NFL's new PSA airs tonight during Steelers and Browns Game

Tonight during the Steelers - Browns game the NFL will air a new PSA aimed at increasing awareness among players, coaches and parents about the importance of recognizing the symptoms of concussion and responding appropriately. The NFL has received a lot of criticism recently about past practices related to the management of concussion, but this is a very positive step. There is still a lot of work that needs to be done to educate those involved in all sporting activities about the danger on repeated concussion. If a young athlete, after suffering a concussion, can be removed from play and the from risk of a second concussion, he/she can avoid the danger of more serious and long-term injury. I applaud the NFL for release of this PSA and hope that other sporting organizations will follow suit.

The risk of Concussion - A Parent's Dilemma

We are a sporting nation – we love to play and to watch others play and compete. We also know the value of sporting activities for our children’s health and for teaching them discipline and teamwork. I remember as a young teen the excitement of stepping onto the field to play in the National Soccer Championships in Nulunbouy Australia. More importantly I remember the sense of satisfaction I felt when I learned that I was one of the eighteen selected from South Australia to represent our State in this national tournament. Engaging in competitive sports contributed significantly to my life and my later accomplishments.

Now I am a parent, a neuropsychologist and a U9 boys soccer coach. As our children grow, my wife and I are confronted with decisions about the sporting and recreational activities that we will allow our children to engage in and the ones that we will not. We will use the desires of our children, our collective wisdom, and the sum of our knowledge and experiences to make the best decisions that we can for our family. As we make these decisions using all of diligence they deserve we will not try of convince ourselves that our children are immune from the risk of serious injury - for we know that there are risks in many of the activities we choose to engage in.

Among the risks associated with sports is concussion and it is every parent’s responsibility to understand concussion and to be able to recognize the symptoms if they occur. Parents also need to know what to do if their child suffers a concussion. Unfortunately, it may not be a simple as going to the ER and getting cleared by the ER doctor. I have heard too many stories of ER physicians telling parents that if they wait a week their child will be fine to return to play. While this may be true for many children, without individual follow up, to assess for the presence of residual symptoms, following this advice may put a child at significant risk.

There are several forces that act upon a parent’s decision making when it comes to activities we choose to allow our children to engage in. There is our own need to experience success through our child’s actions. There is the need to feel that our children are successful in their sporting endeavors. There are the wishes of our children who see sports or TV or just want to be involved in what their peers are doing. There is also peer pressure from other parents – do we want to be the only family on the block whose kids don’t ski competitively? Finally there is inertia - events begin to transpire and we do not have the will or the courage to stop them.

However, as parents we cannot abdicate our responsibility for these important decisions. These decisions become easier as we get to know our family’s risk tolerance and apply it to situations as they arise. If my son decides he wants to play football, my wife and I will judge what we know about the risks involved apply it against our tolerance for risk and make the decision that is right for us. As harsh as it may sound, our son’s desire to play will not be a major deciding factor. He is too young to fully understand all of the risks that may be involved. Whether or not he plays football we will use the decision making process as an opportunity to teach him about the importance of assessing risk when making this type of decision.

For those parents who have made the decision to let their children play and compete the decision making is not over. What do you do if your child suffers a concussion while playing or doing something unrelated, maybe riding his/her bike? When do you allow them to participate in activities that put them at risk for another concussion? We know that if a child suffers a concussion while still not fully recovered from a previous concussion, there can be devastating consequences. Even if nothing as serious as second impact syndrome occurs, the child will take longer to recover and has a greater likelihood of long-term effects.

Being a parent is the greatest thing in the world and while it involves making many difficult decisions, we who have chosen this responsibility do not shirk from doing what we can to make sure our children have the best and safest experiences possible. While the risk of concussion among children in sporting activities is small, it is significant and so we owe to ourselves and our children to be knowledgeable about concussion and to make the best decisions we can about what we allow our to children do.

