Concussion care and awareness have come a long way, particularly in pro football, which prior to the last few decades had a long history of just letting players “shake off” a jarring collision or hit and trot back to the huddle to get ready for the next play.
Today, if a player exhibits symptoms of a concussion, he’ll be ushered to the sideline and examined by an independent neurotrauma consultant. In most cases, his helmet is taken away so he cannot reenter the game. And before an athlete can return to play, he is required to complete modern concussion protocols, which involve a multistep and typically multiday process that includes physical and cognitive testing in addition to assessment of symptoms.
However, an incident in September 2022, when Miami Dolphins quarterback Tua Tagovailoa was allowed to return to a Week 3 game after hitting his head on the turf, stumbling, and appearing woozy, showed that the issue of concussions remains a flashpoint in the NFL and the general public. When Mr. Tagovailoa sustained a clear concussion the following week after being sacked, and was carted off the field and to a local hospital, it created a firestorm of questions – not just around concussion diagnosis and treatment but also whether he should have been on the field at all in Week 4.
As with any serious injury, heightened awareness and an abundance of caution will further enhance player safety. But it’s important to keep a few things in mind regarding concussion:
- There is no single diagnostic test for concussion, and symptoms vary across individuals. That underscores the need for caution but also more research on this complex injury to the brain.
- The NFL has been one of the leaders in concussion protocol development and generally does a good job of identifying players who exhibit concussion symptoms through the use of spotters in the stadium, as well as team doctors and independent neurotrauma consultants. Even referees can report players who they think might have sustained a concussion. In response to Mr. Tagovailoa's recent concussion, the NFL modified its concussion protocols to add ataxia (motor or speech dyscoordination and/or imbalance/instability) to the list of potential concussion signs that will keep a player from re-entering a game.
- Most people recover well from concussions with appropriate treatment. Concussion assessment and treatment protocols will undergo revisions as new information accrues in order to enhance athlete safety at all levels of sport.
As clinical neuropsychologists specializing in concussion care, we are determined to share the most accurate, up-to-date information we have about concussions and the research surrounding them. Public awareness and education are key. We also would like to help clear up some confusion and myths surrounding concussions and the care they require.
(Professor Emeritus and former Chair of Neurological Surgery Hunt Batjer, M.D., contributed to this report.)
1. MYTH: If a player appears woozy and/or stumbles after a hit, it’s definitely a concussion.
REALITY: 'Gross motor instability' can be seen following a concussion, but it is not a definitive sign of a concussion on its own.
Gross motor instability refers to problems with large muscle groups (e.g., legs, trunk, arms) involved in body movements and coordination such as standing, walking, and running. An individual with gross motor instability might wobble, stumble, fall, or appear uncoordinated or off-balance.
A variety of factors beyond concussion can contribute to gross motor instability, such as dehydration, overexertion, and/or pain from musculoskeletal injury. Ataxia can present as similar motor signs resulting from brain injury; thus, careful examination by experienced professionals is critical in making a diagnosis.
Most concussion symptoms are rather nonspecific. Loss of consciousness (LOC), abnormal posturing (also called the “fencing response”), or a seizure are more clearly observable signs of brain injury, but most mild brain injuries (aka concussions) actually occur without such features, so diagnosis is based upon expert clinical examination.
2. MYTH: If you’re not 'knocked out,' it’s not a concussion.
REALITY: About 90% of concussions don't result in loss of consciousness.
Concussion refers to a temporary disruption of normal brain function, but most often this is reflected in specific symptoms and not loss of consciousness per se. Common symptoms of a concussion include:
- Headache or "pressure" in the head
- Nausea/vomiting
- Balance problems or dizziness
- Double or blurry vision
- Sensitivity to light or noise
- Feeling sluggish, hazy, foggy, or groggy
- Concentration or memory problems
- Confusion
3. MYTH: If someone sustains a concussion, don’t let them fall asleep; wake them every few hours.
REALITY: Some rest is good for the brain after a concussion – but not too much.
