There's Still No Surefire Way to Diagnose a Concussion

Doctors can't even agree on what it is.

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Jun 5 2017, 12:00pm

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Last month, NHL star Sidney Crosby did a sailor dive into the boards during a playoff game between his Pittsburgh Penguins and the Washington Capitals. Crosby was slow to get up from the fall, but continued to play.

After the game, he told reporters that a team doctor had checked him out, while his coach said otherwise. Meanwhile, an NHL official said the league's designated concussion spotters did not flag Crosby for removal from the game because his head hit the boards, not the ice, and the boards are not considered a "mechanism of injury" that should trigger mandatory benching.

It's difficult for concussion experts to hear these sorts of stories without letting disgust creep into their voices. "You can get a concussion from falling on your butt and having reverberations go up to your brain," says Kimberly Harmon, a physician and concussion researcher at the University of Washington.

While the NHL may be correct that a head-to-ice hit is more likely to cause a concussion, its protocols—like every other sport's—are clearly in need of an overhaul.

To be fair to the NHL, quickly and accurately diagnosing a concussion is still a challenge. "The tests and criteria we have now are not great," Harmon says. While she and others are working hard to come up with new and better diagnostic tools—a spit test is showing major promise, at least among concussed youth—a lot about concussion-spotting is still subjective, and so prone to human error.

"The best way for us as physicians to know is if the player tells us they have symptoms," Harmon explains. Those symptoms include a headache, dizziness, sensitivity to light or sound, feeling disoriented or "in a fog," or being knocked unconscious for any period of time, she says.

Earlier this year, experts in the field published a consensus statement outlining proper protocols for diagnosing a concussion. "We recommend a four-legged platform that includes a cognitive assessment, a balance assessment, an eye-tracking assessment, and a symptom checklist," says Robert Cantu, a clinical professor of neurosurgery at Boston University and one of the authors of that consensus statement.

Why is prompt diagnosis so important? A second blow to the head can both exacerbate concussion symptoms and also cause them to persist much longer than they would have otherwise, Cantu says. "In very rare cases, there could also be second-impact syndrome, which is a loss of regulation of blood flow that causes rapid intracranial pressure that can lead to death," he says.

But the criteria Cantu and his colleagues developed "is not like an X-ray that can show you a broken bone," he says. "There is no marker that tells a team doctor that an athlete has a concussion, and the big problem we run into is that players refuse to let us know about their symptoms."

He says a lot of athletes—at all levels—don't want to risk losing their position on the field or having their teammates think they're weak or, worst of all, being in the doghouse with a coach. You would hope that, in 2017, coaches would be well-versed in the dangers of concussions. But misconceptions about the causes and nature of concussions are still rife among coaches, players, and their parents.

"One of the most common myths is that you need to be knocked out," Cantu says. "But more than 90 percent [of concussed individuals] don't lose consciousness." Another big one is that helmets protect against concussions. "Helmets are more about preventing skull fractures and internal bleeds," he says.

"There's actually no standard definition of a concussion," Harmon says. "Most of us say it's an alteration of brain function secondary to an indirect or direct blow to the head." She explains that your brain is "just sloshing around" in your skull. Many varieties of impact can cause it to slam into its protective shell, or to move or twist in a way that causes trauma.


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"People have this impression that football is especially dangerous, but a player's risk for concussion is a product of their sport's concussion rate and how much they play it," she says. She points out that, while a high school football player may be at greater risk for a concussion each time he steps on the field, his season is relatively short compared to, say, a woman soccer player who may participate in her sport year-round. "So the high school women's soccer player may have greater odds of a concussion because of her high number of on-field exposures," she says.

Cantu reiterates many of Harmon's points, and says most people are also unaware of the less-acute symptoms of concussion. Problems sleeping and mood issues like anxiety, irritability and depression are common. "It depends on the area of the brain that is concussed," he says. "Those symptoms clear up for 80 percent of people within ten to 14 days, but for a small percentage they can persist for months, or even years."

He says it's also a myth that each successive concussion is worse than the last, and that an athlete can only suffer a set number of concussions—three or four or five—before they need to give up their sport. "It depends on the severity of the concussion, and not all are created equal," he explains. "Some clear up within minutes." An athlete could have "quite a high number" of minor concussions and continue to play without much concern, he says, while a few whoppers could end a career.

Cantu says it's also important not to conflate concussions with chronic traumatic encephalopathy, or CTE, which is the brain disease linked with repeated blows to the head that plagues many former athletes—most notably ex-football players. "Total exposure best correlates to CTE pathology, and that includes every hit to the head, not just concussions," he says. "A lineman in the NFL may take tens of thousands of hits during his career, while a quarterback may only take two or three per game—if that—so their exposures and risks for CTE are incredibly different."

Unfortunately, current treatment methods for concussion haven't developed much beyond the wait-and-rest approaches doctors have advocated for decades. There's some newer evidence showing that light activity—rather than bed rest—may help a concussed brain recover more quickly. But there are few hard-and-fast rules.

Experts like Harmon and Cantu are still in the data-gathering stage of concussion medicine, which is why so much focus is being placed on developing better tools for identifying this category of head trauma. The better we become at spotting a concussion, the more information we'll have to develop proper treatment and recovery protocols. But for now, unknowns abound.

"I'd say that the best way to keep our athletes safe, especially young athletes, is to invest in qualified athletic trainers," Harmon says. These professionals are needed on the sidelines during games, but also during practices. "The best team physicians are with their players every day and know them really well," she says, "and so they can see when something's off even when [the player] passes all the tests and says they're fine."

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