Final paper - Bibliography included

Taegen Hill

Engl. 102 - 5:00 pm

Dr. Sonia Apgar Begert

9 March 2015

Final Research Paper

The Decision to Return or Retire After Receiving Multiple Concussions

Sports related concussions are a very common and yet a considerably vague condition. Often, athletes who receive a concussion will return to play as soon as possible, or lie about how they feel so they don’t have to get treated and be required to abstain from playing their sport. Many times when the athlete keeps playing, they will continue to get worse or will obtain a secondary concussion.  This is called “second-impact syndrome,” when additional injury occurs from a relatively small force, due to already having a concussion and being more susceptible to getting injured further. Secondary concussions can lead to worsening symptoms, a more severe brain injury, brain damage, or even death. Eventually, after having multiple concussions, an athlete may acquire a condition known as Chronic Traumatic Encephalopathy (CTE), or other brain ailments. All of these athletes have at least one thing in common: they have all chosen to return to play, and keep playing their sport, on their own regardless of the severity of their condition. This fact brings on my question, “Why do athletes choose to keep playing their sport, even after receiving one or more concussions?” Is it a psychological issue, or is it maybe a chemical imbalance? Could it simply be just an undying love, respect, and drive to play the game? The fact remains that athletes do not know the seriousness of receiving more than one concussion or the effects it could have on the rest of their lives. Doctors, athletic trainers, and the medical community must educate athletes on conditions they are likely to get if they keep playing and putting themselves at risk for further injury. At the same time, doctors should be empathetic towards the athlete because of the feeling of undying love for their sport.

Concussions are one of the most common injuries in sports. Pat F. Bass III says in article “Managing a Patient After a Concussion,” that “according to the Center for Disease Control and Prevention,” they consider a concussion a mild traumatic brain injury (MTBI) and their definition is “a complex pathophysiologic process affecting the brain, induced by traumatic biomechanical forces secondary to direct or indirect forces to the head. MTBI is caused by a blow or jolt to the head that disrupts the function of the brain. This disturbance of brain function is typically associated with normal structural neuroimaging findings (i.e., CT scan, MRI).’” “Mild traumatic brain injury in sports has become a significant public health concern which has not only received the general public's attention through multiple news media stories involving athletic concussions, but has also resulted in local, state, and national legislative efforts to improve recognition and management” (Doolan). The symptoms an athlete will have from the concussion vary from person to person and injury to injury. Some injuries are more severe than others, depending on the sport they play, the position, and the mechanism of injury.  As well, some athletes have more susceptibility for headaches or other symptoms than others do. These symptoms are divided into two categories: pathophysiological, and physical. Pathophysiological symptoms refer to “[neurological] dysfunction resulting from metabolic and physiologic changes” (Bass), such as distorted blood flow to the brain, altered glucose metabolism, and lactic acid build up. Physical symptoms are the better-known signs for concussions and they include, “difficulty concentrating and completing tasks… dizziness, fatigue, headache, noise sensitivity… sleep disturbances… light sensitivity and doubled or blurred vision” (Bass). Depending on the athlete, or the severity of the injury, these symptoms can last from hours to days to months and even years. To determine the severity of the concussion, doctors use imaging or neuropsychological testing (Pellman). “In most cases, patients recover in 7 to 10 days with 85% to 95% recovering in 3 months” (Bass). Treating a patient and managing their concussion symptoms is where doctors and athletic trainers can come to a dilemma. Doctors want to take a more structured, intense route, where as athletic trainers want to use a more conservative route to get their athlete back as soon as possible (Pellman). The first step, if someone is suspected to have received a concussion, is removal from play. “Required by law in some states, removal from play is the most important factor because of potential complications, prolonged recovery, and second impact syndrome, which can lead to long-term brain damage or even death” (Bass). Sometimes, if the athlete is unconscious or is experiencing severe symptoms, they should be transported to the nearest hospital’s emergency department as soon as possible. If they receive a blow to the head and remain conscious, but are experiencing concussive symptoms, they are just taken off the field and evaluated further. The athlete will go to their personal doctor when convenient after that. Following up with a specialist or their personal doctor, is advised for both the athletes who are improving and those who are not. Most doctors and athletic trainers will have the same basic 6-step return-to-play protocol. According to May KH’s table the first step is complete “physical and cognitive rest…for at least 24 hours.” The second is a “[increased] heart rate for 5-10 minutes through mild activity such as walking, light jogging, or an exercise bike.” The third step is to exercise moderately which May KH defines as, “limited body and head movement through more moderate intensity activities such as brief running or moderate weight lifting.” Phase four includes increasing the magnitude of exercise or activity, such as “more intense running, stationary biking, or…sport-specific drills,” but without contact.  Next, the athlete may participate in “full contact practice,” and finally after all of these phases are completed without having symptoms, they may go back to competition.

