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On 2/23/09, an article entitled Being of sound mind and body, Koskie returns to the diamond was written by Jim Souhan of the Star Tribune in Minnesota. The article discusses the return of former professional baseball player, Corey Koskie to the Canadian Team for the World Baseball Classic.
The article discusses how Koskie fell backwards and hit his head in on 7/5/06 while chasing a pop-up and how he had been dizzy and “sick” when exercising for the next two years. The article does not provide enough information to determine if a concussion occurred during the fall. For the sake of argument, however, let us assume there was a genuine alteration in mental status reflecting a mild traumatic brain injury (concussion). Is there evidence to support that such an injury alone would cause two years of persisting symptoms? No, there is not. Thus, there was a good reason why many of his doctors were mystified. As McCrea (2008) summarizes nicely in his widely acclaimed book on mild TBI, symptoms from concussion should resolve by a week to several months post-injury at the most (particularly in sports players) based on numerous prospective research studies that follow concussed patients with assessment measures from pre-injury to multiple post-injury dates. As McCrea also points out, when symptoms become chronic and persistent, non brain-injury related factors are typically the explanation.
To make it clear to all who read this, I never evaluated Mr. Koskie and am not offering any type of diagnosis in his case. However, it is worthwhile to highlight some aspects of the case that are available for educational purposes. First, questions can clearly be raised as to whether other factors contributed to his persisting symptoms besides brain injury. Given the nature of the injury, in which he fell backwards on his head, a neck injury would not be uncommon. Neck injuries, cervical strains, or whiplash injuries as they are sometimes called can cause symptoms that are literally identical to what some label as “post-concussion syndrome”. This is a fundamental error I see repeated over and over, in which neck injuries are ignored and all symptoms are attributed to brain injury. A perfect example is dizziness, which is a common symptom of neck injuries (Anderson, 2001) but is also reported by concussed patients. The main point is that all “post-concussive” symptoms are actually non-specific and are seen in a plethora of conditions besides concussion. The article actually supports the notion that a neck injury played an important role in symptom persistence because it was not until Mr. Koskie went to a neck specialist who provided treatment for neck problems that he stated he was able to return to the baseball field. If this is accurate, it is a good illustration of why the term “post-concussion syndrome” is misleading because it implies that brain injury is the cause of all of persisting symptoms (which is opposite of what the research literature supports).
Mr. Koskie claims to know more about concussions than many of the physicians he has seen including those who staff professional sports teams. However, to clarify a statement attribute to him in the article, physicians are not managing concussions based on guidelines from 1982. In actuality, most physicians and neuropsychologists rely on the Prague guidelines (McCrory et al., 2005) which are fairly conservative and advise not returning a concussed player to sports until symptom free under various conditions.
Lastly, Mr. Koskie expressed dismay that some physicians questioned whether or not he truly wanted to return to play. While his frustration is understandable, especially if he truly wanted to return to baseball, it is important for the public to know that such considerations (e.g., assessment of motivation and psychological factors such as depression) are the job of the health care provider evaluating such cases where there is persistent symptom reporting after a concussion (or suspected concussion).
In the late 1990s and early 2000’s, Mr. Koskie’s career was at its zenith, culminating in him signing a three-year, $17.5 million contract with the Toronto Blue Jays on 12/14/04. However, he was plagued by injuries in 2005 and was thus not able to live up to the expectations of the contract. His productivity and playing time diminished significantly, as evidenced by his individual statistics compared to prior years. On 1/6/06, he was traded to the Milwaukee Brewers for a little-known pitcher, which was widely viewed in the sports community as a salary dump for the Blue Jays. One would naturally assume that this must have been difficult to deal with since he had recently been the marquee free agent signing of the team that had just traded him. He had guaranteed money ($11.6 million) in his contract for 2006 and 2007, which was paid out regardless of whether he played. Having never evaluated Mr. Koskie, I cannot say one way or the other whether these factors played any role in why he did not return to baseball for so long. However, these points are mentioned here because the public should be aware that it makes all the sense in the world for those who evaluated him to assess for the role that motivation, psychological factors, and social factors may play in persisting symptom reporting. This is because the research literature has repeatedly demonstrated that these issues can contribute significantly to persistent symptom reporting after concussion (see McCrea 2008 for a discussion of this, with references).
REFERENCES
Anderson AV. (2001) Cervicogenic processes: results of injury to the cervical spine. Pain Practitioner, 9-11.
McCrea, M. (2008). Mild traumatic brain injury and postconcussion syndrome. The new evidence base for diagnosis and treatment. New York: Oxford University Press.
McCrory et al. (2005). Summary and Agreement Statement of the 2nd
International Conference on Concussion in Sport, Prague 2004. Clin J Sport Med, 15, 48-55
Dr. Carone offers paid lectures on MTBI, “post concussion syndrome,” and symptom validity testing upon request. He can be contacted at info@mtbifacts.com.
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