When I was little, I used to love the days when my dad brought me to work. For some kids this meant playing around in an office, but my dad sold programs at Fenway Park, and so some of my favorite childhood memories were walking around this historic ballpark and watching the Sox play at home. And when I watched the impossible happen in the ’04 American League Championship Series, I realized that sports are as close to magic as it gets. And so my desire to work in sports medicine has always come from a place of protecting the athletes who make us all believe in the impossible.
It is with this spirit that I attended the UCLA/PAC-12 conference on sport-related concussion. As a former college ski racer, I am all too familiar with the negative consequences of concussion and the ways in which its management has changed dramatically. Concussion has garnered a great deal of press in recent years especially, with further insight into Chronic Traumatic Encephalopathy (CTE), a progressive neurodegenerative disorder that can develop years after repetitive head trauma in some patients. In response to the increasing concern for the safety of our athletes, the NCAA has partnered with the U.S. Department of Defense to host the largest long-term concussion safety study ever done, titled the CARE Consortium. This study so far has enrolled over 28,000 athletes from 30 colleges across the U.S., including four military education sites, and has gotten baseline evaluations of cognitive functioning and brain imaging for all enrolled athletes. The goal is to perform follow-up cognitive, imaging and serum biomarker testing on athletes post-injury at acute (24-48 hours), subacute (time of return to play), and long-term (six months) intervals. This should give a more complete picture of concussion and hopefully will be able to elucidate if there is a window of neurological vulnerability that extends beyond the symptomatic time period, and if so, how this could impact players’ development and risk for long-term complications.
And while it is an ongoing issue to be addressed, I was encouraged to hear how much progress we’ve made over the years. First of all, the length of time before a player is allowed to return to play has lengthened substantially, from an average of 6.65 days as measured in the late 1990s to 14.3 days in the most recent data from the CARE Consortium. Furthermore, the preliminary data shows that 65 percent of injuries occur during practice or training, a finding which coincides with the recent much-needed revamp of the NCAA guidelines for football. The most recent guidelines support better health for players by restricting live contact in practice to three days per week in preseason and two days in season, as well as eliminating “two-a-days.” This isn’t a perfect answer, but it is a step in the right direction, and I look forward to seeing more change happen in this field as a result of the CARE Consortium findings.
Concussive Symptoms: Understanding the Challenges
Concussions, however, pose a unique challenge to sports medicine physicians because the presentation can be vague and varies greatly among athletes. The preliminary data showed that only 6.1 percent of athletes with a mild TBI reported loss of consciousness, and while 47 percent report some form of altered mental status, this can range greatly in severity between patients. There does appear to be a requirement for an underlying susceptibility to development of concussive symptoms, with the same force of impact affecting two athletes in very distinct ways. Further complicating the sideline evaluation is the finding that 70.5 percent of head injuries in contact sports had a delayed onset of symptoms, with an average delay time of 60 minutes. This creates a unique challenge for the sideline sports medicine physicians, who typically have less than 15 minutes to assess a player for their capacity to return to play, during which time they experience significant pressure from coaches and the players themselves. Several of the physicians present at the UCLA conference, one of whom worked as the team physician for an NFL team, relayed that this is often the hardest part of their work.
The Importance of Brain Injury Awareness
However, they did note that the percentage of college athletes immediately self-reporting concussive symptoms has increased dramatically since the late 1990s. And there are a few investigations currently underway looking at how the overall climate of college athletic programs may impact a players’ willingness to report symptoms. This is perhaps the most important part, because all of this knowledge about the neurological burden of concussion doesn’t change anything if the athletes themselves don’t recognize that concussion is a serious injury or if they feel that they are letting the team down if they admit to concussive symptoms. In fact, studies show that when players immediately report symptoms of concussion and are evaluated, on average, they have a shorter return to play protocol than those who ignore the symptoms and continue playing. It is my hope that with the tremendous research efforts in this field, including the CARE Consortium, that there will be a shift in the culture of athletics to further appreciate the importance of brain injury awareness and prevention.
Lastly, in the CARE Consortium study, they asked student-athletes with a history of head trauma why they had delayed reporting concussive symptoms. And while some did note the aforementioned pressure from coaches and teammates, the overwhelming majority reported they kept going solely for love of the game. And so these efforts to make athletics safer are vital not only for optimizing the health and wellness of athletes to prevent adverse future outcomes, but also to preserve their ability to participate in the sports they love. Many of us, myself included, would not be the people we are today without athletics. I’ve been lucky to be a part of some great teams and I’ve also had the pleasure of watching some of the greatest athletes to ever compete (including the greatest quarterback of all time). Athletics teach us perseverance, teamwork, and pure hard work. They also perpetuate the childlike belief in miracles by showing us that no adversity is too great to be overcome. That inspiration, that confidence to be the best version of yourself, is worth protecting.