             Receiving another concussion, or sometimes a concussion on top of an existing concussion is called “second-impact syndrome.” This results in more severe symptoms. “There were similar signs and symptoms with single and repeat concussions, except for a higher prevalence of [physical] complaints in players on their repeat concussions compared with their first concussion,” Elliot J. Pellman relayed in his study of NFL players who have received repeat concussions. With these more intense symptoms can come other conditions, the most prevalent of which is psychological disorders.

Depression is regularly associated with concussions and affects almost all of the athletes who have gotten more than one concussion (Pellman). Doctors use imaging and fractional anisotropy (FA) map to measure the severity of the depression. “What the imaging has shown is that depressive symptoms in retired NFL athletes correlate negatively with FA…” (Strain, et al). Depression can cause suicidal thoughts and attempts, and it has been known to be deadly (Fainaru-Wada & Fainaru). One of the other conditions that occur from recurrent concussions is “gridiron dementia,” where permanent brain damage occurs caused by blows to the head during games or practice” (Omalu). The most serious condition that comes about from receiving one or more concussions is Chronic Traumatic Encephalopathy (CTE). CTE “is described as a slowly progressive neurodegenerative disease with pathological tau accumulation at the depths of the sulci in superficial layers of the cortex” that show similar properties to other brain conditions such as dementia (Hazrati, et al). As Lili-Naz Hazrati and her colleagues note, CTE is thought to become evident years after the actual “concussive or subconcussive events” that involves “neuropsychiatric, cognitive and motor deficits.”  CTE is condition that the medical community doesn’t know enough about yet. There is large debate on whether CTE is actually caused by multiple brain injuries and the medical community, legal community, NFL, and media all weigh in on it (Gardner). Because CTE is manifested later in life, multiple concussions were not thought to be as dangerous as doctors have come to find out.  Since having been discovered, they have realized that CTE “bears resemblance to other neurodegenerative diseases…which includes Alzheimer's disease (AD) and frontotemporal lobar degeneration (FTLD)” (Hazrati, et al). Late-life cognitive impairment and Alzheimer’s disease was also found to be associated with previous head injuries from sports in Kevin M. Guskiewicz’s (et al) study of former football players. This study found that the athletes who have received multiple concussions are more likely to have “dementia-related syndromes” (Guskiewicz, et al) than the average male American. Many former professional football players have had CTE. Some have died early from just the brain damage that cause symptoms such as constant pain, erratic behavior, headaches, and paranoia, for example Mike Webster, former center for the Pittsburgh Steelers (Fainaru-Wada & Fainaru). “Webster played 17 seasons, winning four Super Bowls, becoming the strongest man in the NFL, and going six years without missing a single offensive play. However, his struggles with mental illness would define his legacy as much as his Hall of Fame career” (Fainaru-Wada & Fainaru 208). Others are remembered for CTE related suicide like Junior Seau, former linebacker for the San Diego Chargers (Fainaru-Wada & Fainaru 324). “Junior Seau, one of the greatest linebackers in NFL history, was a San Diego icon. When he killed himself in 2012, several prominent research institutions engaged in an ugly battle for his brain [because CTE was widely discredited and little was known about it].”

