Concussion in Road Cycling: A Call to Action

The authors of an April 2019 paper that systematically reviewed all literature on concussion and concussion management in road cycling call for a cycling-specific concussion protocol. They call upon the Union Cycliste Internationale (UCI) to hold a consensus meeting with road cycling medical teams to develop this cycling-specific concussion protocol.

The Need for a Cycling-Specific Concussion Protocol

Cycling reportedly accounts for almost 20% of concussion cases in the U.S -- the highest percentage of any sport

Cycling reportedly accounts for almost 20% of concussion cases in the U.S -- the highest percentage of any sport (1). In an analysis of Tour de France races between 2010-2017, concussions accounted for just over 2% of the injuries suffered by professional cyclists (2). More generally, concussions account for 1.3-9.1% of all injuries in cycling events and this rate is increasing (3-6). Concussions in cycling not only place the injured athlete at risk of short and long term harms, but an undetected injured athlete may also cause an accident (for example, due to a lack of balance which is a common side-effect of concussion), thereby potentially harming other cyclists (7).

Current Cycling Guidelines

Unfortunately, there is no internationally agreed-upon protocol for concussion in cycling.

Given the prevalence and consequences of concussion in cycling, it would thus be expected that there are cycling-specific concussion diagnosis and management protocols, yet this is not the case. Unfortunately, there is no internationally agreed-upon protocol for concussion in cycling (8). The UCI and the American Cycling Association (ACA) recommend using the SCAT5 and SCAT2 respectively to diagnose concussion in road cycling. These recommendations are problematic (9). The SCAT2 is out-of-date (having been created in 2008) and the ACA guidelines are largely meant for education and providing a means in which a team can put in place SRC diagnosis and management processes that are “a bottom line of best practice on which team medical staff can build on.” While the SCAT5 is the latest concussion tool published by the Concussion in Sport Group in 2016, this UCI recommendation remains problematic because the SCAT5 requires modifications in order to be relevant and effective in cycling.

Further Cause for a Cycling-Specific Protocol

There are specific challenges that come with assessing concussion in cycling more generally, such as: the fast pace of the sport and the “remote nature of medical monitoring for cyclists” given that sometimes cyclists are in one country and the medical team is in another (10,11). Ultimately, simply using generic concussion tools is not adequate because they do not address the unique qualities of road cycling.

How to Move Forward

Very few studies have examined this issue and the two studies that were reviewed for this paper’s systematic review make broad statements that are not helpful in further developing a cycling-specific protocol (9,12,13).  Some specific recommended developments/changes that the authors of this paper have suggested are to:

  • Use real-time and replayed television images to create a concussion spotting system;
  • “Motor-pace” a cyclist back into position after they are assessed for concussion to reduce the negative impact a concussion assessment may have on the individual/team’s performance and position;
  • Change the Maddocks questions to include cycling-specific questions such as: what is the name of the race, how many kilometers are left in the race, who is the road captain, what was your last race, and what is your coach’s name; and
  • Create a central injury database to understand patterns of injuries which will, therefore, help develop methods to reduce concussion incidences in cycling.

Other changes that could be made are:

  • Adopt the saying ‘if in doubt, sit them out’ as per many other sports worldwide;
  • Provide the cycling concussion guidelines in multiple languages to reflect the internationality of the cycling community; and
  • Potentially consider an independent evaluation to ensure adherence to the concussion protocol (14).

Considerations also need to be made for both medical and non-medical roles -- such as neutral mechanics who may be the first responder at the scene of a concussion-inducing incident.

Any adaptations also need to be evidence-based which means more research must be done specifically on concussion in cycling and what changes will make: 1) the sport safer and 2) concussion diagnosis and management effective in the cycling environment.

The paper can be found here: https://bmjopensem.bmj.com/content/5/1/e000525.

About The Author

Rebecca Babcock is a recent graduate of the University of Otago in New Zealand, completing a Master’s in Bioethics and Health Law. Her thesis examined the ethical and legal issues surrounding concussion management. She currently spends her time working for the Concussion Legacy Foundation – Canada as a programming coordinator and at Sunnybrook Hospital investigating concussion prevention, management, and education services. Her dream is to be a clinical ethicist at a hospital which she is starting to fulfill by volunteering as a bioethics assistant at Humber River Hospital in Toronto.

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Equestrian Helmets May Be Too Stiff to Reduce Risk of TBI

Even in the Equestrian World, Helmets Do Not Prevent Concussions…But They Are Not Even Designed to Try

A recent study, published in Sports Medicine – Open in May 2019, retrospectively found that 70% (139/189) of reported equestrian fall accidents (seemingly focused on horse racing and jockeys’ injuries specifically) resulted in a head injury – 91% of which were concussions. Other head injuries included: skull fractures (4%); diffuse axonal injury (3.6%); subdural hematoma (1%); and cerebral edema (0.7%).

The Study

216 helmets were collected via a damaged helmet return scheme in the UK and USA. Of the 216, 189 accident report forms were provided by the rider or their doctor. These reports were not standardized and the details provided varied. In saying that, associated injuries from the fall were recorded. These helmets also were visually examined to identify damage (or lack thereof) as well as disassembled to inspect any internal damage; all of the helmets were certified.

More to the Story

Little has changed with helmet testing over the last 30 years despite an increased understanding of impact biomechanics

Out of the 139 helmets that also had a report of head injury, 75 (54%) of the helmets showed damage whereas 64 helmets (46%) showed no damage. In fact, the more stringent the certification (i.e. – the stiffer the helmet), the more likely the helmet was to show no damage.

On the one hand, helmets that are very stiff will very likely help protect against skull fracture, more serious brain injury, and death. On the other hand, the researchers of this study suggest that stiffer helmets may be less effective for lower-severity impacts. They argue that this is specifically the case because equestrian helmet certification tests currently do not test helmets under the conditions that falls in equestrian sport occur.

There is a tendency for equestrian falls to occur on softer, uneven surfaces which will ultimately create oblique hits with rotational acceleration and current tests focus on linear acceleration (1-3). In fact, little has changed with helmet testing over the last 30 years despite an increased understanding of impact biomechanics (4).

Finally, the researchers suggest that if helmet testing were to consider these components and helmets were designed with these factors in mind, equestrian helmets may be better suited at reducing incidences of concussion/head injury in low-severity impacts.

Further Considerations Need to Be Made Prior to These Claims

The researchers of this study strongly state that new helmets need to be created by examining detailed accident reconstruction, clinical outcome data, and the needs of helmet users

Yet, in concussion literature, it is widely stated that helmets do not prevent concussion but rather, protect the head against more serious injury. Certainly, ensuring that helmets are designed with the sport in mind is important as is ensuring that helmets are diffusing as much energy from the impact as possible so that they are most effective at preventing these more serious brain or structural injuries. The fact that the researchers of this study strongly state that new helmets need to be created by examining detailed accident reconstruction, clinical outcome data, and the needs of helmet users in a collaborative environment with engineers, clinicians, riders, and equestrian regulatory authorities is reasonable. Certainly, these conditions are vital to achieve this goal of creating a safer equestrian helmet. It may be unreasonable however, given that there is no threshold force to sustain a concussion and that concussion is not prevented in other sports with helmets, to suggest that improving helmets in this way will reduce incidences of concussion.

