How many concussions equal too many? At the University of Texas, the sports medicine staff recently tackled this question with two of its football players.
By Kenny Boyd
Kenny Boyd is the Head Football Athletic Trainer at the University of Texas, where he has worked since 2003. He can be reached at: KennyBoyd@athletics.utexas.edu.
Over the past few years, there has been an increased public awareness about concussions. Physicians, athletic trainers, coaches, administrators, athletes, parents, and state legislators are all talking about how to better detect concussions, guard against them, and manage an athlete's return to play.
But there is one area that isn't being discussed very much--yet. And that is choosing not to return to play at all following a series of concussions. As we learn more about the effects of multiple concussions on the brain, conversations about ending athletic careers early will occur at an increasing rate.
Here at the University of Texas, we have had this difficult discussion with two of our football players within the past 18 months. We ultimately recommended that each athlete discontinue playing football, and they did just that.
Both players had great passion for the sport and came from families with strong ties to football. But in the end, they came to the same conclusion: risking permanent life-altering damage was not worth continuing to play football, even if the sport had helped to define a large portion of their lives.
Nathaniel "Tre" Newton fell in love with the game of football by watching his father, NFL great Nate Newton, play on Sundays every fall. The desire to follow in his father's footsteps drove Tre to have a remarkable high school career that earned the running back a scholarship to the University of Texas. He was one step closer to continuing on his father's path to the NFL when during the last half of his sophomore season, his plan took a life-changing turn.
Tre sustained a concussion during the first quarter of a game at Kansas State University on Nov. 6, 2010. He had suffered a few concussions before, but this one was different. It wasn't caused by a huge collision on the field and he wasn't stumbling or feeling woozy on the sideline afterwards. In fact, he was alert and responding normally to other players and coaches. No one was aware that his brain had just been jarred.
Then Tre made a comment to one of our athletic trainers that he couldn't remember parts of the game. He was immediately evaluated on the sideline and we found that he was slowly becoming more symptomatic. Tre was taken to the locker room for further evaluation. His significant symptoms were similar to previous episodes and included photophobia, fogginess, memory difficulties, and headache.
The medical staff was perplexed because no one--including other players and coaches--could recount a significant blow to the head that would have caused Tre's concussion. We regularly review game film to analyze player injuries, and it wasn't until we did this that we found a kickoff return showing Tre sustaining a helmet-to-helmet hit that must have caused the injury.
Our concussion management plan was set into motion. Tre was to follow up with the medical staff every day, including daily physician check-ins. Communication was made with coaches and professors about limiting Tre's meeting room and classroom interaction for the next few weeks. Our team physician also recommended a dose of supplemental DHA for four weeks.
Upon becoming asymptomatic in just a couple of days, we had Tre complete follow-up neurocognitive and vestibular testing as part of the evaluation process. Just like after his previous concussions, his follow-up tests returned to his baseline scores within days--a very quick turnaround.
While coordinating treatment of Tre's concussion, the sports medicine staff also started talking about Tre's history--and future. This was Tre's first concussion of the season, but certainly not the first of his career. He was diagnosed with two concussions during his freshman year at Texas and could recount a few from high school as well.
However, our deeper concern was that it seemed as though a smaller amount of force caused Tre's concussion this time around. No one even suspected a concussion until the singular symptom of memory loss surfaced. Tre's memory loss had delayed his ability to report his injury to an athletic trainer on the sideline, and that was pretty scary.
At a follow-up appointment with our team physician, Dr. Andrea Pana, just days after the Nov. 6 game, Tre began expressing his own concerns about the long-term effects of his multiple concussions. Dr. Pana and I immediately set up a face-to-face meeting with Tre and his parents to discuss his future as a football player.
Prior to the meeting, I met with the football coaching staff to review our plan for the discussion. It is important to all of our coaches that everyone involved with the athletic program is on the same page when it comes to student-athlete medical issues. The football coaches understand that in any serious medical discussion, including the one we were about to have with Tre, the primary focus must remain on the health of the student-athlete. Football is secondary in these cases and must be emphasized as such, by both the medical staff and the coaches.
In the meeting, Dr. Pana walked Tre and his parents through our findings, the progress of Tre's current concussion, and our overall management plan. She reviewed Tre's known concussion history and explained that our concerns were not necessarily just in the number of concussions Tre had sustained, but in the relative lesser force that appeared to be initiating the onset of symptoms. We also explained that the unknown long-term effects of multiple concussions were a big worry for us.
The next moments of the meeting were pivotal. Tre's parents voiced their own concerns after hearing what Dr. Pana had said. They felt it was important for Tre to hear their fears about his future, and each of them shared stories that revealed the enormous emotional investment they had in Tre's life. They were as concerned as we were, but also made it very clear that it was Tre's decision whether or not to continue playing and they would support him in whatever he chose to do.
