Recent news stories about brain injuries among former NFL players have renewed concerns about the possible risks posed by football and other contact sports for players of all ages. The attention has helped raise awareness about concussion — a type of traumatic brain injury that can cause behavior changes, blurred vision, loss of coordination, disorientation, dizziness, and headaches. As many as 3.8 million concussions happen in sports each year, and nearly 9% of all high school sports injuries involve concussion, according to the American Academy of Neurologists.The organization says that with prompt and proper treatment, most athletes recover fully.
To discuss the latest findings about concussions, WebMD writer Matt McMillen talked to University of Michigan sports neurologist Jeffrey Kutcher, MD. Kutcher recently worked with the NFL Players Association to create an informational pamphlet, “Concussion Questions and Answers.” Here, Kutcher walks us through what’s known about concussions, who’s at risk, and what parents need to do to be sure their child is playing it safe.
1. Are concussions always the result of a single, brutal blow or can they come from an accumulation of less severe hits?
You can have a sequence of not so dramatic hits that absolutely can lead to traumatic brain injury, so we do have to readjust what we think about. It’s not always that big Sports Center-type play. Especially in sports like football, where there is so much going on, we lose track of the fact that the majority of concussions are not obvious just from watching the play as a casual fan.
Hits in succession mean those that occur during a game, over the course of an hour. They result in the transient change in brain function that causes the syndrome we know as concussion. That’s distinct from the thousands of hits that a player can take over the course of a season or career, which may lead to other types of brain injury.
2. Is there any way to judge how many hits is a safe number of hits?
There is no answer to how much is too much. I don’t think we even have a vague idea of what that means. Until we do, we have to bring the medical observation up to the point where we are watching our athletes at all levels across the course of a game, a week, a season, a career, and ultimately a lifetime.
We need to be able to understand individual sports and what is required to play each sport safely. In football, at some point you have to teach players how to hit. If you delay that, are you doing more damage because when they are bigger and faster, will they have learned how to hit safely? What’s the least amount of hits that it takes to teach players how to hit correctly? That should be your ceiling. You should not go above that. Every hit after that is gratuitous. But there’s also the question of how many hits it takes to cause damage, and there’s conjecture across the spectrum on that. Some say only one hit can cause trouble down the road. Others say that can’t be because we have been doing this for a hundred years and our former contact sport athletes in general as a group are doing fine. Somewhere in the middle is the truth.
3. Is concussion and concussion risk variable from player to player?
Let’s say I took everybody on a football team or in an office and lined them up and gave them a blow to the head, somewhere in the sports realm of force between 20 g and 100 g. (Sneezing is around 3 g, jumping off a step is 8, car crash at 40mph is 35 g). When I measure physiologically the changes in the brains of these 20 people, I’m going to get 20 different levels of injury based on genetics and what’s going on with that person at the time. Many things, including dehydration and metabolic status, can affect the amount of injury that’s produced.
But here’s the bigger point: if I could somehow have a device that hit people in such a way that they had exactly the same level of brain injury, I am going to get 20 completely different clinical syndromes. That’s just what brains do. Brains are vastly different in their ability to produce symptoms. There will be differences in its duration, in the type of symptoms that people are describing, and in how significantly those symptoms interfere with their functioning and their life.
That becomes one of our biggest problems. We keep using this term “concussion,” and people think that it is well defined and that it’s the same from one person to the next. But there’s no objective diagnostic tool that can describe what injuries are present, let alone to what degree.
4. Are there ways of identifying particularly susceptible players?
To try to answer that, you use tried-and-true, comprehensive neurological evaluations based on personal history and family history. You look for history of migraine in the family, history of mood disorders, history of people having difficulties with head injuries. While we don’t have the genetics figured out where I can say, “You have this gene that gives you a risk for concussion or long term effects,” we can use family history as a general guide of genetics.
5. Do learning disabilities and disorders like ADHD play any role in concussion and recovery?
A reasonable amount of data suggest that patients with ADHD, or migraine headaches, or a mood disorder, or even a sleep disorder pre-concussion are at risk for a longer clinical syndrome. But what does that mean? If they have symptoms longer, does that mean they have a worse injury? We need to separate out symptoms that are produced by the underlying condition from those produced by the hit. The injury itself could be less in somebody who already has a setup of brain network dysfunction.
6. Does the age of player influence the likelihood or severity of concussion?
The jury is still out, but there is published data that shows the younger you are, the longer the clinical syndrome lasts. There are a few possible reasons for this. One might be that pediatric brains that are still wiring themselves can’t deal with injury as well, and so the injury produces symptoms that last longer. Others have argued the opposite, that the developing brain is better at absorbing injury without producing clinical effects, which would mean it would take a greater injury to produce the syndrome in the first place.
