By Carl Valle
Concussions are a big problem in sport, and as the speed of the game evolves, so does the risk of having a traumatic brain injury (TBI). Lately, most of the articles I have seen on managing sport concussions have been fragmented and very disappointing. Year after year, the problem with concussions has been painfully explained, usually in the form of a dry PowerPoint with a medical professional reading off of the slides.Concussion management is now the new normal for those involved in sports. Click To Tweet
This past March was different. I witnessed the best sport concussion presentation I have ever seen and feel it’s important to share what I learned. If you are involved with sports, concussion management is now the new normal. Even if it’s not a topic you think you need to know, the fascinating and useful information is worth your time to read.
Why Concussion Management Can Help Outside of Traumatic Brain Injury
The concussion crisis is real, and it’s going to take everyone involved in sport to help athletes either get better or, if possible, not get a traumatic brain injury at all. Years ago, concussions were not understood or recognized as a serious injury, but now we are more informed that the long-term effects are real. Athletes are committing suicide and are permanently damaged because of concussions, so it’s time to do something constructive instead of just talking about it.
Most of you reading this article will be looking for better ways to help athletes with concussion management and/or looking at how managing concussions can help with other areas of performance and recovery. Just seeing how a great process works with managing a concussion can help any coach think about the way they run their training preparation. While this is technically a rehabilitation article, view it as a training article. I know I learned how to better apply the science and latest information for concussions, but viewing the outline for managing the injury and thinking big picture really pushed me to reevaluate what I am doing overall to manage athletes in general.
The Origin of the Information – The Holy Cross Sports Performance Seminar
While I have kept abreast of the information on this list for years, nobody did a better job explaining it and making it resonate than John Pallof. Unless you have been under a rock for the last 10 years, the Pallof Press—an exercise used to strengthen the core—is most likely the reason his name looks familiar. I have known of John for over a decade and have used his services, and he is simply world-class. What I like most about him is that he is a straight shooter and a phenomenal communicator with both athletes and coaches.
I listened to John’s presentation for about an hour that Saturday morning, and it clicked so well, I knew I would not be alone. I decided a few days after the presentation to write a review to highlight his talk, but not replace the content of his discussion. Honestly, my primary goal is to expose people who don’t grasp the nature of the injury to the key principles of managing it, and make sure those not appreciating the severity of the problem still value the management process.
I have witnessed many botched rehabilitations in horror and have seen the ugly side of things for too long. If we are going to save American football and provide a better future for other sports, we can’t just hope that the problem will resolve on its own. If you want to make a difference, big or small, this list can serve as a guide to taking action.
Some of the recommendations will diminish the severity or limit the damage of TBI, but prevention is likely going to come in the form of rule changes and athlete skill development. The most common example of this is with American football and tackling. We see athletes playing faster, but also tackling with less fundamentals. Soccer development has also changed, with less exposure to heading the ball at the youth level.
Still, in order to reduce the risk of concussions the body needs to dictate forces, and that comes from preparation. While specific neck training may not be a miracle cure, it is fascinating that the No. 1 option for physical preparation is stiff neck training. A stronger and prepared neck isn’t going save football or reverse the problem, but it will definitely help athletes reduce the risk of a second injury and possibly make a significant difference in the first one.
The research states that a relationship exists with both neck strength and the risk of future concussions. Now I don’t know how specifically a prepared neck reduces injury from an exact biomechanical perspective, but the neck is wonderfully prepared to reduce shock in running with the nuchal ligament and an impressive set of muscles around the spine to brace impacts. I wish this article could go into neck training, but I would rather see the profession allot more to the preparation of the upper spine than hog so much time near the lower spine. Core training is always going to have some gray areas, but if we can be far more evidence-based while being creative, maybe it can help reduce injuries to the gray matter.
We should consider two essential points with a clinical diagnosis: one is baseline and the other is a proper assessment of athletes. Most coaches will think about a medical doctor inspecting an athlete after they become unconscious, but the real problem is when an athlete is injured during a game and doesn’t realize it or masks the injury to keep playing. This means we all, even as fans, need to be a watchdog to injury. You don’t need expertise to point out plenty of types of injuries, and sideline observation is far more important than routine clinical diagnosis.
