Concussions

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Earlier this year, Jordan Parsons, a former Bellator MMA fighter, was tragically killed in a hit-and-run accident. He was subsequently diagnosed with chronic traumatic encephalopathy (CTE) after a post-mortem brain autopsy. CTE is a progressive degenerative disease found in individuals who sustain repeated blows to the head. Parsons is the first MMA fighter to be publicly diagnosed with the condition.

Dishing out and receiving head trauma is part and parcel of the combat sports. Many athletes have understandably become concerned about how head trauma will affect them in the long run.

Today, we will be discussing concussions in detail, with specific focus on recognizing the symptoms of a concussion, the potential complications and what to do should you sustain such an injury.

What is a traumatic brain injury?

Traumatic brain injury (TBI) occurs when an external force injures the brain. It encompasses a broad range of injuries to the brain of varying severity, ranging from a mild concussion to severe bleeding within the brain. For the purpose of this discussion we will be focusing on mild TBI.

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Examples of severe TBI – bleeding within the skull or brain

What is a concussion?

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Concussions are a subset of mild TBI. A concussion is a trauma-induced alteration in mental status that may or may not involve loss of consciousness.

Concussions are commonly caused by a direct blow to the head, face, neck. However blows sustained elsewhere on the body can cause a concussion as long as sufficient force is transmitted to the head.

Symptoms of concussions

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  • Confusion and amnesia

These are the hallmark symptoms of concussions. They may be apparent immediately after the head injury or may appear several minutes later. There is almost always loss of memory of the traumatic event. In addition, there is often loss of recall for events immediately before (retrograde amnesia) and after (anterograde amnesia) the head trauma.

An athlete with amnesia may be unable to recall details about recent plays in the game or sequences in a fight. They may also be unable to recall details of well known current events in the news and may repeatedly ask a question that has already been answered.

  • Headache
  • Dizziness (vertigo or imbalance)
  • Nausea and vomiting

Over the next hours and days, athletes may also complain of:

  • Mood and cognitive disturbances

Cognitive – Feeling mentally foggy or slow, disorientation, difficulty concentrating, slow or incoherent speech, word-finding difficulty.

Mood – Irritability, sadness, emotional instability, nervousness.

  • Sensitivity to light and noise
  • Sleep disturbances (Drowsiness etc.)
  • Seizures

Post-traumatic seizures occur in fewer than 5 percent of mild or moderate traumatic brain injury (TBI), and they are more common with more severe TBI. About half occur within the first 24 hours of the injury; one quarter occur within the first hour.

Other findings include:

  • Issues with balance
  • Lack of coordination
  • Issues with vision
  • Fatigue
  • Numbness/tingling
  • Neck pain

It is important to recognize that the alteration in mental status characteristic of concussions can occur without loss of consciousness. In fact, the majority of concussions in sports occur without loss of consciousness and are often unrecognized.

Complications of concussions

Most athletes make a complete recovery and return to full function. Nonetheless, there are a variety of short and long-term complications that have important implications.

Second Impact Syndrome

Second-impact syndrome (SIS) occurs when the brain swells rapidly, and catastrophically, after a person suffers a second concussion before symptoms from an earlier one have subsided. The condition is rare but it is generally leads to death. No risk factors for SIS could be identified with any certainty and current research is controversial. For example, it is unclear why this is not a more frequently reported occurrence in boxers, who are at high risk of repeated concussions within a short time span.

Chronic Traumatic Encephalopathy

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Chronic traumatic encephalopathy (CTE) is the term used to describe brain degeneration caused by repeated head traumas. Repeated concussions can cause long term cognitive impairment and neuropsychological symptoms (behavior, personality changes, depression, and suicidal thoughts). It can also cause parkinsonism, as well as speech and gait abnormalities.

There have been increasing reports of dementia among NFL players with a history of multiple concussions. One cohort study found that neurodegenerative disease-related mortality was three times higher in retired NFL players compared to the general US population; Alzheimer disease-related mortality was four times higher [1]

The incidence is approximately 20 percent in professional boxers (though much less common in amateur boxers). The number of professional bouts (typically greater than 20) appears to be more important than the number of “knockouts”. The total number and type of head blows, particularly if the angle of impact or failure to stabilize the head results in rotational head movements, may be important as well, but it is difficult to quantify [2,3,4]

Athletes at particular risk of chronic impairments include:

Athletes with more severe symptoms after concussion, in particular early onset of headache after injury, fatigue/fogginess, early amnesia, dizziness, and disorientation. These individuals are likely to also have a longer recovery from concussion.

● Athletes with a history of multiple concussions . Most studies involving professional athletes have found a relationship between sustained neurocognitive impairments and increasing concussion exposure (However, there is insufficient data to make the same association in amateur athletes). A threshold of injury (number/severity of concussions required before CTE occurs) has not been established.

What should you do if you sustain head trauma?

If you sustain any traumatic injury (to head or anywhere else on the body), first determine if there are any new neurocognitive symptoms (dizziness, feeling “slow”, amnesia etc.) or loss of consciousness. If any of these are present, it is likely that a concussion has occurred.

The most important next step is to remove yourself from harm’s way. No athlete should be permitted to return to training or competition the day a concussion is diagnosed. Avoiding repeat head trauma is critical to a quick recovery.

