Over the past several years, the risk of concussion in sports has received a great deal of attention. While concussion among athletes has always existed, reports of long-term damage to the brains of NFL players brought it to the media spotlight.

Dr. Bennet Omalu, a forensic and neuro-pathologist, is credited with identifying chronic traumatic encephalitis (CTE) in NFL players. He performed an autopsy of former NFL player Mike Webster, who died suddenly after struggling for years with cognitive and mood issues, as well as suicide attempts. While the autopsy was normal, Dr. Omalu performed special tests confirming the presence of large amounts of tau protein in the former footballer’s brain. More research studies followed, and we now know much more about CTE.

Although most cases of concussion occur in contact sports, such as football, boxing, and wrestling, we are now seeing it increasingly in other sports such as soccer, particularly girls/womens soccer. It no longer appears limited to professional athletes. In fact, a report in JAMA estimates that one in five adolescents will receive a diagnosis of concussion at some point and that 6% will suffer recurrent concussion.

While the news and research around concussion and CTE continues to grow, doctors on the frontlines need to know how this translates into clinical practice. I had the great pleasure to discuss the issue with Dr. Mahmud Ibrahim, a sports medicine specialist in East Brunswick, NJ.

 

I recently treated a young boy for a concussion he sustained playing football. It seems I’m seeing more kids recently for concussion. Are you seeing the same, and if so, why? Is it that more concussions are happening or that recognition is increasing?
Dr. Ibrahim: I’ve definitely been seeing more kids with concussions lately. Some of it has to do with parents pushing their kids into more and more sports (partly to keep them occupied during the day and partly in hopes of getting some scholarship), but I think some of it also has to do with increased awareness as well. In the past, if a kid complained of a headache, people just assumed he/she didn’t want to go to school or play in a game. But now, with all the discussions about concussion, coaches, teachers, and parents are aware of some of the signs to look for.

Do you think public education on recognizing the signs of concussion has been sufficient?
I think there has definitely been more education about concussions. I have patients asking me about concussion symptoms directly, rather than me having to pry it out of them or another physician referring the patient for that.


On some occasions, I find the parent(s) and/or coach pressuring me to allow the patient to return to play before they are ready. Do you see this, and if so, how do you respond?
Yes, I do too. The problem with concussions is that there is no visible damage to the patient. He/she may look fine on the outside, but there is definitely something going on internally. So it’s hard for parents and coaches to know how an athlete is doing without anything objective to go off of. I try to educate the parents that if the patient goes back before he/she is ready, then the patient won’t perform as well and will likely end up worse than when he/she started, which means even more time away from the game.

Do you follow strict return-to-play guidelines or does it depend on the individual patient?
It really depends on the patient. Generally, I recommend first starting with symptom free day-to-day activities. If they tolerate that, then they can move on to general exercise. If they continue to be symptom free, then they can move on to sport-specific exercises/activities. If they progress through each step symptom free, then I clear them to return to play. If they develop symptoms at any point, they go back to the previous step.

Does your advise depend on the skill level of the athlete, say recreation vs. college level vs pro?
Nope, those are pretty general guidelines. Your brain doesn’t know it’s a weekend warrior or a pro. It just wants to efficiently fire electrical impulses, and it can’t do that if it’s bruised.

As someone who went to college on an athletic scholarship, I was sometimes given steroid shots to help me return to competition, despite still having an injury. Being on an athletic scholarship, I didn’t feel I had much choice whether or not to compete. Do you think this is a big problem in competitive sports in general and in terms of concussion?
Yes, that’s a huge problem in schools. Steroid injections aren’t fixing the issue; they’re just temporarily reducing the inflammation and pain in order to help the athlete get back into the game. However, by doing so, you’re ignoring an injury that your body is trying to tell you about, and so, you risk making things much worse later on.

Do you think growing knowledge of chronic traumatic encephalopathy (CTE) suffered by NFL players has helped the issue?
Yes, the NFL is pretty mainstream, so when they started talking about concussions and all the horrible long-term side effects these older athletes were having, I think it helped people to realize that concussions need to be taken seriously.

Are kids who suffer concussion in recreational sports at risk of CTE?
CTE is due to repetitive trauma. A single concussion is unlikely to cause it. But kids are playing organized sports earlier and earlier, which adds up to more years of potential concussions over time.

Do you think appropriate safety precautions (eg, helmets) are used at all levels of play?
There probably needs to be more regulation with this. I think most schools use helmets for contact sports, but other contact sports—such as soccer and field hockey—and even non-contact sports—such as cheerleading—are still at risk for concussions.

When many people think concussion, they automatically think football. In what other sports is there a risk of concussion?
I’ve seen cheerleaders suffer concussions from falling/being dropped. Many professional wrestlers have suffered concussions, which later on autopsy revealed they had CTE. Pretty much any sport where there is risk of being hit in the head puts you at risk for having a concussion.


I once had a pro boxer see me for a recent concussion after a series of concussions. He wanted a note to return to box. I told him I couldn’t honestly clear him to return. I suspect he went to another doctor(s) until he found one who would clear him. Have you ever had to tell an athlete they could not return to their sport?
I haven’t had to do that specifically, but I do treat a lot of patients with chronic pain and I have had to tell some of them that, due to the nature of their pain, they need to avoid doing certain things, even if it’s something they previously enjoyed doing.


Do you think athletes sometimes lie to get you to clear them to return to play?
Absolutely. That’s why there are objective tests, such as IMPACT, that can determine the cognitive function of an athlete before clearing him/her to play. however, those tests are not without their flaws

Why is there such a big amount of attention being given to concussion?
I think after several professional wrestlers and football players committed suicide, it brought the issue of CTE to light. Then Will Smith made a movie about it. It’s good to see that more people are aware of the risks of concussion and the symptoms to look for, because, generally, the person who has the concussion has no idea that they were concussed.

 

Despite increasing awareness around concussions, we need to continue to do better. More research is needed on the effects of concussion on developing brains, as well as for developing the safest sports equipment possible. Schools and coaches should be educated on return-to-play guidelines, and parents should understand the potential risks of returning to competition too soon.