Sports Related Head Injury

Although sports injuries contribute to fatalities infrequently, the leading cause of death from sports-related injuries is traumatic brain injury. Sports and recreational activities contribute to about 21 percent of all traumatic brain injuries among American children and adolescents.

Traumatic Brain Injury

A traumatic brain injury (TBI) is defined as a blow or jolt to the head or a penetrating head injury that disrupts the normal function of the brain. TBI can result when the head suddenly and violently hits an object, or when an object pierces the skull and enters brain tissue. Symptoms of a TBI can be mild, moderate, or severe, depending on the extent of damage to the brain. Mild cases may result in a brief change in mental state or consciousness, while severe cases may result in extended periods of unconsciousness, coma, or even death.

Types of Head Injuries

Concussions

Cerebral concussions frequently affect athletes in both contact and non-contact sports. Cerebral concussions are considered diffuse brain injuries and can be defined as traumatically induced alterations of mental status. A concussion results from shaking the brain within the skull and, if severe can cause shearing injuries to nerve fibers and neurons.

Grading the concussion is a helpful tool in the management of the injury (see Cantu below) and depends on: 1) Presence or absence of loss of consciousness, 2) Duration of loss of consciousness, 3) Duration of posttraumatic memory loss, and 4) Persistence of symptoms, including headache, dizziness, lack of concentration, etc.

Some team physicians and trainers evaluate an athlete’s mental status by using a five-minute series of questions and physical exercises known as the Standardized Assessment of Concussion (SAC). This method, however, may not be comprehensive enough to pick up subtle changes. More recently, teams have employed ImPACT, a 25-minute computer based testing program specifically designed for the management of sports-related concussion. A player who has sustained a concussion is three to six times more likely to sustain another one. While the decision on when an athlete is ready to return to play isn’t straightforward, every player should receive baseline neurological testing before the season so that the results can be used for comparison in the event the athlete receives a blow to the head.

According to the Cantu Guidelines, Grade I concussions are not associated with loss of consciousness, and posttraumatic amnesia is absent or is less than 30 minutes in duration. Athletes may return to play if no symptoms are present for one week.

Players who sustain a Grade II concussion lose consciousness for less than five minutes or exhibit posttraumatic amnesia between 30 minutes and 24 hours in duration. They may also return to play after one week of being asymptomatic.

Grade III concussions involve posttraumatic amnesia for more than 24 hours or unconsciousness for more than five minutes. Players who sustain this grade of brain injury should be sidelined for at least one month, after which they can return to play if they are asymptomatic for one week.

Following repeated concussions, a player should be sidelined for longer periods of time and possibly not allowed to play for the remainder of the season.

Second Impact Syndrome results from acute, sometimes fatal brain swelling that occurs when a second concussion is sustained before complete recovery from a previous concussion. This causes vascular congestion and increased intracranial pressure, which may be difficult or impossible to control. The risk for second impact syndrome is higher for sports such as boxing, football, ice or roller hockey, soccer, baseball, basketball, and snow skiing.

Coma

The word coma refers to a state of unconsciousness. The unconscious state has variability and may be very deep, where no amount of stimulation will cause the person to respond or, in other cases, a person who is in a coma may move, make noise, or respond to pain but is unable to obey simple, one-step commands, such as "hold up two fingers," or "stick out your tongue." The process of recovery from coma is a continuum along which a person gradually regains consciousness.

For people who sustain severe injury to the brain and are comatose, recovery is variable. The more severe the injury, the more likely the result will include permanent impairment.

The Glasgow Coma Scale is usually administered upon admission to establish a base line of level of consciousness, motor function and eye findings. Frequent evaluations of the patient are imperative to help assess neurologic improvement or deterioration.

Brain imaging technologies, particularly computerized axial tomography (CT or CAT scan) can offer important immediate information about a person's status. The purpose of performing an emergency CT scan is to rule out a large mass lesion (hematoma) compressing the brain that requires immediate surgical removal. Magnetic Resonance Imaging (MRI) is used in a more elective setting to image subtle changes that are not picked up by CT.