Baseline data means a neurological examination or testing done before a season. Notice I said “before the season” rather than “before the injury.” Countless times, just doing routine baseline testing exposes a past injury or possible past injury. To me, baseline testing is just as important as getting a clinical diagnosis after the injury, as plenty of athletes experience problems and need to either be further supported or out of the sport entirely. Nobody likes having an athlete leave a game, but for some reason a bad knee or spine injury is more forgivable than trauma to the brain.Baseline testing before the season is as important as getting a clinical diagnosis after the injury. Click To Tweet
One final suggestion with evaluation: Make sure you go to a qualified specialist who understands sport. A general practitioner is not good enough, as they know more about the promotion of health than sport performance and rehabilitation. There are plenty of specialists available, but see a medical professional, not a guru.
If an injury occurs, the rehab calendar depends on the athlete’s brain, not a game schedule. This is the most complicated and difficult part of sport—the management of politics rather than the management of the brain of the player. Progression is beyond incremental loading; progression is also an emotional journey back to the game and life. While an athlete will forever feel some injuries, like the restriction that seems to linger in an ankle after several sprains, the brain is involved with everything. Instead of thinking about ways to move forward by pushing the athlete incrementally, treat the rehab like a flowing river and just try to remove barriers to the natural recovery rate.
When athletes started using alcohol to sabotage baseline testing with neurological technology 10 years ago, the data simply wasn’t helpful on the return-to-play process. Progression isn’t necessarily about reaching previous levels or incrementally improving to a standard; it’s about small successful steps forward. Again, with brain injuries it appears that athletes need to pass clinical evaluations as well as be able to participate fully without setbacks and rushed schedules.
John Pallof looked at two roads that teams should be aware of, the obvious brain injury and the likely neck therapy. If I had to summarize his presentation, it’s that recovery from a TBI is really about rehabilitation of a traumatic person injury rather than one or two organ systems. A massive blow to the head likely has other collateral damage, so treating the entire event as a total person injury is better than just thinking about healing the brain over time.Recovery from a TBI is about rehab of a traumatic PERSON injury, not just an organ system –Pallof. Click To Tweet
One of John’s strongest talents is his vision for progressing athletes and making rehabilitation actionable. When the rubber hits the road, John ensures the athlete doesn’t skid in place—he moves them forward with the most logical next step. It’s easy to progress exercises from conventional variables, such as simple to complex or slow to fast, but having them blend in harmony is a different ball of wax.
We currently see some opposing points of view with early stage concussion treatment. While everything is individualized and should support the athlete and how they respond, they need an overall strategy to put them on the road to discharge and success. Some athletes need dark and quiet environments, others need stimulation that is healthy and progressive, and some others might be in need of more emotional support. Remember, we are still early days in knowing all of the body’s reactions after a TBI, so what we have in place now will likely change and expand differently. If you are not ready for concussion treatment today, imagine the advancements in 10 years.
The biggest takeaway I got was the need to address specific light sensitivity and general input. Smartphones are part of the challenge, but unplugging isn’t about turning off the phone—it’s throttling down all sensory information. Some sports are experimenting with float tanks like those used by the Navy Seals, but the other side of the coin is not shutting down all inputs but letting the right ones come in at the right time and the right speed.
Progression is also about filtering noise and cancelling the negative signals, not just stopping all outside inputs. The brain may need some noise (indirect signals) for stimulation to heal, and that can even be daydreaming and meditation.
We still don’t understand brain regeneration, and science is finding that the brain heals from more than just time. For example, walks outside that are at a healthy threshold may be more than just getting forest bathing in—they could be stimulating growth. I am looking at BDNF and outdoor training now, as concussions could see a change in recovery from being in a polarized living condition of deep rest and active exercise. Time will tell if this is just good on paper or a pioneering change.
Monitoring athletes is an instrumental part of progression, and it is both subjective and objective. Earlier in the progression discussion, I wanted to share the details of incremental loading and improvement, but without monitoring it would have been difficult to be both clear and detailed. When I use the word “monitoring,” most coaches quickly think about heart rate variability and GPS systems, but good monitoring could be just paying attention and communicating that information later. Sure, technology makes things easier and more automated, but without a plan, it’s just collecting data to appear innovative and relevant.
Measurement, from the weight of a dumbbell all the way to the genetics of an athlete, is a spectrum of responsibility for coaches today. Monitoring may just be vigilance in looking for signs and symptoms during training, as even just doing that isn’t easy today. Monitoring works both ways, as the athlete has to be responsible and honest with the subjective information they share. Giving inaccurate information to the staff isn’t helping the team, because a neurologically compromised player is just like a player limping around with a bad leg when you need them to perform at their best.
