Head Injuries: A Q&A With a Clinician

Dr. Neal McGrath has been a practicing neuropsychologist for over 25 years. In 2003, when his oldest son sustained a concussion playing high school football, McGrath became much more interested in providing information and support about head injuries to athletes and the families in high school and youth sports programs. For the past seven years he has been committed to the mission of supporting assessment, treatment and education for young athletes who have sustained concussions.

At Sports Concussion New England (www.sportsconcussion.net), McGrath utilizes today’s latest research, tools, and testing to help athletes back to a complete recovery playing the sports they love. By providing referral care as well as partnering with a host of local high schools, McGrath’s clinical expertise has become well recognized in both the treatment and education modalities.

Dr. Neal McGrath says progress is being made in the battle to prevent head injuries, but a change in culture must take place.

Dr. Neal McGrath says progress is being made in the battle to prevent head injuries, but a change in culture must take place.

The following Q&A with McGrath sheds some additional light on trends in contact sports; where to look for resources; and precautions today’s athletes can take in collision sports like hockey and football.

USCHO: What trends are you seeing in concussions among young athletes today?

McGrath: Today, we see some sports being played year round at a high level of intensity. Many youth program participants frequently play for more than one team and generally have little or no down time in the sport they are most committed to. Add today’s specialized training and nutrition, and you have bigger, stronger and faster athletes playing as many as five, six or seven times per week in full contact practices and games — and the exposure to such intense activity makes a concussion event more likely. The largest number of participants is seen at the youth sports and high school levels. And the number of events reported has increased, probably also due in part to better education and awareness.

USCHO: In your opinion, how does the number of reported events (concussions) compare with the number of actual events occurring in contact sports?

McGrath: If you look at studies with young athletes regarding events they have experienced in the past that included concussion symptoms like headaches and nausea, etc., the number who admit past events is very high — in the 50 to 60 percent range per season. In our program we see rates of reported concussions at about 5 to 10 percent per season for football and about 5 to 7 percent for hockey, and we know those are only the most obvious injuries. It is very hard to get completely accurate information because many young athletes do not understand the risks, or do not want to stop playing, or be seen as letting the team down, or lose their position on the team. So it is likely that there are still many concussions that remain unreported.

USCHO: What are the most common misconceptions among players, coaches and parents regarding head trauma?

McGrath: There are many areas where education is changing former misconceptions. First of all, an athlete does not have to be unconscious to have a concussion. In most concussions, athletes remain awake even if they are dazed and lose track of what has happened. Second, it’s not safe to return to play a contact sport like hockey just because symptoms have become less intense. It is an essential starting point that symptoms are fully cleared before return to play can be considered. Third, full recovery usually takes longer than people think.

USCHO: What is the average recovery time among athletes that come through your program?

McGrath: The time frame for full recovery is usually measured in weeks, not days. Over the years it has been a minimum standard for athletes to be completely symptom-free for a full week or more before return to play is considered; this is a good starting point but is sometimes not enough recovery time. Recovery is always an individual matter but a more realistic time frame for a full recovery in a contact sport like hockey is at probably two weeks on average. It may take longer if there is a history of multiple concussions or if such injuries have come too close together in time.

USCHO: What are the long-term psychological and physical effects that may be seen in athletes suffering single or multiple concussions?

McGrath: It’s very possible for a young athlete to have more than one concussion and still recover fully and continue in sports. This is more often the case if the injuries are less severe, spaced out, and properly managed. But if there is a particularly severe concussion or too many events in too short a period of time, some of the typical symptoms of a concussion can be longer lasting. These include physical problems such as headaches, dizziness, light or noise sensitivity, or fatigue; cognitive problems such as poor concentration and short-term memory resulting in poor reading comprehension and difficulty keeping up in school; sleep dysfunction such as trouble falling or staying asleep or sleeping soundly; and emotional changes such as irritability, mood swings, anxiety, or depression. The more concussions an athlete sustains, the more likely he or she will develop longer lasting symptoms.

USCHO: What is Second Impact Syndrome?

McGrath: There are three primary risks associated with returning to play and sustaining more head trauma too soon after a concussion. First and most commonly, symptoms will very likely last much longer — often for months. Second, some symptoms may become permanent, which can entirely alter the direction of a young person’s life. Research coming out of Boston University’s Center for the Study of Traumatic Encephalopathy suggests that these cases involve a newly discovered type of brain pathology. Third is Second Impact Syndrome. In a small fraction of such cases, additional trauma while still symptomatic results in uncontrollable brain swelling — which can lead to severe, permanent disability or death. While the number of these cases is small, probably measured in dozens in the U.S. each year, virtually every case involves an athlete at the high school level, so that is the age range of greatest risk for Second Impact Syndrome.

USCHO: How do athletes, parents, and sports organizations get educated on this subject?

McGrath: There are many resources available today, and that was not the case just a few years ago. Overall, awareness of the symptoms and risks of concussions has substantially increased and many schools and organizations are now utilizing tools like ImPACT to help manage their student athletes. The Internet has many sites with good educational information such as www.sportsconcussion.org, and www.cdc.gov/concussion/HeadsUp/youth.html. Our website, www.sportsconcussion.net, has been designed to be informative for athletic professionals, parents, players, physicians and educators. And, in our work with local schools, we have found that on-campus presentations by concussion experts to players, coaches, parents, and school staff make a real difference.

