Concussion, the NFL and other related musings

By Jodi Pinn, Ph.D.

Getting evaluated after a traumatic brain injury is critical

San Francisco 49’ers coach Jim Harbaugh’s decision to start quarterback Colin Kaepernickand demote starter Alex Smith to backup in this Sunday’s game at St. Louis has sparked some interesting debate over players reporting concussion.

Alex Smith suffered a concussion during a home game against St. Louis on November 11th and left the game early in the 2nd quarter after reporting that his vision was blurry, but not before throwing a touchdown pass just a few plays after the brutal, concussion-causing hit.

He sat out the following week against Chicago, whose own quarterback was also out due to concussion, because he couldn’t pass the final neurological test, an impact test.

Craig Massei of the Associated Press notes that Smith has been deemed “completely healthy from that concussion he suffered in that November 11 game and has been medically cleared to play” this Sunday.

Is Smith really “completely healthy from that concussion”?

Is he regretting reporting his concussion?

Will other NFL players (or non-professional athletes in football and other sports) stop reporting concussion symptoms for fear of losing their job, position, starting status, or playing time?

In November 2001, the first International Conference on Concussion in Sport took place in Vienna, Austria.  As a result, a document was drafted with recommendations for a concussion protocol.

The document included definitions, evaluation and treatment guidelines, suggestions for prevention and safety, and future research considerations.

The 2nd International Symposium on Concussion in Sport was held in 2004 in order to revise and update the Vienna consensus recommendations. The following information is drawn from these documents as published in the British Journal of Sports Medicine in 2002 and 2005.

What is Concussion?

Concussion is a process affecting the brain, caused by traumatic forces, usually a direct blow to the head, face or neck.  Concussion can be simple or complex. All concussions need evaluation by a medical doctor.

  • Causes short-lived impairment in neurological function
  • There may or may not be loss of consciousness
  • Symptoms are caused as functional problems rather than structural injury, and neuroimaging studies (xray, CT scan, MRI) are generally normal

Simple concussion resolves in 7-10 days. In complex concussion the athlete suffers persistent symptoms, had more than 1 minute loss of consciousness, or has continued cognitive impairment such as memory problems. Also included in this group are athletes with multiple concussions over time, or where repeated concussions are caused by less impact.

Signs and Symptoms of Concussion

Any one of the following symptoms or problems can signal sport-related brain injury/concussion:

  • Unaware of period, opposition, score of game
  • Confusion
  • Amnesia
  •  Loss of consciousness
  • Unaware of time, date, place
  • Headache
  • Dizziness
  •  Nausea/vomiting
  • Unsteadiness/loss of balance
  • Concussive convulsion/impact seizure
  • Feeling stunned or dazed
  • Seeing stars or flashing lights or “having my bell rung”
  • Inappropriate/changed/decreased playing ability
  • Ringing in the ears
  • Blurry or double vision
  • Sleepiness, sleep disturbance, feeling slowed
  • Unusual or inappropriate emotions such as laughing or crying
  • Vacant stare/glassy eyed

Return to Play

There are guidelines about return to play decisions.  Many are common sense, but medical professionals must determine others. No symptomatic athlete should ever return to play. Rest is the best treatment for concussion. Athletes tend to underreport symptoms, and even when an athlete feels symptom free, his/her brain may still be healing and recovering. Premature return to play can be harmful or even fatal, resulting in permanent brain damage or death in youth and adult athletes who experience repeated concussive and/or subconcussive blows to the head.  For this reason, numerous professional sports teams, colleges, and high schools have mandated baseline testing and concussion programs. There is a variety of state and federal legislation proposing the mandating of such programs.

The importance of neuropsychological testing by a licensed psychologist cannot be underscored.  Neuropsychological evaluation of athletes who have experienced sport related concussion is important and advised. Neuropsychological testing is more sensitive to the effects of concussion than neurological or radiological examination, and measures the areas known to be affected by concussion: memory, attention, speed of processing and reaction time.

Harbaugh’s Message

Did Harbaugh’s decision not to start his post-concussive starting quarterback send the right or wrong message?  Since he has not elaborated on the factors that went into his decision making process, we can only surmise that this week he decided to play it safe and go with the “hot hand” who has not recently suffered a significant concussion and persistent neurological symptoms.

Whether or not his decision will encourage other athletes to “play through it” as former 49’er Bill Romanowski suggested they do, so that they don’t lose their job, is as yet unknown.  I hope that the message players receive is something more along the lines of  “do not return to play until you are 100% capable” and “there is someone concerned about your brain function, health and future”; but then, I’m an optimist.

At Neuropsychological Assessment Group we have the skills and experience to evaluate the cognitive effects of a traumatic brain injuyry. As we have stated above, it is critical to have both a medical examination and a neuropsychological assessment as soon as possible.  Please feel free to call our office should you or your love one suffered a traumatic brain injury.