Tre said that "he knew what the right decision was" and chose to give up football. This was not a revelation for him. He had already spent a lot of time thinking, even prior to his last concussion, about what the next concussion might bring. In a lot of ways, hearing himself say out loud that leaving football was the right decision was all it took for him to commit to doing it.
Not many medically-related questions followed the meeting, but rather more practical questions about Tre's future. What would his new role be with the team? Would he even have a role? What would happen to his scholarship?
In the end, Tre was granted a medical scholarship. Financially supporting our student-athletes following a career-ending injury is not a topic this school thinks twice about. We're invested in our student-athletes' futures and commit to them when they commit to us. And Tre wasn't about to leave his teammates. He is now a student coach and mentors the younger players on the team. (For more from Tre, see the sidebar "A Year Later.")
CONCUSSION OR MIGRAINE?
Nolan Brewster aspired to be a Longhorn long before suiting up for his first game. The son of Tim Brewster, a former assistant coach of the team, Nolan was a hard-hitting defensive back with expert knowledge of the game. Like Tre, he had embraced the sport at an early age and was living out his dream of playing football for Texas.
Also like Tre, Nolan had a history of head injuries before stepping foot on our campus. But his medical history was quite unique. Nolan reported to our medical staff that early in his high school career, he began having migraine headaches, which seemed to occur after contact to his head. His symptoms always resolved quickly after taking a typical migraine medicine. Following each episode, he was evaluated by a physician and returned to play only after he was asymptomatic.
Eventually, Nolan's parents became increasingly concerned that his recurring migraines might actually be concussions and arranged for more in-depth evaluations with physicians who specialize in treating athletes who suffer from migraines. The evaluations resulted in a diagnosis of post-traumatic migraines--not concussions--that resulted from the hits he sustained while playing football. The medical staff here at Texas received this information and documentation upon Nolan's arrival his freshman year and we set in place a concussion management plan specifically for him.
Concussion evaluation, treatment, and return-to-play plans for an athlete who suffers from migraines should be carried out with extreme caution. It has been proven that athletes who suffer from migraines are more susceptible to concussions than their peers who do not. With Nolan's history, any time he presented with any concussion symptoms--including a headache--we approached the situation more conservatively than we would an athlete with no history of migraines.
Each of Nolan's migraine episodes was treated as a concussion until proven otherwise. Differentiation between a migraine and a concussion included type of symptoms, duration of symptoms, memory disturbance, and whether conventional migraine medicine helped alleviate the symptoms or not. During his first year on the team, Nolan had a few episodes. After each one, Dr. Pana included balance and neurocognitive assessments in Nolan's acute management plan to determine whether it was a migraine or a concussion. Some were migraines and some were concussions.
Nolan red-shirted his sophomore year due to a shoulder injury, and returned to the team last fall. Then, during a game at UCLA on Sept. 17, 2011, he sustained a hit that triggered what he believed to be a migraine. He reported it to our medical staff as such, which was typical for him to do when he felt an episode coming on. Dr. Pana took him immediately to the locker room. We knew that if it was the beginning of a migraine episode, he needed his medications promptly.
Nolan's primary symptoms included headache and visual changes. Upon further evaluation in the locker room, his symptoms quickly worsened and he began experiencing photophobia, nausea, vomiting, and memory difficulties. It became evident that this was not another migraine episode. We told Nolan that it was unlikely his symptoms were due to a migraine and informed the coaches that he had likely sustained a concussion. Either way, he would not be returning to play that day.
By the end of the game, many of Nolan's symptoms decreased significantly. We monitored him on the flight home and he was instructed to see us the next day, when he reported with a headache, slight nausea, and some mental fogginess. It was clear to our medical staff that Nolan had suffered a concussion and not another migraine episode. We initiated our concussion management plan, which began with continued daily evaluation.
The following day, Nolan began voicing concerns about his symptoms and repeated head trauma throughout his football career. As the week progressed, his symptoms began to improve but his worries about long-term effects grew. Nolan's parents expressed similar concerns and we concluded it best that he seek additional consultation.
By the week's end, Nolan's case was reviewed by a neurologist and neuropsychologist. It was clear to them that some of Nolan's more recent migraines were being triggered by less force than when he was in high school. The doctors also agreed that those episodes we had diagnosed as concussions and not migraines--including the one on Sept. 17--were indeed concussions.
