Concussions have been a hot topic for a number of years, and with a recent injury to Miami Dolphins quarterback Tua Tagovailoa, the urgency to weigh in on the topic seems to be at an an all-time high. To have a discussion on the topic, it’s important to develop an understanding of what a concussion is, rather than offer a surface-level argument that “they are bad.”

What is a concussion?

To develop a better understanding of concussions, let’s discuss the brain. Our brain accounts for about 2% of our bodyweight (about 3 pounds on average), but uses roughly 20% of our body’s energy. The brain is a complex system that uses electrical signals to store memories, interpret our senses (touch, smell, sight, etc.), control our movement, regulate hormones—the list could be an entire blog post itself. A good way to think of the brain is that it is our body’s control center. So where is the energy needed in the brain? Essentially the fuel (remember ~20% of our energy) is used to power these processes through a series of electrical impulses. Without getting too deep into the science, there are BILLIONS of connections that perform these electrical impulses in the brain, all of which need energy.

Let’s take a second to talk about the body’s response to a trauma-related injury. Imagine an impact resulting in a bruise anywhere else on the body—there will be some swelling in the area, which is necessary! The swelling helps to bring healing factors to the area to help repair any damaged tissues affected by the impact. As you may suspect, repairing these tissues takes additional energy. Keep this concept in mind—any injury will take additional energy for the repair process.

MRI of the brain, demonstrating the lack of space between the brain and skull

What happens when there is trauma to the brain? The brain is tightly housed inside of the skull, which provides the delicate brain a crucial protection barrier from outside trauma. However, the brain has some ability to move within the skull. With a rapid change in speed (acceleration or deceleration), the brain can compress against the skull, causing damage to the brain tissue. Think about the bruising that was discussed earlier—swelling will happen after an injury. While the brain is able to move within the skull, there is no extra space. So what happens next? The resulting swelling finds whatever space it can, and winds up compressing on blood vessels within the brain, which leads to less blood flow, less oxygen, and less healing factors going to the brain. Think about the bolded sentence at the end of the last paragraph— an injury will take additional energy for the repair process. The brain is now in what we consider an energy crisis: there is an increased demand for energy to heal the damaged tissues, but there is less energy available due to the swelling in a closed skull. This is the real issue with concussions—the body has more difficulty healing the brain tissues due to the nature of the skull. There are a few more complexities to concussions, but we’ll keep things simple for the purposes of this blog post.

*Understand this is an overly simplistic description of a concussions. There are other key factors involved in a concussion, but this will give a broad understanding of what can happen with a concussion.

Treating a concussion

How do we treat a concussion? The answer is one that nobody likes to hear—it depends. No two concussions are the same! Think about all of the functionalities of the brain, there were too many to list in this blog. Any one (or combination) of these can be affected by a trauma to the brain. Therefore, it’s important to treat the individual based on their signs and symptoms. Symptoms can involve light sensitivity, headache, dizziness, poor tolerance to exercise, decreased balance, brain fogginess, and fatigue. We can use images (CT Scan, MRI, etc.) to see if there are any visible signs of swelling or brain injury, although these often do not show conclusive evidence.

Blurred vision, light sensitivity, and dizziness are examples of concussion symptoms

When developing a treatment plan, more evidence is pointing towards a gradual return to activity, rather than complete rest. This involves slowly introducing aerobic exercise, resistance training, and sport-related activities in a controlled environment before getting back on the field. We want to make sure the brain can handle the ~20% of the energy responsibilities before returning to sport. If we cut this rehabilitation process short, the result could be deadly.

second impact syndrome

Now that we have an understanding of the energy crisis and the inverse relationship between an energy need and supply, let’s talk about the worst case scenario—a second concussion before complete healing. Before getting into this, it is worthwhile saying that second impact syndrome is a rare occurrence. A 2016 review article only found 36 cases in 15 publications through an exhaustive search of the literature (McLendon et al, 2016). That being said, this is an extremely serious condition, and should not be taken lightly.

In an existing concussion, there is already swelling of the brain within a closed space. A second impact would result in additional swelling and pressure within the skull, furthering the energy crisis already present within the head. The general consensus is that second impact syndrome can result in the brain herniating through the bottom of the skull, and thus pressing into the brainstem. The brainstem controls many vital, subconscious systems in the body. In many cases (some experts say up to 50% of the time), second impact syndrome can result in death within a matter of minutes from the second impact. This is why treating a concussion to complete resolution of symptoms is of the utmost importance.

the nfl concussion protocol

The NFL Concussion protocol has made leaps and bounds over recent years. It has certainly helped players manage concussions appropriately when the algorithm is followed. According to the NFL’s website, a player enters the concussion protocol if:

the player exhibits or reports symptoms or signs suggestive of a concussion or stinger (a nerve pinch injury); or,

the team Athletic Trainer, booth ATC spotter, team Physician, NFL game official, coach, teammate, sideline Unaffiliated Neurotrauma Consultant (UNC) or booth UNC initiates the protocol.

