Protecting the neurological health of athletes is an important topic in both sports and medical science. As more information comes to light about protecting the brain during athletics, it is important for practitioners to educate themselves and their patients about neurological safety.
Among athletes, two to fifteen percent experience a sports-related concussion (SRC) during their season. Adolescents and children are especially at risk, around 400,000 SRC occur in athletes who are high school age. While some of these injuries are mild, there is increasing concern about the long-term effects of repeated concussions. Providers must understand prevention strategies, immediate responses to injury, and long-term management of concussions in athletes.
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Understanding Concussions and Brain Injuries in Sports
A concussion is defined as traumatic forces on the brain resulting in neurometabolic disruption, this may or may not result in a loss of consciousness. This injury occurs due to acceleration, deceleration, or rotation from direct impact to the face, neck, or head. Sports-related concussions have both short-term and long-term risks. Short-term risks include headache, loss of consciousness, and risks of repeat injury. Long-term risks after concussion include mental health problems and chronic traumatic encephalopathy (CTE). Clinical features of CTE include cognitive impairment, disturbance in gait, mental health issues, tremors, and difficulty speaking. As the severity of features associated with CTE becomes better understood, the importance of neuroprotection during sports becomes even more vital.
The rates of concussion are highest in sports with a high level of combat or contact, but it can occur in all sports. SRCs can also occur in training outside of the sport, such as injuries from equipment. The most reported SRCs occur in rugby, boys’ football, girls’ soccer, boys' ice hockey, and wrestling. In general, more concussions occur during competition compared to practice. Reporting rates differ, but data suggest that females have a higher rate of concussion compared to males. Cadets undergoing training for the military are also at risk for head injuries.
Understanding risk factors for concussion can help providers screen patients and aid in preventing brain injuries from sports. A prior concussion is one of the most significant risk factors for sustaining neurological injury during athletics. Repeat injury to the brain appears to be significantly dangerous. A second brain injury is most likely ten days after the initial neurological insult. Female sex is a risk factor for SRCs, possibly related to differences in hormones, style of play, and relative muscle weakness. Age is also a risk factor, injuries to the developing brain can be significant. Teens and prepubescent adolescents may take longer to recover and have more symptom persistence than their adult counterparts. Baseline mental health status may have an impact on concussion risk, but more evidence is needed to examine causality. Anxiety symptoms appear to have an impact on the risk of concussion and general injury.
Prevention Strategies
Injury prevention strategies are important for athletes of all ages to preserve neurological health and prevent long-term effects. Rule changes are an evolving aspect of youth sports. Youth hockey has high concussion rates, and delaying body checking may result in reduced rates of brain injury. Rule changes in other sports do not have established causality in existing studies, but more research is ongoing about rule changes for soccer. A reduction in brain injuries may occur with changes in tackling technique. Rule changes have been implemented by the National Football League and the International Rugby League to prevent injuries. These include a reduction in helmet-to-helmet contact and no contact rules if a player’s helmet comes off. Rugby has imposed more strict rules about contact above the shoulder. Reducing contact during practice may also expose the player to fewer scenarios that can cause head trauma.
Helmets are a major aspect of head injury prevention. Technology is evolving to provide greater protection against concussion and skull trauma. Football in particular has headwear designed for the unique impact forces specific to position. Offensive and defensive linemen and quarterbacks have options for unique helmet design. Helmets with a multi-directional impact system (MIPS) design show promise in reducing concussions. This design reduces rotational motion after impact. A plastic sheet inside a harness allows slip motion between the helmet and skull, reducing rotational forces. While new helmet technology shows promise in reducing head injuries, more research is needed before providing clear recommendations. It is important for coaches to emphasize that new, protective equipment should not result in more aggressive play.
Mouthguards should also be implemented to protect athletes from facial and dental trauma, as well as reducing the risk of SRC. Mouthguards can prevent SRC in ice hockey and other collision sports.
Other prevention measures include warming up the neck before practice and games, and exercises to prime balance and strength. Neuromuscular warm-ups can improve body awareness, balance, reaction time, and movement technique. Additionally, interventions by coaches to reduce aggressive play during practice and proper technique (tackling, body checking) can play a role in reducing concussions and other injuries.
Proper education for players, parents, coaches, and trainers is necessary for the prevention and identification of sports-related neurological injuries. This may include emphasizing the importance of helmets, and mouthguards, and education about the risks of aggressive play.
Immediate Response to Concussions and Brain Injuries
Immediate response protocols for suspected concussions are evolving based on available evidence. It is vital to remove the athlete from play and seek immediate medical evaluation if a neurological injury is suspected. The Sport Concussion Assessment Tool (SCAT6) is a compilation of the best available evidence to guide sideline evaluation. The SCAT6 is a standardized assessment for healthcare providers that utilizes a step-wise evaluation of the athlete.
