It’s not hard to stumble across a story about concussions these days. They seem to be everywhere. Regardless of your media of choice, whenever the talk turns to sports or head injuries, that topic pops up, sooner rather than later.
While such stories can offer stark reminders of what can eventually happen when head injuries are misdiagnosed or undiagnosed — the saga of Pro Football Hall of Famer and suicide victim Junior Seau being one keen reminder, as are the steady stream of lawsuits from retired athletes — many questions today involve finding ways to avoid such trauma, and treating it more promptly when it does occur.
While helmets are helpful for different reasons, they’re not the answer to the concussion issue. “They can prevent fractures of the skull and cuts and bruises to the skin, but can’t stop the forced movement of the brain within the skull,” said Dr. Robert Graw, Jr., medical director the Head First Concussion program, a division of Crofton-based Righttime Medical Care.
Today’s questions concern if there are really more athletes and people in general suffering more concussions, or if the attention paid to them has simply been heightened.
Just how much demand is there for concussion care today? To illustrate, Righttime opened Headfirst three years ago; this year, Graw says the company is on course to treat more than 16,000 patients between its 13 locations in the Baltimore-Washington region.
So the flow of patients, while somewhat seasonal, is fairly constant. “We see patients who come in for evaluation from the general population, others who athletic trainers and coaches send over, and more from parents who want their child tested,” Graw said.
There are various reasons why concussions have come to the forefront of the medical community. Graw feels kids emulating who and what they see on television is high among them. “The kids constantly watch a variety of pro and amateur athletes on TV, and they’re playing hard,” he said. “Often, the coaches and parents alike counsel them to emulate what they see, not realizing that their bodies have not matured enough” to withstand such rigors.
In addition, the kids often want to play at a prominent college, Graw said, “and [the coaches] want the player who works out hard and is aggressive. That mindset gets embedded into the psyches of the kids.”
But while the “bigger, stronger, faster” sporting mentality works on the field, the problems can begin when the game’s over, regardless of whether the injury is a knee sprain or a concussion. “It’s important to get the athletes who are suspected of having a head injury off the field, to get them tested by certified athletic trainers and to refer them for medical evaluation, if necessary,” Graw said.
He pointed to various tests that are used during a comprehensive 30-minute neurologic examination, like the Standardized Concussion Assessment Tool and Sway Balance, with the ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) used to monitor recovery. In addition, the Center for Disease Control offers the Acute Concussions Evaluation Scale, which is available online.
However, CAT scans and MRIs are not on the agenda. “We don’t see a role for the routine use of a CAT scan or an MRI for the evaluation of concussions,” said Graw. “There is nothing identifiably abnormal found with these imaging studies in relations to concussions, only in patients with other neurologic abnormalities, such as bleeding within the brain.”
The good news is that about 85% of patients get better with proper treatment and a brief amount of rest, which can mean no school and no sports — as well as no computers, no television and no cellphones for the first 48 hours — before starting a carefully-monitored program to facilitate the patient gradually returning to school, work, physical activity and the rest of his or her daily routine.
“Girls can take a little longer to recover, partially because, we think, they’re more honest about how they feel and their progress,” Graw said. While boys typically heal faster, “they’ll lie about saying they’re better so they can go back to school and get back on the field.”
There are still plenty of cases, however, where recovery can take several months or longer. In the case of former Baltimore Oriole Brian Roberts, who suffered two concussions earlier this decade and had issues with dizziness, nausea and disorientation, it took more than a year to regain his health.
Other members of the medical community also feel that the focus on treatment has increased.
One reason that’s critical is that there “is usually no medical equipment on the sidelines to assess players, so the measurement is what is seen with the naked eye and common sense,” said Dr. Samip Patel, director of epilepsy and clinical neurophysiology at Anne Arundel Medical Center, in Annapolis. “As far as playing the games go, you have to take your chances. The key is going in with your eyes open.”
“People are asking if [concussions] are more prevalent now. I don’t know, but I don’t think people were as concerned about long-term issues until more recent times,” said Dr. Matthew Sedgley, who specializes in sports medicine with MedStar Health in Ellicott City.
“Now, more people are taking it seriously and taking time out from athletic activities, and even work and school responsibilities. Patients need that cognitive and physical rest,” said Sedgley “If they have a concussion and take a test, for instance, their scores can suffer; but we’re finding that many school systems have been good about letting patients make up tests after patients have recovered.”
What’s next on the agenda, he said, is doing “a lot more research,” like what he’s involved with at the Medstar Research Institute.
Dr. Stacy Susskauer, who runs the Columbia office of the Kennedy Krieger Institute’s Neuro Rehabiltation Concussion Clinic, which was founded in Baltimore in 2010, agreed.
“Until recent years, we were seeing occasional concussions at different Kennedy Kreiger clinics in the area,” said Susskauer, “but when the problem seemed to get worse, we opened in Columbia about two years ago. In the five years since, we’ve doubled our services.”
She echoed Sedgley in saying that research is key. “I think, over time, we’re learning more about how to best treat concussions. I think there has been a little bit of progress in the past couple of years,” she said, though adding that “unlimited rest is not the best treatment. Part of what we do here is help find out when to reintroduce [patients] to school and other activities.”
While Susskauer feels that, “In the past, a lot of people thought it was normal to get your bell rung,” she added what is really needed now is to focus on improving treatment for concussions.
“We’re never going to stop children and teenagers from playing sports. That wouldn’t be healthy either,” she said. “There’s also room to learn how to decrease cumulative exposure in children, such as not allowing heading of the ball in soccer for kids until they’re 14.”
Graw agreed. “We encourage kids to play sports. It wouldn’t be healthy if they stopped,” said Graw. “But even with the precautions, there will still be head injuries.
“It used to be that only the coaches were around the kids,” he said. “That’s a whole philosophy that needs to change, but we are definitely making progress. The parents are more aware and more people are getting experienced in addressing the problem.
But there is no simple answer, he said. “Every concussion for every patient is different and requires individual management. It requires the parent, coach and athletic trainers to be on the patient’s team and assist in recovery.”
Whether the media attention paid to concussions is really the only thing that’s changed or not, what’s important today is the increased awareness and that more people come in for care.
“It’s very important,” said Graw, “that people understand what to do and not be fearful.”