If you watched the Super Bowl, it’s fresh in your mind: Football is violent, as are many other sports. Even with protective gear, players can sustain serious injuries – and if they hit their heads, the damage may not just be physical.
In the NFL, players are amply compensated for the risks and get expert medical care. But what about high school and college-age young people? They can get badly hurt too.
That’s where Memorial Hospital of Rhode Island’s sports concussion management program comes in. Started by Dr. Mason C. Gasper, a neurologist at Memorial Hospital of Rhode Island and assistant professor at Brown University’s Warren Alpert School of Medicine, and Janet Grace, a Brown professor and a neuropsychologist at Memorial, the program provides comprehensive care for concussion patients, from diagnostics to rehabilitation.
Gasper answered questions about the program.
PBN: How long has Memorial had this program, and how big is it?
GASPER: We began discussing sports-related concussions two years ago because of the growing concern, especially in the NFL. We thought we could provide professional assistance on the local high school and college level. We opened the clinic about a year ago with a team of experienced professionals in concussion care and sports medicine, including adult and child neuropsychologists, sports medicine and family care physicians, pediatricians, a neurologist – myself – and a physical therapist who has special training in vestibular therapy, for treatment of balance problems.
Student athletes are scheduled with our team through the memorial neurology department. Our goal is to evaluate them as quickly as possible, the next day in most cases. Based on our initial assessment, we develop a care plan, including a return to play and to school, depending on their neurological status and cognitive status. We may recommend medications or other professional care, such as physical therapy. We also have longer-term follow-up for those who have symptoms that persist beyond the typical two-week acute recovery period and for those who develop post-concussive syndrome (e.g. persistent memory problems, vertigo/balance problems, headache, fatigue, sleep disturbance and other lingering symptoms).
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PBN: How common are sports concussions?
GASPER: By some estimates, there are 1.5 million to 3.5 million concussions in sports per year, and many go unreported. It’s estimated that 50 percent of high school football-related concussions are not reported to medical personnel, coaches or athletic trainers.
Athletes can suffer a concussion in most sports, but it is well known that athletes are susceptible to concussions in football, hockey, soccer, lacrosse, volleyball and basketball, and even in non-varsity sports such as rugby and Ultimate Frisbee. Both boys and girls sustain concussions. Younger brains, especially in girls, are more prone to injury than those of well-conditioned professional athletes. With children starting football, hockey and other contact sports at young ages, they can be exposed to many blows to the head by the time they reach adulthood.
PBN: What are some of the symptoms of a concussion, and what are the short-term and long-term consequences?
GASPER: A concussion is defined as a complex pathophysiological process affecting the brain, induced by traumatic forces. It may be due to a direct blow to the head or to a force transmitted to the head, such as in blast injuries in Iraq. Concussions are not usually visible on a CT scan or MRI, but dangerous rare complications such as subdural hematoma can be seen on those images. And while there may not be structural changes to the brain that can be “seen,” a concussion may set off a cascade of brain disturbance (biochemical, metabolic, even expression of genetic susceptibilities). We do not fully understand these processes yet.
Symptoms may include loss of consciousness, loss of memory, momentary disorientation, headache, neck pain, balance/coordination problems, dizziness, nausea and vomiting, vision problems, hearing problems, fatigue, irritability, difficulty concentrating, difficulty remembering, distractability, sleep problems and even emotional changes (feeling depressed or anxious). There may or may not be a loss of consciousness. In most cases, symptoms are short-lived and resolve on their own with rest, but recovery is a gradual, sequential process.
Current guidelines recommend medical evaluation of concussions and no return to play while the athlete is symptomatic. “When in doubt, sit them out!” This same logic applies to return to demanding cognitive activities such as school or work.
PBN: Where do your patients come from?
GASPER: Our patients are referred from local primary care physicians, university health centers, sports medicine doctors, athletic trainers and concerned parents. We have been developing relationships with local colleges, athletic trainers, and high schools. We have started a sports concussion interest group focusing on sharing information and increasing public awareness of the importance of concussion care in athletes. Our main concerns are ensuring that coaches who do not have on-field medical personnel understand what a concussion is, are able to recognize one and know how it should be managed.
PBN: Have the standards for treating concussions changed in recent years? How unusual is your program, and is it indicated for all concussion cases, or just really serious ones?
GASPER: There are consensus guidelines for the treatment of concussions. Depending on the severity, it can be a matter of physical and cognitive rest for seven to 10 days, or more complicated. In all cases, there should be a period of physical and cognitive rest; as the symptoms resolve, physical and cognitive activity are gradually increased. If symptoms return, then the individual goes back a step. Some patients develop persistent headaches, sleep disturbance, persistent dizziness or vertigo that may benefit from medical intervention or physical therapy. Others develop problems with mental focus, attention or memory that can interfere with school. Temporary modifications to their school program may be recommended by the neuropsychologist.
Our program is available to athletes of all ages who experience a concussion. Professional support is often limited in youth sports. … For professional sports, rules are in place to protect players on the field … and management of concussions is actually less complicated, since the goal is to return to playing. Our student athletes, however, also have to return to learning and being kids. Some avoid medical evaluations because they do not want to be restricted from play, … but while most mild traumatic brain injuries do not have long-lasting effects, some do have persisting symptoms … [and] multiple concussions can lead to long-lasting cognitive problems and even premature dementia, as seen in some boxers.