***Link to the Full NFL Concussion Protocol***

The NFL’s concussion protocol is logical, sound, and overall good. I’ll start by saying that I don’t envy those making these decisions. One key area to highlight on the protocol is the progressive/worsening symptoms. Due to the progressive swelling that the brain can undergo during a concussion, I can see this as a potentially limiting factor with the protocol. However, those with decision-making responsibilities are left not only with the burden of responsibility for player’s safety, but also for the team’s potential win/loss. It would be great to hold any player out that took a hit to the head to see if symptoms do progress or worsen—this is a common phenomenon to see with concussions. This being said, if you’ve ever watched a football game, it’s just not realistic to expect the medical doctors to sit tight and wait to see if a player’s condition progresses, or if they’re okay. The game won’t wait for one player to see if they’re okay to go back in the game—the show must go on. Whether we like it or not, playing through injuries is part of the game.

In my personal opinion, I think the NFL is doing it’s best to place checks and balances in an undoubtedly violent sport. Too many checks and balances will start to tear at the fabric of what football is at its core—there are collisions and hits to the head on every single play in football. Dedicating multiple professionals to monitor these situations is crucial to help reduce the potential for second impact syndrome. Realistically, concussions are a part of football and the NFL, and they won’t be going anywhere anytime soon. It’s an unspoken inherent risk within the sport.

my take on the tua situation

This is VERY multi-factorial.

Towards the end of the first half against the Buffalo Bills, Tua demonstrated signs of unsteadiness on the field after hitting his head on the ground (knees buckling while walking). Note that within the NFL’s concussion protocol, one of the signs for removal from the game is gross motor instability. However, the language of protocol is that this is a sideline evaluation—it’s very possible that Tua’s presentation off the field was different than it was on the field. In addition, there is a footnote on this section, stating that the gross motor instability is determined by the team physician. Tua was taken to the locker room for further evaluation, and as reported, passed the SCAT exam and full neurological exam. The team determined that Tua did not have a concussion. He then returned to play in the second half and led the team to a victory.

Tua then returned 4 days later for Thursday night football, and was carted off the field after hitting his head on the ground. Just after hitting his head, Tua layed on the ground in a postured position, with his fingers in extended in front of his face. Unfortunately, posturing is a cardinal sign of increased intracranial pressure (swelling around the brain). Although repeated concussions can result in the postured positions, it can also happen with a first time concussion. As easy as it is to point at the first alleged concussion from the Buffalo Bills game, we have to keep in mind that correlation does not imply causation. Is it likely that an initial injury led to a more severe injury? Yes. Can we say this without a doubt? I don’t think so.

Most of the scrutiny is aimed at the team’s medical staff for an undiagnosed concussion during Sunday’s victory over the Bills. Unfortunately, we simply have no way of knowing. We can use film, but unless we were in the room with the professionals as they were performing the concussion protocol, we can’t know for sure. I’d like to give the medical examiners the benefit of the doubt, as they presumably follow the Hippocratic Oath that all medical professionals follow: “first, do no harm.”

Another consideration is Tua himself. Due to the nature of concussion symptoms, it can be seen an “invisible injury.” From the outside observer, we can’t measure the headache, dizziness, fogginess, fatigue, etc. These are reported, or subjective symptoms from the individual. Objective measurements and screening can only take us so far (images are often inconclusive)—it takes cooperation from the individual for accurate reporting of symptoms. It’s plausible that highly competitive individuals may downplay some of their symptoms to stay out there on the field. While this may or may not have happened in this case, this is an overlooked factor when considering concussions. If you are an athlete with a suspected concussion, being honest with your symptoms is an extremely important piece of determining an appropriate diagnosis and plan of care.

This was a very unfortunate situation, and appeared to be a serious concussion. I don’t find it productive to point fingers without convincing evidence, and in this case, I don’t see enough information to point all the fingers in the direction of the medical professionals. Hopefully the NFL and other athletic organizations can learn how serious these head injuries can be, and how appropriate management is crucial.

A protocol administered and monitored by medical professionals is the safest option when considering return to sport

What to do about a concussion

Concussions are serious, and should not be downplayed. Physical Therapy can be a great option when it comes to managing concussions. Your physical therapist will consult with your doctor, and help determine an appropriate management strategy.

If you or someone you know are experiencing concussion-type symptoms, feel free to schedule an appointment with your local physical therapist!

Concussions in the NFL