The following week, Nolan was asymptomatic and his neurocognitive, vestibular, and balance test results neared his baseline scores. The recommendations from his neurology consult supported a return to play only if Nolan was asymptomatic throughout a gradual return to play progression. It was also recommended that he increase his migraine medicine dosage as a preventative measure, but with the caveat that this was certainly not guaranteed to work.
Nolan was at a crossroads. He wanted to continue playing football, but was concerned that the cost would be too great. He feared that more hits would result in a confusing downward spiral of more migraines and even worse repeated concussions. Ultimately, he feared what hitting or being hit would continue to do to his brain.
Like Tre, Nolan's concerns about continuing to play football replayed in his mind like a bad movie. Even before the last hit of his career, he already feared that this decision was coming.
Nolan's parents also shared in his struggle to solve the mystery of his post-traumatic migraines. They had lived it since his high school years and openly voiced their concerns to Nolan and our medical staff. His parents said it was his decision. They just wanted him to have all the information and support he needed to make the right choice.
Nolan came to us and said he knew what he needed to do. He was confident in his decision and that he had the support of his parents. Nolan stepped away from football and has stayed pretty distant. He still supports his teammates on the sidelines during games but does not do much else with the team. He is pursuing his degree with a medical scholarship and his time previously spent in the team meeting room or on the practice field has been replaced by his dedication to do well in school.
EDUCATION IS KEY
The decision to discontinue playing football was Tre's and Nolan's alone. Both players' parents made it clear to their sons that it was up to them and they would support them regardless of their choice. The Texas sports medicine staff also put no pressure on them either way. But what we did do was give them the resources to make a good decision.
I believe that Tre and Nolan arrived at the correct choice for them due to their education about concussions. A cornerstone of our concussion policy here at Texas, and now required by the NCAA, is an annual concussion education session that is attended by all of our student-athletes. They must acknowledge in writing that they have received proper concussion education and that they understand their responsibility to report possible concussion symptoms to our medical staff.
Listening to Tre and Nolan describe their fears about the lasting effects of multiple concussions was sobering. And listening to their parents voice concerns about their sons' futures was tough. But it was important for me as an athletic trainer to give them as much time as they needed to talk about their injuries.
Tre and Nolan each had a unique set of circumstances that brought them to their final decision to walk away from football. It was in their decision that I saw their strength. Though you could say they both had their dreams taken away from them, you could also say that they will surely have future dreams because of their choice.
Sidebar: A Year Later
The decision to stop participating in a sport you love, even if it's for health reasons, is never easy. Former University of Texas running back Nathaniel "Tre" Newton made that difficult call in 2010 after suffering a series of concussions. For many players, the most challenging part isn't the initial goodbye, but adjusting to a new life without sports. In this Q&A, Newton talks about his decision and shares advice to others going through the same transition.
AM: What was the decision-making process like for you?
Newton: It was tough. After my last concussion, the athletic training staff here explained the possible long-term effects if I were to continue playing and suffered more concussions. It was difficult to hear because I've always been around football, and it's something I'm very passionate about. But the fact that I was getting concussions more often and from hits that weren't as big had a major impact on my decision.
How long did it take you to make up your mind?
About a week. Since I'd had a number of concussions before my last one, I knew it was getting serious. I didn't think about getting hurt while I was playing, but I had been thinking about it off the field. After talking it over with my parents and the sports medicine staff, I realized that the right thing for me to do was give up the game.
How did you feel after you made the decision to stop playing?
It took me a few weeks to adjust. It was difficult to see my teammates play every week without me. The first couple of games after I quit, I was a little bitter because I wanted to be out there playing. But I had to realize that life goes on, and I had to move on and find something else I'm passionate about.
Did you find something else to be passionate about?
I was blessed to get a scholarship here at Texas, a school which offers a great education, and I'm making the most of my academic opportunities. I always knew football wasn't everything for me. I knew that even if I were lucky enough to go on to the NFL, I was going to need to get a job after that. I just graduated, and I'm staying at Texas to get a master's degree in sports management. I know I can be successful without football.
Are you still involved with the team?
Yes. I work with [Running Backs] Coach [Major] Applewhite, helping the young guys learn the scheme. Everyone here has been really supportive, and has made me feel like I'm still a part of the team. That's made it easier.
Are you still physically active?
I still lift weights, run, and play pickup basketball. I love playing sports and being competitive, so I'm going to continue to be as much of an athlete as I can.
What advice would you give to other athletes to help them adjust to life after sports?
I would encourage them to get involved in something, even if it's not their team, like other on-campus organizations. You don't want to go off and be a loner and feel sorry for yourself. After you've been playing for awhile, you get used to a schedule, so I think it's important to find something else to have in your schedule.
-- Patrick Bohn
A version of this article is being published in Training & Conditioning, a sister publication to Athletic Management.