How to Move Forward

Equestrian sports are incredibly high risk with higher reported rates of concussion and mild traumatic brain injury (mTBI) than American football or boxing

In saying that, equestrian sports are incredibly high risk with higher reported rates of concussion and mild traumatic brain injury (mTBI) than American football or boxing and it is important to start exploring ways to reduce incidences of concussion (5-12). Perhaps exploring the circumstances in which head injuries are arising may lead to changes to the sport/environment/rules/etc. that will help reduce concussion.

About The Author

Rebecca Babcock is a recent graduate of the University of Otago in New Zealand, completing a Master’s in Bioethics and Health Law. Her thesis examined the ethical and legal issues surrounding concussion management. She currently spends her time working for the Concussion Legacy Foundation – Canada as a programming coordinator and at Sunnybrook Hospital investigating concussion prevention, management, and education services. Her dream is to be a clinical ethicist at a hospital which she is starting to fulfill by volunteering as a bioethics assistant at Humber River Hospital in Toronto.

Works Cited

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Hope on the Horizon: Progressing to a Better Concussion Assessment

Study shows concussion assessments comprising of multiple tools is the best method to assess concussion

It is well known that assessment tools are required to identify concussion. Most organizations promote the use of multiple tools to evaluate several domains known to be impacted by concussion (1-4). Yet few studies have examined which tool individually or which tools in combination best assess and most accurately identify concussion. A recent study -- which examined 22,057 player seasons collected during 2014-2017 for multiple sports from various NCAA and military schools -- has found that concussion assessments comprising of multiple tools, including a subjective symptom tool, is the best method to assess concussion.

One Assessment Tool to Rule Them All?

In the study, all “full models” -- meaning concussion assessments comprised of multiple tools -- outperformed all individual tools

Unfortunately, no singular tool that assesses concussion is more effective than a combination of tools. In the study, all “full models” -- meaning concussion assessments comprised of multiple tools -- outperformed all individual tools, suggesting that testing batteries are more effective at identifying the effects of concussion (5-9). Interestingly, removing the SCAT total symptoms from the full model resulted in the greatest reduction in a model’s performance. On the other hand, removing the BESS minimally impacted the model’s performance, highlighting the BESS assessment’s possible lack of utility in assessing concussion. Ultimately, these results suggest that symptoms better indicate concussion than neurological status and balance assessments. These results differ from other studies that suggest neurological assessment has the highest sensitivity, but this difference may be attributed to methodology and sample size (5,6,8-10).

Are Baseline Tests Necessary or Useful?

Completing baseline testing is becoming more common, but the presumed problem arises when the baseline data is not available to the medical professional assessing the concussed individual.

Some assessment tools use baseline tests to examine the difference between an athlete’s performance before and after the concussive injury. Completing baseline testing is becoming more common, but the presumed problem arises when the baseline data is not available to the medical professional assessing the concussed individual. Even when the data is available, the usefulness of this data remains questionable (11-13). The study found that while there is utility in baseline test scores for the SAC and SCAT (but not the BESS), it is still possible to adequately assess concussion without baseline tests and therefore baseline results may not be clinically valuable (7,10,12,13). In saying that, since this study examined only the assessment of acute concussion, it is possible that baseline information may be useful beyond this acute stage but research is needed to explore this train of thought.

Subjective vs. Objective Data

The underreporting of symptoms (at a rate as high as 50%) may greatly impact how effective concussion assessments are

Since the study showed that symptom scores have a higher sensitivity and specificity than objective measures, the underreporting of symptoms (at a rate as high as 50%) may greatly impact how effective concussion assessments are -- many concussions could go unidentified (14). Unfortunately, all objective assessment tools were outperformed. This raises the importance for developing better objective means in which to diagnose concussion. In saying that, it is possible that the objective tools play an important role once symptoms resolve; examining the utility of objective assessment tools beyond the acute stage is important.

Potential Areas of Improvement

The simultaneous use and interpretation of multiple tools with multiple domains is challenging especially when it does not have a method to combine the results into a single measure

The findings of this study provide some direction as to how to improve concussion assessments. For instance, since the BESS does not provide much value, it may be worth considering removing the tool from assessments; removing the tool would also reduce the time it takes to assess concussion. Furthermore, since this study combined risk modifiers and standard assessments into one score which can be gathered within the time constraints of most sports, there is potential for this to be applied to sideline concussion assessment/management. Indeed, the simultaneous use and interpretation of multiple tools with multiple domains is challenging especially when it does not have a method to combine the results into a single measure (1,3,4,15).

Finally, while the study did not find significant relationships in terms of age, sex, or previous numbers of concussion, it still may be important to incorporate modifying factors (the ones mentioned above as well as numerous others not examined in this study) into acute concussion assessments. Indeed, they can be important factors to consider. For instance, this study found that males were found to have an increased risk of acute concussion (25, 51-53). At first, it looks like this result is contradictory to many other studies that have found females experience more symptoms and a worse cognitive decline (24,26,50,53,54). However, this study’s finding seems to suggest that male athletes may still be concussed despite having fewer symptoms and closer-to-normal neurocognitive deficits compared with female athletes. This fact/trend would be worth knowing and considering when assessing concussion and should be built into the assessment.

Areas to Explore

While this study did find concrete ways in which to improve concussion assessment, it also highlighted areas that are certainly lacking in information and require more research.

  • First, similar research is needed for high school, recreational, and professional athletes to examine whether these findings are similar across all categories of athletes.
  • Second, this study has limitations in the fact that it only looked at specific concussion assessments -- examining both individual components of each assessment, as well as other assessments, will be important.
  • Third, as mentioned above, research on the usefulness of these tools, baseline scores, and objective data beyond the acute stage is required.

Finally, this study does highlight the need for research on other clinical measures that can be used when certain objective data is either unavailable or not as clinically valuable and self-reported symptoms are unreliable.

The study can be found here: https://www.ncbi.nlm.nih.gov/pubmed/29488165

About The Author

Rebecca Babcock is a recent graduate of the University of Otago in New Zealand, completing a Master’s in Bioethics and Health Law. Her thesis examined the ethical and legal issues surrounding concussion management. She currently spends her time working for the Concussion Legacy Foundation – Canada as a programming coordinator and at Sunnybrook Hospital investigating concussion prevention, management, and education services. Her dream is to be a clinical ethicist at a hospital which she is starting to fulfill by volunteering as a bioethics assistant at Humber River Hospital in Toronto.

Works Cited

  1. McCrory P, Meeuwisse W, Dvorak J, Aubry M, Bailes J, Broglio S, et al. Consensus statement on concussion in sport: the 5th international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med. 2017;51:838–47.
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  8. Resch JE, Brown CN, Schmidt J, Macciocchi SN, Blueitt D, Cullum CM, et al. The sensitivity and specificity of clinical measures of sport concussion: three tests are better than one. BMJ Open Sport Exerc Med. 2016;2:e000012.
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What Is Known About the Psychological and Social Impacts of Sports-Related Concussion in Youth

It is well-known that sports-related concussion (SRC) can produce a variety of physical, cognitive, and emotional symptoms (1-3). In comparison to neurocognitive outcomes of concussion, however, far less is known about the psychological and social consequences of SRC in youth athletes.

