Expert: Vic Winnek - 11/4/2008

Question
Hi Vic,

I'm hoping you can help me with this question.  If a DI college quarterback suffers a concussion in a game, what is his eligibility for the next game, i.e. can he play?

Also, what is the NCAA rule on the subject?

Thanks!

Mike

Answer
FOLLOW UP  
MIKE,
As promised I did some extensive research on your question concerning the return to play time for a QB following a concussion.  There is no set rule or time frame set by the NCAA for a player who has suffered a concussion to return to play.  It is left up to the team's trainer and doctor to clear the player to return to play.

The NCAA funded a study on concussions that suggests college football players are much more likely to sustain a concussion during a game than during a practice. Given that concussions most often result from sudden acceleration/deceleration of the freely moving head, this finding can most likely be attributed to the intensity and speed at which the games are played relative to average practice conditions. Linebackers, offensive linemen, and defensive backs may also have an increased risk of concussive injury, which is consistent with previous findings and most often explained by the increased size and speed of players in these positions.

Most conferences and Colleges follow similar guidelines as the ACC. The ACC's Current Concepts in Concussion developed by Drs. P.Gunnar Brolinson, D.O. and Dan Elliott, D.O. Virginia Tech Sports Medicine provides:
 
Sports related concussions are often referred to as "dings." It is important to remember that there is no such thing as a "minor" head injury. Concussion largely remains an "invisible" injury that has no defined timeline for recovery. Even with improved technology and understanding of neuroscience, there is still no universal agreement on the definition or grading of concussion. The American Academy of Neurology defines concussion as "a trauma-induced alteration in mental status that may or may not involve loss of consciousness. Confusion and amnesia are the hallmarks of concussion." More importantly, recognition of brain injury is the key to evaluation and management.

 Concussion management in athletics continues to be a challenge for both team physicians and athletic trainers. Over the past four decades, many strategies have evolved that include improved recognition, prevention, and rehabilitation of concussive episodes.   

 Historically there has been a decline in brain and cervical spine deaths among high school players. In 1968, brain and cervical spine injuries among high school and college football players resulted in 36 deaths. Over the past thirteen years, the rate has dropped to approximately 5 per year. There are multiple reasons for this decline including rule changes, improved equipment standards, heightened awareness by coaches, players and clinicians, and improved assessment techniques. However, there is still room for improvement.  

  Sports with potential for contact with other players or the ground obviously carry an increased potential for head injury. A heightened awareness at these sporting events is the first step of management. Examples of high-risk sports include boxing, football, gymnastics, ice hockey, wrestling, soccer, lacrosse, and basketball. We expect that the incidence of concussion, or mild traumatic brain injury (MTBI), will increase as the popularity of these sports increases. The Centers for Disease Control (CDC) estimates the incidence of concussion at 300,000 cases per year. Of those, one third occurs in football. Concussion is a major source lost player time and accounts for 13.3% of all football injuries. There are approximately 62,800 cases seen in high school varsity athletes. These numbers are impressive but are likely lower than the actual occurrence as many concussions go undiagnosed or unreported.   

  Difficulty with diagnosis of concussion stems from the protean nature of the entity and often vague clinical symptoms. Athletes with concussion may have a vacant stare, delayed verbal and motor response, confusion, decreased ability to concentrate, disorientation, slurred speech, labile emotions, and/or loss of consciousness. It should be noted that loss of consciousness does not have to occur during a concussive episode. Players will often hide symptoms because they do not want to be removed from the game or lose playing time. Sometimes, the diagnosis is made days after the injury based on late symptoms such as headache, light-headedness, inability to focus, decline in classroom performance, easy fatigability, irritability, visual disturbances, anxiety, depression, and sleep disruption.  

  Functional MRI, neuropsychological testing, and color flow Doppler ultrasound are some of the cutting edge technology that has been helpful in assessing the brain's response to concussion. In addition, there are new methods for the assessment of concussion being developed presently. Virginia Tech has been involved recently in developing the Head Impact Telemetry (HIT®) System.

