Treatment is generally straightforward. Concussed athletes are placed under complete physical and cognitive rest until their symptoms improve. I always withhold television, computers, phones, and video games and may keep them home-bound if their symptoms warrant. There is no pharmacological treatment that has been shown to improve outcomes. Acetaminophen and NSAID’s may help some bothersome symptoms. An athlete should not be cleared for any activity until they have stopped all medications. A graded activity progression back to full clearance should start only after the athlete is asymptomatic and only proceed if they stay asymptomatic. The SCAT2 assists with clearance. Based on the Zurich Consensus, below age 18, athletes should not return until they are asymptomatic for seven days and have passed a graded activity progression. This is longer than Missouri law mandates. Always lean toward the side of being conservative in return of athletes from concussion is paramount.
Treatment is directed towards preventing long-term post-concussive syndrome. This can be related to a single or multiple concussions. There are also concerns with long term histological changes to brain tissue, called “chronic traumatic encephalopathy,” a progressive degenerative disease that may be caused by multiple concussions.13 It has been noted on autopsies of former athletes with known recurrent concussions.
Other new unique research was performed by placing force transducers within football helmets to measure impact levels over the gridiron season. Steven Broglio, PhD has shown that the average high school football player sustains about 650 hits (major impacts) per season. A concussion usually occurs with a 90 to 100 g-force; this is equal to an unprotected head smashing against a wall at 20 mph.14
A common misconception is that the harder the hit, the worse the outcome. Broglio’s studies show that the magnitude of an impact doesn’t predict the severity of injury.15 Hit impact of varying magnitudes may, or may not, cause a concussion. Injury levels vary among individual athletes and may vary in the same athlete at different times. His research found that there is no cumulative effect of sub-concussion forces that summate in an acute concussion. There is concern that repetitive sub-concussive impacts may lead to long-term cerebral pathology.14
“Second Impact Syndrome” is an infrequent concussion associated severe brain edema often leading to death. There is controversy whether this syndrome can be treated or actually exists.16
Prevention of sport-related concussions is the ultimate goal of physicians, coaches and sporting equipment manufacturers. Although there are many devices that are advertised to prevent concussions, there is a paucity of evidence-based research. These devices range from expensive mouth guards to padded soccer headbands. Most concussions occur with rotational force that is difficult to prevent unless the head is completely immobilized. Two companies, Riddell and Xenith, have developed new football helmets but there are no studies that demonstrate reduced concussions over older models.
Education of football players and coaches on proper tackling stressing a “heads up” technique and rigid officiating by game officials is the best approach to prevent concussions from occurring.
From 2001 until 2009, an estimated 2,651,581 children ≤19 years were treated annually for sports and recreation related injuries. Approximately 6.5%, or 173,285 of these injuries, were concussions. An estimated 6.6% of these concussions were hospitalized.1 Fatalities among youth athletes involved in organized sports remains rare according to a study published in Pediatrics in 2011.17 Analysis of the U.S. National Registry of Sudden Death in Young Athletes over a period of 30 years showed the highest number of deaths, 16 of them, due to blunt trauma usually to the head/neck occurred in 1986. The average number of head/neck injury fatalities over the entire time period was nine per year. Seventeen high school athletes died from head trauma after sustaining concussions in the days or weeks prior to their death.17 In North Carolina in 2008, two football-related fatalities from concussions were reported related to a release from untrained health providers. This lead North Carolina to pass a law requiring high schools to employ athletic trainers.
Figure 2 lists the causes of accidental death in young people. Summating organized and informal sports participation deaths in young people would not remotely approach these numbers. The Centers for Disease Control reported in 2009 that approximately 3,000 teens in the United States, aged fifteen to nineteen, were killed, and more than 350,000 were treated in emergency departments for injuries suffered in motor vehicle crashes.18 In an Arizona study reviewing drowning deaths (aged eighteen or less) from 1995 to 1999, most children/youths died in the home swimming pools. One hundred thirty-one of the 187 (70%) drowning victims were under five-years-old, and eighty-one of 131 (62%) died in a private swimming pool. The second highest drowning rate was in males, aged fifteen to eighteen.19 According to recent data published by the CDC, the rate of poisoning deaths increased among teens aged fifteen to nineteen, by 91% from 2000 to 2009, largely due to prescription drug overdose. The death rate was 3.3 per 100,000 in 2009.20
The risk of serious injury or accidental death to our youth is much higher than football participation while riding their bicycles, swimming in home pools, walking or riding to school or living in homes where alcohol, prescription drugs and household poisons/toxins are stored. Yet there is no serious effort to ban or prohibit these activities. The effort to ban football from schools and universities is unwarranted.
Personally, if I had a son, I would not be concerned with him playing football. I would, however, make sure that his coaches understand the proper football techniques that decrease the risk of concussions. I would also ascertain that a Certified Athletic Trainer, working under a protocol from a physician who understands the care of concussions, works at their school.
Brian L. Mahaffey, MD, MSPH, MSMA member since 1999, is Director, St. John’s Sports Medicine in Springfield; Head Team Physician, Missouri State University; Team Physician, Springfield Cardinals; and Team Physician, St. Louis Cardinals.
Read more from Dr. Mahaffey about the toll the sport takes on players of all levels — and ways to better protect athletes.
Published December 10, 2012.
Editor's note: This article is part of a special series brought to you by Missouri Medicine, the Medical Journal of the Missouri State Medical Association (MSMA). MedHelp, Missouri Medicine, and MSMA are collaborating to educate and empower health consumers by making the latest scientific studies and medical research available to the public. Learn more about MSMA and see more from Missouri Medicine.
This article was originally published in the November/December 2012 issue of Missiouri Medicine.