Concussions in sport
The examples and perspective in this article deal primarily with the United States and do not represent a worldwide view of the subject. (March 2013) (Learn how and when to remove this template message)
Concussions, a type of traumatic brain injury, are a frequent concern for those playing sports, from children and teenagers to professional athletes. Repeated concussions are a known cause of various neurological disorders, most notably chronic traumatic encephalopathy (CTE), which in professional athletes has led to premature retirement, erratic behavior and even suicide. Because concussions cannot be seen on X-rays or CT scans, attempts to prevent concussions have been difficult.
The dangers of repeated concussions have long been known for boxers and wrestlers; a form of CTE common in these two sports, dementia pugilistica (DP), was first described in 1928. An awareness of the risks of concussions in other sports began to grow in the 1990s, and especially in the mid-2000s, in both the medical and the professional sports communities, as a result of studies of the brains of prematurely deceased American football players, who showed extremely high incidences of CTE (see concussions in American football).
As of 2012, the four major professional sports leagues in the United States and Canada have concussion policies. Sports-related concussions are generally analyzed by athletic training or medical staff on the sidelines using an evaluation tool for cognitive function known as the Sport Concussion Assessment Tool (SCAT), a symptom severity checklist, and a balance test.
- 1 Dangers
- 2 Incidence
- 3 Policies
- 4 Concussions in other sports
- 5 Female sports
- 6 Prevention efforts and technology
- 7 Media coverage
- 8 See also
- 9 References
Concussion symptoms can last for an undetermined amount of time depending on the player and the severity of the concussion. A concussion will affect the way a person's brain works.
There is the potential of post-concussion syndrome, defined as a set of symptoms that may continue after a concussion is sustained. Post-concussion symptoms can be classified into physical, cognitive, emotional, and sleep symptoms. Physical symptoms include a headache, nausea, and vomiting. Athletes may experience cognitive symptoms that include speaking slowly, difficulty remembering and concentrating. Emotional and sleep symptoms include irritability, sadness, drowsiness, and trouble falling asleep.
Along with the classification of post-concussion symptoms, the symptoms can also be described as immediate and delayed. The immediate symptoms are experienced immediately after a concussion such as: memory loss, disorientation, and poor balance. Delayed symptoms are experienced in the later stages and include sleeping disorders and behavioral changes. Both immediate and delayed symptoms can continue for long periods of time and have a negative impact on recovery. According to research, 20-25% of individuals who have sustained a concussion experienced chronic, delayed symptoms.
Playing through concussion makes people more vulnerable to getting hit again, and that is why most sports have test that trainers will perform to prevent getting hit a second time. A second blow can cause a rare condition known as second-impact syndrome, which can result in severe injury or death. Second-impact syndrome is when an athlete suffers a second head injury before the brain has adequate time to heal in between concussions.
It is estimated that as many as 1.6-3.8 million concussions occur in the US per year in competitive sports and recreational activities; this is a rough estimate, since as many as 50% of concussions go unreported. Concussions occur in all sports with the highest incidence in American football, ice hockey, rugby, soccer, and basketball. In addition to concussions caused by a single severe impact, multiple minor impacts may also cause brain injury.
|Sport||Injury rate per 1,000 athletic exposures|
|Women's ice hockey||0.91|
|Men's spring football (American)||0.54|
|Men's ice hockey||0.41|
|Men's football (American)||0.40|
|Women's field hockey||0.18|
Major League Baseball
Major League Baseball's (MLB) policy was first started in 2007, and injured players are examined by a team athletic trainer on the field. On March 29, 2011, MLB and the Major League Baseball Players Association announced that they have created various protocols for the league's concussion policy. The new policy includes four primary components:
- All teams are to run baseline neurocognitive testing for all players and umpires using the ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) system during spring training or after a player signing.
- If a player sustains a concussion, or is suspected to, play is stopped and the player’s injury is assessed.
- A Certified Athletic Trainer (ATC) can evaluate and treat a player during a game.