The Particular Importance of Understanding This Area for Youth

This is an incredibly important area to explore as youth typically have longer lasting symptoms – 14-20% of youth experience symptoms beyond 3 months and 12% beyond 12 months – which has a direct impact on multiple aspects of daily life including academic and social areas (4-7).

The Current State of Literature is Underwhelming

A review of the current state of literature on the social and psychological impacts of SRC in youth found 6 main domains that youth’s issues and struggles fall under: emotional and social dysfunction, behavioural problems, academic difficulties, sleep disturbance, headache, and quality of life (QoL). Unfortunately, as explored below, the amount of information specific to SRC is underwhelming. Oftentimes, the authors of this study had to extrapolate conclusions based on studies about general mild Traumatic Brain Injury (mTBI) (i.e. not sport-specific mTBI), but even that research leave questions unanswered.

The Six Domains Impacted by SRC

Emotional and Social Dysfunction: Changes in mood are well associated with SRC and it is hypothesized that the biochemical changes that occur after SRC may directly impact mood (8). Yet, there are other factors that also can compound or produce emotional or social disturbances, such as symptoms of SRC (concentration, headaches, sleep disturbance, etc.) and potential frustration or stress-inducing restrictions in sport (9).

Highlighting the prevalence of emotional and social impacts of SRC, one study found that 50% of children with SRC experience emotional symptoms (10). In the same study, poorer psychiatric outcomes was associated with symptom burden at the time of injury as well as post-concussive syndrome (PCS), highlighting the importance of properly managing symptoms right from the start (10). A concerning statistic in this study is that a new or worsening psychiatric disorder occurred in 10% of the group with 25% of those children being left untreated (10). Another interesting find is that in comparison to other injuries, youth with SRC had more pronounced maladaptive coping (11).

Depression: In regards to depression, no SRC-specific studies have examined depression in youth. In saying that, depressive symptoms appear in youth with mTBI but often are at the subclinical level meaning that the child would not be diagnosed with depression. In one study, criteria for major depressive disorder were met by 4-6% of patients with uncomplicated mTBI (12). In another study, youth were 9x more likely to have a new mood diagnosis at 6 months (13). A third study found that youth with mTBI experience greater mood swings and withdrawal – but not necessarily clinical depression – 2 years after concussion (14). These statistics may highlight the fact that healthcare professionals managing concussion cases should be aware of the possibility that depression and other mood disorders may arise – potentially at the subclinical level – and regardless, should be addressed. One reason youth may experience depressive symptoms is that other symptoms and academic or QoL outcomes may produce or exacerbate low mood, suggesting that addressing these areas may help manage or resolve depressive symptoms (15).

Anxiety: Similarly, anxiety-related symptoms have not been explored in pediatric SRC. One study in pediatric mTBI literature suggests that around 10% of youth with mTBI develop “a new anxiety disorder within a year” and another study found that concussed children were “4x more likely to have a new anxiety diagnosis within 6 months” (16, 17). Fortunately in the latter study, in comparison with orthopaedic controls, the anxiety symptoms in mTBI youth were comparable 1 and 2 years later (18,19).

Social Functioning: There is a void of information in this area regarding pediatric SRC. The authors of this literature review suggest “it could be” that an extended disruption in a concussed child’s integration back into school and sports may “temporarily interfere with social relationships at a critical time in personal development.” One study examined uninjured, moderate/severe TBI, and mTBI children, finding that the mTBI group had the poorest social competence (20). These difficulties emerged after 2 years and are likely representative of the fact that children with mTBI receive less support because mTBI is an invisible, and not as severe, head injury in comparison to other traumatic brain injuries (19,21). Social support after traumatic brain injury aids in improving physical health and overall QoL and any negative impacts on social functioning due to concussion should be adequately addressed, but more information is required (22).

Behavioural Problems: Following the trend, there is very little research investigating behavioural disorders following pediatric concussion, sport-related or otherwise. In a New Zealand study, children with a history of mTBI during preschool years were at a greater risk of “attention-deficit/hyperactivity, conduct, or oppositional defiant disorder during adolescence” (23). Once again, this may be as a result of a disruption in the child acquiring behaviour skills during a “critical development period” (23, 24). In saying that, in one study, behavioural problems were either an issue or not present depending on who was asked about child conduct (parent vs. teacher) (25). Regardless, more research on this topic specific to SRC and mTBI generally is necessary.

Academic Difficulties: It is well-known that the symptoms of concussion can have negative impacts in the school environment, such as challenges with learning new material or difficulties concentrating, especially if one returns to school too soon which exacerbates symptoms (26). One study found that 45% of concussed students returned to school too early and suffered from worse symptoms (27, 28). Cognitive rest and slowly returning to school via a step-by-step program is important. Yet, it is important to find a balance between mental rest and activity as cognitive stimulation is important in recovery and there is a concern that the student may suffer from social isolation if withdrawn from school for too long (29).

Sleep Disturbance: Much like cognitive stimulation, it is important to find a balance between too much and too little sleep. Sleeping patterns often change immediately after a concussion -- 33% of concussed youth claimed they slept too much or had troubles sleeping (30, 31). Excessive sleep – identified in one study as longer than 9 hours – was associated with “reduced visual memory, visual motor speed, and reaction time” and prolonged symptoms (32,33). On the other end of the spectrum, sleep difficulties are associated with poorer functional, social, and emotional outcomes ( but these difficulties are not necessarily associated to concussion) (34,35). Sleep is an important restorative measure for the brain after concussive injury and these side-effects should be acknowledged and addressed for the most effective recovery (31, 32, 36, 37).

Headache: Chronic headaches are a common symptom after concussion, reported in more than 90% of high school concussions (31). The prevalence of chronic headache in youth 3 months after injury range from 8%-31% depending on the study (38, 39). Headaches, and pain in general, can have a negative impact on daily activities, mental health, sleep, and personal relationships (40). Interestingly, in one study that looked at post-injury headache in mTBI compared to arm fractures, more concussed females suffered from headache, highlighting that there are differences in concussion symptomatology and severity between males and females (41). More research is required in this area, particularly to understand the prevalence and duration of chronic headache in youth suffering from SRC as well as to understand the transition of acute post-concussion headache to chronic headache pain.

Quality of Life (QoL): The impact concussion has on overall QoL is up for debate. Some studies have found that athletes with greater post concussive symptoms or longer recovery had reduced QoL (42, 43) One study even found that QoL remained “significantly below normative levels even after symptom resolution” in 11% of children at 3 months and 13% at 12 months (44-47). This may be an important finding because it reinforces the idea that just because concussion symptoms are resolved does not mean all of concussion’s effects are resolved. This fact ultimately should have an impact on return to play (RTP) and treatment decisions. On the other hand, there are studies that also have mixed findings (48). Ultimately, QoL impairments seem to be minimal, with symptom burden likely being the cause of a lower QoL (46).

Final Conclusions

Ultimately, more information is required on these topics to fully understand what psychological and social components youth with SRC suffer from as well as to understand how to address these side-effects to most effectively manage concussion and promote recovery. Regardless, for the time being, it could be suggested that medical professionals managing concussion cases consider these 6 areas as potential areas that may be impacting the youth’s recovery.

