Concussions & Football, Getting Back to Some of the Basics

I am not sure any of you watched the NFL game with the Bills and the Dolphins on Sunday September 25, 2022? If you did you would have seen the Dolphin’s QB Tagovailoa get pushed backwards, causing him to fall and hit his head on the turf. He was able to get up on his own. However, as he jogged across the field his legs looked like the scene of Bambi on the ice. If you missed it, here is a REPLAY.

With that, if you are like me, you were thinking that he was definitely going to be out for the rest of the football game. Then, the shocker came when he was allowed to resume play.

Did he sustain a concussion?

What are the signs and symptoms of a concussion?

Recognizing and evaluating concussion in football and other sports can be a challenge. Based on the Consensus statement on concussion in sport from 2016, the suspected diagnosis of concussion can include one or more of the following:

a. Symptoms: somatic (eg, headache), cognitive (eg, feeling like in a fog) and/or emotional symptoms (i.e. lability). Of note, headache is the most common symptom after a concussion.

b. Physical signs (i.e. loss of consciousness, amnesia, neurological deficit).

c. Balance impairment (i.e. gait unsteadiness).

d. Behavioural changes (i.e. irritability).

e. Cognitive impairment (i.e.slowed reaction times).

f. Sleep/wake disturbance (i.e. somnolence, drowsiness).

The statement later goes on to say that if symptoms or signs in any one or more of the clinical domains are present, a concussion should be suspected and the appropriate management strategy instituted. It is important to note, however, that these symptoms and signs also happen to be non-specific to concussion. Their presence simply prompts the inclusion of concussion in a differential diagnosis for further evaluation, but the symptom is not itself diagnostic of concussion.

So, with Tagovailoa he obviously had some temporary balance issues so now what.

Initial concussion treatment

According to the consensus statement, if any of the above are noted then:

a. The player should be evaluated by a physician or other licensed healthcare provider on site using standard emergency management principles.

b. The appropriate disposition of the player must be determined by the treating healthcare provider in a timely manner. If no healthcare provider is available, the player should be safely removed from practice or play and urgent referral to a physician is arranged.

c. Once the first aid issues are addressed, an assessment of the concussive injury should be made using the SCAT5 or other sideline assessment tools.

d. The player should not be left alone after the injury, and serial monitoring for deterioration is essential over the initial few hours after injury.

e. A player with diagnosed concussion should not be allowed to return to play on the day of injury.

So, from this it looks like with Tagovailoa this is where things may have gone wrong. He demonstrated signs of a concussion and was taken to be assessed by the team physician who for some reason did not make the diagnosis of a concussion and allowed him to resume play.

What is a concussion?

The definition we like the best comes from the American Medical Society. They state that a concussion is defined as a traumatically induced transient disturbance of brain function and involves a complex pathophysiologic process. Concussion is a subset of mild traumatic brain injury that is generally self-limited and at the less severe end of the brain injury spectrum.

Is imaging or other investigations needed if a concussion is suspected?

Based on the 2016 consensus statement, “Advanced neuroimaging, fluid biomarkers and genetic testing are important research tools, but require further validation to determine their ultimate clinical utility in evaluation of sport related concussion.”

Now we must also understand that this is from six years ago. A new concussion statement will be available shortly.

Return to play after a concussion

So, if Tagovailoa was initially diagnosed with a concussion when could he be back playing football? This is a great question and there is a simple answer. There is a 6 stage plan that has been generally accepted to ensure a safe return to sport. Each stage takes place with 24 hours between and as long as there are no symptoms with each stage the athlete is allowed to progress to the next stage. With six stages, it would then take six days to return to play with the return to play being the sixth stage.

In case you are not familiar, here are the 6 stages:

Stage 1 - symptom free at rest

Stage 2 - symptom free with light aerobic exercise (i.e. walking or stationary bike at slow medium pace)

Stage 3 - symptom free with sport specific exercise (i.e. running or skiing drills)

Stage 4 - symptom free with non-contact training drills (i.e. passing and catching drills and may start resistance training)

Stage 5 - symptom free with full non-contact practice, but needs medical clearance first

Stage 6 - return to sport

If there are any symptoms with any particular stage, the athlete reverts back to the previous stage.

Note: this return to play outline is intended for dealing with an acute injury. If it has been 2 or more weeks since the injury there may be some deviations from this as consideration of other causes of ongoing symptoms (i.e. neck injury, mental health) should be investigated.

With Tagovailoa he was back playing football within four days and unfortunately had to be taken off of the field, this time in a stretcher.

How long does it usually take to recover from a concussion?

According to the concussion statement from 2016, adults usually recover in 10-14 days and children within 4 weeks. Some groups will claim this is longer, but what we have observed is you sometimes have to question their research. There can be small sample sizes and other research flaws. Sometimes the research group also has a product to sell, questioning the bias of the study. Regardless, if symptoms are persisting a multidisciplinary approach is recommended.

Conclusions

We have come a long way in treating concussions along with our attitude towards concussions. Do you remember the Mars Bar football concussion commercial?

There has been a push for education along with changes to rules, policies, and equipment which have all been great. However, based on what recently happened in the NFL, we still have a ways to go.

And, let's not forget about Tagovailoa. We wish him all the best with his recovery.