There are several technology solutions that show the progress of the reflexes and motor functions of the brain, but nothing beats a great system of quantified training. Great training has a natural way to observe progress, and each stage of progression can be monitored easily for benchmarking improvement. Right now we see a lot of efforts to quantify readiness after a concussion, such as various treadmill protocols like the Buffalo Protocol and recent work with the HiTrainer by Central Michigan. However, we need more research here to ensure coaches provide more than maximal performance testing with return to play.
Sleep is perhaps more important to concussed athletes, so if your athletes are not sleeping well to begin with, they are in double jeopardy. I know nearly every coach values the importance of sleep, but athletes are very human and sleep is in a tug of war with the fun that happens after midnight. Mentally, it is hard to be in “Monk Mode” during a long season, with the temptations of the road and the natural urge to unwind and have a little mental break from the pressures of the game. It seems like every coach is an expert on sleep, but athlete compliance isn’t keeping pace with the research and education.
Simply put, we all likely know how important sleep is, but the gap is not yet closed for athletes also valuing that importance. Telling a student athlete to go and get sleep when they are trying to get into a better college or graduate with honors is tough, as most are not going to be a pro athlete. In the pros, the compliance is worse because they are empowered from athlete union contracts and have more time and money to enjoy the nightlife.
It isn’t easy to move on from describing the problems of sleep and the athlete to solving the sleep challenge, but I have learned that focusing on education and sleep monitoring is the only way to truly know if the advice is translating to better outcomes. Talking to athletes and sharing the values of sleep is emotionally satisfying to coaches because it feels good to address a problem, but without measurement and knowledge of the results, it is an incomplete solution.
Talk is cheap, and many relationship-building methods don’t hold water because they have no feedback loops. Without taking the next step to objectively evaluating progress, all the education and soft skill talking is just noise. I used to believe that having a strong relationship with an athlete was enough, but false trust happens because the athlete is not accountable to themselves without a clear summary of what they are actually doing with sleep.We all know sleep is recovery, but it needs to be a priority like physical rehabilitation. Click To Tweet
The good news is that I have seen athletes starting to realize that sleep is more than just recovery, and not getting shut-eye is like smoking—in the long run, hazardous to their health. Concussions may impair sleep later after the injury, and then the vicious cycle of impairment begins as recovery needs sleep to manage waste products. All of the same ways to support uninjured sleep can usually help concussed athletes, and sometimes it takes a TBI to buy into disciplined sleep. A simple takeaway is that we all know sleep is recovery, but if you don’t make it a priority like physical rehab, you are only solving half the equation.
The last strategy on this list is one that should be easy to implement. If you play sports, you should supplement with Omega-3s and several other nutrients daily, without question.
During the presentation that John Pallof led, he also elaborated on magnesium, which is a very important mineral for the body. I outlined why testing magnesium status is tricky, but his recommendation of taking the supplement in the morning and at night was smart for two reasons. The first is somewhat known: Magnesium, if taken in a large dose, can cause loose stools. The second is less known: Athletes might respond to magnesium better hormonally than to zinc. Magnesium is not just for electrical functions of the nervous system; it’s a major part of the chemical reactions that occur throughout the body.
Two performance food nutrients that mingle with the brain’s biochemical and organ health are coffee and creatine. While nothing of real note is known about concussions and brain health outside of correlative studies on disease and general benefits to the brain, I do think it makes sense to consume these two nutrients for good measure. We should consider countless other nutrients that help brain function as well, as it’s unknown whether stacking other brain health supplements creates a synergistic interaction and either amplifies the other nutrients or adds on other benefits to the brain and nervous system.
Another disturbing issue that nobody talks about is the massive amount of prescription drugs athletes are on. While psychiatric medications can be argued for, many athletes are on unnecessary health medications like we see in with senior populations. I am not accusing the medical community of overprescribing medications, but I do think we are in an age where more information is not always helpful unless there is a process to manage the decision-making tree smarter.
Get Educated and Start Helping
Don’t put concussion management as part of a to-do list—cut the line and make it a priority. I have seen some horror stories and know the suffering firsthand, but like many coaches, I didn’t know the severity of the problem. I didn’t write this article as a how-to piece, as I am not qualified to do that, but I do think it provides an important list of things to think about when working with athletes.Don’t just put concussion management on your to-do list—cut the line and make it a priority. Click To Tweet
The sooner you get experienced with internal or external concussion education, the more you can make a difference. Personally, I can’t do as much as I wish, but the new generation of performance coaches are now equipped to make a bigger difference than ever, and it’s our responsibility to make sure we drive change.