The immediate assessment and neurological screen should ideally be completed right away on the field or court. The athlete should be removed from play if any signs or symptoms of concussion are noted. Initial observable signs include a fall to the playing surface, lying motionless, difficulty walking, changes in responsiveness or confusion, facial injury, vacant expression, seizure, and a high-impact injury. The patient should be assessed for reg flags, and if any are present they require immediate medical transport to an emergency department. Red flags include double vision, seizure activity, neck pain, loss of consciousness, extremity weakness/tingling, vomiting, changes in consciousness, headache, restlessness/agitation, Glasgow Coma Scale (GCS) <15, and any visible injury to the skull. A cervical spine assessment is necessary and a collar should be placed if cervical injury is suspected. Step four is a screening of coordination and ocular/motor observation. An immediate memory assessment is necessary for step five. The questions involve forced recall of events prior to the suspected concussion.
The second aspect of the concussion assessment tool is an off-field assessment which should be performed after the immediate neurological screen. This is comprised of a background assessment (neurological and concussion history), symptom rating performed by the athlete (headache, drowsiness, confusion), and a brief cognitive screening. Coordination and balance are examined, as well as delayed recall. An athlete removed from play with a suspected concussion should not be returned to play on the same day.
Return to activity timelines are based on the severity of injury, symptom progression, and medical follow-up. Many athletes have a full return to school/learning in ten days but may take 20 days to fully return to sport/activity.
Diagnosis and Evaluation Techniques
Diagnostic tools for the evaluation of an athlete with a suspected concussion include cognitive assessment tools and imaging (when indicated). Cognitive assessment is part of the initial evaluation but more specialized testing is sometimes necessary. Executive function can be evaluated in-depth after a suspected SRC, especially if the patient is struggling at school. These specialized tests are often performed by a neuropsychologist. Although a concussion typically does not result in abnormalities in neuroimaging, there are instances where further imaging is necessary. If the athlete is showing signs of cervical spine injury, head trauma, skull fracture, or bleeding, imaging is indicated and the patient should receive urgent medical evaluation.
An interdisciplinary approach to diagnosis and evaluation is helpful when a suspected concussion has occurred. Neurologists and neuropsychologists can assist with cognitive assessments and evaluation. Sports medicine specialists are often highly trained in initial concussion assessments, including sideline examination. These professionals work in tandem to provide the best care for the patient.
Long-Term Management and Rehabilitation
Rehabilitation strategies are necessary for the long-term health of the athlete. Initially, prescribed rest after a neurological injury should be part of the initial interventions for a concussion. Cognitive and physical exertion should be limited for the initial 24 to 48 hours. Driving should not be performed until a medical follow-up is performed. Limiting exposure to screens, loud sounds, and video games can help promote recovery. Previous recommendations included “cocoon therapy” which involves the total removal of light and stimulus. This is no longer recommended because it does not appear to promote neurological recovery.
Light exercise is permitted if it does not cause symptoms to worsen. Returning to activity gradually allows the patient time to recover while maintaining fitness. Physical therapy can be helpful for rehabilitation balance, adaptation, and muscle recovery.
Cognitive rehabilitation should be considered after a concussion. Treatment options include cognitive-behavioral therapy (CBT), motivational interviewing, and medications.
Mental Health Considerations
The psychological impact of concussions should be understood when treating a patient holistically. Anxiety and depression can occur after neurological injury and may affect the return to learning and sports. In more severe cases of repeated head trauma that results in CTE, mental health problems are often present. These can include, depression, anxiety, aggression, and suicidality. A healthy support system and mental health professionals can aid the patient in working through the mental health challenges after injury. Integrative therapy for behavioral health can help address depression and anxiety.
The Future of Concussion and Brain Injury Management in Sports
Ongoing research is addressing the future of preventing concussions in sports. Emerging technology such as specialized helmets and impact detection sensors aim to progress the field of concussion prevention. Impact sensors in helmets and mouthguards can obtain data about contact forces the player may experience over time. These technologies are relatively new, and further research and technological advancements may improve their sensitivity and applicability. Longitudinal data through cognitive testing of athletes before and after a concussion can aid in long-term rehabilitation and recovery.
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Key Takeaways
Athlete health and safety is the collective responsibility of parents, providers, professional leagues, and coaches. Education about the impacts of concussion and prevention through rule changes, safety equipment, and proper warm-ups can help empower athletes and parents. The sports community as a whole has a responsibility for protecting athletes and placing brain health above profit and competition. Continued research into proper prevention, treatment, and technology can reduce the burden that concussions can have on the athlete's lifelong health. Parents and players should advocate for continued change and protective measures for athletes to prevent the damage associated with concussions. These collective measures can help change the landscape of sports for the better.
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