Prior to the New Orleans Saints' triumph in Super Bowl XLIV, there wasn't a more talked about ankle in the country than Indianapolis Colts' superstar defensive end Dwight Freeney's. Analysts debated how the absence of one of the league's most talented pass rushers would affect the game, and dissected the torn ankle ligament from every strategic angle. As is so often the case in football, Freeney played through the injury. Despite the seriousness of the injury, it was almost expected: Football players are supposed to “tough out” injuries for their teams and the greater good.

This culture, and the respect it brings from millions of fans, isn't likely to completely abate. However, it is changing in regard to head injuries. In 2009, in response to numerous popular football players suffering concussions, the National Football League (NFL) sought to revise its guidelines for returning players to the game. In addition, it considered evaluation by neurologists or similar personnel, as well as other possible options for protection, diagnosis, and treatment. That work is ongoing.

The term concussion is a layperson's term. As our understanding improves along with technological advances in imaging and accurate mechanical modeling, this previous diagnosis of exclusion might be much better characterized. Numerous articles in the literature have begun generally referring the severity of brain injury into three main categories: mild, moderate, and severe.

Based on the Glasgow Coma Score (a response including spontaneous eye opening, appropriate verbal response, and following motor commands) a perfect score of 15 might still be present in a person who suffered a transient alteration of consciousness (hence a concussion), who appears normal at time of assessment. Alternatively, a designation of 12 to 15 is considered a mild brain injury, 9 to 11 is considered a moderate brain injury, and a score from 3 to 8 considered a severe brain injury (or coma, to some).

Some variation in this definition for moderate and mild brain injury has been suggested, as well. Ultimately, though, whether we refer to an injury as a concussion or a mild brain injury, most patients care less about the classification and more about the sequelae. In this article, I will share the present understanding of concussions and hope to provoke thought as to whether any sport whose goal is to cause injury can ever be made completely safe. If it cannot, how can head injuries be prevented, detected, and treated?

Definition
A concussion can be defined as a transient alteration in the level of consciousness. While many different versions of a definition for concussion exist, this is the functional definition to be used in this paper.1,2

Under this definition, it should be noted that a person does not have to suffer loss of consciousness, although a brief loss of consciousness can be part of a concussion. Most definitions of concussion would exclude an intracranial bleed—if one exists, the diagnosis of a concussion is no longer applicable. Various classification schemes have attempted to address the severity of concussion. For example, actual loss of consciousness and extent of amnesia each correlate with a more severe concussion.3

Mechanisms. The actual mechanism of a concussion is not fully understood, but several mechanisms have been proposed.4 A blow to the brain severe enough to transiently alter function appears to be sustained. Whether this involves a direct hit of the skull and subsequent hit of the brain against the opposite side of the skull (contre-coup injury) or same side (coup injury) is not fully known.

In addition, rotational forces involving fibers from the brainstem extending to the cortex or viceversa may be involved. Also, a not-so-often-considered mechanism linked with impact to the lower jaw subsequently translating energy to the skull base at the temporo-mandibular joint has been implicated.5

Numerous studies, especially with advanced imaging, have suggested more specific tracts in the brain being implicated—for example, cortical projection fibers, rather than association fibers, may have a role.

Diagnosis. Having defined a concussion as a transient change in the level of consciousness, it is important to differentiate a concussion from a more severe injury, such as a coma or vegetative state. Other than the transient alteration in consciousness, a concussion is not associated with focal neurological deficit (such as numbness, weakness, speech, visual, or auditory difficulty, for example).

Also, the presence of any imaging finding, such as a bleed or severe brain edema, seen on CT or MRI scan effectively exclude the diagnosis of concussion. However, the dilemma is acknowledged that as imaging techniques become more sophisticated, 6 subtle imaging findings (e.g., involving diffuse axonal injury), perhaps apparent on sensitive FLAIR high-tesla MRI imaging may be consistent with the diagnosis of “concussion.”7 More insight into mechanism of concussion might be revealed with such sophisticated imaging, as well.8,9

Treatment and Prevention. The treatment of concussions really needs to consider two issues: prevention and subsequent care. The best prevention, of course, would be never sustaining a concussion. Unfortunately, for the thousands involved in competitive contact sports, or who have traumatic accidents, avoidance might not be an option. However, precautions in terms of safety gear worn are worthwhile.

Sports like mixed martial arts,10 boxing,11 tackle football,12 ice hockey,13 soccer,14 and others have varying degrees of protection available. Many are expanding their respective repertoire of required protective gear, especially in response to recent pressure from regulatory agencies, citing recent famous players suffering concussions in the NFL and other sports leagues ans associations.

Helmet design, for example, has undergone various changes in the NFL. In addition, some martial arts or boxing venues require headgear use, whereas others still may not. While hockey players wear helmets, soccer players do not. For players heading the ball, especially when simultaneously attempted by two players, a concussion is imminent.

Should these players be required to wear some headgear? Purists would contend that it takes away from the sport of soccer. Certainly, the newer NFL helmets are very different than the leather headgear worn by the forefathers of modern-day football. Other gear, including the dual-arch jaw stabilizing device (e.g., from Brainpad) may allow stabilization of the mandible so that it does not impact with force into the skull following a hit in football or mixed martial arts.