USCHO: You mentioned tools like the ImPACT test. What is the ImPACT test and how is it used?

McGrath: The ImPACT test is one of four computerized tests available to measure cognitive functions before and after a concussion. It takes only about 20-25 minutes and includes tests of short-term memory, processing speed, reaction time and multi-tasking. ImPACT is probably the most well-known and widely used test of its kind and has substantial clinical research behind it. It was developed by Drs. Mark Lovell and Micky Collins in their original work with the Pittsburgh Steelers of the National Football League. The test is a valuable tool. It does not, however, take the place of a doctor’s clinical judgment in determining the condition of the athlete. Rather, it is an important part of a larger clinical assessment. Testing of this type can be more sensitive to subtle cognitive effects of a concussion and helps professionals to manage athletes in a safer way than a through a clinical interview alone. It is now in widespread use in professional sports and can be used every bit as much to help protect our children in youth programs and high schools.

USCHO: What do you believe to be the biggest cause of concussions today in sports like hockey and football?

McGrath: I believe that concussions are an unavoidable aspect of collision sports, but how the games are played and how often full contact occurs are important variables. Much has been done and still more can be done to protect athletes through rule changes that prohibit hits to the head. Chris Nowinski of the Sports Legacy Institute has made the point that reducing the number of practice sessions in which contact is allowed for all teams in a league will result in less trauma to all of those players in a season and in a lifetime.

USCHO: On the subject of equipment, is there adequate protection for today’s athletes and what should athletes, parents and coaches be looking for in protecting the head?

McGrath: In sports such as hockey, football and lacrosse, a helmet should be properly fitted and worn by the athlete correctly in order to maximize its effectiveness. Helmets should be new or annually reconditioned. While there is no such thing as the concussion-proof helmet, taking the appropriate steps to ensure use of current technology and proper fitting will reduce risk.

In sports like basketball and soccer, there are now padded headbands which are intended to minimize the impact of inadvertent collisions. We do not yet have proof, however, to show that these devices will actually reduce the frequency or severity of concussions.

Another area of interest is the use of mouthguards in collision sports. The technologies have evolved well beyond the “boil-and-bite” mouthguards used in the past. The Maher Mouthguard, other custom-fitted mouthguards, and some well-cushioned off-the-shelf mouthguard products have all seen increased use at both the professional and amateur levels. While there are no controlled studies yet to show that mouthguard use reduces the rate or severity of concussions, there may be protection associated with the combined use of the mouthguard and helmet for athletes in collision sports like hockey and football.

USCHO: Besides equipment, what other areas can be addressed to lessen the frequency of concussions?

McGrath: We may have a trend in contact sports over the years in which athletes who have been outfitted with more protective gear have evolved more violent styles of play. You’ve made the point in a previous column, Tim, that hockey seems to have more hits to the head today than in the era before helmets. I don’t think, however, that we will see organizations moving toward having athletes wear less protective equipment in the hope of reducing violence in the game. In hockey, going from a full face cage to a half-shield may increase other kinds of injuries and there is no guarantee that it would directly reduce the number of concussive events in hockey.

I think rule changes and enforcement are the likely spots where an impact can be made. The NHL has just recently changed the penalty for hits to the head. The rule change is a good start and I think, Tim, that the idea you mentioned in your previous column regarding the suspension of an offending player to match the duration of time the injured player cannot participate after taking an illegal hit is quite interesting. It would be difficult to manage logistically but would clearly be a fair deterrent.

USCHO: What is your prognosis for head injuries in collision sports in the future?

McGrath: I think that we will see continued advancements in technology to better protect athletes, but efforts to reduce the occurrence and effects of concussions must continue, as they are today, on a number of coordinated fronts. We are at a new height of public concern with more data and high-profile injuries raising awareness and education in this area — just look locally over the past couple of years at the way that sports fans have better understood the seriousness of concussions by following the injuries and recoveries of players like Patrice Bergeron and Marc Savard for the Bruins.

You now have major professional organizations committing to providing support to research, data and awareness. The NFL has pledged $1 million in research funds and the NHL continues to set a strong example in professional sports in the evaluation and management of these injuries.

Lastly, in Massachusetts, Governor [Deval] Patrick has recently signed into law a bill that mandates concussion education for coaches and parent volunteers in youth and high school sports. Other such mandatory education bills are currently pending in Connecticut, Rhode Island and several other states and will hopefully become the norm across the country.

Progress is being made on many fronts today. Our hope is the continue to change the culture in sports to one of more reasonable safety in light of what we are coming to understand about the short-term and longer-term risks of these injuries. Understanding the nature of concussions and how to best manage recoveries so athletes can play hard but safely and look forward to a healthy life — that’s the goal. I think we have come a long way and can still do much more.

For more information, contact Sports Concussion New England at (617) 959-1010 or visit www.sportsconcussion.net.