Category: Concussion

Throughout the past two decades there have been more than 20 National Football League (NFL) player suicides, like Terry Long, Dave Duerson and Junior Seau (See Appendix A). Finding a link between these suicides and playing pro football is the reason behind an ongoing joint study being done by the Department of Veterans Affairs and Boston University. The autopsy reports from 87 out of 91 former NFL players (96%) has revealed Chronic Traumatic Encephalopathy (CTE) in their brains (Breslow, 2015). CTE is a degenerative neurological disease that is “widely believed to stem from repetitive trauma to the head, and can lead to conditions such as memory loss, depression and dementia “(Breslow, 2015). NFL players are sustaining multiple concussions during their careers, which this evidence indicates is having a long-term impact on their health and quality of life.

After years of denial, the NFL has acknowledged concussions are a problem. They have responded by addressing three significant areas of concern to increase the safety of the game by minimizing the head trauma among its players. While measured progress is being made every year in reducing the number of player concussions, there are still further opportunities for improvement. These include additional policy enhancements for concussion management, rules and regulation changes to prevent direct head hits, and utilizing design advancements to helmets that will lessen the force of hits. Each of these areas of development will serve to better protect the players from exposure to repeated head trauma and decrease the risk of concussions.

History and Cultural Shift

From 1994-2009 the NFL publicly denied that there was any connection between concussions and long-term health hazards for its players (Ezell, 2013). The League believed that “concussions are a part of the profession, an occupational risk” (Petchesky, 2013). This era of NFL denial simultaneously corresponded to a growing movement of concussion awareness, understanding and research being carried out in the science community. However, the NFL repeatedly opposed validity of the emerging concussion warnings. In 2003, sports medicine researcher Dr. Kevin Guskiewicz published a paper indicating that multiple concussions “may lead to a slower recovery of neurological functioning” (Petchesky, 2013)). The NFL dismissed Dr. Guskiewicz findings and published their own paper where they reported that more than half of their concussed players returned to play symptom free in one day (Petchesky, 2013)). This is only one example, in a consistent chronological timeline of events, where the NFL responded in a way that directly contradicted a piece of newly released concussion research (See Appendix B).

It wasn’t until 2010 that the NFL decided to take responsibility for the health and safety of its players by acknowledging the seriousness of concussions. There were two catalyst events that caused the NFL to get ahead of the concussion situation and became advocates for change. Firstly, at this point a number of studies and data had been collected following the suicides and deaths of former NFL players (See Appendix A). Researchers found increasingly undeniable evidence linking every deceased player to CTE, and that retired players were 19 times more likely to develop dementia, Alzheimer’s and depression (Petchesky, 2013)). Secondly, starting in 2011, over 4,500 ex-NFL players brought hundreds of lawsuits against the NFL. These players were seeking millions of dollars in restitution for the long-lasting effects to the health of their brains which were sustained during their NFL careers. These lawsuits accused the NFL of “hiding the dangers of concussions” and that the players believed their concussions were “fraudulently” managed (Press, 2014).

Both of these events caused the NFL to reevaluate its previous resistance to concussion prevention. Moving forward the NFL began a noticeable campaign to improve the safety of their players in regard to decreasing the risk of concussions. They supported medical professionals involved with concussion research by donating millions of dollars. The NFL partnered with helmet designers to understand how to lessen impact from hits, developed a league-wide concussion policy, instituted return to play guidelines, made rules and regulation changes to limit hits to the head, and mandated player education on the risks of concussions (See Appendix C).

Stakeholders

In every ethical dilemma, there are always stakeholders involved. In this specific discussion, the main stakeholders involved are the NFL, the teams, officials and sponsors of the league. The team stakeholder includes the players, players’ families, the medical staff and coaches. The players are personally affected by these concussions and the long-term health consequences because they are the ones taking the repeated hits to the head in games and practices. The players’ families have to help take care of them through every injury and recovery process when they happen, and then again with the later onset symptoms of these concussions (dementia, memory loss, anger, depression). The medical staff and coaches are responsible for a player’s immediate health and safety on the field. They are the ones that pay attention to every player and know when they are not ok. The medical staff has to make educated and immediate decisions on a player’s ability to return to the game and are responsible for getting them better.

There have been noted incidents of unethical behavior in response to injuries in the heat of a game. Barry Sanders a former Detroit Lion, stated that back in the ‘90s, concussion protocol was left up to the players. He stated, “How do you feel today? Are you getting any better?” Sanders said, describing the questions players were asked. “God forbid, it’s a guy who’s fighting for a job, who wants to prove he’s a tough guy and he just wants to get back onto the field. It’s a tough situation.” (Hewett, 2013) This is something that teams must monitor so that its players health is protected.

The NFL is an important stakeholder on this issue because the players are their investment. When the players are injured and not on the field, then the League loses money. If player safety is ignored then the League is open to liability, like what recently happened with the concussion lawsuit over negligent care. The league has the responsibility of keeping players safe through the rules and regulations of the game. They are able to implement policies and protocols, necessary rule changes, and required equipment that every team in the League must abide by in hopes of keeping players healthy and protected. The more dangerous the fans believe the sport is becoming, then parents stop letting their kids play and the future of the league could be in trouble.

