Experts debate: How many concussions are too many for an athlete?

Concussions were once dismissed as as “bell ringers” or “dingers,” and thought to have just short-term effects. It’s now known that concussions can have longer-lasting consequences, especially when a player sustains several of them. In fact, high-impact concussions have been linked to a degenerative brain disease called chronic traumatic encephalopathy, or CTE.

Some schools and sports clubs disqualify an athlete from continuing in a contact sport after a set number of concussions. Others don’t. STAT asked several concussion experts how best to determine whether an athlete who has had one or more concussions should keep playing.

Micky Collins: Pre-existing conditions affect concussion severity, rehab
William Meehan: Athlete’s goals must be part of the decision
Chris Koutures: Athletes deserve a thorough, individualized process

By Micky Collins: Determining whether an athlete should play a sport again after a concussion is far more nuanced than relying on a number. I don’t believe in using a cutoff for the number of concussions because every case is different.

Our research group at the University of Pittsburgh Medical Center has identified six distinct clinical profiles following concussion:

• difficulty thinking and concentrating (cognitive)
• difficulties interpreting movement and balance problems (vestibular)
• issues with vision and ocular-motor function (ocular)
• migraine
• neck pain
• anxiety and changes in mood

Think of those as interlocking circles. Some athletes have symptoms mainly from one circle; others have symptoms from several of them.

Each circle has different recovery trajectories and treatments. We have made great strides in learning how to rehabilitate these areas of dysfunction. We have learned, for example, how to retrain the vestibular system to interpret dynamic movement, and how to exercise the eyes to reestablish normal, healthy vision.

It isn’t necessarily how hard an athlete gets hit in the head, or how many concussions he or she has had, but what the athlete brings to the table that often determines the response to the trauma, how bad the symptoms get, and how amenable the athlete is to therapy. Athletes with car sickness are more likely to get vestibular problems after a concussion, those with learning disabilities are more likely to develop cognitive problems, those with anxiety are more likely to have anxiety and mood issues.

When it comes to concussion, the pendulum has swung from a giving an athlete a dose of smelling salts and asking, “How many fingers am I holding up?” to widespread fear. I believe the truth is somewhere in between — having a concussion is worse than what we used to think it was and not as bad as it is being made out to be.

While we certainly need more research and randomized controlled trials, I believe that concussion is now a fully manageable, treatable condition. If an athlete responds to rehabilitation in a robust, predictable way, and we fully treat that problem, I have no problem with him or her returning to play and, in fact, encourage it.

Micky Collins, PhD, is the clinical and executive director of the University of Pittsburgh Medical Center’s Sports Medicine Concussion Program.

By William Meehan: The number of concussions an athlete has sustained is an important data point to consider when deciding whether or not he or she should return to play. That’s because concussions can have cumulative effects — the more concussions sustained, the higher the risk of developing long-term problems.

But evaluation goes far beyond the number of concussions. We consider the severity of the symptoms and the cognitive difficulties a player experiences after injury. We evaluate whether successive concussions are being caused by less and less force, and whether the athlete is taking longer and longer to recover from successive concussions.

The athlete’s overall goals and the benefits derived from participation in sports must also be taken into consideration. An athlete who is playing at a high level, has a contract lined up with a professional team, and is planning to build a future career around a sport might choose to play longer and accept a greater risk than someone who wants to become a veterinarian and is playing just for fun.

The decision is often straightforward. It can be challenging, however, to counsel an athlete who has sustained multiple concussions but who doesn’t want to stop playing. Over a series of meetings, we discuss with such an athlete the medical studies that point to the risks of continuing to play. He or she must then weigh the risks against the benefits. Most of the time, the athlete makes a reasonable, well-informed decision.

A few times in my career I have had to tell an athlete that I couldn’t, in good conscience, sign a letter clearing him or her to return to play because the risk was too great. These athletes were, of course, free to get a second opinion. Many found a physician who then determined it was safe to return to play and cleared them to do so. I have also worked with some athletes for whom I thought the risks of returning to play were minimal, but they decided that the risks were too great and stepped away from the sport.

William Meehan, MD, directs the Micheli Center for Sports Injury Prevention in Waltham, Mass.

By Chris Koutures: First off, it’s important not to make any decisions while an athlete has symptoms. You have to give him or her time to heal. Then you have to look at the big picture and the individual’s full history. I try to tease out important details about each concussion: how it happened, the number of symptoms, how long they last, and their impact on the athlete academically, socially, personally, and athletically.

An interdisciplinary approach helps provide return-to-play guidance. I check the athlete’s balance, eye movement, sleep patterns, and more. I ask neuropsychology colleagues to look at the athlete’s brain function and dysfunction. I involve people who are important to the athlete, such as family members, a significant other, coaches, and other medical staff. The athlete’s long-term goal — where does he or she want to go with this sport — also factors into the equation.

Athletes who have suffered concussions deserve a thorough, individualized process. It would make things easy to rely on a number, such as you can’t play after three concussions. But there’s no evidence for such a cutoff.

I’ve worked with athletes who I counseled not to return to playing a high-risk sport after a single concussion. Then there are athletes with multiple concussions whose recovery patterns are benign and who acknowledge and accept what we know and what we don’t know. I will clear them to play as long as they are comfortable with the ambiguity that comes with that clearance.

Just as a doctor would go deep to find a possible cancer, I think it’s important to do the same thing for athletes who have suffered a concussion, many of whom want to keep playing. If there’s a way for them to keep playing, or at least stay involved with their sport, great. If not, and the athlete is not cleared for play, most of them appreciate the effort and the time that went into making that decision.

Chris Koutures, MD, is a pediatrician and sports medicine specialist in Anaheim Hills, Calif. He is the team physician for the US Men’s and Women’s National Volleyball Teams.