HEAD INJURIES, PART IV

By Dr. Ken

 

“Split North, Slant 40 Veer, Quick Count, Ready Break”. Greg Cook, the All America quarterback for the University Of Cincinnati Bearcats football team, called the play in the huddle. The team turned and hustled to the line of scrimmage, the fullback being the last in line and the last to settle into his designated position. Just as Cook surveyed the defense, the fullback, in his stance, looked around and asked in a distressed and rather loud voice, “Hey, what’s the play?”  This evoked smirks and laughter from both sides of the line of scrimmage and when Cook turned to softly repeat the play, the fullback then shouted, “Got it, what’s the snap count?” At that point, the laughter was audible from most of the players on the field except the befuddled fullback who happened to be me! Welcome to the world of concussion. Having had my first two concussions in high school, there may have been some awareness that I wasn’t “quite right”, and I wasn’t, but thought I could “gut it out” and continue to play if I could just focus well enough to run each designated play. As with most concussions, the individual who has been “dinged” is in no position to determine what he can or should do at the moment.

 

“If you wear a football helmet and take a blow to the head, should you suffer a concussion?” “Can my son play next week?” “If you get a concussion, I was told it is easier to get another one. Is this true?”  These are the typical questions asked by those who suffer a concussion, or the coaches and parents of the player who has been injured. With approximately 300,000 sports related concussions per year in the United States, this condition obviously affects many.  A summary of some of the major points made in the Helmet News series on head and neck injuries and concussion can provide the answers to these questions:

-Cell damage can occur if one suffers a hard blow to the head.

-Cell damage can occur from the direct blow to the head that causes the brain to strike the inside of the skull, opposite the point of initial contact.

-If the brain is accelerated and/or decelerated by a hard hit, nervous tissue can be stretched or damage and with sufficient stretch of the tissue, chemical reactions are initiated that produce damage to the brain cells.

-If the chemical response is extensive enough, the damage and recovery from that damage may last for an extended period of time.

 

One of the key points that previous articles made, is that the perceived degree of damage, either by the player or by those observing the player, may not be accurate in determining the true extent of physical damage or eventual behavioral changes and responses.  Because the chemical cascade that produces metabolic changes that in turn cause an alteration in the cells’ function with accompanying changes in behavior can vary and last a number of days or weeks, the behavioral changes too can vary tremendously.  Some long-term changes in behavior or response may take time to realize or observe. Some changes may be transient or obvious only in very specific situations or circumstances. In the personal case I noted above, my obvious inappropriate responses as we broke the huddle and lined up indicated that “something was wrong”. Could the true extent of the damage be determined just by looking and listening to me? Absolutely not and in this case, there was not a lot of cellular damage but a lot of “chemical damage”.  Dependent upon how the doctor classified my injury and how it was graded, the length of time that I would have been held out of a game or practice situation would be directly affected. In “the old days”, one was frequently sent back into the game or practiced within a day of injury if they seemed lucid and aware. Unfortunately, this was not a definitive system of determining either damage or the ability to safely resume contact.  Even today, there are a number of different “grading systems” for the severity of concussion, some of which demonstrate variability, which can and does, create confusion for the athlete, his family, and coaches.

 

GRADE ONE:  Confusion without amnesia and no loss of consciousness (LOC)

Another system notes: “Post-traumatic amnesia of less than 30 minutes in duration”

GRADE TWO: Confusion with amnesia

Another system notes: “LOC less than 5 minutes in duration or Post-traumatic amnesia of 30 minutes to less than 24 hours”

GRADE THREE:  LOC

Another system notes: “LOC of more than 5 minutes or Post-traumatic amnesia of more than 24 hours

 

With variability in grading a concussion as demonstrated by these two most frequently used criteria, there is a great deal of latitude in deciding when a football player can resume normal practice and game participation.  “What is safe” is often a matter of what has traditionally been decided by that university or professional program, or what is “standard” for that doctor or medical group. Some players will be held out of contact for twenty-four hours, others for days or a week. High school regulations vary greatly from one state to another and even from one county or state athletic jurisdiction to another. What can be said with definite concern is that because the severity of concussion is sometimes not apparent for days, many athletes are placed at risk for long term or permanent injury by being put back onto the field too early in their recovery from traumatic brain injury.

More next month.