by Brian L. Mahaffey, MD
Following the suicide death of All-Pro National Football League (NFL) linebacker Junior Seau and the avalanche of lawsuits filed by more than 2,000 former NFL players, the subject of the inherent violence of the gridiron and noxious effects of cumulative head trauma, especially concussions, have been widely discussed. (American Medical News:“Doctors Key Players in NFL Concussion Litigation” Alicia Gallegos, 8/6/12 p1A)
This is the second of two articles dealing with football-related injuries. In the September/October 2012 issue former University of Missouri Academic All-American Jake Stueve, MD, discussed his experience and opinions as an outstanding high school and college tight end. The following article by the Journal’s Sports Medicine Editor and Mercy-Springfield Primary Care Sports Medicine Specialist Brian L. Mahaffey, MD, thoughtfully discusses diagnosis, treatment and prevention of conclusions, and whether football is inherently too dangerous and should be banned.
Read more from Dr. Mahaffey about the toll the sport takes on players of all levels — and ways to better protect athletes.
In the past several years, the interest in sport-related concussions in the lay press has increased dramatically. Almost weekly there is a story on sport-related (usually football) concussions. This involves every level of sport from youth to professional. Sports medicine-neurology-neurosurgery physicians began research on the diagnosis, treatment and rehabilitation of sports concussions many years ago. Consequently over the last fifteen to twenty years the recognition and care of these injuries has dramatically improved.
A study by Gilchrist at the Center for Disease Control (CDC) found that the number of emergency room visits for patients diagnosed with concussions increased 62% from 2001 to 2009.1 The study did not address why this occurred. Did concussions really become much more frequent during the study? Or did the prevalence of concussions remain relatively constant but emergency room visits increase secondary to heightened awareness and better diagnosis? I believe that it is likely the latter than a true increase in the incidence of concussions.
The publicity of sport-related concussions has facilitated a general understanding that concussions can be devastating injuries with long-term consequences. In the past as team or personal physician, I have had players, parents, and coaches argue with my treatment recommendations; now this rarely occurs. The overwhelming majority of people, including coaches, involved in high school and college sports are truly concerned for the short-and long-term health of their athletes. There are a few, usually highly publicized, exceptions. The most egregious being some NFL teams surreptitiously paying cash “bounties” for injuring opponent star players.
There are increasingly strident calls from a variety of groups and individuals for the elimination of football from high school and college campuses. A school board member and teacher in Council Rock, Pennsylvania tried to ban high school football, which she compared to “gladiator fights of ancient times.”2 Friday Night Lights author Buzz Bissinger argued in a Wall Street Journal editorial that college football should be banned.3 One of his arguments was the risk of serious head injuries. Malcolm Gladwell, in a 2009 New Yorker article titled, “Offensive Play: How Different are Dog Fighting and Football?” discussed their “similarities” ultimately questioning whether football is “worth it”?4 As usual it was just a matter of time before government became involved. The state of New York in 2009 banned dodge ball, tag, red rover, and wiffle ball at children’s summer camps to “make them safer.”5 This was later reversed because of widespread public outcry. Nevertheless, the efforts of those that believe that all risk can be legislated and regulated out of sports and children’s play continues unabated.
Many states, starting with Washington (2009), have passed concussion legislation. These laws restrict the return to competition of high school athletes diagnosed with concussion for at least 24 hours and only after evaluation by a medical professional. In Missouri, a similar law was passed in 2011. Even with these laws, head trauma deaths still occur.
Concussions are potentially very serious injuries and youth between ages thirteen to eighteen years are the most vulnerable.6 The prevention and care of concussions is controversial but most sports medicine providers follow the 2008 Zurich Concussion Consensus Statement.7 There remains many challenges in concussion recognition, care, and return to play criteria. Therefore caution and conservative treatment, especially in teenage athletes, is appropriate.
Concussion is an easy diagnosis to make, as long as it’s considered in the differential diagnosis of sports trauma. It is defined by a graded set of clinical symptoms that may or may not involved loss of consciousness. Its resolution will typically follow a sequential course. A small percentage of concussions may have prolonged symptoms leading to a diagnosis of post-concussive syndrome. Concussions are a clinical diagnosis, with standard radiology studies being negative. If any abnormality is noted on a CT scan or MRI, concussion is ruled out and a neurosurgeon should assume care. A common mistake in diagnosing concussions is to assume that no headache means no concussion. There are over 20 symptoms, including headache, which may occur in concussions. These can range from minor, such as a mild change in sleep patterns or emotions, to severe personality changes and disabling vestibular symptoms. See Figure 1.
Due to the wide variability and severity of concussion symptoms, researchers have long looked for ways to improve diagnosis and treatment. Sport Concussion Assessment Tool 2 (SCAT2) is a standardized, sophisticated, widely-used diagnostic test for concussion that can be performed in any setting. It uses cognitive and physical testing including balance assessment. It is useful in determining if an athlete may return to play. SCAT2 has not been validated.8 A baseline test ideally is completed before the athletic season begins. We perform SCAT2 baselines on high school athletes in contact sports; in diagnosing concussion after an injury; in following and clearing athletes to return to play. Recently, we held a high school athlete recovering from a concussion because his balance testing was below his baseline score, even though he was “asymptomatic” for 48 hours.
There are numerous computer-based concussion tests, with Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) being the most widely used including by the NFL. A baseline ImPACT score should be obtained on every athlete; subsequent testing can help with conclusion diagnosis, recovery and return to play. Population-based ImPACT baseline scores are published if an individual baseline test is not available. The ImPACT takes 20-30 minutes to complete and costs $10-20 per test.
Some problems exist with computer-based testing. One of the confounding factors is “gaming the results.” All NFL Pro quarterback Peyton Manning, in 2011, purposefully scored low on NFL baseline concussion testing stating, “They have these new tests we have to take before the season, then after a concussion, you take the same test and if you do worse than you did on the first test, you can’t play. So I just try to do badly on the first test.”9 Allegedly some NFL players use Ritalin to mask concussion symptoms during return to play evaluation.
Some experts question the validity of computerized testing.10 Randolph, a neuropsychologist, reviewed11 the risks associated with sport-related concussion and the validity and reliability of the ImPACT program. He concluded there is no evidence that the use of baseline testing alters risk from sport-related concussion and questioned the rationale of using the test. “Given the poor sensitivity and low reliability of these measures, they have an associated high false negative rate (i.e. classifying a player’s neurocognitive status as normal, when it is not). The use of baseline neuropsychological testing, therefore, is not likely to diminish risk, and to the extent that there is a risk associated with ‘premature’ return-to-play, the use of these measures even may increase that risk in some cases.” A more forceful argument against computerized testing is made by Robert Sallis, MD, past president of the American College of Sports Medicine, “It’s a huge scam. They’ve done incredible marketing, and they’ve managed to establish this test as the standard of care with no evidence that it has any benefit.”12 I do not use any computerized testing preferring the SCAT2.