My Brother's Keeper

In an AP article from ABC it was reported that “nearly a fifth of 160 NFL players asked said they hid the effects of concussion.” If you talk to college and other school aged athletes in all sports you would likely find a similar sentiment. Athletes love to compete and if they do not fully understand the implications of playing with a concussion, (and sometimes even when they do) they will try to “play through it.” This issue is even more acute for athletes who are at risk of not making the team or who perceive some risk of losing their spot on the team. If you add this group of athletes who are reticent to report concussion to those who are unable to, either because they are too confused or do not recognize the symptoms, you have a significant number of athletes that are at risk of a second, possibly debilitating, concussion.

In order to increase the likelihood that those who have suffered a concussion are quickly identified the NFL “wants players to keep tabs on each other and tell their teams if they believe someone else has a head injury” according to the ABC report. This kind of front line peer support is essential in the process of keeping athletes safe from the cumulative effect of repeated concussion over a short period of time. An athlete with a suspected concussion that is indentified by his/her teammates can be evaluated by someone trained in concussion management and the proper disposition can be achieved. The athlete may be fine and can return to the game or she/he may need to sit out for further evaluation.

If the process of using teammates to help indentify athletes who may have sustained a concussion is going to be effective there needs to be a process in place to educate players about concussion. The CDC has some helpful information to assist in the process, but it also requires that coaches and other athletic staff take this problem seriously. If everyone who is involved in athletics understands the signs and symptoms of concussion we can make second impact syndrome and other serious consequences of repeated concussion within a short period of time a thing of the past.

A Case for Pre-Testing

Half way through the second half of a game, Carol the star forward on the girls soccer team jumps to head the ball and collides solidly with a defender from the other team. The girls both fall backward and Carol strikes her head on the ground. She reaches for her head and as the other girls gather around her the coach comes onto the field. After a few tense minutes Carol gets up and walks off. She is slightly unsteady on her feet, but she makes it unassisted to the sideline where she sits on the bench holding her head. It was clear to Carol’s coach, and others who were there, that Carol had suffered a concussion, and there was no question of her returning to the game.

As straight forward as this situation seems, there are still many questions that need to be answered. Does Carol need to be taken to the emergency room to be evaluated? Does she need a CAT scan? Should she go back to school right away? Will she be able to play in the big game next week? These questions are less straight forward, and having some objective data can help. Objective test data can make these important questions more manageable and can increase the likelihood that the right decisions will be made.

The decision about the emergency room will depend on the symptoms and the availability of medical professionals who can evaluate Carol, but if there is any question that it could be something more serious than a concussion a visit to the ER is probably indicated. The ER staff will make the call about the CAT scan. However, CAT scans, while useful in moderate and severe head injuries, are not helpful in the diagnosis and treatment of concussion.

The decisions about returning to school (or work) and returning to play are more complicated and require a good understanding of all of the symptoms of concussion. Fortunately there are tools to help evaluate the seriousness of concussion, and none is more widely used than ImPACT – mandated in the NHF and NHL and used extensively in professional, college and high school sports. ImPACT is a computerized test that takes about 30 minutes to complete and measures mental abilities that have found to be affected by concussion.

In my opinion one of the best features of the test is the ability to gather information on athletes before they are put at risk for concussion – a kind of pre-testing (or baseline testing as we call in the professional arena). In sporting organizations where the test is systematically used, all of the athletes are pre-tested at the start of the season. This pre-testing establishes what is “normal” (baseline) functioning for players. If a player subsequently suffers a concussion, he/she is re-tested and a comparison of the two tests provides information about how serious the concussion is. Over time, as the post-concussion results look more like the pre-test (baseline) results we have some confidence that the athlete is recovering from the concussion.

In Carol’s case, if she had taken a pre-test, we could retest her and know how serious the concussion is and if we need to keep her out of school. As she is re-tested over time the test results can be used to help make the decision about how soon she should return to normal activity including school, exercise and soccer.