Brain Injury Symptoms

  • Pain: Constant or recurring headache
  • Motor Dysfunction: Inability to control or coordinate motor functions, or disturbance with balance
  • Sensory: Changes in ability to hear, taste or see; dizziness; hypersensitivity to light or sound
  • Cognitive: Shortened attention span; easily distracted; overstimulated by environment; difficulty staying focused on a task, following directions or understanding information; feeling of disorientation and confusion and other neuropsychological deficiencies.
  • Speech: Difficulty finding the "right" word; difficulty expressing words or thoughts; dysarthric speech.

Head Injury Prevention Tips

Buy and use helmets or protective head gear approved by the ASTM for specific sports 100 percent of the time. The ASTM has vigorous standards for testing helmets for many sports; helmets approved by the ASTM bear a sticker stating this. Helmets and head gear come in many sizes and styles for many sports and must properly fit to provide maximum protection against head injuries. In addition to other safety apparel or gear, helmets or head gear should be worn at all times for:

  • Baseball and Softball (when batting)
  • Cycling
  • Football
  • Hockey
  • Horseback Riding
  • Powered Recreational Vehicles
  • Skateboards/Scooters
  • Skiing
  • Snowboarding
  • Wrestling

Head gear is recommended by many sports safety experts for:

  • Bull riding
  • Martial Arts
  • Pole Vaulting
  • Soccer
  • Vintage Motor Sports

General Tips

  • Supervise younger children at all times, and do not let them use sporting equipment or play sports unsuitable for their age.
  • Do not dive in water less than 12 feet deep or in above-ground pools.
  • Follow all rules at water parks and swimming pools.
  • Wear appropriate clothing for the sport.
  • Do not wear any clothing that can interfere with your vision.
  • Do not participate in sports when you are ill or very tired.
  • Obey all traffic signals, and be aware of drivers when cycling or skateboarding, or rollerblading.
  • Avoid uneven or unpaved surfaces when cycling or skateboarding, or rollerblading.
  • Perform regular safety checks of sports fields, playgrounds and equipment.
  • Discard and replace sporting equipment or protective gear that is damaged.

Rule Changes in College Football to Prevent Head and Neck Injuries

The National Athletic Trainers’ Association and the American Football Coaches Association (NATA/AFCA) Task Force, headed by Ron Courson, director of sports medicine for the University of Georgia, has focused on two primary problems associated with head contact.

  • Head-down contact still occurs frequently in intercollegiate football
  • Helmet-contact penalties are not adequately enforced.

Rule changes implemented by the NCAA related to head-down contact and spearing in collegiate football have been distributed to all coaches and officials throughout the country. The objective is to eliminate injuries resulting from a player using his helmet in an attempt to punish an opponent.

With the rule changes and more diligent enforcement of the rules, there is hope that a significant reduction in head and neck injuries will result.

The National Collegiate Athletic Association revised its 16 year-old guideline on treatment of concussion in the NCAA Sports Medicine Handbook to better provide member institutions with appropriate responses to concussion injuries and procedures for returning athletes to competition or practice. "It is essential that no athlete be allowed to return to participation when any symptoms persist, either at rest or exertion." The guidelines details circumstances in which an athlete should be withheld from competition pending clearance by a physician.

Football-Related Head and Neck Injury Prevention Tips

  • All players should receive preseason physical exams and those with a history of prior brain or spinal injuries, including concussions, should be identified.
  • Football players should receive adequate preconditioning and strengthening of the head and neck muscles.
  • Coaches and officials should discourage players from using the top of their football helmets as battering rams when blocking, hitting, tackling, and ball carrying.
  • Coaches, physicians and trainers should ensure that the players' equipment is properly fitted, especially the helmet, and that straps are always locked.
  • Coaches must be prepared for a possible catastrophic SCI. The entire staff must know what to do in such a case, because being prepared and well informed might make all the difference in preventing permanent disability.
  • The rules prohibiting spearing should be enforced in practice and games.
  • Ball carriers should be taught to not lower their heads when making contact with the tackler to avoid helmet-to-helmet collisions.
Source: The American Association of Neurological Surgeons

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