 Using monitoring devices located in the players' helmets, this technology can record the magnitude and direction of blows to the head during play. This technology is evolving, and we hope it will provide future help in the field of concussion research, diagnosis, and management.   

 Management of the injured athlete involves both immediate and long-term care. Immediate care of an athlete with a suspected concussion includes basic life support, a neurological exam on the field, and immobilization on a spine board if warranted. Hospital transport may be necessary if the athlete was rendered unconscious, had a neurological deficit, or sustained a suspected neck injury. If the athlete required assistance to the sideline, he or she should undergo further assessment including vital signs, a detailed neurological exam, mental status exam, provocative testing, and neuropsychological testing. The athlete should then be closely monitored for warning signs of further neurological damage such as persistent nausea and vomiting, changes in mental status, worsening headache, and/or seizures. Once the athlete stabilized, the decision to return to activity should be addressed by the treating sideline sports medicine team.  

  In determining return to play status, many clinicians use a concussion grading scale; however, there is no universally accepted scale to date. Some examples of grading scales are the Cantu, Colorado Medical Society, and the American Academy of Neurology. More recently, the Vienna Conference and the Prague Conference suggest that these scales should not be absolute rules, but each concussion should be managed individually and that grading scales may not be appropriate.   

   The hesitation regarding return to play issues arises from a complication known as second impact syndrome. Premature return to play may result in an additional head injury while the athlete is still in the recovery phase from the initial concussion. This then could result in brain swelling and death. This sequence of events can occur rapidly leaving no time for intervention. Other complications of concussion include post concussion syndrome (PCS), cumulative brain damage, and depression. PCS may last up to six months and is characterized by headache, dizziness, fatigue, irritability, decreased concentration and impaired memory. Athletes should be restricted from play until all symptoms have resolved.   As with any sport injury, athletes removed from play should undergo a rehabilitative program prior to return to sports. Special attention should also be given to addressing not only the sport specific but also the position specific nature of the athlete's sport.   

  Concussion diagnosis, management, and understanding will continue to be a challenging and dynamic issue for everyone involved in athletics. With continued efforts in research, diagnosis, prevention, and rehabilitation, concussion prevention and management will continue to improve.


In determining return to play status, many clinicians use a concussion grading scale; however, there is no universally accepted scale to date. Some examples of grading scales are the Cantu, Colorado Medical Society, and the American Academy of Neurology. More recently, the Vienna Conference and the Prague Conference suggest that these scales should not be absolute rules, but each concussion should be managed individually and that grading scales may not be appropriate.

Studies find Football Players Need Several Days to Recover From a Concussion: Collegiate football players may need up to 7 days to recover from a concussion, including full recovery of cognitive function and balance, according to an article in the November 19 2007 issue of The Journal of the American Medical Association (JAMA).

According to the article, concussion is one of the most common injuries in collegiate sports. Recent data from the National Collegiate Athletic Association (NCAA) Injury Surveillance System reveal that concussion accounted for a significant percentage of total injuries among athletes participating in collegiate ice hockey, football, and soccer during the 2002-2003 season.

Studies in basic neuroscience have demonstrated that mild traumatic brain injury (concussion) is followed by a complex cascade of events that can adversely affect cerebral function for several days to weeks. Clinically, concussion can result in neurological deficits, cognitive impairment, and other symptoms. Lack of data on recovery time following a sport-related concussion has hampered clinical decision making about when it is appropriate for an athlete to return to play after the injury.

Michael McCrea, Ph.D.(Neuroscience Center, Waukesha Memorial Hospital, Waukesha, Wis.) conducted a study to measure the effects of concussion and the time course to recovery following the injury in competitive athletes participating in collegiate football. The study included 1,631 football players from 15 U.S. colleges. All players underwent preseason baseline testing on concussion assessment measures in 1999, 2000, and 2001. Ninety-four players with concussion (based on American Academy of Neurology criteria) and 56 noninjured controls underwent assessment of symptoms, cognitive functioning, and balance stability immediately, 3 hours, and 1, 2, 3, 5, 7, and 90 days after injury. A total of 79 players with concussion (84 %) completed the protocol through day 90. Compared with controls, players with concussion exhibited more severe symptoms, cognitive impairment, and balance problems immediately after concussion. On average, symptoms gradually resolved by day 7, cognitive functioning improved to baseline levels within 5 to 7 days, and balance deficits dissipated within 3 to 5 days after injury. Mild impairments in cognitive processing and verbal memory evident on neuropsychological testing 2 days after concussion resolved by day 7.