- If the trainer seems that the player has sustained a concussion and seems that it is necessary, he or she can remove the player from the game and move to the clubhouse for further evaluation.
- The Team Physician may also evaluate the player in the clubhouse. Player completes the SCAT3(Sport Concussion Assessment Tool, version 3)form in the clubhouse. If the player seems to not have sustained a concussion, he can return the game.The trainer can then evaluate the player throughout the entirety of the game after the injury occurs. If the player is thought to have a concussion, the team, the trainer, and team physician can determine whether to place the player on the 7-day or 10 day injured List (IL).
- If a player on a 7-day concussion IL is still unable to return to play after nine days, he is automatically transferred to a 10-day IL.
National Basketball Association
The National Basketball Association (NBA) does not have a policy, and team procedures after concussions vary by team. The NBA has a meeting to educate the players each year about concussions. Players also go through a neurological and cognitive assessment after each season.
- After the player is diagnosed with a concussion, he is removed from the game immediately and monitored to ensure his safety.
- Following 24 hours, the player may then begin the return-to-play process, provided they have not shown any symptoms. The NBA player must then complete a series of exercises of increasing difficulty and display that he is at his baseline testing and without concussion symptoms after each test.
- First the player must complete a workout on a stationary bike, then jogging, then agility drills, then non-contact team drills. After completing each step, the player will undergo testing and must not present any concussion symptoms to advance to the next activity.
- If the player experiences any symptoms while doing these activities, he is shut down for the day. He will pick up with the last activity he completed the next day.
- After completing the concussion protocol activities, the team physician meets with the director of the NBA Concussion Program, Dr. Jeffrey Kutcher, before clearing the player to play.
- There is no set timetable for the concussion protocol. It can be completed very rapidly in nature or take a few weeks. Ultimately, it depends on the player and what type of symptoms he is experiencing. For example during Game 2 of the 2016 NBA Finals on June 5, 2016, Kevin Love was placed in the NBA Concussion Protocol.
National Football League
The National Football League's (NFL) policy was first started in 2007, and injured players are examined on field by the medical team. The league's policy included the "NFL Sidelines Concussion Exam", which requires players who have taken hits to the head to perform tests concerning concentration, thinking and balance. In 2011, the league introduced an assessment test, which combines a symptoms checklist, a limited neurological examination, a cognitive evaluation, and a balance assessment. For a player to be allowed to return, he must be asymptomatic.
If a player is cleared by the Unaffiliated Neurotrauma Consultant (UNC), then they will be allowed to play but will be monitored closely throughout the game. If a player is diagnosed with a concussion, then that player is not allowed back in the game. A return to play process is issued, which includes five steps, “1. Rest and recovery 2. Light aerobic exercise 3. Continued aerobic exercise/strength training 4. Football specific activities 5. Full football activity/clearance” 
Almost every team has experienced a player who will “keep playing, then manage to stumble off the field, unnoticed by the coaches, cameras or press. He might take a breather for a series or two. But he can walk, so he wants to play. He gets back in the game and back to his teammates.” 
According to Johns Hopkins University, a study took place which “researchers recruited nine former NFL players who retired decades ago and who ranged in age from 57 to 74. The men had played a variety of positions and self-reported a wide range of concussions, varying from none for a running back to 40 for a defensive tackle." 
National Hockey League
The National Hockey League's (NHL) concussion policy began in 1997, and players who sustain concussions are evaluated by a team doctor in a quiet room. In March 2011, the NHL adopted guidelines for the league's concussion policy. Before the adoptions, examinations on the bench for concussions was the minimum requirement, but the new guidelines make it mandatory for players showing concussion-like symptoms to be examined by a doctor in the locker room.