Unless there are focal neurologic signs (such as differences in pupil size) or evidence of a more severe brain injury (e.g., prolonged loss of consciousness, seizure, etc.), most patients with concussion benefit from sleep. Many years ago, there was a fear that patients who fall asleep after a concussion were at risk of slipping into a coma, but research has shown that’s not the case for most concussions. When in doubt, consult a health care professional.
4. MYTH: If you hit your head today but don’t have symptoms until tomorrow, it’s not a concussion.
Reality: Some patients won’t experience symptoms until the next day.
Most concussions are associated with an acute onset of symptoms, but there is a subset of patients who develop a headache or other post-concussive symptoms the next day. That’s why symptom monitoring and reporting are key following a concussion.
5. MYTH: Concussions inevitably lead to chronic traumatic encephalopathy (CTE).
REALITY: CTE is a rare neuropathologic condition, and its association to concussions is unclear.
CTE is not a clinical diagnosis, so we do not know what, if any, symptoms are related to the underlying pathology found in an autopsy in CTE. Although CTE has been found in the brains of some individuals who have had a history of repetitive head hits, it has also been found in others with no such history.
At this point, we don’t know why CTE develops in some people and not others nor what all its risk factors are. More research is needed to address these questions.
6. MYTH: Concussions sustained early in life will cause memory problems or dementia later.
REALITY: Other factors are more likely causes of dementia.
Most people who sustain a concussion do not develop dementia, and linking the onset of dementia later in life with a brain injury that occurred decades ago is not possible with any certainty in an individual case. No two brains or people are alike, but the vast majority of people who sustain a concussion recover within days or weeks and do not develop dementia when they get older.
7. MYTH: You have to hit your head to have a concussion.
REALITY: A concussion can be sustained whenever there is a sudden, significant jolt to the brain.
A hit to the torso, or any hit causing rapid acceleration/deceleration of the brain in the skull, can result in concussion. So, not every concussion is from a hit to the head. You can get a concussion from any hit if your brain is jostled enough.
8. MYTH: You can return to play as soon as you feel OK after a concussion.
REALITY: Athletes should complete a multistep process to be cleared for play.
When a concussion is suspected or diagnosed, the athlete should be removed from play until he or she is evaluated and cleared by a health care professional experienced in dealing with a concussion.
All 50 states now have laws requiring removal from play of a teen athlete after a suspected concussion, and schools are mandated to follow specific protocols before allowing the injured athlete back into full-speed competition.
9. MYTH: A concussion isn’t an actual brain injury.
REALITY: Brain injuries vary in severity, and a concussion is a mild brain injury.
Severe brain injuries are associated with greater symptoms (for example, extended loss of consciousness, post-traumatic amnesia, etc.), functional impairment, and worse outcomes. Although concussion symptoms aren’t typically severe, they are brain injuries.
10. MYTH: You always 'see stars' if you suffer a concussion.
REALITY: No two concussions are alike.
While some people have reported "seeing stars," and while various visual disturbances can occur after a concussion, there are a number of other symptoms that can occur. You don’t necessarily see stars.
11. MYTH: There are blood tests and brain imaging tools that can diagnose a concussion.
REALITY: At this point, there are no blood tests or brain imaging tools that can diagnose a concussion.
Many researchers are working to identify markers that might someday help identify concussions, but as of now a concussion is a clinical diagnosis based on a health care professional’s evaluation of symptoms.
12. MYTH: There are no treatments for a concussion.
REALITY: There are a variety of treatments for symptoms of a concussion.
Initial light rest for a day or two is generally recommended, but a return to normal activities as soon as possible has been found to be helpful. Too much rest or "total rest" without any physical or mental activities may perpetuate or bring on symptoms. Treatment should be targeted to the symptoms the patient is displaying (for example, headaches, nausea, etc.), and a gradual return to normal activities should be encouraged. Light exercise has been shown to be associated with more rapid recovery after a concussion.
Most concussions resolve without any long-term problems. However, if you or your loved one has concussion symptoms that don’t seem to go away, or if you’re concerned, please reach out to us and request an appointment with one of our specialists.
Also, you can find more information about concussions in sports at any level on the websites for the CDC’s Heads Up program and the Sports Neuropsychology Society.