There were no significant differences in symptoms or functional impairments in the concussion group and the control group 90 days after concussion.  "These findings suggest that clinicians cannot necessarily expect that all collegiate football players will reach a complete recovery within 7 days after a concussion, as approximately 10 percent of players in this study required more than a week for symptoms to fully resolve. Furthermore, not all players demonstrated the same pattern of recovery in symptoms, cognition, and balance," the authors write. "There was clear and consistent evidence of cerebral dysfunction in cases of concussion without classic indicators of mild traumatic brain injury, such as loss of consciousness and posttraumatic amnesia. These data support a movement in the neurosciences toward a revised definition of concussion that emphasizes an alteration (as opposed to a loss) of consciousness or mental status as the hallmark of concussion and stresses the potential seriousness of all head injuries, even what has historically been referred to as a simple 'ding.' Sports medicine professionals especially should be aware that the diagnosis of concussion does not require loss of consciousness, significant amnesia, or other focal neurological abnormalities associated with more severe head injury," the researchers add. (Editor's Note: This research was funded in part by the NCAA and the National Operating Committee on Standards for Athletic Equipment (NOCSAE). The National Center for Injury Prevention and Control and the University of North Carolina Injury Prevention Research Center also contributed to the success of this project.

In another article titled: FOOTBALL PLAYERS WHO SUSTAIN A CONCUSSION MORE SUSCEPTIBLE TO ADDITIONAL CONCUSSIONS in the November 19 JAMA, Kevin Guskiewicz, Ph.D., A.T.C., of the University of North Carolina, Chapel Hill, estimated the incidence of concussion and repeat concussion among collegiate football players. The authors also examined the association between history of previous concussions and the likelihood of experiencing recurrent concussions, and compared time to recovery following concussion between athletes with a history of previous concussion compared with those without a previous concussion.

Approximately 300,000 sport-related concussions occur annually in the United States, and the likelihood of serious adverse effects may increase with repeated head injury, according to background information in the article. This study included 2,905 football players from 25 U.S. colleges who were tested at preseason baseline in 1999, 2000, and 2001 on a variety of measures and followed up to ascertain concussion occurrence. Players injured with a concussion were monitored until their concussion symptoms resolved and were followed up for repeat concussions until completion of their collegiate football career or until the end of the 2001 football season. During follow-up, 184 players (6.3%) had a concussion and 12 (6.5%) of these players had a repeat concussion within the same season.

"There was an association between reported number of previous concussions and likelihood of incident concussion. Players reporting a history of 3 or more previous concussions were 3 times more likely to have an incident concussion than players with no concussion history," ..."Headache was the most commonly reported symptom at the time of injury (85.2%) and mean overall symptom duration was 82 hours. Slowed recovery was associated with a history of multiple previous concussions (30% of those with 3 or more previous concussions had symptoms lasting greater than 1 week compared with 14.6% of those with 1 previous concussion).

Of the 12 incident within-season repeat concussions 11 (91.7%) occurred within 10 days of the first injury and 9 (75%) occurred within 7 days of the first injury."

"Given our finding of a 3-fold greater risk of future concussions following 3 concussions vs. no concussions, athletes with a high cumulative history should be more informed about the increased risk of repeat concussions when continuing to play contact sports such as football," the researchers write. "1 in 15 players with concussion may have additional concussions in the same playing season and that these reinjuries typically take place in a short window of time (7-10 days) following the first concussion."