           

            When talking about concussions, most people think about the physical symptoms. Effects such as headaches, nausea, dizziness, sensitivity to light and noise, fatigue, etc., are what most treatments address. However, over time an even more difficult issue emerges. It is less obvious and unexpected, but can be just as severe. This condition is depression. Enduring the physical symptoms causes emotional wear and tear, and for athletes, it’s even more difficult to deal with since they experience disappointment and loss from not being able to play their sport(s). Most of the athletes who have received one or more concussions have depressive symptoms and white matter dysfunction (that causes dementia-like conditions) (Strain, et al). Briana Scurry, an athlete suffering from a career ending concussion was “plunged into a more than three-year fight for her mental and physical health” (Span). That concussion was not her first.  She had 2 others previous. Emma Span relayed quotes from Scurry talking about the concussion and her depression. “’After a while I started to get depressed," says Scurry. "My brain chemistry had changed. My mind was broken.” It took Scurry three years to find a doctor to help diagnose her and treat her properly, and when she did, he found that the depression she’d been experiencing had been from the concussions she received and the damage to her occipital nerve. Of course, Briana Scurry is not the only athlete to experience depressive symptoms from past concussions. Junior Seau, who was mentioned earlier, killed himself because of these symptoms, and who was described as, “a man whose love of life had seemed as real and unflagging as the sun” (Fainaru-Wada & Fainaru 324). Dave Duerson, a defensive back for several teams in the NFL also committed suicide after playing for several years and receiving a lot of concussions (Fainaru-Wada & Fainaru 293-304). John Grimsley, a linebacker for the Houston Oilers and Miami Dolphins shot himself after suffering through years of depression and irritable and erratic behavior (Fainaru-Wada & Fainaru 258-59). Terry Long, guard for the Pittsburgh Steelers, fell into “a dramatic downward spiral marked by bouts with depression and mood swings…” (Fainaru-Wada & Fainaru 193).  His football career ended when he drank antifreeze to commit suicide. The list goes on, and still athletes continue to suffer through these symptoms. The Webster Dictionary defines depression as “a serious medical condition in which a person feels very sad, hopeless, and unimportant and often is unable to live in a normal way.” Depression causes loneliness, weakness, fatigue, and several other subsequent symptoms that change athletes’ lives and affect everyone around them.

            The medical community takes the issue of multiple concussions very seriously. Often times, athletes don’t know the seriousness of receiving more than one concussion, leading them to return back to their sport prematurely and uninformed. Most athletes do not want to retire early, but some have to face this reality. What influences their decision? Is it theirs, or their doctor’s? “Such decisions remain a complex and controversial area, not only due to an absence of evidence-based recommendations but also because of the possibility that providing inappropriate advice, at least at the professional level, may lead to engagement in a medico-legal challenge” (Gardner). When deciding to retire, there are many factors an athlete must consider. They have to go through personal quarries and they have to decide if they want to “self-report” or continue playing (Kurowski, et al). They must consider their “history of sports-related concussion and the potential impact that they may have on [their] future quality of life” (Gardner). Athletes’ doctors and athletic trainers put them through several neuropsychological tests, psychological functioning tests, functional tests (physically), and questionnaires to determine their level of ability related to cognitive function and physical ability (Gardner). The scores can reveal normality or anomalies. Depending on how they did, athletes can determine if they’re suited to keep playing. If they are experiencing strong cognitive impairment, they may want to retire. Levels of depression and anxiety play a part in deciding. Doctors can take it upon themselves to keep the athlete from playing because of their alarming physical and psychological impairments. Others can play a part in the decision as well. Athletes will “[consult their] employer (i.e., [their] club), club medical staff, [their] player agent and [their] family, who [can] all [make] considered contributions in light of the neuropsychological and medical evidence presented to them” (Gardner). The “clinical guidance,” that Andrew Gardner points out, for athletes who are deciding whether to retire or not, are concussion history, such as number, cause, symptoms, protocol, and objective data of their concussion(s), and their current clinical profile. Other considerations include “general common sense issues,” for instance the athletes “developmental history…; neurological conditions or other medical conditions…; alcohol or other drug use; psychiatric and psychological history; possible genetic contributors (i.e., a family history or dementia [etc.])…” (Gardner). Gardner also states that the athlete can also consider many non-medical related aspects. For example, they may think about whether the sport had a future for them in pursuing it as a career, if the athlete completely understands their potential risk for further injury, their personal resilience when returning to play from other injuries, “personality and/or behavioral style/traits,” and “financial management and future occupational planning.” The decision of retirement from contact sport should always be made independently and without coercion, but with appropriate education and recommendations for the athlete to make an informed decision” (Gardner). Athletes and their doctors also talk about the timeline of retirement (Sedney, Orphanos, & Bailey). They discuss if, according to their medical history and possibility for further injury, retiring now is the best option or if it’s feasible to retire in a few years. Doctors weigh in on the decision, but their input varies from athlete to athlete. Athletes who have received more than one concussion and are experiencing severe symptoms would be highly advised to consider retiring as soon as possible. Other athletes who have also received more than one concussion, but haven’t experienced the same severity of symptoms will be advised differently. To avoid CTE or other late-life conditions, it is better to avoid the possibility of getting another head injury. Some athletes decide to keep playing if they’re younger than 26 because of the fact that their brains will continue growing and healing until they reach that age (Cantu, et al).

