Head Injuries in Athletics
Laurence E. Mermelstein, M.D.
As athletes and spectators, we are frequently reminded that a young athlete’s career can be derailed or cut short by injuries. Specific serious injuries are sometimes associated with specific sports: shoulder injuries in throwers, spine injuries in gymnasts, knee injuries in football, etc. Sometimes these injuries may carry consequences well into the future for the athlete – sometimes requiring late reconstructive surgery as older adults. But one specific injury may have a seemingly benign intial course with the athlete able to continue to play at a high level initially, only to have the most devastating late consequences down the road – the head injury.
Head injuries comprise 4.5% of all sports related injuries in high school and football accounts for the highest incidence of head injuries among all sports. The mechanisms of these injuries are usually from player to player contact, but can also occur with stick – to – head contact and ball – to – head contact.
Whereas concussion is the most commonly thought of brain injury, there are many, usually more serious focal brain injuries that can occur. The specific signs and symptoms of a focal brain injury usually involve focal neurologic deficits and loss of consciousness. Subdural hematoma, epidural hematoma, cerebral contusions and intracerebral hemorrhages are the more common specific injuries and must be suspected with any focal weakness, incoordination or deterioration of mental status or pupillary abnormalities. The mortality rates of subdural hematomas can be as high as 50% and any suspicion for these injuries requires emergent evaluation by a neurosurgeon.
Concussion is a diffuse brain injury characterized by immediate but transient of neurologic function secondary to trauma. Concussion does NOT have to cause loss of consciousness and will typically NOT be associated with abnormalities of CT scans or MRI’s. The hallmark of concussion is confusion. Amnesia, or memory loss, both retrograde (forgetting things that happened before injury) and posttraumatic, are important symptoms as well. The remainder of the symptoms can be quite non-specific. (see Table 1). Headache alone is not a usual finding of concussion.
Evaluation of the head injured athlete must occur rapidly on the field or sideline. After a cervical spine injury is ruled out, any loss of consiousness must be noted and for how long. Questions to the athlete should test his orientation, memory and cognitive function. Questions about the score of the game, name of opponent and previous game results are more reliable than the date or name of the president. Any amnesia at all is worrisome. As noted before, any focal motor weakness or progressive deterioration of mental status creates an emergency situation to be evaluated at a hospital with sophisticated imaging studies.
The biggest problem with these types of head injuries is determining prognostic classification. It used to be thought that loss of consciousness indicated the most severe of concussions. Recent research actually indicates that posttraumatic amnesia is a more sensitive indicator of significant brain injury. Neuropsychologic Testing is becoming the gold standard whereby the severity of a concussion can be measured. These are sophisticated tests that measure speed of information processing, attention, concentration, reaction time, visual scanning, tracking, memory and problem solving. The NFL has adopted baseline testing of athletes. After a head injury, repeat neuropsychologic testing can assist the clinician in determining even the most subtle of changes in brain function and in this way can more accurately determine appropriate return to play.
The feeling among physicians who deal with mild traumatic brain injuries is that no player should return before ALL symptoms resolve. After resolution of symptoms, the first step to return to competition is a cardiovascular challenge – 15 minutes of cardiovascular exercise without risk of trauma. If no symptoms are experienced, then non-contact drills can begin. The last step is full activities at practice. Each step should take 24 hrs to see if symptoms develop.
Serious complications can develop even after a single concussion, but are much more likely to develop with repeated, chronic injuries. Postconcussive Syndrome refers to the state of persistent symptoms of headaches, fatigue, irritability, sleep and gait disturbances, visual complaints and emotional lability. Etiology and treatment of these persistent symptoms is poorly understood.
A serious, life threatening complication is the Second Impact Syndrome. This syndrome is characterized by suffering another head injury before fully recovering from the first concussion. The second injury could be quite minimal, but rapid and total deterioration occurs within minutes leading to mental status changes, respiratory failure and death. The etiology of this is thought to be related to rapid changes in cerebral blood flow that occur after injury. Because the outcome of this complication can be so devastating, complete recovery must be documented before return to play is allowed.
Chronic Traumatic Encephalopathy, also called “punch drunk syndrome”, occurs from repeated head injuries over the course of years. Whereas boxers are the most well known athletes with this syndrome (Muhammad Ali), repeated head injuries over the course of a much shorter span of time can cause late, premature personality deficits, balances issues, cognitive dysfunction, speech issues and incoordination. Many a promising career has been cut short out of fear that late neurologic decline may occur with repeated head injuries (Wayne Chrebet).
In summary, mild traumatic brain injuries are quite common in all contact sports. Management of these injuries consists of recognizing focal injuries early on and referring for appropriate diagnostic studies and neurosurgical consulation. Neuropsychological testing can help recognize subtle changes in brain function. Any persistent symptoms, even the most subtle of findings, should preclude return to sport to avoid serious complications. Complications which can show up much later in life are also major concerns in athletes who have had multiple injuries. Unfortunately if they occur, there may be little that can be done. Return to sport needs to structured in a stepwise fashion with any return of symptoms delaying full activities indefinitely.
Signs and Symptoms of Concussion
- Loss of Consciousness
- Postraumatic amnesia
- Retrograde amnesioa
- Delayed verbal and motor responses
- Inability to focus
- Visual disturbances
- Feeling “out of it”
- Emotional lability
- Slurred Speech