Concussion: Contractions, Conflicts of Interest, and Confusion

The world of concussions continues to be embroiled in contradiction, conflict of interest and confusion. In an excellent article by Shelia Dingus, the topic of academic fraud and its ramifications to concussion research and concussion care are discussed. Author and reporter Ted Tatos and The Athletic "revealed evidence of LD/ADHD [Learning Disorders/Attention Deficit Hyperactivity Disorder] rates among incoming college football athletes at UNC of over 50% in some cohort-years and UNC’s failure to disclose these diagnoses as the football athletes participated in the school’s concussion research." 

Previous research showed that athletes with LD/ADHD are more susceptible to concussions and required a longer period of recovery than athletes without LD/ADHD. This means that there may have been attempts "cover up the effects of recurrent head trauma" in those athletes. Even more troublesome is that "numerous scientists refuted their own research in an effort to discredit" these findings. Adding to the confusion is the fact that large numbers of "experts" have signed letters that support the research performed at UNC and voice concern over this research.

A research paper just published states that "It was observed that the youth athletes in this study experienced concussions at biomechanical levels that are lower than what has been reported for high school and collegiate football players."

Yet the article discussing this paper adds two contradicting caveats: 

• "it is important to note that the overall head acceleration exposure in youth football is much lower than in adult football."
• "Younger, lighter players collide with less force than adult athletes, so they're less likely to jostle their brains enough to cause serious injury."

The Washington Post article "From Scientist to salesman" describes the conflict surrounding Dr. Bennet Omalu and whether or not his research findings and conclusions about youth sports participation hold any lasting credibility. The article places him at odds with Dr. Ann McKee, the Boston University researcher.

What the article does not discuss is the additional conflict between researchers at Boston University and others like Dr. Lili-Naz Hazrati and Dr. C. Munro Cullum. 

"Throughout the last century, research has clearly correlated repetitive head trauma with long-term cognitive effects. However, the current scientific literature is limited and the pathophysiology of TBI-induced damage is still largely unknown. The pathological hallmarks and clinical presentations of CTE are widespread and variable both within and between case series, making it difficult to uniquely and definitively characterize CTE as a neurodegenerative disease." Assessing the Limitations and Biases in the Current Understanding of Chronic Traumatic Encephalopathy

"CTE is still in the early stages of research as a neuropathological condition and no specific clinical criteria exist. Claims about CTE being a progressive disease entity and caused exclusively by head trauma/impacts are not well supported at present. Such assertions may have impeded our understanding of the frequency and significance of this disorder. Refining diagnostic criteria to reduce ambiguity in classifying cases will be essential before risk factors and/or possible clinical markers may be identified." Chronic Traumatic Encephalopathy: Understanding the Facts and Debate

"There is little doubt that some athletes may suffer from long-term adverse effects from multiple sport-related concussions. At present, despite anecdotal and case series reports, it is my opinion that there is no compelling empirical evidence to indicate that sport-related concussion or Subconcussive impacts are the sole and direct cause of psychiatric illness, suicide, MCI, or neurodegenerative disease/CTE." Chronic traumatic encephalopathy in sports: a historical and narrative review

“Chronic traumatic encephalopathy is a unique neurodegenerative disease associated with a history of exposure to RHI [repetitive head impact].”

“Currently, the diagnosis of “Probable CTE” is limited due to the lack of validated biomarkers. This is problematic because the clinical manifestations of CTE are somewhat similar to other neurodegenerative diseases (e.g., AD, FTD), and there is much symptom overlap with psychiatric disorders (e.g., post traumatic stress disorder, depression), notably for CTE cases with predominantly behavioral/ mood symptoms. In addition, clinically differentiating between CTE and persistent postconcussive syndrome among young individuals with active or recently concluded RHI exposure is challenging, as highlighted by a recent published case report.”  The long-term consequences of repetitive head impacts: Chronic traumatic encephalopathy

"This study adds to the emerging literature indicating that CTE pathology is present in people not known to have experienced multiple concussions or subconcussive blows to the head." Mild Chronic Traumatic Encephalopathy Neuropathology in People With No Known Participation in Contact Sports or History of Repetitive Neurotrauma

Finally, this paper Paediatric traumatic brain injury addresses many areas of lack of conflict.

Computerized field side testing: "There remain many areas of debate in the field of paediatric concussion including the role of computerized pitch-side cognitive testing and use of biomarkers of injury."

Relevance of subconcussive blows to the development of CTP: "The significance of demonstrations of subclinical alterations of brain physiology, and whether such altered function has any relevance to risk of development of CTE, remains unclear."

The Diagnosis of Concussion: "For now, concussion remains a clinical, symptom-based diagnosis. Management is based on rest (and a veto on return to play) until symptoms of headache, fatigue and psychomotor slowing have resolved."

How long do concussions (signs and symptoms) last? Almost every article and paper states that most concussions resolve in 7 - 10 days or 30 days but this paper states, "Postconcussive symptoms (PCS) are common up to 2 years after mild TBI with headache being commonest early, and irritability, forgetfulness and fatigue the commonest late symptoms [9]. Many of these symptoms have migraine-like qualities to them and respond to migraine treatments. A preinjury history of migraine is a risk factor for prolonged PCS, at least in female individuals [10], again raising uncertainty about the relevance of PCS to risks of late CTE."

If there is this much conflict of interest and this much disagreement between "experts," how are clinicians, coaches, and parents going to know what to do?

Parents, you simply MUST be present, ask questions and DEMAND safety training, procedures, and equipment be in place.

It is YOUR CHILD out there. Think about that carefully.

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Schedule a free 30 minute safety and risk assessment with Dr. Steve Horwitz, CEO and Founder of TeamSafe​®Sports and prepare today!

Click here: calendly.com/drstevenhorwitz

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