Take Concussions Seriously

Researchers find extra healing time needed, especially in repeat cases

TUESDAY, Nov. 18, 2003 (HealthDayNews) -- What experts have historically known about concussion is a lot like how a person feels after sustaining one: woozy, wobbly and a little unclear.

Two new papers, part of a National Collegiate Athletic Association (NCAA) study on concussion, try to clarify not only how the condition is defined, but how athletes and sports officials should react to it. Both papers appear in the Nov. 19 issue of the Journal of the American Medical Association.

The first study found most college football players need a full week to recover from a concussion and shouldn't play for another week after that. The second study found more reason for players with concussions to stay off the field until they are well: Those with a history of concussions were more likely to have similar injuries again and also had a slower recovery time. They may even end up with second-impact syndrome (when the second trauma occurs before the first has healed), a phenomenon that can end in rapid brain swelling, respiratory failure and even death.

Concussion, or mild traumatic brain injury, is one of the most common injuries in many college sports, including football, ice hockey and soccer. Football has a larger actual number of concussions (and one that is growing), simply because of the large number of high school and college players involved.

Still, there is no consensus on how to manage this type of injury.

"We've never had any type of guidelines and still don't know how to deal with concussions," says Dr. Douglas B. McKeag, chairman of the department of family medicine at Indiana University's School of Medicine and director of the IU Center for Sports Medicine in Indianapolis.

"There are about 17 different concussion guidelines and grading systems, and none of them have been based on what is best," says McKeag, author of an editorial accompanying the study.

"If you look at textbooks as recently as three or four years ago, they still write that loss of consciousness is required for there to have been a concussion, and that clearly is not the case," adds Michael McCrea, lead author of one of the papers and one of two principal investigators on the overall NCAA study. A host of other symptoms, including cognitive impairment and balance problems, can also constitute concussion. But this basic definitional confusion has led to confusion about how long it takes a player to recover and how long he should be off the playing field.

McCrea and his colleagues looked at 1,631 football players from 15 U.S. colleges to see the effects of concussion and the time it took to recover. The authors collected information on cognition, balance and various other indicators before the season started.

In all, 79 players who had sustained concussions (defined as an injury induced by a blow to the head or some other force that causes an alteration in one's mental status) were followed for 90 days after their injury and compared with 56 players who had not been injured.

Most of the players who had sustained a concussion resolved all their symptoms and returned to play at the end of seven days. About 10 percent required more than a week.

Current guidelines state players should be kept off the playing field for seven days after their symptoms go away (not after the injury), yet most go back within five days after the injury. "The clock doesn't start until someone is completely symptom-free," McCrea points out.

The second paper found players who have had a concussion are at the greatest risk of sustaining a repeat concussion in the first week after the injury.

That paper, which looked at 2,905 football players from 25 U.S. colleges, found that, in general, players who had had one concussion were more likely to have another. Players who had had three or more concussions were three times more likely than people with no concussions to have another. Players who had had more than one concussion generally took longer to recover as well.

The two papers essentially confirm what others have found. "We probably have enough information now to say what we've been saying, only more forcefully," McKeag says.

The bottom line? "Nobody should be sent back into a game situation at any point who still has symptoms or signs surrounding a concussion," McKeag says.

Also, different individuals react to the same injury in different ways, so brain injuries need to be treated individually. Moreover, losing consciousness, which used to be the hallmark of concussion, is not really that big of a deal.

"If your son's or daughter's concussion is properly assessed, their recovery is closely monitored and there's cautious decision-making about return to play, your son or daughter is going to be fine," McCrea says. "If the injury is improperly assessed, the recovery is not closely monitored, or someone makes an ill-advised return-to-play decision -- with the worst being that an athlete would return to play while still having symptoms -- that's when you're opening yourself up to the risks of potentially negative outcomes."

Teams in the National Football League appear to be taking a more cautious approach after seeing concussions shorten many careers. Wayne Chrebet, a star wide receiver for the New York Jets, sustained the latest in a history of concussions when he was hit in the helmet on Nov. 2. He briefly went back into the game, but nervous team doctors later put him on injured reserve for the remainder of the season.

More information

For more on concussion, visit the U.S. Centers for Disease Control and Prevention or the National Institute of Neurological Disorders and Stroke.

SOURCES: Michael McCrea, Ph.D., director, neuroscience program, Waukesha Memorial Hospital, Waukesha Wisc.; Douglas B. McKeag, M.D., chairman, department of family medicine, Indiana University School of Medicine and director, IU Center for Sports Medicine, Indianapolis; Nov. 19, 2003, Journal of the American Medical Association
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