#1  The word concussion is derived from the latin term concutere, meaning to shake violently. It is a type of traumatic brain injury with short-term neurologic impairment caused by biomechanical force (ie. the violent shaking).

#2  The most common symptoms of concussion are headache, dizziness, ringing in the ears, blurred vision, and balance problems.  After a concussion, patients often describe feeling “like in a fog” with cognitive deficits of attention, concentration, and memory.  Loss of consciousness occurs in less than 10% of cases.

#3  The diagnosis of concussion is vague and is typically a combination of history (have you experienced head injury?) with the onset of symptoms described above.

#4  Despite all the press, football is not the only sport with the risk of concussions, and sports-related concussions may actually be more common among girls sports than boys.  Soccer is the leading cause of concussions in girls sports, but not because of what you might think: heading the soccer ball.  In soccer, concussions are more likely to occur during collisions with other players or being unexpectedly struck in the head with the ball kicked at close range.

#5  Having a concussion increases the risk of subsequent concussions and slows the recovery time of each sequential concussion.  This is particularly important to evaluate the risks for long-term complications (see #9 below).  Last fall, Syracuse University quarterback A.J. Long suffered 3 concussions and was confined to his apartment for a week after the last one, unable to participate in practice or go to class.  Syracuse doctors deemed the risk too high for Long to continue playing football.  However, the story was not yet over, as other division I football programs immediately started recruiting Long.  The National Collegiate Athletic Association (NCAA) does not set a limit on the number of concussions an athlete may incur nor do they prohibit athletes from transferring to another program after a history of concussions.  Unsurprisingly, Long is in the process of transferring to another university to continue his football career.

I don’t blame Long, I feel sorry for him.  He has been defined not by who he is as a person, but by the sport he plays.  This narrow mindset leaves athletes thinking that they cannot contribute to society in other ways, which really couldn’t be farther from the truth.  Consider this, according to the NFL Players Association, the average NFL career is just 3.3 years.  What is a football player to do after retirement at the ripe old age of 25 if football is all that defines him?

#6  According to Stephania Bell, ESPN injury analyst and senior writer, there is no such thing as a “mild” concussion. Yes, there are grades of brain trauma as measured by the Glasgow Coma Scale, but all concussions fall into the ‘mild’ form of brain trauma.  Further striating concussions into mild, moderate, and severe is a dangerous endeavor that undermines the risk assessment for further brain injury.

#7  The treatment for concussion is restricting physical and mental activity until symptoms resolve and to slowly increase physical activity thereafter.  Athletes should not return to play until they experience no symptoms during rest and exercise.  Just as there are no hard-and-fast rules for diagnosis, there are no firm guidelines for treatment, which obviously leaves too much room for interpretation and misjudgment at the expense of the athlete’s health.

#8  Helmets do not prevent concussions.  Unless there was something you could insert between your brain and your skull, there is no protective device that can stop a concussion.  That being said, helmets are very important equipment for limiting skull fractures during collisions.  Helmets have undoubtedly been critical advances for the health of football and hockey players, they just can’t prevent your brain from jiggling around in your skull during impact.

#9  The movie Concussion is not about concussions at all, but about the discovery of chronic traumatic encephalopathy, or CTE.  In the movie, forensic pathologist Dr. Bennet Omalu, played by Will Smith, first discovers signs of CTE in brain sections from former Pittsburgh Steeler Mike “Iron Mike” Webster.  From Omalu’s Neurosurgery paper, these clues were neurofibrillary tangles (think “hair tangle” mess of brain cells) and plaques (large areas of dead cells).  With the behavioral changes in some former NFL players plus the newly identified brain pathology, Omalu thought about animals with repeated head ‘trauma’, such as woodpeckers and rams.  He theorized that these animals would suffer similar brain damage if it weren’t for the evolution of shock absorbers in their heads.  Man wasn’t designed for repeated head collisions, so even small, unknown trauma over the course many years may lead to CTE-related dementia.  Despite the fascinating and ruthless tale of Omalu’s discovery and the NFL’s vehement denial, the movie is a distracting amalgamation of immigration, micromanagement, family gains and losses, mixed with the intrigue of the medical finding.

“Apparently the NFL owns neuroscience.  Who knew?”
“The NFL owns a day of the week.  The same day the church used to own.”
“They have to know” [the dangers of their profession], emphatically stated by Dr. Omalu

#10  Finally, and perhaps most frightening of all:  there is currently no way to diagnose CTE in a living patient.  An athlete, with or without a documented history of concussions, may have suffered enough sub-concussive blows to cause the brain damage that will lead to his or her inevitable cognitive decline.  At that point, with the behavioral manifestations of dementia, it is too late to do anything about it.

Which leads me to this: we need to discuss the dangers inherent in all sports–even limited-contact sports like soccer.  We need more research on concussions including studies of imaging and biomarkers for diagnosis, as well as trials comparing different treatment regimens and timing.  We need proper documentation and statistics to determine the the true magnitude of the problem.  And we need to be cognizant that all athletes at all levels are subject to the possibility of concussions.  I say this all as a former athlete and an undeniably huge sports fan.  Unregulated, sports today are no better than the to-death gladiator matches of our past, except that those were more humane.

More resources:
The Concussion Blog
NFL concussion protocol
Sports Concussion Assessment Tool 3 (SCAT3)
2DocsTalk podcast on concussions
A.J. Long’s story as reported on STAT
Concussion movie