Save Your Brain – Why Wait?

Are concussions part of the cost of playing sports? Unfortunately yes! While we can certainly improve equipment, improve identification, change the reporting culture and change the rules I don’t think we can eliminate them from sports.

What we have to do is eliminate ‘ second incident syndrome’, which is the other and often untold story.

As we grapple with the issues around concussions we are slowly beginning to realize that it is not a singular event. The impact sets off a series events that occurs over several days and may take several weeks or months to resolve.

Those who return to sports on the day of or the day after the impact have no knowledge of the degree of damage because the full extent of the damage has not occurred and cannot be evaluated.

This is where the second incident syndrome becomes so important. Although symptoms may have eased the healing process has just begun. Hence repeat concussions with significantly less force that the initial blow often can cause even more damage than that experienced from the initial blow.

Seminal work done by Dr. Joseph Clark at the University of Cincinnati has identified that free radicals are released as a result of a subarachnoid hemorrhage – the result of a concussion action on the brain causes a release of bilirubin and possibly heme to produce bilirubin oxidized products or BOXes. These contribute to produce vasoconstriction and vasospasm which will prolong and magnify the adverse effects of the initial blow, which turns the so called singular concussion into an process with a time line.

A concussed athlete actually experiences damage to the nerves or axons in the brain which can take from 12 – 72 hours to reach its peak levels of damage.

With this information they were able analyze cerebrospinal fluid, which bathes the brain and detect structures consistent with BOXes. This gives us the ability to assess rising, plateauing and resolving chemical biomarkers in the cerebrospinal fluid they are a result of a concussion.

This will help us take the guess work out of managing concussed athletes.

What are some other measurable aspects of brain function that we can monitor to assess return to play decisions? Impaired eye movement has been identified in concussed athletes indicating suboptimal brain function Dr. Barry Seiller, a noted opthamlogist in the United States reports that the most common event accompanying brain trauma is convergence insufficiency or the inability for the eyes continue to focus and re-focus on an object traveling toward you.

Attentional deficits have also been linked to concussed athletes that will further deteriorate under stressful situations.

The above information appears to be in conflict with the ‘Consensus Statement on Concussions in Sport’ at the 3rd International Conference on Concussion in Sport – Zurich 2008 which states that concussions typically result in the rapid onset of short lived impairment of neurological function that resolves spontaneously.

Who is right and are we putting our athletes at risk for permanent neurological damage by sending them back to sports prematurely?

Testing now exists to identify biomarkers, eye function, cognitive function, attention deficits just to name of few. While this is useful it has not real value unless you can compare the results of pre-concussion values. It still is a guessing game with the stakes very high.

Sports medicine has come an awfully long way. Pre-season physicals and fast acting sports specific treatments are the hallmark of good care. So why do we reverse out stand on concussions and ignore the value of pre-season concussion testing and let symptoms fade before we start active treatment?

We now have the technology to assess healthy athletes and make smart objective based decisions on return to play timelines. Why are we so reluctant to act faced with such compelling evidence. What would it take to effect a call to action? Do we have the will?

Kevin Honsberger BSc.P.T.