Wednesday, December 12, 2018

Sonoma Medicine

The magazine of the Sonoma County Medical Association

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At the Confluence of Diagnostic Ambiguity and Public Fear

Rob Nied, MD

Chris doesn’t remember the play. He has heard that after he caught the basketball at midcourt, he dribbled toward the basket, got knocked off his feet and came down head first. His parents told me the sound of his head hitting the floor was loud enough that it silenced the entire gym. He lay unconscious for perhaps 20 seconds. Then came the ambulance ride to the hospital strapped on a backboard, the discussion about radiation risk from a head CT scan (his parents opted not to), and ultimately a diagnosis of concussion.

Chris (not his real name) is 13. He and his parents came to see me not only for treatment guidance, but also to ask questions. When can he safely play again? Should he play again? What about school? Are there long-term implications for his injury?

Although new information about diagnosis and management of concussions is constantly being published, our global understanding of concussion is still in its infancy. Studies with advanced imaging continue to show more varied and longer-lasting changes following sport-related head trauma. Researchers in Israel, for example, recently used dynamic-contrast enhanced MRI to demonstrate damage to the blood-brain barrier in six of 16 asymptomatic football players mid-season.1 Their findings are concerning, but the true implications are unclear. Is the 40% incidence rate they found due to different genetic susceptibility or a spectrum of injury exposure? What are the consequences of continued play or repeat injury before complete resolution?

For now, physicians are left with an obligation to treat concussion conservatively and hold athletes out until we can be reasonably sure there is an acceptable risk of further injury. But what is reasonably sure or an acceptable risk?

Add to this clinical uncertainty a widespread exposure rate (high school football players suffer 11.2 concussions for every 10,000 games and practices2); the high-profile violent deaths of athletes blamed on concussions; the link between concussions and chronic traumatic encephalopathy; and the lawsuits that have inevitably followed. Is it any wonder that the popular media and the Internet are abuzz with concussion discussion?

At the confluence of diagnostic ambiguity and public fear there will always be those who seek, whether well-intentioned or self-servingly (and often both), to fill that space with new, untested or questionable treatments. We have certainly seen this phenomenon with concussions and the myriad novel treatments and protective equipment for sale on the Internet. Unfortunately, to date there remain no helmets or other equipment proven to significantly reduce the risk of concussion, and no specific treatment that enhances or speeds up healing.

What happens when government tries to fill that void? All 50 state legislatures have now passed laws regulating concussion management. This January, after the enactment of AB 2127, California will become the 20th state to limit full-contact football practices in an effort to minimize the number of sub-concussive head blows. Far more significantly, AB 2127 also mandates that high school student athletes diagnosed with a concussion sit out a minimum of seven days from the date of injury and follow a defined graduated return-to-play protocol. I know of no other medical condition in which the expected treatment is outlined in a legal document. In justifying this regulation, the law states that “many high schools lack access to the standard of care” because they “cannot afford” it.

And that is the crux of where we are in concussion management at the beginning of 2015: limited resources in our schools, legitimate public health concerns, and reactive elected officials. As physicians, we have an obligation to our patients and a vested interest in the health of our community. We should be the experts, driving public policy and perception, in areas of medicine.

Locally, we can make a difference. North Coast Concussion Management (NCCM) is a nonprofit coalition of local physicians, city school administrators, athletic trainers and other community leaders. NCCM’s goal is to improve the concussion care of all school-aged athletes in Sonoma County. To increase the number and the expertise of Sonoma County physicians treating concussion, NCCM is sponsoring an educational forum this spring. I encourage all interested physicians to attend.

Chris is lucky. Although his collision with the floor was dramatic, his concussion was actually relatively minor: he had no symptoms by the end of the weekend. He had a coach, parents and teachers who were aware of concussions and acted in his best interest. Every young athlete in our com munity should have a similar experience. ::

Dr. Nied, a family and sports medicine physician at Kaiser Santa Rosa, is president of SCMA.


1. Weissberg I, et al, “Imaging blood-brain barrier dysfunction in football players,” JAMA Neuro, 71:1453-55 (2014).
2. Institute of Medicine, National Research Council, Sports-Related Concussions in Youth, National Academies Press (2013).

SONOMA MEDICINE  |  Winter 2015  |  Sonoma County Medical Association

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