Understanding concussion: football’s greatest medical challenge

Understanding concussion: football’s greatest medical challenge

The crowd braces for the inevitable impact as two energetic under-17 players on a collision course with one another refuse to let up in a challenge near the sideline. The larger of the two players immediately bounces back up, rubs his shoulder and grimaces. The other player remains motionless on the ground.

A trainer and coach evaluate the injured player who’s visibly showing signs of disorientation. His coach, taking the proper course of action, subs the player off. A muffled applause echoes across the field as the injured player staggers to the bench where he begins to vomit. He briefly gets back up to his feet and jogs back and forth before another dizzy spell forces him to sit down next to the trainer.

All of a sudden a man shouts, “He’s fine, coach! Get him back on the field!” People continue to chat. I notice nobody sees anything wrong with the outburst. “That’s his son. He always yells when his son comes off,” a parent tells me after seeing my horrified expression.

I think about the incident and decide to write about concussions from my perspective. It seems that concussions aren’t a pressing issue unless someone is a well-known player or pundit dealing with concussion-related effects and makes it a talking point. For an injury that occurs between 1.6-3.8 million times a year according to the National Center for Health Statistics, it’s a necessary topic. As important as those well-known individuals are to the educative process, I write from the perspective of the everyman — someone who has played the game, but not professionally.

Concussions aren’t mutually exclusive for professional or amateur players, or sports for that matter. However, the injury affects sport at all levels. People tend to shelve the issue of concussions not out of malice, but out of lack of knowledge — until a concussion affects them or their child. I admittedly don’t know where to start, so I consult with people who dedicate their time to concussion education. The purpose, for me, is to dispel some myths, educate anyone willing to be educated, and encourage more exploration into the world of concussions and Traumatic Brain Injuries (TBI) to hopefully push for increased awareness and proactive change in safety protocols.

According to the Sports Concussion Institute: “A concussion is defined as a complex pathophysiological process that affects the brain, typically induced by trauma to the brain. It can be caused either by a direct blow to the head, or an indirect blow to the body, causing neurological impairments that may resolve spontaneously. Symptoms usually reflect a functional disturbance to the brain, and may include physical (e.g., headaches, nausea), cognitive (e.g., difficulty with concentration or memory), emotional (e.g., irritability, sadness), and ‘maintenance’ (e.g., sleep disturbances, changes in appetite or energy levels) symptoms. A concussion is considered a brain injury.”

I think about how I got here, attempting to shed light on this heavy topic and it takes me back a bit. According to the medical forms my mother has kept, my first documented concussion occurred 25 June 1996.

Like many young players I took my turn as a goalkeeper in a game. Just before the start of the game, I was standing out of the goal mouth when a gust of wind toppled the goal over and the crossbar hit me in the back of the head, driving it into the ground. I remember grabbing my face and feeling my shattered jaw just dangle. I refused to remove my hands from my face out of pure terror and shock. The off-white foam of the goalkeeper gloves was now soaked with blood. The rest is lost in a void of nothingness. I’d later hear about my irate coach screaming at the referee for not checking that the goals were anchored while my father carried me to a bench where another parent tried to pry my hands from my bloody face.

I awoke several hours later in the hospital with gauze packed into my mouth and wires and protruding through my cheeks and chin attached to some brace device on face. I recall trying to scream and call out, but my mouth was wired shut. Strapped to a table for a CT scan, I began to panic while exhibiting many of the indicators the American Academy of Neurology has laid out as concussion guidelines such as: suspicion of intercrainial structural injury and haemorrhaging (subdural, epidural, intracerebral, or subarachnoid), loss of consciousness (LOC) exceeding 30 seconds, poor orientation, loss of coordination, and significant drowsiness.

I spent the next week in a dark room as lights were too bright for me. The doctors informed my parents that I suffered a fractured jaw and orbital bone, moderate trauma to the back of my skull, and a grade three (severe) concussion. I learned about this laundry list of injuries much later even though I was in the room when the doctor read them off. As horrific as the incident sounds, it could have been much worse.

Recovery from the broken jaw, orbital bone, and several visits to an oral surgeon took a few months, but the migraines and dizzy spells never really went away. Fast forward several years later and I learned to live with the migraines. I continued playing and never feared heading the ball or a hard challenge. Back then, coaches reinforced how toughness was of the utmost importance.

The axiom was reinforced by culture-based principles lodged in the value of robustness as an attribute of the American player. The takeaway was timid play led to worse injuries, which is oftentimes correct. On the field, the game was as it had always been — part of my identity and I continued playing competitively despite momentary episodes of dizziness and slight vertigo. Off the field, I felt out of sorts and knew something was wrong. By the time I stopped playing competitively, I had suffered three more documented concussions through 2009.