Dr. Paul Echlin and Dr. Martha Shenton of Brigham and Women’s Hospital and other researchers, conducted a study where “Forty-five male and female Canadian university hockey players were observed by independent physicians during the 2011-12 season. All 45 players were given M.R.I. scans before and after the season. The 11 who received a concussion diagnosis during the season were given additional scans within 72 hours, two weeks and two months of the incident. The scans found microscopic white matter and inflammatory changes in the brains of individuals who had sustained a clinically diagnosed concussion during the period of the study.” 
— NHL Commissioner Gary Bettman
Many children and teenagers participate in sports and extracurricular activities that create a risk of a head injury or concussion, including basketball, cheerleading, soccer, and football. As a consequence, schools and youth sports groups should implement programs to reduce the risk of concussion, ensure prompt diagnosis and provision of medical care, and that young participants are not endangered by a premature return to sports.
In 2010, more high school soccer players suffered concussions than basketball, baseball, wrestling, and softball players combined, according to the Center for Injury Research and Policy. According to a study in the JAMA Pediatrics medical journal, many girls do not get necessary care and prevention regarding concussions, and 56 percent of players (or their families) reporting concussion symptoms never sought treatment.
A growing topic is concussions in girls' soccer, predominantly among high-school girls. Studies show that girls are reporting nearly twice as many concussions as boys in the sports that they both play. The number of girls suffering concussions in soccer accounts for the second largest amount of all concussions reported by young athletes.
This study was performed to compare the clinical recovery patterns after sport-related concussions for high school and collegiate athletes. It was important for them that these findings help us get a better understanding of how developmental factors influence the response to and recovery after different levels of play. Determining if college or professional athletes are more resilient to concussive injury on average than more heterogeneous high school samples.
The study was performed with Division 1, 2, and 3 football players at 15 universities across the United States. Then there was project sideline that followed football, hockey, and soccer players in Milwaukee, Wisconsin. They also looked at male and female high school and collegiate athletes mostly in southeaster United States. For every athlete they did a preseason baseline testing to see if anyone had a concussion already. They conducted these tests in the athletes’ schools in classrooms or other quiet indoor settings. All the athletes were individually proctored by the trained research assistants.
From this study they concluded that the collegiate athletes were older, taller, and heavier and have played their sport for more years then the high school athletes have. The high school group had more concussions and a higher proportion of females then the collegiate or control samples did. They had a total of 621 concussed athletes and 150 non-injured controls. They found little evidence that there were different rates of clinical recovery from the concussions between the high school students and the collegiate athletes. They saw that for the collegiate players that the elevated symptoms through day 5 of post-injury resolved by day 7. The high school athletes took 1–2 days longer to recover, but they both showed rapid recovery within the few days of the injury. The high school athletes did have more severe concussions though.
The information that the authors give are relevant to only people who play sports at the high school or college level. This information would not benefit someone who does not play sports or does not get concussions often. They were testing to see what the effect of the concussions had on these athletes and how they recovered from them. This information could also be good for coaches and parents to know as well.
Limitations they could have had for this experiment would be if the majority of the team’s players were injured or if none of them have ever had concussions or no one got concussions from their sports. I don’t think there was any data missing that they didn’t tell us about in their report. Other limitations that may have existed in this study was if a player already had a concussion and continued to play contact sports and did not let it heal that would be disrupting their data that they are looking for.
|League||Year policy first introduced||Year baseline testing occurred||Year current policy became effective||First step after injury||Person who approves/denies player to return||Person who decides player return|
|NFL||2007||2008||2009||Evaluation by medical team||Medical staff||Medical staff/Consultant|
|MLB||2007||2011||2007||Evaluation by an athletic trainer using National Association Guidelines||Medical staff||Head physician/Medical director|
|NBA||Never||Never||Never||Depends on team||Depends on team||Depends on team|
|NHL||1997||1997||2011||Neuropsychological evaluation by team doctor off rink||Team doctor||Team doctor|
|MLS||2011||2003||2011||Evaluation by medical team||Team physician||Team physician/Neuropsychologist|
|NASCAR||2003||2003||2003||Ambulance to infield care center||NASCAR||NASCAR|
Concussions in other sports
American football causes 250,000 concussions annually, and 20% of high-school football players experience a concussion every year. In 2000, researchers from the Sports Medicine Research Laboratory at the University of North Carolina at Chapel Hill analyzed 17,549 players from 242 different schools. 888 (5.1%) of the players analyzed have at least one concussion a season, and 131 (14.7%) of them have had another concussion the year later. Division III and high-school players have a higher tendency to sustain a concussion than Division II and Division I players. In 2001, the National Football League Players Association partnered with the UNC to determine whether professional football players suffer any health effects after any injuries, although the findings were criticized by the NFL for being unreliable due to being based on self-reporting by the players.
