely release them in the coming week's and year. Munce did say head impact exposure in middle school football players is intermediate to the findings of high school football players.

What does the future hold for the game of football, and sports, in general?

The game is at a crisis, and if the game wants to continue to thrive, Mathers says people need to start understanding the seriousness of a concussion. "A concussion isn't just a bruise or bump. It's a health risk we need to take care of. There are exercises from a strength and conditioning perspective. Athletes can work on the neck, trapezium, and shoulders to cut back the snapping of the head or whiplash from front to back, or side to side. Coaches can continue to make sure we are tackling the right way, and officials can make sure targeting or head to head contact is severely punished. People say those changes ruin games, but they make them safer."

In the medical community, there is a few possibilities for future studies, but Munce says players will need to age and develop for the studies to create results. "One, Sanford Hospital and SD Youth Football may study fifth and sixth graders, and follow them for four years in the junior football system. Two, Sanford Hospital may team up with an area high school, like Tri-Valley or Brandon Valley, as those kids stay with each other from youth football to high school football. Third, Sanford Hospital may use 20 to 25 players and check their injury information."

In addition to finding new studies, Munce adds that he thinks the game still has some of its toughest years ahead, and it will be key for the game to weather all the hype around the concussion crisis.

"I think there will be a time when alarming research comes out and it costs people to second guess the viability of sport. If the sport is able to weather that, I think that medical advances and other improvement will cut the risk. It's not goingto be one thing, but will have to be through rule changes, improved blocking and tackling, better instructions and supervision, better equipment, other training methods, more rapid diagnosis, and better clinical management."

Conclusion 

To sum up this series on concussions, Munce wanted to share a message for football players, athletes, and parents.

"There's no fault for parents to take a conservative approach for looking out in the best interest for their son or daughter. Before we know enough, it's better to err on side of caution. I urge parents to exercise measure of patience, to talk to health care professionals, and other experts in field of health and safety in sports and seek out their opinions. Get as much information to make informed decision. The goal in the future is to make more evidence based decisions, and to make sure they are not hearing from just negative sources, but to make your own decisions."