            Deciding to retire will most likely benefit the rest of an athlete’s life because they may avoid further injuries or avoid depression many athletes get from multiple concussions or avoid the life-threatening brain conditions, like CTE. To abstain from playing their sport competitively for the rest of their life is something so hard for an athlete to grasp. For as long as they can remember that sport has been apart of them. Without it they feel like a whole different person or as if a piece of them is missing. Understanding that their sport could endanger their lives is heartbreaking. It is necessary to find something for the athlete to fill this void because otherwise they could experience depression caused from a lack of activity. Even though living without their sport is something they would consider devastating, living with CTE, depression, dementia, early-onset Alzheimer’s, chronic headaches or other serious disorders is much more devastating. Countless athletes have suffered through these illnesses and several have died because of them. Dave Duerson, John Grimsley, Terry Long, Tom McHale, Junior Seau, Justin Strzelczyk, Andre Waters, and Mike Webster are names of some of the athletes who suffered through the “silent-killer” known as CTE and fought the related depression, but sadly died because of it’s affects. Several athletes who are still alive are living through these conditions, such as Troy Aikmen, former quarterback for the Dallas Cowboys, Al Toon, former wide receiver for the NY Jets, and Steve Young, former quarterback for the San Francisco 49ers. These athletes either decided to retire early or intercepted the symptoms before they took their lives, and are still having success. They should be examples for the athletes who are discouraged because of the need to retire early.  They are role models for these athletes who feel depressed without their sport(s), and feel like they can’t go on. Deciding to retire may not feel like the best decision, but it could keep athletes alive and benefit the quality of their lives and the lives of their family, doctors, teammates, coaches, and athletic trainers.

            Ultimately, the decision lies in the hands of the athlete. With all the information and studies about the conditions that can come as a result of multiple head injuries and the athletes who have experienced them, they should be able to make an informed decision on if they should retire or not. Most of the time when athletes decide to keep playing, even with the risk of further, more severe injury, it’s because they don’t full understand that either continuing could put them at risk for additional injury and that because of their past concussive history they are more susceptible to obtain another concussion, or that they do not comprehend the severity of CTE and that it is a life-threatening ailment that effects every aspect of their lives. The medical community not only needs more definitive evidence of CTE and its seriousness, but they also need to make it more accessible to the public so they can make informed decisions. The athletic trainers for schools and professional sports teams need to pair up with the doctors so that they can educate the students and athletes about CTE, depression, dementia, Alzheimer’s and all the other brain illnesses that can come about from getting multiple concussions. When advising athletes on retiring or not, doctors and athletic trainers need to be compassionate for the athlete because the sport that they play is one of the most important things in their lives.

           

Works Cited

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4. Gardner, Andrew. "The Complex Clinical Issues Involved in an Athlete's Decision to Retire from Collision Sport Due to Multiple Concussions: A Case Study of a Professional Athlete." 27 Sept. 2013. Frontier Neurology. Web. 12 Feb. 2015.

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