Growing up, every member of my family was an elite or professional athlete in football, gymnastics or track and field. My commitment to sport allowed me to attend Stanford University on an athletic scholarship. It was here that I saw the serious impact of concussion on the physical and mental health of my fellow student athletes. I have spent my career exploring how we can use technology to improve brain health and support the recovery process after brain injury or illness.
Four years ago, this work led me to start a company called Neurovine. Neurovine's mission is to advance the status quo in brain health, making recovery accessible for patients while connecting them with doctors virtually.
Sports-related concussion and the impact of this injury on long term player health have been an area of interest for the media, sports teams and legislators for years. Whether you follow the NFL, FIFA or are generally interested in brain health, you may have heard of some recent incidents that took the neuroscience community by storm, quite notably the incident involving Miami Dolphins quarterback, Tua Tagovailoa.
THE TUA RULE AND CONCUSSION PROTOCOL
On September 29th 2022, in a game against the Bengals, Tua Tagovailoa sustained a concussion and lost consciousness. This happened four days after a game against the Bills, where Tua cleared the concussion check and was allowed to return to the game. In the Bills game, upon sustaining the head injury, Tua was exhibiting signs of ataxia. According to the National Ataxia Foundation, ataxia can be caused by “damage to the cerebellum, the part of the brain responsible for coordinating movement”. This in turn leads to poor motor control and muscle coordination, and can be seen by clumsy movements.
As a result of this incident, the Tua rule was enacted. This update to the league's concussion protocol states that if a player is exhibiting unusual behavior, abnormal balance, or signs of ataxia, they will not be allowed to continue to play and are placed in concussion protocol. It’s encouraging that the league is taking measures to support their players, and to reduce the risk of further injury.
The fact is, concussion is still an invisible injury that is hard for patients and doctors to measure. This is more evident in youth and minor league sport where concussion experts are not involved in game time decisions.
With the enactment of the Tua Rule, more athletes are being pulled from games and placed in concussion protocol. This is significant progress, however, the lack of objective markers of concussion is a key reason that many concussions go undiagnosed and that players are allowed to return to the game too early.
UNDIAGNOSED Sports-Related Concussion
In a study published by the Clinical Journal of Sports Medicine, 486 athletes who were currently seeking treatment for concussion were asked if they had “previously sustained a blow to the head that was not diagnosed as a concussion, but followed by one or more of the signs and symptoms listed on the post-concussion symptom scale”. They found that nearly 30% reported a previously undiagnosed concussion. They also found that those with a previously undiagnosed concussion were more likely to have lost consciousness with their current injury.
A 2005 study by LaBotz et al., found that only 17% of collegiate athletes reported sustaining a concussion even though 48% reported a head injury that led to experiencing signs of concussion. Another survey by Kaut et al. found that 32% of collegiate athletes reported experiencing dizziness after suffering a direct blow to the head while only 20% were officially diagnosed with a concussion.
Over the years, many athletes have spoken out about their experiences of playing through concussions, in hopes to raise awareness and understanding of the injury. Super Bowl champion Ted Johnson describes his experience while playing for the Patriots in 2002, years before game day protocol was first implemented.
"Officially, I've probably only been listed as having three or four concussions in my career. But the real number is closer to 30, maybe even more. I've been dinged so many times I've lost count." - Ted Johnson
Undiagnosed concussions pose a significant risk to athletes. Evidently, sending an athlete back into the game without ample treatment and recovery time poses a significant risk. Athletes who sustain a concussion and don't fully recover are at greater risk of acquiring a second concussion before the first one has healed. Those currently seeking treatment for mTBI that reported sustaining a previous concussion, also scored higher on the Post Concussion Syndrome Scale. Hopefully with more awareness, research, and evidence-based support for athletes' brain health, we can help reduce that risk.
Martin Mrazik, concussion researcher from the University of Alberta, studied the effect that concussion can have on an athlete's mental health, when compared with other bodily injuries. This 2020 study, published in the Archives of Clinical Neuropsychology found that concussed athletes displayed an increase in anxiety and depressive symptoms overtime. Anxiety was reported to be higher 24-48 hours post-injury, when compared with the baseline. Depressive symptoms also increased between 24-48 hours post injury and 1 month post return to play. While the outcomes of this study on mental health of athletes' post-concussion are not as severe, it is noteworthy that athletes who experienced a concussion or had a history of concussion were more likely to experience symptoms of depression and anxiety.
A concussion can either exacerbate pre-existing mental health conditions or incite new ones. Common signs that a concussion patient is struggling with mental health include mood changes, anxiety, depression, PTSD and more. There are many potential reasons why mental health can be impacted after a brain injury. This could be due to physiological changes of the brain, or struggling with the pressures of returning to work, school and life.
For athletes, especially for those whose career revolves around being active, there's the added stress and urgency to return to play. Some players might also believe that they just have to brush it off and be tough. This tough mentality can lead to many complicated repercussions down the road. Thankfully, with more research being done in this area and technology being developed and refined, we can find ways to better support our athletes' mental and physical health post-concussion.
GRADUATED RETURN TO PLAY
Most current guidelines for concussion recovery prescribe conservative rest. Ability to perform physical and cognitive activities can decrease after a concussion, and immediate rest might help mitigate symptoms. Complete rest, on the other hand, might not be the most effective way to manage recovery. There are some studies to support that gradually increasing activity can facilitate concussion recovery and reduce the risk of post concussion syndrome.
Dr Anne M. Grool et al. investigated whether or not early physical activity (within 7 days following acute concussion) resulted in lower rates of persistent symptoms, when compared with conservative rest.
They found that 28.7% of the 69.5% that participated in early physical activity experienced post-concussive symptoms. This is a significant difference from the 40.1% experiencing symptoms of the 30.5% that were at complete rest.
Another study from the Journal of the American Medical Association found that personalized subsymptom threshold aerobic exercise might be a more effective path to recovery than just stretching. This consensus statement on concussion in sport by Dr. Paul McCrory et al. shares a graduated return-to-sport template, with guidelines for rest included.
Current guidelines are relatively vague and difficult to measure. There is risk of overexertion and worsening symptoms when it comes to performing physical and cognitive tasks post-concussion. This is where pacing comes in. Neurovine has built a cognitive pacing solution that is designed to provide objective AI-driven insights that help you pace your activities after an acquired brain injury.
We’ve partnered with Atlético Ottawa and are actively working on building more partnerships to support athletes with their performance and mental health upon sustaining a concussion. To learn more about partnering with us, get in touch, and together we can carry out our vision for the next-generation of brain health.
Let Us Know What You Thought about this Post.
Put your Comment Below.