Association football— also known as soccer— is a major source of sports-related concussions around the world. Even though 50-80% of injuries in football are directed to the legs, head injuries have been shown to account for between 4 and 22% of football injuries. There is the possibility that heading the ball could damage the head, as the ball can travel at 100 km/hour; although most professional footballers have reported that they experienced head injuries from colliding with other players and the ground. A multi-year study by the University of Colorado published in JAMA Pediatrics confirmed that athlete-to-athlete collisions that occur during heading, not impact with the ball itself, is generally the cause for concussion.
A Norwegian study consisting of current and former players of the Norway national football team found out that 3% of the active and 30% of the former players had persistent symptoms of concussions, and that 35% of the active and 32% of that former players had abnormal electroencephalogram (EEG) readings.
During the 2006-07 English Premier League season, Czech goalkeeper Petr Čech suffered from a severe concussion in a match between his club Chelsea and Reading. During the match, Reading midfielder Stephen Hunt hit Čech's head with his right knee, knocking the keeper out. Čech underwent surgery for a depressed skull fracture and was told that he would miss a year of playing football. Čech resumed his goalkeeper duties on January 20, 2007 in a match against Liverpool, now wearing a rugby helmet to protect his weakened skull.
According to Downs DS and D Abwender in their article Neuropsychological Impairment in Soccer Athletes, “participation in soccer may be associated with poorer neuropsychological performance, although the observed pattern of findings does not specifically implicate heading as the cause”.
On November 2, 2013 in a match between Tottenham and Everton, Tottenham goal keeper Hugo Lloris sustained a blow to the head by on -coming player Romelu Lukaku's knee. The blow left Lloris knocked out on the ground. Reluctantly manager Andre Villas Boas decided to leave the player on after regaining consciousness and having passed a medical assessment. This broke the rules of the PFA, which state that any player who has lost consciousness must be substituted.
There has been a widespread debate on protective head gear in soccer. Known as a sport associated with intricate footwork, speed, and well-timed passes, soccer also is classified as a high- to moderate-intensity contact/collision sport, with rates of head injury and concussion similar to those seen in football, ice hockey, lacrosse, and rugby. While the benefits of helmets and other head protection are more obvious in the latter sports, the role of headgear in soccer is still unclear.
There are clear rules from FIFA regarding what to do when a player gets a concussion. FIFA's guidelines say that a player who has been knocked unconscious should not play again that day. The rules do however allow for "a transient alteration of conscious level" following a head injury, which says that a player can return to play following assessment by medical staff. The rules also state that a player who is injured with head damage is not to be played for five days.
The death of Dale Earnhardt at the 2001 Daytona 500, along with those of Kenny Irwin, Adam Petty and Tony Roper in 2000, and serious injuries sustained by Steve Park in a wreck in September 2001 at Darlington, led to NASCAR establishing numerous policies to assist in driver safety, such as the introduction of the Car of Tomorrow. Drivers were eventually instructed to wear both head and neck restraints, and SAFER barriers have been installed on racetrack walls, with foam-padded supports on each side of the helmet that would allow a driver's head to move in the event of a crash. Despite this, 29 identified concussions occurred between 2004 and 2012.
