Christine Hammer, MD, Neurosurgery Resident, Thomas Jefferson University (left)
Analiz Rodriguez, MD, PhD, Neurosurgical Oncology Fellow, City of Hope National Medical Center (middle)
Clemens M. Schirmer, MD, PhD, Geisinger Health System (right)
As the world focused on the competitive athletes of the summer 2016 Olympic Games in Rio, we were inundated with stories of athletes overcoming adversities to achieve greatness. Concussions and the resultant side effects were central in many of these. While some of the athletes played contact sports, such as former NFL running back Jahiv Best, who transitioned to track and field, non-contact sports such as trampoline and cycling also impacted the athletes. Not surprisingly, a focus on concussions and post-concussive injury appears to be trending among former Olympic athletes as well. The soccer icon Brandi Chastain, who ripped off her shirt to celebrate the 1999 win of the Women’s World Cup, has decided to donate her brain posthumously to further the understanding of the potential neurodegenerative processes occurring from concussive injury among soccer players. Our co-author, Analiz Rodriguez, not necessarily famous for her middle school soccer plays, remembers falling backward during a game after making contact with another player. She blacked out for several minutes, and then after a short break was allowed back into the game. Nowadays, this immediate return to play would not be allowed due to increased concussion awareness and strict guidelines, which were created following concerns about long-term resultant neurologic deficits. The importance of this topic led Neurosurgery Blog to launch a concussion awareness campaign to put the spotlight on key issues surrounding traumatic brain injury (TBI). In the classic spirit of medical education, this grand rounds presentation gives a sweeping overview of the current state of #ConcussionFacts on this issue in the greater blogosphere.
What is a concussion?
Historically described as “punch drunk” or “seeing stars,” concussions are a type of mild traumatic brain injury usually caused by a blow to the head and may or may not cause a loss of consciousness. Concussions can result in a wide range of symptoms including:
- Blurred vision
- Double vision
These symptoms can occur with varying combinations and degrees of severity making a definitive diagnosis difficult. Neurocognitive tests, like the immediate post-concussion assessment and cognitive test, or ImPACT, have been developed to assess both children and adults for concussion. There are efforts underway to ensure this score is calculated for every TBI presenting to hospitals by integrating a function into the medical record. It remains to be seen whether this score can help improve our care for patients with concussion, but as a first step, it at least allows an objective measurement of what we are discussing.
Concussion and Sports
Concussions have garnered significant media attention, particularly focused on the association with sports, especially football. Here are some important sports #ConcussionFacts:
- 2 million sports-related concussions occur in the United States, according to the Centers for Disease Control and Prevention (CDC);
- Equestrian events carry the highest risk of concussion for athletes; and
- Martial arts and diving are in the top five sports with a propensity for sustaining a concussion.
However, given the popularity in American culture, football remains the most covered sport in relation to concussions. As concussions can occur during youth athletics, concussion safety laws are now present in every state. Guidelines urge that return to play after concussion be assessed on an individual basis with more conservative measures for children and teens. Re-injury through repeated concussions can result in long-term deficits. The Sports Concussion Institute has developed return to play protocols to help guide when and how it’s appropriate to reintroduce someone to sports play.
Professional sports have widely divergent guidelines on return to play that are sometimes enforced with variable diligence. At the World Cup Final in 2014, German soccer player Christoph Kramer continued to play for 14 minutes after obviously sustaining a concussion. Subsequently, Fédération Internationale de Football Association’s (FIFA) rules on return to play came under scrutiny. Alternatively, when British judo champion, Kelly Edwards sustained a concussion in February 2016, she was mandated to take six months off and therefore had to forego the Rio Olympics.
Less appreciated is the fact that concussions also occur in women’s sports. A recent study indicates that in high school, young women are 1.5 times more likely to sustain a concussion in comparison to young men. In March 2016, Pink Concussions and Georgetown University co-hosted the International Summit on Female Concussion and TBI. Women who are victims of domestic violence can also suffer repeated concussions.
Chronic Traumatic Encephalopathy
Repetitive traumatic brain injury including concussions may lead to chronic traumatic encephalopathy (CTE). Concussion, a 2015 movie which features actor Will Smith who played the scientist that discovered CTE after studying the postmortem brains of professional football players who had exhibited aggressive, suicidal or dementia-like behavior before their death. The conclusion of the movie, as well as the beliefs of many in the science world, is that CTE is a neurodegenerative disease and symptoms reveal themselves later in life, many years after participation in sports. CTE symptoms include:
- Personality changes;
- Suicidal potential;
- Trouble thinking clearly;
- Impaired memory; and
- Problems with balance.
Bubba Smith, an NFL defensive end and actor, was one of several players found to have CTE after donating his brain to a research bank. Early athletes felt to have suffered CTE and its consequences, have motivated many current players to pledge to donate their brains for research (such as Brandi Chastain) to elucidate the cause of CTE further.
Our armed forces have significant interests in understanding concussions and CTE. Of note, 85 percent of concussions in the military occur during training, sports or vehicle accidents, rather than combat. More than a quarter million service members sustained a TBI from 2000 to 2012 during combat in Iraq and Afghanistan. The majority of these injuries were concussions from being struck, falling, or affected by a nearby blast or explosion. The military has developed guidelines for return to duty following concussions since it is believed that the ramifications of a concussive injury on a stressed brain (e.g. fatigue, anxiety, etc.) are more severe than those of concussive injury among most athletes. The guidelines are similar in that progressive activity is allowed in a step-wise fashion until being allowed back to active duty. For those veterans suffering more severe post-concussive injury, they are eligible for up to 100 percent of disability compensation.
Health Care Policy
In the landscape of health care policy, influential stakeholders and interest groups have often driven highly focused efforts within the overarching issue. A few notable efforts:
- CDC’s HEADS UP effort features an excellent policy page;
- The National Conference of State Legislatures features information detailing the current state of sport concussion-related local legislative efforts;
- Many professional sports associations like the S. Ski and Snowboard Association and National Basketball Association feature their policies online for everyone to find; and
- Earlier this year, the U.S. House Energy and Commerce Committee hosted multiple roundtables to conduct a broad review surrounding the causes, effects and treatments for concussions.
The internet and social media are abuzz on the topic on concussion, some useful but also much incorrect and inflammatory. To this end, Neurosurgery Blog has made a point to focus on #ConcussionFacts as we are at a crossroads in our understanding of and interventions for patients with concussions. There is increasing awareness, and interest, which is great. Technical capability will increasingly enable measurements and tracking of these patients and hopefully allow us to find a solution for this burgeoning problem with its huge impact! Neurosurgeons will continue to lead the way in all aspects of this public health concern.
Editor’s Note: We encourage everyone to join the conversation online by using the hashtag #ConcussionFacts.