In the past four years, two neurologists have told me to “exercise caution” should I partake in physical activity. In 2010, after suffering from multiple episodes of fainting and unexplained and debilitating wooziness at work, a doctor specialising in concussion-related injuries and effects told me, “You’ll still have intense migraines and sometimes feelings of sudden depression and nausea. The reality is some days will be fine and some will be difficult. Like any player, you’ve hit your head more times than you think. I’ve seen similar symptoms in boxers who are what we call ‘punch drunk’. Their disorientation becomes part of their normal day-to-day life. Most of these aggravations cure themselves over time. Some do not.”

I contacted Samantha Sanderson, a former soccer player and a co-founder of an organisation called Concussion Connection that aims to educate, facilitate research, answer questions, and bring concussion-related issues to the forefront of discourse. Sanderson is a third year doctoral student in Clinical Psychology at Wright State University’s School of Professional Psychology and much of her research and knowledge base is rooted in psychology. One of my questions revolves around the myth that concussions are rare injuries. According to Sanderson:

“There is a misnomer that concussions are rare and that is detrimental. While there can be lasting effects from one concussion, the vast majority of these injuries resolve within 7-10 days (more liberally 30 days). Cognitively the symptoms should resolve in this time or within a few months, depending on who you ask. If cognitive symptoms linger there is typically an underlying psychological reason which remains as a result of the injury and does not mean the person is “making it up” or “it’s all in their head”. Nobody wants to talk about the psychological effects and that is detrimental to many athletes who experience these symptoms.”

Ever since professional players started wearing “scrum caps” and protective headgear, concerns over whether protective headgear should be required for youth players along with suggestions of eliminating headers entirely from the game at youth levels has become a hot-topic debate. Implementing more technical work will enable and encourage players to keep the ball on the ground. However, collisions are part of the game. According to Sanderson, protective headgear isn’t the solution. “There is actually evidence not only that headgear doesn’t work, but that it can increase risk of concussions due to the increase weight on the neck,” Sanderson states, “there is evidence they may reduce force, but we don’t know what that means clinically as the brain is still moving around inside the skull.”

It is evident society is drawn to the intense aspects of sport. Fans far away from the action adopt an impersonal attitude to player safety. Mainstream media still airs “Top 10 Hits” highlight reels and big hit compilations are extremely popular online. Societies have been conditioned to champion the “big hit” as something to celebrate and replay with a sadistic fascination. “While I agree with this, I don’t think the bulk of the responsibility of changing the culture will be on parents and coaches (though coaches have a greater responsibility),” writes Sanderson.

“The sport culture will resist change due to fans. The attitude of fans is they don’t care because they are just watching for entertainment and thinking isn’t this what athletes get paid for?”

Of course, this is true — sport and entertainment are a massive money-making industry, so the degree of risk involved is trumped by the reward and spectacle. However, fault is shared by society and its athletes alike. As the modern athlete becomes bigger, faster, and stronger— valuable attributes that supersede the value of technique, body control, and coordination— players continue to play recklessly and assume the risks associated with the overt emphasis on physicality in soccer.

Current medical studies linking concussions to heading remain inconclusive. Heading has become the low-hanging fruit to blame for concussions. Many questions remain whether heading a ball increases risk for concussions and in some cases, traumatic brain injury (TBI). The majority of concussions suffered are the result of collisions between players or contact with the ground.

A former teammate of mine and a Division 1 goalkeeper in his playing days, who’s now a physician and has studied the effects of head injuries and concussions, extensively weighed in on the issue, “We don’t understand much about the brain compared to other body parts. Personally, I believe elbows to the head in headers and head-to-head contact is far more to blame than most headers. The exception being those ones [headers] every once in a while that make your head ring.” We discuss the mood-related effects linked to head injuries. “Concussions do lead to mood issues like depression and headaches. But that can and should be treated.”

Perhaps one position most at risk for concussions is that of the goalkeeper. Petr Čech continues to wear a scrum helmet years after his skull fracture. Last November Tottenham Hotspur goalkeeper, Hugo Lloris, collided with Everton striker Romelu Lukaku. While Lloris should have been evaluated and removed from the field of play, he played the remainder of the game despite the fact he was knocked out.

The media reported that he “recovered quickly” and like most players, he insisted he play on. Reports surfaced that Tottenham’s medical team “wanted him to be replaced”. In a later interview Lloris acknowledged the danger of the incident, “I was a subject of that and so it is easier for me to understand the decision. I realise now that I had taken a risk with my health. It will not happen again.”

