Following their team's meltdown last season after Jay Cutler was sidelined with a thumb fracture, Chicago Bears fans are sure to be holding their collective breath as they await their signal-caller's return.
Fortunately, the situation this year is very different. But that doesn't mean it is any clearer.
Sunday night, Jay Cutler suffered a concussion at the hands of Houston Texans linebacker Tim Dobbins. Dobbins made a helmet-to-helmet hit on Cutler, an infraction for which he was fined $30,000 by the NFL (via ESPN.com).
Four days later, ESPN Chicago reports that, even though Bears head coach Lovie Smith states that his QB is "getting better," it remains unclear if Cutler will be able to start for the Bears' Week 11 matchup against another elite NFC squad, the San Francisco 49ers.
How can that be?
Simply put, concussions are not just a "brain bruise." They are injuries that result in very complex changes within the brain itself. When an athlete is hit in such a way that his or her head decelerates very quickly (such as his or her head hitting the turf or during helmet-to-helmet contact) the skull stops.
But the brain keeps moving.
What results is similar to the following comparison, as described by a former head team physician for a Division I university:
Take a bowl of Jello.
Now shake the bowl back and forth.
The bowl is the skull, and the Jello is the brain.
Pretty scary, right?
In the most basic sense, the shaking "stuns" the brain, and the following occurs as a result, among other changes:
1. The brain enters a state of decreased metabolism, meaning its maximum fuel-burning capabilities are decreased.
2. Blood flow to the brain is decreased (the reasons behind this change remain a mystery to the medical community).
In other words, the brain gets less fuel, and its ability to burn this fuel is decreased, as well.
This causes the many symptoms of concussions, which include (but certainly not limited to) headache, nausea, sensitivity to light, sensitivity to sound, difficulty concentrating and confusion.
These symptoms usually show up right away following the injury, and on multiple occasions, the TV cameras caught Cutler shaking his head from side to side, trying to shake off the symptoms he was experiencing immediately following Dobbins' tackle.
Concussion symptoms resolve with time (with very, very few exceptions). Once they do, athletes begin undergoing testing to determine if they can be cleared to return to competitive play.
The testing protocol is as follows:
1. No symptoms for 24 consecutive hours.
2. Symptoms do not return with light activity (swimming, biking).
3. Symptoms do not return with sport-specific activity (for example: running in soccer and football, skating in hockey).
4. Symptoms do not return with non-contact practice.
5. Symptoms do not return with full practice.
Each test is 24 hours long. If the athlete passes all five tests, he or she can return to competitive play. If symptoms return at any step, the athlete is rested for 24 hours and then resumes the testing at one level below where he or she was when symptoms returned.
What is the reasoning behind this testing schedule?
As mentioned, concussions decrease blood flow to the brain for unknown reasons. Yet, during exercise, blood flow to the muscles in the body increases. This means that during exercise, less blood is available for the brain.
This is not a problem for a healthy athlete, but for a concussed athlete, it can bring on symptoms.
Can the Bears win in San Francisco on Monday without Cutler?
If an athlete can maintain full exercise without symptoms returning, meaning blood flow and fuel supply to the brain is back to normal, their brain has healed.
This slow, stepwise process is lengthy. But it is necessary. Stressing a brain that is not yet healed can delay the process and worsen symptoms. Sidney Crosby is the unfortunate example of such a scenario.
It is safe to say that Cutler is somewhere in the middle of the testing protocol. However, given the five-day structure of testing and the possibility that an athlete may have to take a step or two back vis-a-vis symptoms, it is impossible to predict when Cutler will be ready.
In addition, each athlete recovers from concussions at their own rate.
Once it is clear that Cutler will not be able to complete step five before Monday night, the Bears will likely announce that Jason Campbell will be under center against the 49ers.
Time will tell.
The author of this article is a soon-to-be Family Medicine resident physician with plans to specialize in Primary Care (non-operative) Sports Medicine. He has been fortunate enough to work extensively with several concussion specialists and Sports Medicine physicians that have worked or are currently working with NFL players. The information discussed herein is based on the author's personal research and clinical experience in the evaluation and treatment of concussions under the direct supervision of these physicians and specialists, and it can be confirmed by the International Consensus Statement on Concussion in Sport. Additional input is welcomed and encouraged.