Concussions: A childhood epidemic
By Jon-Michael Cook, MD
Our student athletes are facing an epidemic and it is our job as primary care physicians to help protect our athletes. It is estimated that 1.6-3.8 million sports-related concussions occur every year with more than 300,000 occurring to high school athletes. For young people ages 15-24, only motor vehicle accidents cause more traumatic brain injuries than sports.
Concussions were once thought of as a temporary injury much like a sprain or strain of the brain that would completely resolve with time. We also used to think that a hit to the head was not concussive unless there was an associated loss of consciousness. We are learning this is not the case.
Studies suggest the cumulative impact of both concussive and sub-concussive impacts may lead to permanent changes in the brain and this is something that needs more attention. Studies looking primarily at professional-level athletes have shown autopsy findings similar to those seen in elderly individuals with Alzheimer’s disease. This finding has been termed Chronic Traumatic Encephalopathy, which was the basis of the recent Will Smith movie,“Concussion.”
The problem with concussions is that they are subtle, usually manifesting as headache, amnesia, and sensitivity to light or sound as well as mood and sleep changes after some sort of impact. Unlike other injuries that require a cast, a walking boot, or crutches, concussions lack an outward sign to signify injury. Because of this, many parents and patients alike, question the need for caution and a slow return to play.
The fear of many physicians is something known as the second impact syndrome in which a second concussion occurs before the brain has had enough time to heal from the first. Due to the brain’s inability to auto-regulate pressure, substantial swelling can occur that typically has catastrophic consequences. This is one of the primary reasons it is recommended that the athlete participate in no contact-related activities and the reason all states have passed “return to play” laws.
Time and time again I have had discussions with parents about the certainty regarding the diagnosis of a concussion and the protocol sports medicine physicians and athletic trainers follow. This desire to bypass protocol stems from the importance placed — typically on the part of the parent — of some upcoming game or tournament. There is the fear of not impressing some scout or college recruiter and somehow altering their child's life trajectory.
According to the NCAA in 2014, there were approximately 7.4 million athletes participating in high school sports (men's & women's basketball, football, baseball, ice hockey and soccer) per year. Approximately 460,000 or roughly 6 percent will become NCAA athletes; of those 2 percent will continue on to the professional level. What this means is that 99 percent of high school athletes will go “pro” in something other than sports. For every kid that becomes the next Wayne Gretzky, Michael Jordan, Tom Brady, or Mia Hamm, there are thousands that become people like you and me.
The need for children to be involved in some sort of physical activity in today’s society is paramount. According to the Centers for Disease Control, approximately one-third of children and adolescents are overweight or obese. This rate has nearly tripled since 1980. In addition to the psychological stresses of being overweight or obese, these children are at an increased risk for high blood pressure, high cholesterol, diabetes, and other maladies. In those who participate in sports, the risk of injury and the potential for disability is increased but these risks are far outweighed by the benefits. So as important as it is to keep our kids physically active, we also need to keep them safe and capable of carrying out productive careers and lives after sports.
Currently there is no single test to definitively diagnose a concussion. Clinicians take the history of events combined with physical examination looking for exacerbation of symptomatology and neurocognitive testing to see how the brain is functioning to say that someone is in a post-concussive state. Luckily symptoms will usually resolve in a matter of seven to 10 days granted there is sufficient physical and cognitive rest.
As primary care physicians, you can help protect the lives and well being of these athletes by obtaining a concussion history from your student athletes. Recommend baseline cognitive testing each year, especially in those athletes that do not participate in University Interscholastic League sports like ice hockey (high school and club) or club soccer. Repeat these tests after a suspected concussion and while monitoring symptoms and deciding when to start a return to play. Know your area sports medicine physicians and your school-based athletic trainers. Most importantly, educate your patients and their families and be adamant in their return to play.
Jon-Michael Cook, MD, is a PGY4 Primary Care Sports Medicine Fellow at Houston Methodist Hospital – Willowbrook.