Situations similar to the one involving Lloris aren’t rare. Last season, Lukaku himself was also knocked out and played on against West Ham. Robert Huth was knocked unconscious and continued playing for Stoke City against Manchester City and Thibaut Courtois played on for 14 minutes after being hit by Alexis Sánchez.

The world watched as more incidents at the World Cup brought the reality and severity of head injuries and collisions to the forefront when Uruguay’s Álvaro Pereira and Argentina’s Javier Mascherano were both knocked unconscious and both continued to play.

A stunned worldwide audience watched as in the 16th minute of the final, Germany’s Christoph Kramer was blindsided by a shoulder to the head from Argentine Ezequiel Garay. The German was evaluated by team trainers and if his woozy movements were apparent to audiences from around the world, his deteriorating condition should have been obvious to the onsite medical team that authorised the player to continue to play. Kramer continued for about 15 minutes before being substituted.

No player wants to admit they cannot play or absorb the reality they might have lasting cognitive effects, especially as the level of play and the stakes rise. One goal should be more understanding of the injury itself and the recovery of the affected parties. According to Sanderson, there is a need to “bring light to the psychological effects of concussions because it is taboo to talk about. The silence is squandering the opportunities for athletes to recover fully and in a timely manner. Concussions aren’t just a symptoms checklist. There is a person whose life is being upended and he/she is experiencing many different things.”

Much of the lack of attention likely stems from the fact a concussion is an invisible injury. Athletes with mild concussions look normal and will act normal if it keeps them in the game, so to speak. Personally, if my college coach asked me, “Can you play?” I likely would have said yes as athletes are conditioned to play through pain.

Concussion Connection conducted an interview with former U.S. Women’s National Team goalkeeper, Brianna Scurry, who used a fitting analogy to describe a concussion. In the interview, Scurry states, “a concussion is like having a jar full of M&Ms, each colour represents a different concussion symptom. When a person gets a concussion it’s like reaching into the jar and whatever colours you get are your symptoms. No one person is going to have the same ones and in the same severity.”

According to Sanderson, there are many things to take in to consideration with concussions and society wants a quick answer and a quick fix, which just isn’t possible. The other side is the research stems from the paralysing hysteria of chronic traumatic encephalopathy (CTE) development in athletes who have suffered from severe head injuries, concussions, and traumatic brain injury. The stories making the news include athletes struggling with pain, mood swings, and symptoms of dementia, memory loss, aggression, confusion and depression, all of which commonly appear years or even decades after the initial trauma. The stories making the news are the tragic suicides and outbursts of former athletes for an injury and damage that has no known cure.

Samantha Sanderson echoes what so many looking for reform in how society treats concussions have said. “Concussions are a unique injury, but they don’t have to be something to be feared. I maintain that developing a healthy respect for what a concussion is, what it can cause, and how it can impact someone’s circumstance is the best mentality to have. We have a long way to go. Until we can stop comparing concussions to ACL tears and other musculoskeletal injuries and see concussions as an individual experience where we have to trust what the person says they are feeling is indeed what they are feeling, progress will remain slow.”

Perhaps there is no agent for change more vocal and candid regarding head injuries than former New England Revolution and U.S. Men’s National Team forward Taylor Twellman who had to stop playing the game entirely as a result of concussion-related injuries. One of most startling revelations regarding a career cut way too short comes from an article on ESPN describing Twellman’s final game:

He said he got himself ready for his final game, on June 7, 2009, by taking four Vicodin, three Excedrin and “shotgunning a Budweiser”; he entered as a second-half substitute because he could only manage to play for 45 minutes at a time, and scored two goals.

His teammates wondered why he did not celebrate.

“My head was as soft as a sponge,” Twellman said. “I knew deep down I was done.”

Taylor Twellman oversees the ThinkTaylor Foundation, which aims “to create social change in the world of Traumatic Brain Injuries, by generating increased awareness, recognition and education” and has a website, www.thinktaylor.org that offers a knowledge base of resources for the public. Taylor Twellman is justifiably outspoken in his view that the governing entities of the game aren’t doing enough to address the issue of concussions and head injuries.

In a brief Twitter conversation with Twellman, I mentioned the need to “[re]educate parents and players at the lower levels of the game about the dangers of concussions.” In a short response, Twellman related to issue to the dangers of drunk driving in our conversation, “People still drink-drive even when a family member is hurt by a drunk driver.” We end our conversation with a tweet from Twellman: “If I help 1 person by telling my story and educating then it was worth it. #nodoubt”

By Jon Townsend. Follow @jon_townsend3

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