Sports Related Head and Brain Injury
Head Injury in Sports
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.
The U.S. Consumer Product Safety Commission (CPSC) tracks product-related injuries through its National Electronic Injury Surveillance System (NEISS). According to the CPSC, there were an estimated 351,922 sports-related head injuries treated at U.S. hospital emergency rooms in 2008. The actual incidence of head injuries may potentially be much higher for two primary reasons. 1). In the 2008 report, the CPSC excluded estimates for product categories that yielded 1,200 injuries or less, those that had very small sample counts, or those that were limited to a small geographic area of the country; 2). Many less severe head injuries are treated at physician’s offices, immediate care centers, or self-treated.
Included in these statistics are not only the sports/recreational activities, but the equipment and apparel used in these activities. For example, swimming-related injuries include the activity as well as diving boards, equipment, flotation devices, pools, and water slides.
The following 20 sports/recreational activities represent the categories contributing to the highest number of estimated head injuries treated in U.S. hospital emergency rooms in 2008.
Baseball and Softball: 26,964
Powered Recreational Vehicles (ATVs, Dune Buggies, Go-Carts, Mini bikes, Off-road): 25,970
Fitness/Exercise/Health Club: 14,713
Horseback Riding: 11,749
Winter Sports (Skiing, Sledding, Snowboarding, Snowmobiling): 11,723
Water Sports (Diving, Scuba Diving, Surfing, Swimming, Water Polo, Water Skiing): 11,239
Other Ball Sports: 3,935
Roller and Inline Skating: 3,320
Ice Skating: 3,115
The top 10 head injury categories among children ages 14 and younger:
Skateboards/Scooters (Powered): 11,727
Baseball and Softball: 11,672
Water Sports: 9,322
Powered Recreational Vehicles: 6,302
Winter Sports: 5,846
Additional Sports Facts
Over time, professional boxers can suffer permanent brain damage. The force of a professional boxer’s fist is equivalent to being hit with a 13 pound bowling ball traveling 20 miles per hour, or about 52 g’s.
There are boxers with minimal involvement and those that are so severely affected that they require institutional care. There are some boxers with varying degrees of speech difficulty, stiffness, unsteadiness, memory loss, and inappropriate behavior. In several studies, 15-40 percent of ex-boxers have been found to have symptoms of chronic brain injury. Most of these boxers have mild symptoms. Recent studies have shown that most professional boxers (even those without symptoms) have some degree of brain damage.
Every year, more than 500,000 people visit emergency rooms in the United States with bicycle-related injuries. Of those, nearly 71,000 were head injuries in 2008. There are about 600 deaths a year, with two-thirds being attributed to TBI. It is estimated that up to 85 percent of head injuries can be prevented through proper usage of SNELL, American National Standards Institute (ANSI) or American Society for Testing and Materials (ASTM)-approved helmets. It is essential that the helmet fit properly so that it doesn’t fall off while riding or if you take a fall.
The following facts/statistics are from Safe Kids USA:
- Head injury is the leading cause of wheeled sports-related death and the most important determinant of permanent disability after a crash.
- Without proper protection, a fall of as little as two feet can result in a skull fracture or other TBI.
- About 52 percent of children ages 5-14 do not use a bicycle helmet, while 41 percent do, and 7 percent had one but were not wearing it.
- Children whose helmets fit poorly are twice as likely to sustain a head injury in a bicycle crash as children whose helmets fit properly.
- A helmet that is worn too far back on the head is 52 percent less effective.
The National Center for Catastrophic Sport Injury Research tracks a number of head injury statistics related to football annually:
- There were 44 head injury-related deaths from 1995-2004.
- High school players sustained 43 head injuries from 1995-2004 in which there was incomplete recovery.
- College players sustained five head injuries from 1995-2004 in which there was incomplete recovery.
- According to league officials there are about 160 concussions in the National Football League every year.
Head injuries comprise about 18 percent of all horseback riding injuries, although they are the number one reason for hospital admissions and the leading cause of death. Three of every five equestrian accident deaths are due to head injuries.
Severe head trauma accounts for about 15 percent of all skiing and snowboarding related injuries, but is the most frequent cause of death and severe disability.
According to the National Ski Areas Association (NSAA), during the 2007/08 season, 53 fatalities occurred out of the 60.5 million skier/snowboarder days reported for the season. Forty-four of the fatalities were skiers (38 male; 6 female) and nine of the fatalities were snowboarders, (8 male; 1 female). The rate of fatality converts to .88 per million skier/snowboarder visits.
There are no state laws mandating helmets for skiing or any winter sports. Aspen ski resorts mandate that skiers under age 12 wear helmets. Other ski resorts are trying to institute such mandates, and in Michigan, statewide. Following the high-profile skiing-related deaths of Michael Kennedy in December 1997, and Sony Bono in January 1998, an increase in the number of skiers wearing helmets was noted in several studies.
According to the 2007/08 NSAA National Demographic Study:
- Forty-three percent of U.S. skiers and boarders overall wear helmets, up from 40 percent the year before.
- In comparison, only 25 percent of skiers and boarders wore helmets during the 2002/03 season.
- Seventy percent of children age 9 or younger wear ski helmets; 60 percent of children ages 10 to14 wear ski helmets; 59 percent of adults over the age of 65 wear ski helmets.
- The least likely group to wear helmets: men ages 18 to 24, with only 32 percent wearing helmets.
Protection against head injuries in soccer is complicated by the fact that heading is an established part of the game, and any attempt to protect against head injuries must allow the game to be played without modification. Several head guards have been developed to reduce the risk of head injuries in soccer. One independent research study found that none of the products on the market provided substantial benefits against minor impacts, such as heading with a soccer ball.
A McGill University study found that more than 60 percent of college-level soccer players reported symptoms of concussion during a single season. Although the percentage at other levels of play may be different, these data indicate that head injuries in soccer are more frequent than most presume.
According to CPSC statistics, 40 percent of soccer concussions are attributed to head to player contact; 10.3 percent are head to ground, goal post, wall, etc.; 12.6 percent are head to soccer ball, including accidents; and 37 percent are not specified.
Types of Head Injuries
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.
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.
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)
Powered Recreational Vehicles
Head gear is recommended by many sports safety experts for:
Vintage Motor Sports
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.
Avoid uneven or unpaved surfaces when cycling or skateboarding.
Perform regular safety checks of sports fields, playgrounds and equipment.
Discard and replace sporting equipment or protective gear that is damaged.
Rule Changes in Contact Sports 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, focused on two primary problems this year 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.
Source: the American Association of Neurological Surgeons
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