Another advantage of pretesting is that the process itself leads to a greater understanding among the players, the coaches and the parents about the signs and symptoms of concussion. The better everyone understands concussion the greater the likelihood that athletes who suffer concussion can be managed appropriately. The consequences of mismanagement can be devastating. Athletes who have suffered a concussion are at higher risk for serious injury if they experience another concussion before the first concussion has resolved. In rare cases, young athletes have died from second impact syndrome and others have suffered long-term impairments in functioning that could have been avoided if their initial injury had been handled correctly.

At the Center for Human Potential we are committed to educating athletes and their families about concussion and concussion management. We are also committed to making baseline testing available to all who are interested. We are so committed to the importance of baseline testing that we offer it for free to those who work for companies that we provide EAP services for (e.g., Overstock.com) and their immediate family members.

It's better to miss one game than the whole season

Working in sports concussion management we often hear about an athlete who has a concussion and is returned to the same contest where a second concussion is sustained. In many of these cases the effect on the athlete is significant, sometimes devastating. The Centers for Disease Control (CDC) and others in the medical community are doing their best to educate coaches, athletic trainers, athletes and parents about the symptoms of concussion and the importance of early intervention. The most important part of that intervention is removing the athlete from the contest.

The CDC website for coaches includes the following statement: “If you think your athlete has sustained a concussion… take him/her out of play, and seek the advice of a health care professional experienced in evaluating for concussion. “ It also admonishes the coach “don’t assess it [the concussion] yourself… seek the advice of a health care professional.” Along with this advice the CDC provides lots of information and resources for coaches including posters and guidelines to help coaches recognize a concussion.

While the coaches are often in the best position to first observe the symptoms of concussion in their players, they should not be left alone with this responsibility. Other team staff, players, parents and other spectators can participate in the process of identifying the symptoms of concussion. The risk of further injury, including the rare condition referred to as second impact syndrome, make the identification of concussion crucial so that the athlete can be removed from the game until the seriousness of the symptoms can be assessed.

The CDC website also includes the following statement “It's better to miss one game than the whole season”

A Personal Experience with Concussion

In 1991 I graduated with a Ph.D., in clinical psychology with an emphasis in neuropsychology. I completed additional training in neuropsychology at the Cambridge Hospital (a training hospital for Harvard Medical School) and then at the University of Michigan Medical School. I was in my fourth year as a staff neuropsychologist at a residential brain injury facility in East Lansing when I had my first and only concussion.

I was at the Michigan Athletic Club, a sprawling recreational facility in East Lansing, where I spent several hours every day playing basketball and lifting weights. There was a regular crowd of us that played pickup basketball there daily and we all knew each other pretty well. On this particular day there were not yet enough of us to play a full game so we were messing around playing a kind of half-court free for all.

I remember jumping and reaching for a ball that was coming off the hoop when a good friend of mine got under me. As I started to fall, he tried to help me but in his effort to do so he tied up my hands so I could not use them to help break my fall. With my hip on his shoulder and my momentum going sideways I quickly pivoted and hit the back of my head on the floor with significant force. I remember a bright flash of light and some localized pain at the site of the impact. I did not lose consciousness (only about 10% of concussions involve loss of consciousness) and I remember feeling alarmed that I had hit my head with such force.

As a neuropsychologist I had seen many people whose lives had been devastated by trauma to the head and as I got up off the floor a wave of apprehension swept over me. I walked over and sat on the stairs by the court and began a kind of self-examination. I was not entirely sure what day it was, my mind felt kind of foggy, but other than that I seemed to be OK. After about 15 minutes of sitting and continuing my self-examination I walked to the locker room, gathered my belongings and went home.

As concussions go, mine was relatively minor. I had some residual fogginess through the evening, I developed a low grade headache, and I definitely did not feel as sharp mentally as I usually did. That lack of mental sharpness persisted for a couple of days, but lucky for me it was the weekend and by Monday morning I felt fine resuming my normal duties.

When I think back on this experience I am grateful that I knew enough to not put myself at further risk of injury before I was fully recovered. It is these additional injuries that occur before the initial concussion is resolved that seem to do the most severe damage.