A person's individual strengthening of muscles and conditioning, as well as knowing how to tackle or receive blows, affect not only whether a concussion occurs, but also its severity.

Subsequent Care. Once a concussion has occurred, the most important goals are: First to have the person sustaining the concussion report that something “isn't right” with respect to normal consciousness. Second, have observers recognize this problem even when the person involved may not recognize it. Third, do not allow the person sustaining a concussion to return to the game or circumstance of injury. Fourth, seek immediate medical care (in the opinion of the author), as it is not possible without imaging studies (like a CT or MRI scan) to definitively remark that an injury more severe than a concussion (like an intracranial bleed) has not occurred.

Institutions such as the NFL may be able to facilitate bringing a portable CT scanner to games as part of its medical care. For high school, college, or other agencies, an emergency room visit may suffice instead. Evaluation by a trained medical professional is important.

Future Guidelines
Any future guidelines for improvement of the prevention, diagnosis, or treatment ofconcussion should incorporate lessons from the past and existing new technology. While the NFL has now amended prior guidelines to keep players who have suffered symptoms of a concussion out of play for the remainder of the game, less emphasis has been given to ways to amend the game and urgent imaging diagnosis.

Careful consideration should be given to the goal of certain sports. While football is undoubtedly an enjoyable sport with a very large following, its nature depends upon tackling and causing impact. The most severe example of a sport whose goal is to cause a traumatic brain injury is boxing. By “knocking out” an opponent, the goal is for one contestant to cause a severe-enough traumatic brain injury. Does it really make sense to preach safety when the goal of the sport is to hurt?

In similar reasoning, football fans sometimes commend the force behind “the hit” or tackle. While certain violations have been incorporated into the game like facemask grabbing, clipping (hitting from behind), and unnecessary roughing or personal fouls, the question remains largely up to our society. Should head-on tackles be continued, or is a milder, less traumatic form of the game permissible?

It may be irrational that if head-on tackles increase markedly the likelihood of concussions, and viewers choose to accept them as part of the game, they shouldn't pretend to be concerned about safety around these tackles. While numerous retired professional football players strongly wish they had never played the game in the manner it was played, they may represent a minority of outspoken individuals.

Some may argue that these players willingly consented to the risks and benefits of professional football. Similarly, boxers and boxing fans should be willing to accept the consequences of the sport. Any consideration of safety revolves around acceptance of the known risks and, as long as the nature of the game remains violent, may be limited.

In the context of accepting the game for what it is, despite its known risks of causing a concussion and not being able to change those, we can focus on equipment. Helmets, mouth guards, shoulder pads, and other protective elements are limited in their scope.

Two bodies of force (often 250 pounds or more) running towards each other at top speeds (like after a kickoff return), collide with significant force. The impact has been likened by many NFL players to a drop off a second storey building, sustaining an injury to the head. Data acquired by one company, Brainpad, for example, suggests that a 300-fold decrease in concussions has resulted in its field studies (Brainpad, internal data). However, further study in a prospective fashion is being undertaken to validate this.

Taking an NFL football game as an example, here are possible ways in which to improve the diagnosis and subsequent treatment of a concussion:

(1) Require, with penalty for not reporting, symptoms of alteration of consciousness after an injury. Players, coaches, trainers, and team doctors should be equally responsible for reporting, and the NFL can consider penalties for non- or under-reporting.

(2) Sideline a player upon report of a concussion; they should not return to a game.

(3) Make a portable CT scanner or other imaging study (like an MRI) a requirement at games. It is impossible to tell whether or not an intracranial bleed exists based on physical exam. A CT scan can be instrumental. Given the early detection ability of a CT scanner, its ease of portability, and quickness with which it acquires a scan now (seconds to minutes), an answer will be more readily apparent. This would influence the decision to return to subsequent games. If a bleed is noted, players must have follow-up scans prior to return, to ensure the bleed is resolving. A Japanese study recently sought to determine, and found, criteria that would merit CT scan consideration following mild traumatic brain injury, such as concussion. Factors including amnesia, age 60 or older, or symptom of headache, were positively correlated with need for CT scan.15

(4) Determine based on prior data, the time period of safe return after one, two, or three or more concussions.

(5) A set of guidelines should be formed by a committee of individuals, comprised of athletic trainers, team doctors, and other doctors who deal with traumatic brain injuries routinely (e.g., neurosurgeons). Absent conflicst of interest, this team should comment on the safest approaches, based upon scientific evidence when it exists. If it doesn't exist, this team should design and carry out studies that will give proper evidence.

Conclusion
Concussions remain a major problem in sports, particularly in contact sports. Aside from changing the violent nature of an individual sport, safety equipment innovations, quicker and proper detection, and subsequent exclusion of a more severe problem, all can help improve outcomes.

During this time, when the attention of the country is focused on concussions, the opportunity of formulating safe guidelines must be taken—incorporating the latest technology with detailed CT and MRI scans, and learning from the past as to which athletes must be kept from returning and worsening the injury. Working together with many professionals and players to institute appropriate changes, various sports can remain enjoyable to fans, but safer for respective participants.

Dr. Patwardhan is Founder and Director of Comprehensive Neurosurgery Network, which specializes in minimally invasive techniques treating brain and spine problems.