As far as the risk of being concussed, the risk goes up as you get older and move into high school or college, but that’s mostly due to the changing style of play. As for any other risk you want to describe, such as changing brain function over time or changing the arc of this person’s development, it’s completely unknown right now. There is so little data on concussion in the pediatric population. That’s one thing we are really focusing on, getting better data for kids down to 6, 7, 8 years old.
7. We hear a lot about boys sports. What about girls and women and the sports they play?
Girls may be more susceptible to concussion. They might incur more injuries than boys in the same sports, like basketball and soccer. It’s been shown in some research but not in other research. There are many factors that could lead to that effect. One possible reason that makes sense to us as neurologists is hormone levels. It makes sense that the brain’s ability to deal with a force and not produce injury or limit the level of injury could be affected by hormones, as could the symptoms that occur because of the injury. Girls do represent a difference for us as clinicians, but most of what we know is conjecture that’s not supported by data.
As for adult women, the data are not really there. The data for long term cognitive impairment are only there for male professional sports. To my knowledge there’s not a professional female data set that addresses that issue. And in college and high school sports and below, no clear pattern has been established.
8. Why are we hearing so much more about the degenerative disease chronic traumatic encephalopathy (CTE) now? Are we seeing an increase in cases? An improvement in recognizing and diagnosing it?
What is the incidence of CTE? We don’t know. We don’t have a real sense of that. We only have a case series of individuals. But the idea that repetitive hits to the head, repetitive brain trauma over the course of a lifetime is bad for your brain is not a new concept. What’s new is looking at our popular sports and asking, is this a problem for our popular sports right now? We don’t understand the numbers, the incidence rate, at all, but we do think it is relatively rare. However, it’s also reasonable to conclude that repetitive contact is at least a risk factor if not the determining factor of this degenerative disease.
9. What are the most pressing priorities in concussion research?
For me, the most important question that I would love to have answered with each of these cases is how to measure injury and not simply measure the clinical syndrome. If we could develop a reliable measure of injury that we could use across the population, that would allow us to change everything about our diagnosis and management of concussion.
The second thing: We need to have a clear understanding of the long term effects on brain health from hits over time, not just concussions. Let’s follow athletes through the course of a game, a season, a career. Let’s monitor their brain function clinically and, as much as possible, physiologically, and see what happens to them over time. That would be incredibly helpful.
10. What advice do you give parents whose kids want to play contact sports, football in particular?
For contact sport generally, I’d say, kids should just play one and then give the brain a chance to rest. I have patients who play football and then wrestle and then play lacrosse or rugby. They’re involved with contact sports 12 months out of the year. Don’t do that. Pick a contact sport, get good at it, then play another non-contact sport so that you give your brain a chance to recover from the hits it took.
For football, first you need to really understand the benefits of participation. You can’t make a good decision if you just talk about the risks. Talk to your kid and understand, why football. There are often plenty of reasons why football and not some other sport. Those reasons can be that as a team sport, it’s unique. You have 11 players working together and all trying for the same goal, you have the physicality of it. Those are just two reasons.
As far as the risk goes, I would say a few things. Make sure new helmets or recently re-certified helmets are used. Make sure the proper techniques are being taught. Understand the coaches’ approach to contact. Make sure they respect brain trauma, that they look for it and that they believe it is real. You definitely want to have a conversation with the coaches and get a sense of how serious they are about this. I would also talk to the athletic trainer. If your school does not have one, that may be a red flag. There has to be somebody looking out for these kids.
The next step is to ask, “What happens if my kid gets concussed? What’s your plan? What resources are there in the community? Is there a comprehensive concussion specialist or center?” Identifying that up front before injury is a smart thing to do.
Finally, if all these things line up – if you have good support staff, if the coaches get it, if there are good athletic trainers and a good baseline testing program with good people who can take care of it, if you’re an involved parent, if your kid is at least somewhat up front and will tell you when they’re not feeling good, if when they’re injured, it’s recognized, and when it’s recognized, they are allowed to recover — when all that happens, I feel that our sports, including football, are safe.
Stepping back, though, it’s not just about concussion. If my kid just played a year of football, I would want him to see a specialist who can speak to his overall brain health when he’s not concussed, when he’s not injured, when he’s not playing, and to manage that aspect of things for his lifetime.
You need to have a specialist who looks at the big picture, not someone who is only concerned with when you were hit, what are your symptoms, are you back to baseline, when can you get back in the game. While all that’s important, it’s just the beginning of the story.
In my experience, you need to have a physician or neurologist who will step back and ask, “How is this affecting your brain health going forward?” If this is your third or fourth concussion, I would want to know about each of those concussions, how long they lasted and what the symptoms were and how long you were out of school. I would also want to know, when we deemed that injury to be over, how you were doing. How were you between the injuries? What’s happening to your brain function in a general way? That’s not something we can do with a one-time office visit and our tools for managing concussion. You have to step back and look at overall brain health.