New study highlights flaws in “concussion” diagnosis

New Orleans Saints quarterback Drew Brees spoke with Louisiana high school football players about a program that provides free concussion testing to more than 3,000 middle and high schools. (AP Photo/Bill Haber, File)
New Orleans Saints quarterback Drew Brees spoke with Louisiana high school football players about a program that provides free concussion testing to more than 3,000 middle and high schools. (AP Photo/Bill Haber, File)

With all the publicity concerning harmful brain injuries incurred by professional football players due to repeat concussions, parents of kids who play contact sports have a heightened sense of fear when it comes to a diagnosis of concussion.

Will their child now be more prone to depression, early dementia, a lower IQ? Understandably, many may be tempted to keep their kids out of any sports, like soccer, football, and hockey, where they’re likely to get their head smashed repeatedly.

Taking this to the extreme, the school board in Dover, New Hampshire—led by a retired physician—announced last week that they’re considering banning football at Dover High School because the risk of concussions from the sport is simply too high.

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But some brain experts have begun to quietly raise concerns that perhaps the pendulum has swung too far in the direction of concussion phobia where panicked parents have been known to bring kids to the emergency room after they were hit in the head with a nerf ball or tennis ball.

“They get terrified over the diagnosis of a simple concussion, but historically most kids with concussions do fine,” said Dr. Ann-Christine Duhaime, director of pediatric neurosurgery at Massachusetts General Hospital. “Our species wouldn’t have survived if we didn’t.”

That should be somewhat reassuring to parents who read scary things about concussions during web searches. The federal Centers for Disease Control and Prevention’s website, for example, describes a concussion as “a type of traumatic brain injury, or TBI, caused by a bump, blow, or jolt to the head that can change the way your brain normally works.”

There’s no question that some concussions can be extremely serious, especially those that occur in quick succession. But even with the most sophisticated brain imaging, physicians often can’t distinguish those injuries likely to cause severe and lasting cognitive damage from those likely to have little or no repercussions.

In a study published in the Journal of Neurosurgery earlier this month, Duhaime and her colleagues analyzed data from 450 college football and ice hockey players over the past four years who experienced 486,594 recorded head impacts—measured on specially designed helmets—during practice and games.

Among those athletes, team trainers and physicians diagnosed 48 concussions in 44 of the players, often based on symptoms like mental clouding, headaches, blurred vision, and dizziness. One player lost consciousness. Although the size of the impact usually correlated with the severity of the symptoms, some players with large measured impacts had no apparent symptoms.

And more than one-third of the time, players who were diagnosed with concussions based on their symptoms had no single head blow that was associated with the onset of their complaints. While Duhaime was reluctant to call these concussions overdiagnosed, she said the study highlighted the vagueness of the term concussion and how loosely it’s defined by those in the medical profession.

“There’s no one definition everyone in the medical community agrees on,” she said. “There’s still an enormous amount we don’t understand about concussions, whether it’s the force of the impact that’s most important, the severity of symptoms that result, or a person’s particular genetic predisposition.”

Most likely, it’s a combination of all three, as well as whether the injury results in brain bleeding, which could result in lasting damage if it doesn’t heal before the next impact.

For this reason, Duhaime and her co-authors from Dartmouth, Brown, and Virgina Tech wrote that the diagnosis of concussion, as if it’s a single entity, should be replaced with the term “concussion spectrum” to make it clear that doctors are labeling a description of a number of different things that might have occurred in the head and brain, rather than a distinctly defined condition like, say, diabetes or a heart attack.

Given that the most concussions diagnosed in kids result in a good outcome, is the new state law that restricts high school athletes who have concussions from playing until they get medical clearance really necessary?

“The law isn’t a bad idea to prevent second impact syndrome,” said Duhaime, where a second blow soon after the first, in rare cases, causes severe brain injury and even death. “But it puts doctors in the difficult position of trying to give parents well informed specific recommendations for the more common types of concussions when we really don’t have much to base those on.”

There’s not much evidence, for example, that sitting in a quiet dark room—without stimulation from even a television, book, or laptop—helps the brain heal faster than going about your normal everyday activities. While taking it easy makes sense for children who have a headache, nausea, or difficulty concentrating after a concussion, many neurologists believe that those who feel fine can safely resume their normal routine as long as they avoid high-risk activities likely to cause another impact to their head.

“We still don’t fully understand who needs what to make a full recovery,” Duhaime said. “The new insight from this study is that by calling everything the same name—concussion—we may oversimplifying something that’s far more complicated.”

But until research can determine the best course of treatment for particular individuals, doctors can’t be faulted for playing it a little too safe, she added. “I just think it’s important to reassure parents” that most kids recover fully from concussions.

For those parents looking for a competitive sport for their child that has a minimal risk of head injuries, Duhaime recommends fencing.

Check out our general sports safety tips and tweet chat with a Boston Children’s Hospital expert on this topic. Also, Mass General’s Youth Sports Concussion Clinic has advice on getting kids properly diagnosed and treated for concussions.