RICE & MICE: Coming back from concussion

The playoffs are starting this week. It’s the most exciting time of the year, in my opinion. Coaches are tested and players are pushed to play their limits. I normally hate to write about something that has held so much of the spotlight this season, but the question on so many peoples’ minds (especially the Tampa Bay Lightning) is: will Sidney Crosby finally be cleared for contact and make it back for a postseason run?

Truth is, nobody can predict what will happen if he returns to play. That’s perhaps one of the most frustrating aspects of concussions for players, teams and fans alike; no two brains are the same. No two concussions are the same. The timeline is unpredictable.

Under the NHL Protocol for Concussion Evaluation and Management, players suspected of having a concussion will be removed from the game and sent to a quiet place free from distraction so they can be examined by the on-site team physician.

The physician will use the Sports Concussion Assessment Tool 2 (SCAT2) test to evaluate the player. It is essentially a 15 minute “time-out” for the player to be evaluated away from coaching staff and even training staff.  SCAT2 can be done on site, without the use of a computer.

The Penguins’ applauded the decision to establish a league-wide protocol, but still believe the system is flawed.  They continue to contend that Sidney Crosby didn’t show any concussion symptoms until well after getting hit in the head by Tampa Bay defenseman Victor Hedman. I maintain that Crosby appeared dazed following the collision with David Steckel in the Winter Classic. I believe each team should share the burden of responsibility for recognizing when a player needs to be evaluated. What if Crosby was assessed for concussion right then? It was perfectly feasible, because the hit happened right at the end of the period.

They claim he was symptom free; however the criteria on the SCAT2 and even the other sideline assessment tools may have shown that memory, balance or cognition was impaired at the time of the initial hit.

Maybe the Pittsburgh organization should own some of the blame, rather than have them continue to impress the importance of eliminating head shots in the NHL. Perhaps they are so adamant about the rules pertaining to head shots changing because they realize that they are partially to blame for not recognizing a concussion in a national spotlight on HBO.

Crosby should have been properly assessed, possibly held out of the 3rd period and subsequent practices, and perhaps his injury would not have been compounded by the subsequent hit by Victor Hedman less than a week later.

When the brain is jostled in the skull, there is a disturbance of function and altered awareness or alertness is displayed in the concussed player. Sometimes awareness is altered to the point that the player loses consciousness for seconds or minutes and some concussions can set off a seizure due to the trauma because of a sudden discharge of electricity from the brains cells, the neurons.

The interruption of electrical activity of the neurons causes the altered state of consciousness or awareness because the cells have to recharge or reboot and there is a little short term memory loss surrounding the hit or impact. The player may have lost consciousness or just appear to be dazed at this point and it’s important to assess memory loss of the time surrounding the hit that might help with prognosis.

At the same time, the balance of potassium and calcium is disturbed in the brain cells. Potassium leaves the brain cells, causing calcium to enter the cells. Calcium can be harmful to brain cells, so they have to work even harder to restore the balance of calcium and potassium. This causes the brain to need more glucose to fuel this process, but the glucose travels through the bloodstream and it is especially difficult for the glucose to get where it is needed because the blood vessels of the brain constrict and hamper the transport of blood and glucose.

Sounds like a lot of stuff happening all at once, doesn’t it? It can take days to weeks to months before the brain returns to its “normal” state of functioning.

The lack of fuel for the brain in the form of glucose can cause the extreme fatigue that people will generally feel following a concussion. The fatigue is somewhat of a protective factor to allow the brain to return to normal without causing further stress or strain through exercise or cognitive tasks, such as reading or homework. For this reason physical and cognitive exertion are not allowed because they can cause further damage to brain cells.

So when a player is effectively rehabbed from a concussion, what allows them to be cleared to play?

Baseline testing remains useful in evaluating symptoms and signs of a concussion throughout rehabilitation. The type of hit that caused the concussion is also taken into account as is number of past concussions and when they occurred, if at all. Were there 2 concussions that happened in a week or two-week or month or two-month or 10 year time frame?

The most widely used protocol for returning to play following a concussion begins with holding the player out of activities that require both physical and cognitive effort until they are symptom free at rest. During this time they should refrain from any activity that increases heart rate as well as activities that require a lot of concentration and cognitive effort to include video games, puzzles, reading and school work if it applies.

If any of the activities in any stage causes a reoccurrence of symptoms, the player returns to the previous symptom free stage and must remain symptom free before moving on to the next stage for a period of time that is determined by the doctor (usually 1 day, but may be several days or a week). The 2nd stage allows low impact exercise, such as walking, swimming and stationary bike. This stage may be broken down to specific heart rate targets that the player needs to achieve before moving to a higher heart rate.  The 3rd stage incorporates more sport specific activity, such as skating.  Stage 4 allows for more complex sports activity: passing drills, shooting drills, but no contact whatsoever. Stage 5 allows for contact and the final stage is being fully cleared to return to play.

Crosby seems to be hovering around that 4th stage and it seems that his doctors are employing extreme caution and allowing several days symptom free before advancing. I’d err on the side of extreme caution in that respect, too.  He is only skating with the team during pre-game skates and even though he claims to be symptom-free, he has not been cleared for contact at practices.

“It’s usually the same thing with every step — make sure that you don’t get symptoms,” Crosby said. “It’s not just one day. It’s at least a few days, if not more. The main thing is not to look too far ahead, just try to get through each step and hope it goes well.”

He seems so close to returning, yet he is so far away at the same time. It’s a tough to wrap your mind around if you are a fan, but really, it may not be worth the risk to push for a comeback in the playoffs. There is still a lot we don’t know about concussions and hopefully there will be some research in the near future that allows us to understand the process of recovery and prevention of concussions.

Even one concussion can cause lasting damage and impairment and especially so if the recovery process is rushed and not enough time is given to allow return to normal function.

Will Crosby be back for the playoffs? My guess is no, I don’t think he’ll be back for the playoffs. I don’t see any reason to rush through the last parts of his recovery after they’ve been so careful to move him slowly through the progression of activity level.

Will the extra time guarantee that he remains concussion-free? Maybe; Maybe not. Will he be the same player when he does make his return? I think he will, but there are a couple of variables that may impact this. First, the initial concussion was missed; he was allowed to continue practice and suffered a second trauma to the head 4 days later. Obviously, his brain may have been more vulnerable and this may complicate his recovery.

It wasn’t until the hit from Hedman that Crosby was evaluated by a doctor (yep, 4 days after the initial hit – not a very accurate baseline test). Second, I think his chances of a full recovery are improved by the length of rehab. Finally, the psychological impact of a concussion that has yet to be seen. There is no way to tell if Crosby will shy away from the physical side of the game. Not only that, but concussions can cause anxiety and depression symptoms. The psychological effects remain to be seen and are even more unpredictable than an official timeline for recovery.

I think the doctors are doing the right thing in this case. Pittsburgh and its fans just need to be patient.

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