The original review can be found here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6383087/

About The Author

Rebecca Babcock is a recent graduate of the University of Otago in New Zealand, completing a Master’s in Bioethics and Health Law. Her thesis examined the ethical and legal issues surrounding concussion management. She currently spends her time working for the Concussion Legacy Foundation – Canada as a programming coordinator and at Sunnybrook Hospital investigating concussion prevention, management, and education services. Her dream is to be a clinical ethicist at a hospital which she is starting to fulfill by volunteering as a bioethics assistant at Humber River Hospital in Toronto.

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  8. Mainwaring LM, Hutchison M, Bisschop SM, Comper P, Richards DW. Emotional response to sport concussion compared to ACL injury. Brain Inj. 2010;24:589–597.
  9. Meehan WP., III Medical therapies for concussion. Clin Sports Med. 2011;30:115–124, ix.
  10. Ellis MJ, Ritchie LJ, Koltek M, et al. Psychiatric outcomes after pediatric sports-related concussion. J Neurosurg Pediatr. 2015;16:709–718.
  11. Covassin T, Elbin RJ, Beidler E, Lafevor M, Kontos AP. A review of psychological issues that may be associated with a sport-related concussion in youth and collegiate athletes. Sport Exerc Perform. 2017;6:220–229.
  12. O’Connor SS, Zatzick DF, Wang J, et al. Association between posttraumatic stress, depression, and functional impairments in adolescents 24 months after traumatic brain injury. Journal of Traumatic Stress. 2012;25:264–271.
  13. Luis CA, Mittenberg W. Mood and anxiety disorders following pediatric traumatic brain injury: a prospective study. J Clin Exp Neuropsychol. 2002;24:270–279.
  14. Hawley CA, Ward AB, Magnay AR, Long J. Outcomes following childhood head injury: a population study. J Neurol Neurosurg Psychiatry. 2004;75:737–742.
  15. Lau BC, Collins MW, Lovell MR. Sensitivity and specificity of subacute computerized neurocognitive testing and symptom evaluation in predicting outcomes after sports-related concussion. Am J Sports Med. 2011;39:1209–1216.
  16. Max JE, Lopez A, Wilde EA, et al. Anxiety disorders in children and adolescents in the second six months after traumatic brain injury. J Pediatr Rehabil Med. 2015;8:345–355.
  17. Luis CA, Mittenberg W. Mood and anxiety disorders following pediatric traumatic brain injury: a prospective study. J Clin Exp Neuropsychol. 2002;24:270–279.
  18. Hawley CA, Ward AB, Magnay AR, Long J. Outcomes following childhood head injury: a population study. J Neurol Neurosurg Psychiatry. 2004;75:737–742.
  19. Anderson V, Beauchamp MH, Yeates KO, et al. Social competence at two years after childhood traumatic brain injury. J Neurotrauma. 2017;34:2261–2271
  20. Anderson V, Beauchamp MH, Yeates KO, Crossley L, Hearps SJ, Catroppa C. Social competence at 6 months following childhood traumatic brain injury. J Int Neuropsychol Soc. 2013;19:539–550.
  21. Kennedy JE, Cullen MA, Amador RR, Huey JC, Leal FO. Symptoms in military service members after blast mTBI with and without associated injuries. Neurorehabilitation. 2010;26:191–197.
  22. Lumba-Brown A, Yeates KO, Gioia G, et al. Report from the pediatric mild traumatic brain injury guideline workgroup: systematic review and clinical recommendations for healthcare providers on the diagnosis and management of mild traumatic brain injury among children.
  23. McKinlay A, Grace R, Horwood J, Fergusson D, MacFarlane M. Adolescent psychiatric symptoms following preschool childhood mild traumatic brain injury: evidence from a birth cohort. J Head Trauma Rehabil. 2009;24:221–227.
  24. Kirkwood MW, Yeates KO, Wilson PE. Pediatric sport-related concussion: a review of the clinical management of an oft-neglected population. Pediatrics. 2006;117:1359–1371.
  25. Taylor HG, Orchinik LJ, Minich N, et al. Symptoms of persistent behavior problems in children with mild traumatic brain injury. J Head Trauma Rehabil. 2015;30:302–310
  26. Halstead ME, McAvoy K, Devore CD, et al. Returning to learning following a concussion. Pediatrics. 2013;132:948–957.
  27. Carson JD, Lawrence DW, Kraft SA, et al. Premature return to play and return to learn after a sport-related concussion: physician’s chart review. Can Fam Physician. 2014;60:e310, e312–e315.
  28. Makki AY, Leddy J, Hinds A, et al. School attendance and symptoms in adolescents after sport-related concussion. Glob Pediatr Health. 2016;3:2333794X16630493.
  29. Majerske CW, Mihalik JP, Ren D, et al. Concussion in sports: postconcussive activity levels, symptoms, and neurocognitive performance. J Athl Train. 2008;43:265–274.
  30. Eisenberg MA, Meehan WP, III, Mannix R. Duration and course of post-concussive symptoms.Pediatrics. 2014;133:999–1006.
  31. Meehan WP, d’Hemecourt P, Comstock RD. High school concussions in the 2008-2009 academic year: mechanism, symptoms, and management. Am J Sports Med. 2010;38:2405–2409.
  32. Kostyun R, Milewski MD, Hafeez I. Sleep disturbance and neurocognitive function during the recovery from a sport-related concussion in adolescents. Am J Sports Med. 2015;43:633–640.
  33. Schneider KJ, Leddy JJ, Guskiewicz KM, et al. Rest and treatment/rehabilitation following sport-related concussion: a systematic review. Br J Sports Med. 2017;51:930–934.
  34. Albicini MS, Lee J, McKinlay A. Ongoing daytime behavioural problems in university students following childhood mild traumatic brain injury. Int J Rehabil Res. 2016;39:77–83.
  35. Chan LG, Feinstein A. Persistent sleep disturbances independently predict poorer functional and social outcomes 1 year after mild traumatic brain injury. J Head Trauma Rehabil. 2015;30:E67–E75
  36. Khoury S, Chouchou F, Amzica F, et al. Rapid EEG activity during sleep dominates in mild traumatic brain injury patients with acute pain. J Neurotrauma. 2013;30:633–641
  37. Kostyun R. Sleep disturbances in concussed athletes: a review of the literature. Conn Med. 2015;79:161–165.
  38. Babcock L, Byczkowski T, Wade SL, Ho M, Mookerjee S, Bazarian JJ. Predicting postconcussion syndrome after mild traumatic brain injury in children and adolescents who present to the emergency department. JAMA Pediatr. 2013;167:156–161.
  39. Kuczynski A, Crawford S, Bodell L, Dewey D, Barlow KM. Characteristics of post-traumatic headaches in children following mild traumatic brain injury and their response to treatment: a prospective cohort. Dev Med Child Neurol. 2013;55:636–641.
  40. McCarberg BH, Nicholson BD, Todd KH, Palmer T, Penles L. The impact of pain on quality of life and the unmet needs of pain management: results from pain sufferers and physicians participating in an Internet survey. Am J Ther. 2008;15:312–320. [PubMed] [Google Scholar]
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  42. Houston MN, Bay RC, Valovich McLeod TC. The relationship between post-injury measures of cognition, balance, symptom reports and health-related quality-of-life in adolescent athletes with concussion. Brain Inj. 2016;30:891–898.
  43. Russell K, Selci E, Chu S, Fineblit S, Ritchie L, Ellis MJ. Longitudinal assessment of health-related quality of life following adolescent sports-related concussion. J Neurotrauma. 2017;34:2147–2153.
  44. Zonfrillo MR, Durbin DR, Koepsell TD, et al. Prevalence of and risk factors for poor functioning after isolated mild traumatic brain injury in children. J Neurotrauma. 2014;31:722–727.
  45. Moran LM, Taylor HG, Rusin J, et al. Quality of life in pediatric mild traumatic brain injury and its relationship to postconcussive symptoms. J Pediatr Psychol. 2012;37:736–744.
  46. Yeates KO, Kaizar E, Rusin J, et al. Reliable change in postconcussive symptoms and its functional consequences among children with mild traumatic brain injury. Arch Pediatr Adolesc Med. 2012;166:615–622.
  47. Rivara FP, Koepsell TD, Wang J, et al. Disability 3, 12, and 24 months after traumatic brain injury among children and adolescents. Pediatrics. 2011;128:e1129–e1138.
  48. Fineblit S, Selci E, Loewen H, Ellis M, Russell K. Health-related quality of life after pediatric mild traumatic brain injury/concussion: a systematic review. J Neurotrauma. 2016;33:1561–1568.