In 2012, when Dale Earnhardt, Jr. suffered a concussion after being involved in a crash at the end of the Good Sam Roadside Assistance 500 at Talladega, NASCAR expressed consideration in adding baseline testing to its concussion policies. NASCAR was one of few motorsport organizations that do not have baseline testing, though that ended in 2014, as baseline testing started being performed at the start of the seasons.
In the 2005 high school basketball year, 3.6% of reported injuries were concussions, with 30.5% of concussions occurring during rebounds. Incidence rates for concussions in NCAA men's basketball is lower than NCAA women's basketball, at 0.16 concussion per 1,000 athletes compared to 0.22 per 1,000 athletes respectively. The difference is found mainly in competition activity compared to practice.
Despite boxing's violent nature, a National Safety Council report in 1996 ranked amateur boxing as the safest contact sport in America. However, concussions are one of the most serious injuries that can occur from boxing, and in an 80-year span from 1918 to 1998, there were 659 boxers who died from brain injury. Incidence rates for concussion in boxing may frequently be miscalculated due to the fact that concussions do not always result from a knockout blow. Olympic boxers deliver punches with high impact velocity but lower HIC and translational acceleration than in football impacts because of a lower effective punch mass. They cause proportionately more rotational acceleration than in football. Modeling shows that the greatest strain is in the midbrain late in the exposure, after the primary impact acceleration in boxing and football.
Muhammad Ali, possibly the most famous boxer of all time, was “diagnosed with 'a cluster of symptoms that resemble Parkinson's Disease,' known as Parkinson's Syndrome, which his doctor believed were caused by numerous blows to the head,” which led to his death in 2016.
As many skills as gymnastics involve flipping or a blind landing, incidence of head injury increases. A 15-year study found an incidence of 1.7% for concussion and closed head injury for high school gymnasts.
Ice hockey has also been known to have concussions inflict numerous players. Because of this, the NHL made hockey helmets mandatory in the 1979–80 NHL season. According to a data release by the National Academy of Neuropsychology's Sports Concussion Symposium, from 2006 to 2011, 765 NHL players were diagnosed with a concussion. At the Mayo Clinic Sports Medicine Center Ice Hockey Summit: Action on Concussion conference in 2010, a panel made a recommendation that blows to the head are to be prohibited, and to outlaw body checking by 11- and 12-year-olds. For the 2010–11 NHL season, the NHL prohibited blindside hits to the head, but did not ban hits to the face. The conference also urged the NHL and its minor entities to join the International Ice Hockey Federation, the NCAA and the Ontario Hockey League in banning any contact to the head.
The NHL has been criticized for allowing team doctors to determine whether an injured player can return to the ice, instead of independent doctors.
Concussions are also a significant factor in rugby union, another full-contact sport. In 2011, the sport's world governing body, World Rugby (then known as the International Rugby Board, or IRB), issued a highly detailed policy for dealing with injured players with suspected concussions. Under the policy, a player suffering from a suspected concussion is not allowed to return to play in that game. Players are not cleared to play after the injury for a minimum of 21 days, unless they are being supervised in their recovery by a medical practitioner. Even when medical advice is present, players must complete a multi-step monitoring process before being cleared to play again; this process requires a minimum of six days. In 2012, the IRB modified the policy, instituting a Pitchside Suspected Concussion Assessment (PSCA), under which players suspected of having suffered concussions are to leave the field for 5 minutes while doctors assess their condition via a series of questions. Players who pass the PSCA are allowed to return to play.
However, an incident during the third Test of the 2013 Lions tour of Australia led to criticism of the current protocols. During that match, Australian George Smith clashed heads with the Lions' Richard Hibbard and was sent to pitchside. According to ESPN's UK channel, "despite looking dazed and confused, Smith passed the PSCA and was back on the field minutes later."
