published Thursday, October 22nd, 2009

Cleaveland: Concussion risk puts players in danger

The recent concussion suffered by University of Florida quarterback Tim Tebow highlights the risk of this injury for football players at all levels of the game.

A concussion is a trauma-induced disruption of normal brain function. Most concussions do not result in unconsciousness. Typical symptoms include headache, amnesia for recent events, dizziness and disturbed equilibrium, sleepiness, impaired concentration and depression.

Symptoms may occur in any combination. Some symptoms may clear before others. Symptoms may last for brief intervals or days to weeks. If a second concussion occurs before the first has cleared, the athlete may experience a "second impact syndrome" in which disabling deficits of brain function may become permanent.

Post-concussion imaging of the brain with CT or MRI technology reveals no abnormality in the majority of cases. The changes within the brain occur at an electrical and chemical level. The classification of concussions as mild, moderate or severe is arbitrary at best.

Concussion is a hazard for participants in any sport where there is bodily contact or a risk of falls. As many as 3 million sports-related concussions occur in the United States each year. Boxing carries the greatest risk by far. Basketball, soccer, ice hockey and lacrosse also rank high. Boys and girls, men and women are equally vulnerable.

Football carries the highest risk among nonboxing sports. As many as 20 percent of high school football players who play for four years sustain at least one concussion. Some retired professional football players report dozens of concussions during their careers. A victim of one concussion is five to six times more likely to sustain additional concussions. Statistics related to concussions are shaky since many are unrecognized or not reported.

Recent clinical and autopsy studies describe a debilitating condition -- chronic post-traumatic encephalopathy (CTE) -- in football players with histories of multiple concussions. Detailed studies of brains of middle-aged, former professional players show widespread deposits of abnormal proteins. Similar material is found in brains from elderly sufferers of Alzheimer's disease.

Pathology findings were compared with brain scans obtained during the professional careers of these players. In most instances no post-concussion abnormalities were found on brain imaging. A report earlier this year described similar findings in the brain of a recently deceased 18-year-old football player with a history of multiple concussions.

Clinical studies highlight the plight of former National Football League players who began a drift into dementia before midlife. A recent segment on "60 Minutes" on CBS chronicled the sad state of several victims of CTE, including the legendary John Mackey of the Baltimore Colts.

Earlier this summer, the University of Michigan released a survey that indicates former NFL players under age 50 are 19 times more likely to exhibit symptoms of dementia than nonplayers of similar age. No one knows if there is an increased risk for former high school and college players.

Players, their parents and their coaches assume that helmets protect the brain. Helmets prevent skull fractures but do not block the shock wave from a collision with another player or with the ground. It is this shock wave that disrupts normal brain function. Bigger, faster players deliver a greater shock in all collisions. This accounts for the increasing risk of concussion in football.

Multiple codes and recommendations address concussions among football players. The Tennessee Secondary School Athletic Association prohibits any player who is knocked unconscious from returning to play or practice until evaluated and cleared by a licensed medical professional.

The toughest requirement for post-concussion examination comes from the state of Washington. Its legislature recently mandated examination and written clearance of all athletes under 18 who are suspected of having sustained a concussion, even if there has been no loss of consciousness. Colleges follow individual protocols for assessment of concussion. The Judiciary Committee of the U.S. House of Representatives plans hearings in the near future on concussions among NFL players.

A concussion is not a trivial injury. Players of all contact sports must be encouraged to report symptoms, their own or their teammates. Parents must know the symptoms and ensure a neurologic assessment before their injured sons and daughters return to play or practice. Coaches, trainers and team physicians at all levels of football or other contact sport must be well-versed in recognition and assessment of concussions. The need to return a star player to action must never trump the need for a complete, unbiased medical assessment. Football commentators should cease highlighting ultra-hard hits and direct some of their attention to educating the public about sports-related head injuries.

Football is a great game. We must assure its safety.

I am grateful to Dr. Peter Boehm for discussion and material related to this topic.

REFERENCES

* "Consensus Statement on Concussion in Sport -- Third International Conference." Access online at https://journals.lwn.com/.../Consensus_Statement_on_Concussion_in_Sport_3rd.l.aspx.

* Center for Disease Control (materials for athletes, parents, coaches): www.cdc.gov/concussion in Youth Sports.

* "This Is Your Brain on Football" by Jeanne Marie Laskas in GQ magazine for October 2009. Access online at http://men.style.com/gq/features/full?id=content_10980.

* CBS "60 Minutes," online program for Oct. 11, 2009.

* "Dementia Risk Seen in Players in NFL Study" by Alan Swartz. New York Times, Sept. 30, 2009. Access online at www.nytimes.com.

E-mail Clif Cleaveland at cleaveland1000@comcast.net.

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