Important Factors to Consider When Returning Concussed Youth to School

Study Shows Returning to School is a Unique Consideration for Concussed Youth

In comparison to adults, youth who suffer a sport-related concussion have to manage different factors, such as returning to school (RTS). Therefore, a 2018 study systematically reviewed academic literature concerning concussions in youth and RTS (1). Specifically, the study examined two questions: 1) what factors must be considered in RTS following concussion, and 2) what strategies or accommodations should be recommended following concussion?

Student athletes who continued to play after injury took twice as long to recover and were 9x more likely to have prolonged recovery

Factors To Consider

This study identified elements that tend to negatively impact a student’s ability to RTS. The list below summarizes these factors.

  1. Number of Symptoms or Symptom Severity: a higher number of symptoms or greater symptom severity indicated there was a greater chance of youth missing more days of school and having challenges RTS (2-6).
  2. Types of Symptoms: specific symptoms, such as: headache, fatigue, visual disturbances, memory deficits, difficulty concentrating, executive dysfunction, and vestibular abnormalities, negatively impacted a student’s ability to RTS (2-4,6-8).
  3. Duration of Symptoms: symptoms that lasted longer meant the students had more difficulty with RTS (2,5)
  4. Age/Grade: adolescents/high school students tended to suffer from: a) more symptoms, and b) more severe symptoms which was associated with taking longer to, and having more difficulty in, RTS in comparison to younger children (3-6,9-10). In one study, youth aged 13 years and older was a predictor of persistent symptoms (11). These trends may reflect increased academic and social demands, greater challenges to coordinate management strategies across multiple classes, and “greater independence and decreased supervision in compliance with medical recommendations” (1).
  5. Courses: math caused the most problems for students RTS followed by reading/language, arts, science, and social studies classes (5).
  6. Rest: youth who did not immediately rest after injury took longer to RTS (12). In fact, increased school attendance and higher cognitive loads after injury were associated with persistent or exacerbated symptoms (12-15). Student athletes who continued to play after injury took twice as long to recover and were 9x more likely to have prolonged recovery (16).
  7. Socioeconomic Status: youth with private insurance missed more days of school after a concussion than youth with public insurance (17).

What Accommodations Can Be Made?

Three interesting trends were found that could be helpful in developing specific accommodations other than increased school absence. First, most students were able to RTS after 2-5 days (14,18-19). Second, 45% of students may experience exacerbation or recurrence of symptoms when RTS (9). Third, anywhere from 17-73% of students received accommodations and/or experienced difficulty at school (2-4,7,10,18,20). Most interestingly, schools that had concussion policies were more likely to provide concussed students with accommodations in comparison to schools who did not have a policy (21). Similarly, students who had a medical RTS letter or received outpatient medical follow-ups were also more likely to be provided with accommodations (10,18).

More Research Needed

Due to the study’s reasonable inclusion criteria, only 17 studies were assessed for this systematic review. Ultimately, more research is needed in order to establish RTS processes and accommodations that are guided by clinical evidence.

About The Author

Rebecca Babcock is a recent graduate of the University of Otago in New Zealand, completing a Master’s in Bioethics and Health Law. Her thesis examined the ethical and legal issues surrounding concussion management. She currently spends her time working for the Concussion Legacy Foundation – Canada as a programming coordinator and at Sunnybrook Hospital investigating concussion prevention, management, and education services. Her dream is to be a clinical ethicist at a hospital which she is starting to fulfill by volunteering as a bioethics assistant at Humber River Hospital in Toronto.

References

  1. Purcell LK, Davis GA, Gioia GAWhat factors must be considered in ‘return to school’ following concussion and what strategies or accommodations should be followed? A systematic reviewBritish Journal of Sports Medicine 2019;53:
  2. Baker JG , Leddy JJ , Darling SR , et al. Factors associated with problems for adolescents returning to the classroom after sport-related concussion. Clin Pediatr 2015;54:961–8.
  3. Corwin DJ, Wiebe DJ, Zonfrillo MR, et al. Vestibular deficits following youth concussion. J Pediatr 2015;166:1221–5
  4. Purcell L, Harvey J, Seabrook JA. Patterns of recovery following sport-related concussion in children and adolescents. Clin Pediatr 2016;55:452–8.
  5. Ransom DM, Vaughan CG, Pratson L, et al. Academic effects of concussion in children and adolescents. Pediatrics 2015;135:1043–50.
  6. Ransom DM, Burns AR, Youngstrom EA, et al. Applying an evidence-based assessment model to identify students at risk for perceived academic problems following concussion. J Int Neuropsychol Soc 2016;22:1038–49
  7. Darling SR, Leddy JJ, Baker JG, et al. Evaluation of the Zurich Guidelines and exercise testing for return to play in adolescents following concussion. Clin J Sport Med 2014;24:128–33.
  8. Lovell MR, Collins MW, Iverson GL, et al. Recovery from mild concussion in high school athletes. J Neurosurg 2003;98:296–301.
  9. Carson JD, Lawrence DW, Kraft SA, et al. Premature return to play and return to learn after a sport-related concussion: physician’s chart review. Can Fam Physician 2014;60:e310–e12-5
  10. Zuckerbraun NS, Atabaki S, Collins MW, et al. Use of modified acute concussion evaluation tools in the emergency department. Pediatrics 2014;133:635–42
  11. Zemek R, Barrowman N, Freedman SB, et al. Clinical risk score for persistent postconcussion symptoms among children with acute concussion in the ED. JAMA 2016;315:1014–25
  12. Taubman B, Rosen F, McHugh J, et al. The timing of cognitive and physical rest and recovery in concussion. J Child Neurol 2016;31:1555–60.
  13. Brown NJ, Mannix RC, O’Brien MJ, et al. Effect of cognitive activity level on duration of post-concussion symptoms. Pediatrics 2014;133:e299–304.
  14. Makki AY, Leddy J, Hinds A, et al. School attendance and symptoms in adolescents after sport-related concussion. Glob Pediatr Health 2016;3:1–3.
  15. Silverberg ND, Iverson GL, McCrea M, et al. Activity-related symptom exacerbations after pediatric concussion. JAMA Pediatr 2016;170:946–53
  16. Elbin RJ, Sufrinko A, Schatz P, et al. Removal from play after concussion and recovery time. Pediatrics 2016;138:e20160910.
  17. Zuckerman SL, Zalneraitis BH, Totten DJ, et al. Socioeconomic status and outcomes after sport-related concussion: a preliminary investigation. J Neurosurg Pediatr 2017;19:652–61.
  18. Grubenhoff JA, Deakyne SJ, Comstock RD, et al. Outpatient follow-up and return to school after emergency department evaluation among children with persistent postconcussion symptoms. Brain Inj 2015;29:1186–91.
  19. Thomas DG, Apps JN, Hoffmann RG, et al. Benefits of strict rest after acute concussion: a randomized controlled trial. Pediatrics 2015;135:213–23.
  20. Corwin DJ, Zonfrillo MR, Master CL, et al. Characteristics of prolonged concussion recovery in a pediatric subspecialty referral population. J Pediatr 2014;165:1207–15.
  21. Glang AE, Koester MC, Chesnutt JC, et al. The effectiveness of a web-based resource in improving postconcussion management in high schools. J Adolesc Health 2015;56:91–7.