In 2013, former Scotland international Rory Lamont charged that the current concussion protocols can easily be manipulated. A key part of the current protocols is the "Cogsport" test (also known as COG), a computer-based test of cognitive function. Each player undergoes the test before the start of a new season, and is then tested again on it after a head injury, and the results compared, to determine possible impairment. According to Lamont, some players deliberately do poorly on the pre-season test, so that they will be more likely to match or beat their previous results during play.
Lamont was also critical of the PSCA, noting:
|“||The problem with the PSCA is a concussed player can pass the assessment. I know from first hand experience it can be quite ineffective in deciding if a player is concussed. It is argued that allowing the five-minutes assessment is better than zero minutes but it is not as clear cut as one might hope. Concussion symptoms regularly take 10 minutes or longer to actually present. Consequently the five-minute PSCA may be giving concussed players a license to return to the field.||”|
The Concussion bin was replaced by the head bin in 2012 with the players assessment taking 10 minutes. If concussed the player must then recover by first returning to general activities in life, then progressing back to playing. Returning to play, the player must follow the Graduated Return to Play (GRTP) protocol, by having clearance from a medical professional, and no symptoms of concussion.
Numerous reports have indicated that female athletes suffer more concussions than male athletes. A December 2008 report states that 29,167 female high school soccer players in the United States suffered from concussions in 2005, compared to 20,929 male players. In high school basketball, 12,923 girls suffered from concussions while only 3,823 boys did. Girls also sustained more concussions in softball, compared to boys in baseball. Female athletes also had longer recovery times than males, and also had lower scores on visual memory tests. Girls also have longer recovery times for concussions, which may be due to a greater rate of blood flow in the brain.
Women's ice hockey was reported as one of the most dangerous sports in the NCAA, with a concussion rate of 2.72 per 1,000 player hours. Even though men's ice hockey allows body checking, while women's ice hockey does not, the rate of concussions for men is 46% lower, at 1.47 per 1,000 player hours. College football also has lower concussion rates than women's hockey, with a rate of 2.34 per 1,000.
Women’s basketball is one of the women’s sports with the highest risks of getting a concussion. Women have a greater risk of getting a concussion by dribbling/ball handling rather than defending. Also it was found that female college basketball players typically receive concussions during games rather than practices.
Prevention efforts and technology
There have been numerous attempts at preventing concussions, such as the establishment of the PACE (Protecting Athletes Through Concussion Education) program, which works with the imPACT system, which is currently used by every NFL and some NHL teams. In 2008, the Arena Football League tested an impact monitor created by Schutt Sports called the "Shockometer", which is a triangular device attached to the back of football helmets that has a light on the device that turns red when a concussion occurs. Riddell has also created the Head Impact Telemetry System (HITS) and Sideline Response System (SRS) to record the frequency and severity of player hits during practices and games. On every helmet with the system, MX Encoders are implemented, which can automatically record every hit. Eight NFL teams had originally planned to use the system in the 2010 season, but the NFL Players Association ultimately blocked its use. Other impact-detection devices include CheckLight, by Reebok and MC10., and the online test providers ImPACT Test, BrainCheck, and XLNTbrain which establish cognitive function baselines against which the athlete is monitored over time. The CCAT online tool developed by Axon Sports is another test to assist doctors in assessing concussion.
In 2012, film producer Steve James created the documentary film Head Games, interviewing former NHL player Keith Primeau, and the parents of Owen Thomas, who hanged himself after sustaining brain damage during his football career at Penn. The documentary also interviewed former athletes Christopher Nowinski, Cindy Parlow, and New York Times reporter Alan Schwarz, among other athletes, journalists, and medical researchers.
League of Denial was a 2013 book by sports reporters Mark Fainaru-Wada and Steve Fainaru about concussions within the NFL. The American documentary series Frontline covered the topic in two episodes, one based on the book and also called "League of Denial", and the other called "Football High" Political sports journalist Dave Zirin has also covered the topic in detail.
- Concussions in Australian sport
- Concussion grading systems
- Head injury criterion
- Shock data logger
- Impact sensor
- Sports-related traumatic brain injury
- Concussions in high school sports
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