Certain red flags should prompt you to visit the nearest emergency department immediately, as more serious injury (eg, cervical spine injury, intracranial hemorrhage, skull fracture) may have occurred. These include:

  • Prolonged loss of consciousness (eg, longer than one minute) ‒ Although there is no high quality evidence to support this threshold, one minute is commonly used by doctors to determine that the duration of loss of consciousness may represent a more dangerous condition.
  • Concern for cervical spine injury – based upon the mechanism of injury (eg, falling on your head), complaints of neck pain, weakness or loss of sensation in the limbs.
  • High-impact or high-risk mechanism of injury – For example, the athlete’s head forcefully hitting the floor after a high amplitude throw. This may increase the chance that bleeding has occurred within the skull or brain.
  • Post-traumatic seizure ‒ While seizures may occur in mild TBI, they are more common in severe TBI when there is bleeding within the skull or brain. Therefore, any athlete who develops seizure activity following head trauma should be taken immediately by ambulance to the emergency department for evaluation.
  • Persistent nausea and vomiting – See above
  • Significant and progressive worsening in the athlete’s condition – Such findings suggest a more serious injury and typically become evident within the first several minutes to a few hours after head trauma (may take longer in athletes over 60 years). The patient’s mental and physical status may deteriorate and there may be progressive drowsiness, slurred speech, difficulty or inability to walk.

Cognitive rest (Rest from mental exertion) is also an important element of concussion treatment, particularly during the first 24 to 48 hours. For patients with severe symptoms or concerning medical examination and test results, complete cognitive rest (No use of phone, no texting, no music, no watching of TV, no usage of computer). For those with milder symptoms and less concerning examination and test results, limited activity is permitted provided it does not worsen symptoms. Exposure to video games, loud music, prolonged screen time, or mental activities requiring high levels of focus and concentration frequently induce symptoms and prolong recovery time. Therefore they should be avoided for a few days after injury.

Proper sleep during this period of physical and cognitive rest is also important. Lack of exercise can affect energy and appetite, and can quickly influence sleep patterns. Lack of quality sleep will influence daytime energy, concentration, irritability, headaches, and several other symptoms and can potentially slow recovery

Even if red flags are absent, it is wise to visit a doctor for a complete assessment as it is easy to miss mild concussions. The doctor can also determine the appropriate next steps, including the amount of cognitive and physical rest warranted before returning to school or sport.

It is also important to ensure that a responsible adult is with the concussed athlete for the first six to eight hours after concussion primarily to monitor for any acute worsening during this time.

When can I train again?

The most recently issued 2012 Consensus Statement on Concussion in Sport proposed a six-day graduated return to play protocol in which the athlete makes a step-wise increase in functional activity, is evaluated for symptoms, and is allowed to progress to the next stage each successive day if asymptomatic. If symptoms occur, then the patient should drop back to the previous asymptomatic level and reattempt progression after 24 hours. [5]

graduated-return-to-play-protocolHowever, when in doubt, it is always better to err on the side of caution. Premature return to play, when an athlete is still symptomatic, places him or her at great risk for subsequent injury, including recurrent concussion.

Retirement from contact sports

Making the decision to retire from contact sports is a difficult decision, as there may be significant financial considerations for professional athletes. It should ideally be made with input from a doctor experienced in the assessment and management of sports-related concussions.

Factors to consider:

  • How many diagnosed concussions has the athlete experienced?
  • Are concussions occurring with progressively less force? (I.e low threshold for injury)

  • Are the symptoms experienced after concussion of increasing intensity?

  • Is the cognitive dysfunction experienced after a concussion becoming more severe?

  • Is the duration of recovery progressively increasing?

  • Are there structural brain abnormalities on neuroimaging (CT, MRI scans)
  • Are there non-resolving or prolonged neurocognitive deficits (behavior, personality changes, depression, and suicidal thoughts etc.)

Retirement, while painful, may ultimately spare the athlete from more serious complications further down the line.

Conclusion

Head trauma is always a risk in combat sports.  Coaches and athletes should be educated adequately so that they are able to recognize the symptoms of concussions and are aware of the need for physical and cognitive rest after such injuries. This is important so that a repeat concussion while the athlete is symptomatic does not occur.

While it is unrealistic to assume that concussions can be completely prevented, training safely and intelligently can help reduce this risk. It is probably unwise for athletes to spar hard too frequently.

Concussions, especially if they are recurrent, have the potential to have long-term effects on an athlete. However, with appropriate medical treatment, adequate physical and cognitive rest, full recovery is likely for most athletes.

References

[1] Lehman EJ, Hein MJ, Baron SL, Gersic CM. Neurodegenerative causes of death among retired National Football League players. Neurology 2012; 79:1970.

[2] Jordan BD. Chronic traumatic brain injury associated with boxing. Semin Neurol 2000; 20:179.

[3] Loosemore M, Knowles CH, Whyte GP. Amateur boxing and risk of chronic traumatic brain injury: systematic review of observational studies. BMJ 2007; 335:809.

[4] Ryan AJ. Intracranial injuries resulting from boxing. Clin Sports Med 1998; 17:155.

[5] McCrory P, Meeuwisse WH, Aubry M, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 2013; 47:250.

[6] Concussion and mild traumatic brain injury [Internet]. Uptodate.com. 2016 [cited 18 November 2016]. Available from: https://www.uptodate.com/contents/concussion-and-mild-traumatic-brain-injury

 

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