Moving to 7-Day Disabled List Improves Major League Baseball Concussion Reporting

Major League Baseball’s (MLB) change from a concussion-specific mandatory 15-day disabled list (DL) rule to a 7-day DL rule in 2011 seemingly has improved concussion reporting amongst the league’s athletes.

Study’s Statistics

This study, published in The Orthopaedic Journal of Sports Medicine, examined 112 players between 2005-2016. The average number of concussions increased from 3.7 concussions/year prior to 2011 when the mandatory 15-day DL was enforced to 13.0 concussions/year after the mandatory 7-day DL rule was implemented.

The Importance

There are numerous benefits of this increased reporting of concussion. Most generally, concussion is traditionally underreported and increasing reporting rates is an important improvement in the area of concussion management. More specifically, given the potential harms of inadequately diagnosed and managed concussions, increased reporting and subsequent concussion care benefits the injured player’s health. Specifically to baseball, since a professional baseball player’s career trajectory significantly changes for the worse if a concussion is left unreported, increased reporting and subsequent appropriate concussion care is beneficial for both player and team success.

While concussions are prominent topics in sport leagues such as the National Football League (NFL) and National Hockey League (NHL), baseball is often overlooked. Thus, this study provides valuable insight into concussion identification and management trends in professional baseball. In fact, this study examined which positions had the highest rates of concussion. The top three positions were outfielders (34%), catchers (33%), and infielders (20%) followed by pitchers (8%) and basemen (4%). Pitchers however, had the highest number of days on the DL as well as the highest concussion-associated costs, followed by fielders and catchers.

Financial Benefits

This study also examined the total cost of the player’s injury to the team. The cost per concussed player before 2011 was $1.1 million and that total decreased to $565,000 after the 7-day DL rule change. This decreased cost occurred despite an increase in reported incidents of concussion and an increase in player salaries. This decrease may be partially explained by the decreased average number of days that concussed athletes spend on the DL (from 38.8 days during the 15-day DL rule to 29.2 during the 7-day DL rule) although the study did not speculate as to why the total cost of an injured player to a team decreased by almost 50%.

Cause for Concern

Many studies and concussion protocols, including this one, cite the fact that most concussions typically resolve between 7-10 days [1][2]. The most recent protocols and guidelines however, state that concussions resolve anywhere from 10-14 days to 4 weeks (the latter time period being most relevant for youth) [3][4]. It is thus initially concerning that the MLB reduced the mandatory sit-out period from 15 days to 7 days which may mean players are returning to play too early.

There are two pieces of evidence that may suggest there is no need for worry. First, this study examined average performance metrics between injured players before and after the 2011 rule change – including earned run average, walks plus hits per inning pitched, batting average, and on-base percentage – and found that there were no significant differences. This means that players before and after the 2011 rule were returning to the game at a similar skill level. It would be important and more valuable however, to examine the performance metrics of the specific injured player before and after his concussion to truly assess whether the player is returning at an appropriate time or too early.

Second, the fact that the average number of days an athlete stayed on the DL after a concussion decreased from 38.1 to 29.2 after 2011 but remained around the 4 week mark suggests that players still are taking significant time off to appropriately recover. In short, simply because the rule mandates a 7-day sit-out period does not mean that immediately after 7 days the player is back on the field.

Conclusion

Ultimately, one cannot conclude that the 7-day DL rule increased the reporting rates of concussion amongst MLB athletes as the trend may be attributable to a general increase in awareness and understanding of concussive injuries which positively correlates with increased reporting [5]. However, it can be said that decreasing the mandatory days on the DL from 15-days to 7-days creates an environment where MLB athletes may be more likely to report concussions. This change is beneficial both physically and financially.

The full study can be read here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6383093/

About The Author

Rebecca Babcock is a recent graduate of the University of Otago in New Zealand, completing a Master’s in Bioethics and Health Law. Her thesis examined the ethical and legal issues surrounding concussion management. She currently spends her time working for the Concussion Legacy Foundation – Canada as a programming coordinator and at Sunnybrook Hospital investigating concussion prevention, management, and education services. Her dream is to be a clinical ethicist at a hospital which she is starting to fulfill by volunteering as a bioethics assistant at Humber River Hospital in Toronto.

References

  1. Belanger HG, Vanderploeg RD. The neuropsychological impact of sports-related concussion: a meta-analysis. J Int Neuropsychol Soc. 2005;11(4):345-357.
  2. Karr JE, Areshenkoff CN, Garcia-Barrera MA. The neuropsychological outcomes of concussion: a systematic review of meta-analyses on the cognitive sequelae of mild traumatic brain injury. Neuropsychology. 2014;28(3):321-336.
  3. “Guideline For Concussion/Mild Traumatic Brain Injury & Persistent Symptoms.” Ontario Neurotrauma Foundation, 6 July 2018, www.braininjuryguidelines.org/concussion.
  4. McCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion in sport—the 5thinternational conference on concussion in sport held in Berlin, October 2016. Br J Sports Med 2017;51:838-847.
  5. Gessel LM, Fields SK, Collins CL, Dick RW, Comstock RD. Concussions among United States high school and collegiate athletes. J Athl Train. 2007;42(4):495-503.

 


Rugby Ontario teams up with HeadCheck Health to improve concussion care for provincial athletes

TORONTO – Rugby Ontario is proud to announce a new partnership with HeadCheck Health Inc. (‘HeadCheck’) to implement innovative concussion testing software for Rugby Ontario’s Sevens and XVs Representative Teams.

HeadCheck provides sports organizations with concussion testing software to enhance the implementation and management of their concussion policy. A mobile testing app includes the policy’s concussion tests and leads to faster and more data-driven assessments. An enhanced web dashboard allows for easier and more thorough management of the concussion data collected. In addition to the software, the company provides custom reporting to help organizations continuously improve their policies and procedures.

"The safety and maintenance of our athletes is our number one concern,” explained Paul Connelly, High Performance Manager of Rugby Ontario. “To be able to have our trained SportSide Athletic Therapists assess our athletes immediately, while having access to the most updated personal data is an invaluable tool."

