Fall means football among my family and friends. From local youth teams to collegiate programs to professional organizations, we love them all. As winter begins, we head into the championship series for all these teams, and it is hardly a controversy-free event, whether it means a bad call during a game, questionable rankings, or even unfair recruiting practices off the field. But, lately, one of the biggest controversies in football has been related to mental health. The incidence, risks, and consequences of concussions related to football seem to be on the rise and a debate is raging about what can and should be done about it.

This fall, the Institute of Medicine (IOM) and the National Research Council (NRC) published findings of a year-long review of sports-related concussions in youth athletes. This coupling of sports and medicine has generated a high-profile and hotly-contested examination of head injuries in sports. There is confusion and disagreement about how to define a concussion, as well as how concussions affect future injuries, when it is safe for a player to return to the field, and the effectiveness — or lack thereof — of protective equipment. The diagnosis, treatment, and long-term consequences of concussions are also in question.

Concussion involves a complex physiological process, but it is generally defined as a traumatically-induced disturbance of brain function. Concussion is a subset of mild traumatic brain injury, which is at the less severe and self-limiting end of the brain injury spectrum. An estimated 3.8 million concussions occur every year in the United States during competitive and recreational sports, and as many as 50% go unreported. Certain sports and positions offer higher risks of concussions, and the highest incidence of concussions occurs in football, hockey, rugby, soccer, and basketball. Previous concussions increase the risk for repeat and more severe concussions.

Part of the controversy is owed to the fact that experts and clinicians cannot even agree on what really causes a concussion, let alone how to consistently diagnose and manage one. Prevention is another point of contention, and protective gear already in use, such as helmets, has not been shown to decrease the incidence or severity of concussions. The long-term consequences of concussion are debated, but evidence seems to be mounting that repeated blows to the head are leading to long-term physical and mental health consequences. Concussions may accelerate the progression to negative cognitive, psychiatric, or mental health outcomes. For instance, depression is more likely to occur in football players who sustained concussions during their professional careers; the more concussions, the greater the likelihood of depression. Similar conclusions have been reported with cognitive impairment, premature aging of the brain, and dementia.

Concussion can also lead to physical, emotional, and sleep problems. While symptoms of a concussion usually resolve within 2 weeks with physical and cognitive rest, some symptoms may persist for months or years. Pre-existing mood disorders, attention-deficit disorders, and headache disorders complicate the diagnosis and management of concussion.

There are no evidence-based guidelines for disqualifying an athlete from returning to play after a concussion, though most athletic associations have themselves implemented rules for coaches, players, and sports medicine physicians to follow. However, skeptical observers believe that conflicts of interests between these parties, who are all interested in a winning team and may not follow the guidelines, may put players at increased risk of injury.

The IOM/NRC report acknowledged that education is paramount to addressing and correcting concussion-related consequences in sports. Players, parents, coaches, and physicians should all be educated about identifying and managing symptoms of a concussion. Prevention efforts also need to be considered. But, there is also a need for a change in culture and attitude when it comes to sports injuries. Players need to self-report concussion symptoms on a more regular basis, and adherence to return-to-play guidelines is critical. Social norms about acceptable athletic risks and behaviors may also need to change, according to many experts. Tougher is not always better, and getting hit harder does not always make you stronger.

While almost no one in America wants to see the gridiron turned into an emasculated field of gentle taps and easy passes, we do owe some consideration to the future mental well-being of the men that play the games we love to watch.

References

Harmon KG, Drezner JA, Gammons M, Guskiewicz KM, Halstead M, Herring SA, Kutcher JS, Pana A, Putukian M, & Roberts WO (2013). American Medical Society for Sports Medicine position statement: concussion in sport. British journal of sports medicine, 47 (1), 15-26 PMID: 23243113

Institute of Medicine (US), & National Research Council (US) (2013). Sports-related concussions in youth: improving the science, changing the culture National Academies Press PMID: 24199265

Karr JE, Areshenkoff CN, & Garcia-Barrera MA (2013). The Neuropsychological Outcomes of Concussion: A Systematic Review of Meta-Analyses on the Cognitive Sequelae of Mild Traumatic Brain Injury. Neuropsychology PMID: 24219611

Kerr ZY, Marshall SW, Harding HP Jr, & Guskiewicz KM (2012). Nine-year risk of depression diagnosis increases with increasing self-reported concussions in retired professional football players. The American journal of sports medicine, 40 (10), 2206-12 PMID: 22922518

Ma R, Miller CD, Hogan MV, Diduch BK, Carson EW, & Miller MD (2012). Sports-related concussion: assessment and management. The Journal of bone and joint surgery. American volume, 94 (17), 1618-27 PMID: 22992853

McClure DJ, Zuckerman SL, Kutscher SJ, Gregory AJ, & Solomon GS (2013). Baseline Neurocognitive Testing in Sports-Related Concussions: The Importance of a Prior Night’s Sleep. The American journal of sports medicine PMID: 24256713

Mihalik JP, Register-Mihalik J, Kerr ZY, Marshall SW, McCrea MC, & Guskiewicz KM (2013). Recovery of posttraumatic migraine characteristics in patients after mild traumatic brain injury. The American journal of sports medicine, 41 (7), 1490-6 PMID: 23696213

Newton JD, White PE, Ewing MT, Makdissi M, Davis GA, Donaldson A, Sullivan SJ, Seward H, & Finch CF (2013). Intention to use sport concussion guidelines among community-level coaches and sports trainers. Journal of science and medicine in sport / Sports Medicine Australia PMID: 24252427

Partridge B (2013). Dazed and Confused: Sports Medicine, Conflicts of Interest, and Concussion Management. Journal of bioethical inquiry PMID: 24249203

Image via winui / Shutterstock.