Concussions

“If he has a 2nd concussion that destroys his season or career, everyone involved will be sued & should lose their jobs, coaches included.”
**Chris Nowinski (tweeted 3 hours prior to the game against the Buffalo Bills 9/25/22)

According to the CDC, a concussion is a type of traumatic brain injury—or TBI—caused by a bump, blow, or jolt to the head or by a hit to the body that causes the head and brain to move rapidly back and forth. This sudden movement can cause the brain to bounce around or twist in the skull, creating chemical changes in the brain and sometimes stretching and damaging brain cells. (3)

By now, we have all heard about Miami Dolphins quarterback, Tua Tagovailoa and his recent concussion(s). If you have not, stop reading and go watch the videos. In my opinion, he should have never been cleared to return to the game on Sunday, September 25, 2022 against the Buffalo Bills. He is clearly tackled and his head hits the ground with significant impact. He is unsteady as he walks across the field, even “shaking the cobwebs” off, but is somehow cleared to return to play and is diagnosed with “back spasms.” Four days later, during the game against the Cincinnati Bengals, his head again makes contact with the ground. Cameras zoom in and his fingers are contracting next to his head. This is an involuntary neurological response that the body can assume after a head injury. The forearms can be flexed or extended after the brain sustains the trauma.

The focus of this blog is not on the diagnosis, treatment or even return to play following a concussion, but rather on what is being done behind the scenes. How prepared are we? What are we doing to prevent, protect and prepare for such events? As a former licensed and certified athletic trainer, current physician assistant in orthopedics/sports medicine and mother of two young children who are very active in youth sports, this topic is important to me.

So, what is an athletic trainer anyways?
“An athletic trainer is a licensed or regulated health care professional who, under the direction of or in collaboration with a physician, provides primary care, injury and illness prevention, wellness promotion, emergent care, examination and clinical diagnosis. They also provide therapeutic intervention, and rehabilitation of injuries and medical conditions, as well as, return-to-activity recommendations.” (4)

In order to become a certified athletic trainer, one must graduate with a bachelor’s or master’s degree from an accredited professional athletic training education program and pass a comprehensive test administered by the Board of Certification. Once certified, they must meet ongoing education requirements in order to remain certified. Athletic trainers must also work in collaboration with a physician and within their state practice act. (1).
What is astonishing is the number of parents and high school student-athletes who report they do not have access to an athletic trainer at their school. Despite the proven benefits of having a qualified healthcare provider on staff, research from UConn’s Korey Stringer Institute (KSI) has determined that 34% of high schools with athletic programs in the U.S. do not have an athletic trainer, creating a clear need for research and advocacy in this area. (5)

We need to do better. Here are a few questions you as a parent/caregiver should be asking your athletic department, school administrators and coaches:
• Are there licensed and certified athletic trainers at the school? Do they attend both home and away games? Do they also have training room hours?
• Are there emergency action plans in place at the local schools which are reviewed annually with local EMS? How do these plans change when hosting an event off-site?
• Are AEDs available? Who is in charge of AED maintenance?
• Is there a concussion protocol in place? Baseline neuropsychological testing? Is there a Return to learn (RTL) protocol in place?

Here are some common concussion myths:
• “Loss of consciousness (LOC) is necessary for a concussion to be diagnosed.”
• FALSE – Most concussions do not involve a loss of consciousness.

• “A concussion is diagnosed by neuro imaging tests (CT scan, MRI).”
• FALSE – Concussions cannot be detected by neuro imaging tests. A concussion is a “functional” not “structural” injury. A CT scan or MRI may be used to rule out bleeding or bruising in the brain. A negative scan does not mean that a concussion did not occur.

• “A helmet or mouth guard can prevent a concussion.”
• FALSE – A helmet is important and can prevent more serious injuries, but cannot prevent a concussion. They are designed to protect against skull fracture and lacerations. A mouthguard can prevent dental injury.

• “It is important not to go to sleep after a concussion.”
• Historically, we were instructed to wake the athlete every hour to assess symptoms. This idea was related more to possible brain bleed to monitor for “red flag” symptoms. If there is no concern for this, let them sleep.

COMMON SYMPTOMS  
Headache/Head pressure
Fatigue
Nausea
Memory problems
Confusion
Dizziness
Blurred vision
Sensitivity to light and noise
Anxiety
Irritability
Depression

“RED FLAG” SYMPTOMS
Worsening headache that does not subside
Weakness, numbness, decreased coordination
Repeated vomiting or nausea
Slurred speech
Change in mental status – drowsy, stupor
Unequal pupils
Convulsions, seizure
Cannot recognize people or places
Increasing confusion, agitation
Unusual behavior
Loss of consciousness

Being on the sidelines as a medical professional presents many challenges. There is the pressure from the coaches asking WHEN can their athletes return to play. There is the concern from the parents asking IF their child can return to play. There is the “spotlight effect” as you feel the eyes of the spectators watching your every move as you carefully evaluate the athlete’s condition. (Hence why you now see the portable tents at most college and professional football games).

Not to “Monday morning quarterback” the Miami Dolphins medical staff, but being at the highest level of “spotlight,” comes with the responsibility to set the tone. We will not make forward progress regarding concussion management when the general public watches players inappropriately cleared to return to play, as Tua clearly was.

Recovery following a concussion is individually based and should be driven and monitored by a trained medical professional, MD, DO, PA, NP, ATC, PT, OT. It must also involve a multidisciplinary team approach involving parents, teachers, administrators, coaches, athletic trainers, school nurses and school psychologists/counselors. This is not a “one size fits all” recovery plan.

Although I am no longer practicing as an athletic trainer, I will forever be their biggest fan. They are the ‘unsung heroes’ in sports medicine. They deserve recognition, increased compensation and support. The profession is dying. Athletic trainers should not be a luxury to those that can afford it, they should be a necessity…but that’s a topic for another blog.
#AT4ALL

For more resources, please see the references listed below:
1. www.bocatc.org
2. www.nata.org/practice-patient-care/health-issues/concussion
3. www.cdc.gov/heads-up/index.html
4. www.NATA.org/about/athletic-training/athletic-training-glossary
5. www.today.uconn.edu/2022/06/athletic-trainers-in-secondary-schools-of-primary-importance-for-uconn-kinesiology-researchers/
6. www.biari.org/resources/reap/
7. https://www.bu.edu/cte/

**Chris Nowinski is co-founder and executive director of the Concussion Legacy Foundation (CLF) formerly known as the Sports Legacy Institute (SLI), a non-profit organization dedicated to solving the sports concussion crisis through education, policy, and research. He also serves as a member of the Outreach, Recruitment, and Education Core of the Boston University Alzheimer’s Disease Research Center and Chronic Traumatic Encephalopathy Center. Chris also serves as an advisor on the Mackey White TBI advisory committee to the NFLPA, The Ivy League Multi-Sport Concussion Committee, and as a consultant to Major League Lacrosse.