“We are pleased to partner with a great organization in Rugby Ontario to implement our technology and help raise the standard of concussion care for all athletes,” said Harrison Brown, Co-Founder and CEO of HeadCheck Health.

The partnership will equip Rugby Ontario team therapists with HeadCheck on their mobile devices to perform concussion testing on all athletes participating in provincial activities. In addition to supplying Rugby Ontario with the HeadCheck technology, the company will also provide full training, onboarding, and data management support to the organization. The implementation of HeadCheck will allow Rugby Ontario officials to easily monitor the effectiveness of their concussion policy.

About HeadCheck Health, Inc.
HeadCheck provides sports teams, leagues and organizations with a comprehensive concussion testing and management solution. This includes mobile technology to run concussion assessments, an enhanced web management dashboard, and custom reporting. The platform includes today’s gold standard concussion tests and is flexible enough to incorporate the tests specified by any organization’s concussion policy. The technology provides comparable data to help medical professionals make appropriate concussion management decisions. All data is securely stored for convenient 24/7 access and can follow the athlete to all future sports and teams. For more information on HeadCheck Health please visit https://www.headcheckhealth.com/

About Rugby Ontario
Rugby Ontario is the provincial sports governing body responsible for the organization of rugby in Ontario. Our mission is to lead the sport of rugby in Ontario into a new era of growth through increased participation, community involvement, sound administration and successful player development. Our vision is to establish a stronger identity for rugby in Ontario by promoting the sport’s core values and by fostering a culture of inclusiveness and excellence on and off the field of play. Rugby Ontario is a proud member of Rugby Canada and is extremely proud to be part of the pathway to representing Canada on the international stage. For more information on Rugby Ontario please visit http://www.rugbyontario.com/


BC Hockey Partners with HeadCheck Health to Improve Concussion Care for BC Hockey Players

VANCOUVER – BC Hockey has partnered with HeadCheck Health, Inc. to establish standardization and improve concussion care for all players across BC Hockey. With this partnership, both organizations share a mutual goal to provide innovative approaches to making the game safer at all levels of play in British Columbia and the Yukon.

The program implements an evidence-based standard for concussion testing and management province-wide which will proactively limit league and association liability for mismanagement of concussions. The goal is to increase awareness surrounding the importance of proper concussion testing and management across BC Hockey member leagues, associations, stakeholders, and communities.

“Player safety is of upmost importance to us,” said Barry Petrachenko, Chief Executive Officer of BC Hockey. “Our goal is to increase awareness surrounding the importance of proper concussion testing and management across our membership.”

HeadCheck is a concussion testing and management solution, which simplifies the way concussion protocols are implemented and executed by leveraging mobile, cloud and analytic technology. The solution is available on both Apple and Android devices and features a web-based reporting dashboard enabling administrators to monitor concussion protocol compliance.

HeadCheck will be providing concussion testing software and services to Junior A, Junior B, Major Midget, Minor Midget and Female Midget AAA teams as well as Minor Hockey Associations (MHA) in BC and the Yukon. The company’s mobile app allows concussion testing to be conducted at the time of the event with the information collected digitally stored in a secure electronic system where it can be accessed by authorized individuals. This process builds a usable concussion history for every athlete and improves the level of care they can receive.

“We are pleased to provide a technological solution that can meet the variety of concussion testing and management requirements of a large organization such as BC Hockey,” said Harrison Brown, CEO of HeadCheck Health, Inc. “Our partnership will continue to seek innovative approaches to making the game safer at all levels.”

HeadCheck’s software can accommodate the different concussion testing requirements at each level of play. The company provides technology training to safety offers or medical professionals as well as contracted certified athletic therapist support when needed. Enhanced clinical care is available through an agreement with Sport Concussion Management to help safely return concussed athletes back to school and play. Additionally, administrators will be provided with reporting and analysis on testing activity to monitor the effectiveness of their concussion policy.

Learn more about how HeadCheck can help your local minor hockey association.

About BC Hockey
BC Hockey is a not-for-profit organization and member branch of Hockey Canada in charge of governing amateur hockey at all levels in British Columbia and the Yukon Territory. Approximately 130 Minor Hockey Associations plus Junior and Senior teams, 60,000 players, 4,500 referees, 10,000 coaches, 20,000 official volunteers and countless others make our great game possible here in Pacific Canada. For more information on BC Hockey please visit http://www.bchockey.net/

About HeadCheck Health, Inc.
HeadCheck provides sports team, leagues and organizations with a complete concussion testing and management software. This includes mobile technology to run baseline and post-injury concussion assessments, an enhanced web management dashboard, and custom reporting. The technology provides comparable data to help medical professionals make appropriate concussion management decisions. All data is securely stored for convenient 24/7 access and can follow the athlete to all future sports and teams. For more information on HeadCheck Health please visit https://www.headcheckhealth.com/

 

Media contacts:

Keegan Goodrich
Manager, Communications
BC Hockey
250.652.2978
kgoodrich@bchockey.net

Kari Kylo
604.889.8057
kari@somaworks.com


Faster recovery from concussion following immediate removal from play

Getting off the field is key to getting athletes back in the game

A recent study out of the University of Florida confirmed the importance of immediately removing athletes from play after they have suffered a sports-related concussion.

Shorter symptoms and quicker return to play

The study, which looked at more than 500 athletes across 18 different sports, showed that immediate removal from sport not only reduced the number of days that the athlete experienced symptoms but it also resulted in quicker return to play. According to the report, student-athletes immediately removed from activity experienced symptoms for two days less— and were able to return to play three days earlier— than their peers who experienced a delayed removal from activities.  The data also suggests that immediate removal may lessen the severity of acute symptoms.[i]

These findings echo previous research, adding weight to current management practices that require athletes suspected of having a concussion be immediately removed from play.[ii] For those working with adolescents, immediate removal from play may be even more important—one study showed that adolescents immediately removed from activity returned to play 22 days earlier than their peers who were not.[iii]

The right rest

Multiple studies show that immediate rest is key, but this study suggests that too much rest may not be the best approach. While there is a consensus that 24-48 hours of rest immediately after sustaining a concussion is crucial to a speedy recovery, prolonged rest may increase the risk of an extended recovery. [iv] Instead, properly timed physical activity could improve outcomes. [v] Researchers believe physical activity may encourage better outcomes by increasing the brain’s uptake of proteins associated with healing and neural repair and could speed up a return to homeostasis.[vi]

Catch it when you can

Despite the strong evidence that immediate removal is essential, as many as 50% of athletes are delayed in being removed from sport after sustaining a concussion.[vii] It’s unlikely that all of these delays are simply caused by a failure to report or non-compliance with concussion guidelines. In this study, a high proportion of those who were not immediately removed from sport were people who experienced delayed symptom onset— helping to explain why so many athletes continue to play after the impact responsible for the concussion.

Unfortunately, not every concussion is immediately detectable. Still, as soon as symptoms are noticed, it is time to get off the field immediately. Mounting data shows that removal from play at the time of symptom onset— even if that is after the impact that caused the concussion— gives the best chance of avoiding a prolonged recovery. [viii]

Further to go

There have been great strides in the recognition and reporting of sports-related industries over the last two decades, but there is still a long way to go. Too many athletes are still not immediately removed from play.