In an EDITORIAL: UNDERSTANDING SPORTS-RELATED CONCUSSIONS  Dr. Douglas B. McKeag, M.D. of the Indiana University School of Medicine, opined mild traumatic brain injury (TBI) in college football players help to provide an opportunity to see where there is agreement and evidence-based consensus on concussion. "First, any athlete with a concussion should be removed from competition. Second, no athlete should return to play or practice until he or she is completely asymptomatic at rest and with exertion. Third, any athlete with a prolonged loss of consciousness or evidence of amnesia should not return to play that day. Fourth, careful and repeated assessments by individuals with training and experience in evaluating concussive injuries should be the rule. Fifth, any patient with a concussion whose symptoms evolve downward requires immediate neurologic evaluation and possible hospital admission."

"Now is the time to consider sports-induced mild TBI differently. Several collaborative efforts have provided an opportunity to move in this direction. Using these suggestions, clinicians caring for athletes and sports medicine researchers need to identify more areas of agreement while continuing research on the substantial knowledge gaps that remain. The picture is coming into focus but still remains a bit fuzzy," he opined.

Guidelines for return to play following a concussion have been published by several authors [Listed below]20-25; however, none has emerged as a criterion standard or been followed with any consistency by sports medicine clinicians. The majority of these guidelines were developed on the premise that athletes may have a reduced threshold for subsequent concussions after an initial concussion. Although this theory has yet to be confirmed in a human model, animal research has identified acute metabolic dysfunction following cerebral concussion that might explain the increased neuronal vulnerability that can exist for several days following injury. Within a given season, there may be a 7- to 10-day window of increased susceptibility for recurrent concussive injury, but this finding should be further studied in a larger sample of athletes with recurrent in-season concussions.

Authors of Guidelines:
-Cantu R. Guidelines for return to contact sports after a cerebral concussion. Phys Sportsmed. 1986;14:75-83.  

-Cantu RC. Posttraumatic retrograde and anterograde amnesia: pathophysiology and implications in grading and safe return to play. J Athl Train. 2001;36:244-248.

-Jordan B. Sports injuries. In: Proceedings of the Mild Brain Injury in Sports Summit. Dallas, Tex: National Athletic Trainers' Association Inc; 1994:43-46.  

-Nelson WE, Jane JA, Gieck JH. Minor head injury in sport: a new classification and management. Phys Sportsmed. 1984;12:103-107.  
-Colorado Medical Society Sports Medicine Committee. Guidelines for the management of concussion in sports. In: Proceedings of the Mild Brain Injury in Sports Summit. Dallas, Tex: National Athletic Trainers' Association Inc; 1994:106-109.  

-American Academy of Neurology. Practice parameter: the management of concussion in sports. Neurology. 1997;48:581-585.   

-Giza CC, Hovda DA. Ionic and metabolic consequences of concussion. In: Cantu RC, Cantu RI. Neurologic Athletic and Spine Injuries. Philadelphia, Pa: WB Saunders Co; 2000:80-100.27. Giza CC, Hovda DA. The neurometabolic cascade of concussion. J Athl Train. 2001;36:228-235.

-Hovda DA, Yoshino A, Kawamata T, Katayama Y, Becker DP. Diffuse prolonged depression of cerebral oxidative metabolism following concussive brain injury in the rat: a cytochrome oxidase histochemistry study. Brain Res. 1991;567:1-10.

-Nilsson B, Ponten U. Experimental head injury in the rat, part 2: regional brain energy metabolism in concussion trauma. J Neurosurg. 1977;47:252-261.

-Yang MS, DeWitt DS, Becker DP, Hayes RI. Regional brain metabolite levels following mild experimental head injury in the cat. J Neurosurg. 1985;63:617-621.


I hope this helps explain the NCAA Concussion protocols and guidlines adopted by colleges.

Mike
I will post a follow up in greater detail, I am still researching material that may give you the most detailed response.  I', half way through 12 years of NCAA Bulletins, Press-Releases, news articles, NCAA Committee Minutes, proposed guidelines and National Athletic Trainers Association materials dealing with concussions.

However, the short answer to  your question is: the eligibility for a QB to return to a game or the next game after a concussion is up to the individual school's sports medicine professionals.  The NCAA does not have a set rule.  Concussions are taken on a case by case basis.  "Generally" there tends to be a recommended 7-10 day waiting period before returning to full contact.

Vic Winnek
NCAA Football Official