Concussion: When Is It Time to Retire?

With the NFL preseason underway, Barrow Neurologist Dr. Javier Cárdenas explained the factors that go into recommending retirement for an athlete who has had multiple concussions and discussed the role neurologists play in making sports safer for athletes at all levels.

The American Academy of Neurology defines a concussion as a trauma-induced alteration in mental status that may or may not include a loss of consciousness. The Glasgow Coma Scale is the most common scoring system used to determine whether a brain injury is mild (a concussion), moderate, or severe.

Other concussion symptoms include a vacant stare, delayed verbal or motor responses, disorientation, slurred speech, incoordination, and memory deficits.

“Nobody thinks that any concussion is good for you,” said Dr. Cárdenas, who created the Concussion and Brain Injury Center at Barrow, “but the question is: how many are too many in order to participate in athletic activity?”

Photo of phoenx concussion doctor javier cardenas

Dr. Javier Cárdenas
Barrow Neurologist

Dr. Cárdenas said there is a common belief that the magic number is three. This stems from a study in the 1980s, which stated that an athlete should be removed from contact sports for the remainder of the season if he or she has had three concussions that involved a loss of consciousness for any period of time. However, the study noted that there was no scientific validity to support that approach.

“What we really try to do is build a framework to make a recommendation as best we can instead of just throw out a number of injuries,” Dr. Cárdenas said. “We look at as much objective data as possible. Based on the objective data, what do we see and how can we make that recommendation for their health?”

Dr. Cárdenas may recommend an athlete retire if he or she has persistent postconcussion symptoms, a traumatic intracranial abnormality, an abnormal neuropsychological evaluation, concussion symptoms with decreasing impacts, or a pattern of prolonged recovery. Regardless of what the athlete’s evaluation shows, Dr. Cárdenas also asks the athlete whether he or she wants to continue playing the sport.

“We never want to talk an athlete into participating in a sport in which they can be injured,” he said.

Dr. Cárdenas said the role of neurologists in the field of brain injuries goes beyond treating individual athletes; they also work to make sports safer in general.

“One way to do this is to get involved in things like legislation,” he said. “In our state, we had the opportunity to draft legislation that was going to educate kids about concussion, remove them from play in the event of a concussion, and allow them to return only after an evaluation by a professional.”

Dr. Cárdenas said Arizona was the first state to recommend a policy requiring athletes to go to the sidelines if their helmets are dislodged. He said that following this recommendation, the number of helmets dislodged during games dropped by more than 80 percent in a matter of weeks. The following year, the National Federation of State High School Associations (NFHS) made recommendations to adopt Arizona’s policy.

What we really try to do is build a framework to make a recommendation as best we can instead of just throw out a number of injuries.

-Dr. Javier Cárdenas, Barrow Neurologist

In 2013, there were recommendations to limit the amount of contact practices in football to no more than one-half of practice time during the preseason and no more than one-third of practice time during the regular season. This applied to padded athletes in contact with each other. The NFHS later recommended that all state associations limit the amount of contact practices.

To educate high school athletes about concussions, Barrow launched Brainbook in 2011. The online program is mandated by the Arizona Interscholastic Association, making it the nation’s first mandated education and testing module for student athletes.

The Barrow Concussion Network provides Arizona high schools with access to computerized assessment tools, statewide concussion research, and concussion consultation through telemedicine.

Barrow also provides consulting services at the collegiate and professional levels by having neurologists available on the sidelines during games, including the Super Bowl.

“This is where we’re involved,” Dr. Cárdenas said. “We’re not necessarily criticizing the sports but trying to work to make them safer.”

Watch Dr. Cárdenas’ presentation here.

About Barrow Neurological Institute
Since our doors opened as a regional specialty center in 1962, we have grown into one of the premier destinations in the world for neurology and neurosurgery. Our experienced, highly skilled, and comprehensive team of neurological specialists can provide you with a complete spectrum of care–from diagnosis through outpatient neurorehabilitation–under one roof. Barrow Neurological Institute: Discover. Educate. Heal.