This study, like several before it, highlights the importance of educating athletes, coaches, and trainers on how to identify symptoms and the importance of immediate removal from play—it’s what is best for recovery, and the fastest way to get athletes back in the game.

 

 

References

[i] Asken, B. M., Bauer, R. M., Guskiewicz, K. M., McCrea, M. A., Schmidt, J. D., Giza, C. C., ... & Broglio, S. P. (2018). Immediate removal from activity after sport-related concussion is associated with shorter clinical recovery and less severe symptoms in collegiate student-athletes. The American journal of sports medicine46(6), 1465-1474.

[ii] Asken BM, McCrea MA, Clugston JR, Snyder AR, Houck ZM, Bauer RM. “Playing through it”: delayed reporting and removal from athletic activity after concussion predicts prolonged recovery.  J Athi Train. 20016; 51(4):329-335.

[iii] Elbin R. Sufrinko A, Schatz, et al. Removal from play after concussion and recovery time. Pediatrics. 2016; 183(3):e20160910

[iv]  McCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion in sport—the 5th International Conference on Concussion in Sport held in Berlin, October 2016 [published online April 26, 2017]. Br J Sports Med. Doi: 10, 1136/bjsports-2017-097699

[v] Silverberg ND, Iverson GL. Is rest after concussion “the best medicine?” Recommendations for activity resumption following concussion in athletes, civilians, and military service members.  J Head Trauma Rehabil. 2013 28(4) 250-259

[vi] Griesbach GS, Hovda D, Molteni R, Wu A, Gomez-Pinilla F. Voluntary exercise following traumatic brain injury: brain-derived neurotrophic factor upregulation and recovery of function, Neuroscience. 2005; 125(1):129-139.

[vii] Asken (2016).

[viii] Asken (2018).


What Risk Managers Need to Know about Concussions

The following article was written by Robin Bowman. Robin is a certified athletic trainer and risk manager with nearly 20 years experience in recreational and varsity athletics.

Concussions are arguably the biggest hot-button issue in sports today. As more research comes out on the complex and sometimes long-lasting effects of even a single concussion, those involved with sports and recreation at all levels are left with some difficult questions. Should children be participating in contact and collision sports? If so, at what age is it appropriate to begin? What should athletes, parents, coaches, officials, and administrators know about concussions? Who is responsible for recognizing and responding to a suspected concussion? How can we balance all the benefits of athletic participation with the very real risks?

Risk managers are tasked with weighing these questions and developing sensible concussion plans. These plans should include strategies for minimizing the number of concussions; a concussion education plan for athletes, coaches and parents; and a well-defined protocol to be followed whenever a concussion is suspected.

The New Standard of Care

Gone are the days of brushing off concussions as “getting your bell rung” and returning to play the same day as the injury. As Maya Angelou said, "I did then what I knew how to do. Now that I know better, I do better." As a society, we now know better, and those working in and around athletics are held to a higher standard of care than they once were. The expectation is that every team and every league have a plan in place for concussion education, recognition and response.

Concussions Can be Managed

While we still have much to learn, we know that concussions are serious injuries that can have long-lasting effects. While we can’t eliminate the injuries altogether, we can take measures to reduce the incidence and ensure all potential concussions are taken seriously and athletes are offered appropriate care.

In an ideal world, there would be an athletic trainer/athletic therapist on the sideline of every practice and competition to look after the wellbeing of the athletes, but this isn’t realistic for many youth sports leagues. Even without an AT on the sideline, every team should have access to someone trained in concussion recognition and response.

Concussions Must be Managed

Effective concussion management is going to take a change in the culture. Risk managers, athletic administrators, and coaches play a vital role in setting the tone for a team, an athletic department, or a league. Those in these roles share responsibility for making sure athletes look at concussions with proper perspective and help them understand the rest of their career and rest of their life is more important than any one game or any one season.

We need to replace any thoughts an athlete may have of playing through a concussion as a sign of “toughness” with an understanding of the seriousness and potentially life-altering effects of the injury. Hiding a concussion and playing through isn’t tough, it’s just a bad idea.

We need to instill in athletes the responsibility to care for oneself, one’s teammates, and one’s opponents. Sportsmanship and fair play are more than just positive character traits, they help reduce unnecessary injuries.

Risk managers have a duty to ensure there is a plan in place to educate athletes, coaches, and administrators on how to recognize concussions, and what to do when an athlete is suspected of having a concussion. When dealing with youth leagues, it is also important to educate the parents. Create a shared understanding that athlete safety is paramount and everyone associated with the league is expected to take concussion seriously and work together to care for the athletes.

Preventing Concussions

The physical nature of sports means that concussions are going to happen from time to time. This is a risk inherent with athletic participation. There are ways to minimize the incidence of concussions, though.

Provide safe playing facilities and equipment. Conduct a safety audit of all facilities used for practice and competition. Are there obstacles in the way? Is there equipment lying around that could cause a tripping hazard? Are there walls or posts that need to be padded? Are playing surfaces well-maintained and free of holes? (Even a poorly maintained grass field can increase the chance of concussion by being too hard or causing athletes to fall.)  What can be done to make the athletic facilities safer? Is the equipment being used in good repair, and do athletes have the appropriate and properly fitted safety equipment? Prioritize and address any issues uncovered in your safety audits.

Train athletes to use proper technique. From the earliest stages of sports participation, athletes should be trained to use good form and proper technique that does not put themselves or others at unnecessary risk of injury.

Insist on good sportsmanship. This is part of changing the culture of sports, but good sportsmanship is non-negotiable. Create a culture in which foul play is discouraged. (While a hockey player may get a concussion from falling on the ice, there is no excuse for getting one from engaging in a fight.) Have zero tolerance for dirty play.

Consider low- or no-contact versions of sports. For example, a league could play flag- or two-hand-touch football instead of tackle football. Limiting contact in practice is another option for lowering the risk of concussion. Even some NCAA Division I football programs have moved to eliminating tackling in practices.

While it’s unlikely we’ll completely eliminate concussions anytime soon, we can have an impact by proactively managing the risks we have control over.

Have a Plan

Since it is impossible to prevent all concussions, you must have a plan in place for how you will respond when an athlete is concussed. Don’t wait until an injury happens to think about how you’ll handle it. Have a well-thought-out plan in place long before a competitive season starts, and communicate this plan to everyone involved with the team, athletic department, or league. A plan can only work if people are aware of it. Make sure everyone knows what their role is in preventing, recognizing, and responding to concussions.

Maintain Proper Documentation

It’s hard to overstate the importance of thorough documentation. Risk managers should ensure that every team keeps thorough and up-to-date documentation of:

  • Facility and equipment inspections
  • Pre-participation physical exams
  • Concussion policies and protocols
  • Proof of concussion training
  • Waivers and releases
  • Injury reports with follow-up/progress notes
  • Proof of medical clearance to return to activity following a concussion

In the event of legal action, the judge will want to see both documentation of the organization’s concussion policies and protocols and proof that they were followed.

Putting it All Together

Concussions aren’t going away anytime soon, but neither are athletics. A risk manager should provide leadership on concussion education, prevention, and response efforts for their team or league. There are many proactive steps than can be taken to minimize risk, but it takes consistent effort and a team approach to make real change.

Reference

Br J Sports Med 2017 51: 838-847 originally published online April 26, 2017