The officials are stakeholders in this situation as well because they hold the responsibility of policing the safety of the game. They must be able to watch every hit simultaneously and not allow any dangerous plays to happen without penalty. They can never be manipulated by the crowd or coaches. Their job is on the line every time they step on the field. They must make every call as accurate as possible to keep the players safe. Manufacturers and sponsors of the league are involved in the NFL concussion issue because they are responsible for letting the NFL know whether a piece of equipment is safe and suitable to be used in the field of play. They are able to work together with the League on developing new equipment and technology for the players to decrease injury. The more their product is supported, the more money they can earn.

Concussion Policy Clarifications and Enhancements

The development of an official concussion policy by the League in 2013 was an important step in collectively managing the safety of the players, decreasing concussions, and attempting to protect the league from further litigation (League). The NFL concussion policy delineates specific protocols for recognizing, diagnosing, preventing and managing concussions. Every player must participate in pre-season concussion education trainings, and baseline physical and neurological assessments (League, 2013). These baseline assessments are invaluable in making a quicker sideline diagnosis during the season because they allow the clinician to compare results immediately and notice deficits. There is also a standardize Sideline Concussion Assessment the must be performed on any player suspected of a concussion (League, 2013). The Sideline Assessment is intended to streamline the evaluation process from team to team and eliminate differential treatment. It can also be used on a player multiple times to track their recovery.

Additionally, every team is now required to provide an Unaffiliated Neurotrauma Consultant (UNC) (League, 2013). The UNC is expected to be involved with all sideline evaluations once a concussion is suspected. They are meant to offer an unbiased view in identifying a concussion. These supplementary medical staffers add an extra layer of protection to the gameday safety of a player and increase the transparency of evaluations so fewer concussions will be missed. The clarification that needs to be introduced into the Concussion Policy is to say that the UNC has the sole power to remove a player from the game when a concussion is suspected. Currently, the team doctor can overrule the UNC and remain the exclusive judge for this decision which leaves room for manipulation by the coaches and opens the league to liability.

The last part of the Concussion Policy outlines a specific return to play protocol. Currently the five steps of the protocol are clearly outlined and meant to be completed in a progression (See Appendix D). However, the NFL needs to determine a specific timeline for this protocol to occur. Currently, there is nothing to stop a player from completing his steps in a day. The NFL needs to enforce a 24-hour wait in between each step of progression so that symptoms can be fully monitored. This timeline is adapted from the International Concussion Consensus Guidelines and utilized by medical professionals around the world (CDC, 2015). This means the full protocol will take almost a week to complete before clearance is attained. Adapting these guidelines will eliminate the risk of sustaining another concussion before the first has healed which may reduce the long-term health problems associated with repetitive head trauma.

Safer Rules and Regulations

The violent contact in the sport of football is so severe that the NFL is taking steps to help ensure the safety of its players. Along with stricter concussion management policies for practices and games, the NFL is making changes to the rules of the game itself to better protect their players (See Appendix E). In 2011, the NFL changed the kick-off rule by five yards “in hopes of reducing the speed of collisions” during kick-off (Ezell, 2013). Since then over 40 other rules have been put into effect to limit dangerous hits, especially to the head, but still allow Football to remain a competitive contact sport (League, 2015b). Some of these rules include, “The Defenseless Receiver”, “Peel Back Blocks”, “Chop Blocks”, and allowing “Medical Timeouts” (See Appendix E). The NFL implemented every one of these rules to make the game safer for the men playing it.

“Medical Timeouts” are a new regulation for the 2015/2016 season. The idea behind a “medical time-out” is that a third pair of eyes will now be on the players in addition to the officials on the field and their own medical staff. If both the team’s medical staff and the officials on the field miss a player looking disoriented and unstable then a “medical timeout” can be called by the ATC’s in the press box. The ability to stop the game is a good safety precaution, but the practicality of anyone actually doing it is yet to be seen.

Even with these new rule changes, concussions and injuries are still a risk of the game of football. However, there has been measured success since the limiting of helmet hits and head contact. In the 2014 Injury Data Report filed by the NFL the data revealed, “Concussions caused by helmet-to-helmet hits [were] down 43% from 2012-2014” (League, 2015a). Aside from the NFL removing contact completely from the game, which would forever change the sport, a next step for continued player safety could be for the NFL to add the verbiage “if the defender is going for the ball” to the “defenseless receiver” rule. It would free up the defender and still make plays on the ball without putting the receiver in danger.

The game of football is violent, and the injuries one can suffer playing it can be so absolute that careers can be ended in the blink of an eye. The NFL realizes that they need players to have a league. They are doing what they can to help maintain the safety of the players while performing on the field. One of the fears is that the NFL is becoming too soft with all the rule changes and not allowing defenders to get those “big hits” anymore. It is the responsibility of the league to protect the players no matter what the backlash is from the public. Although they weren’t for many years, the NFL is now consistently making rule changes to decrease the risk of concussions and injury for their players.

Helmet Advancements

The NFL has made numerous changes since the beginning of football when it comes to the use and durability of its equipment. The role of protective gear and equipment in making football safer for the players follows a fine line. Manufacturers have used innovating methods over the years to produce smarter and up-to-date models. Helmets were brought to the game to prevent skull fractures and subdural hematomas in the 1900’s (League, 2012). They’ve evolved over the past century from leather to the first hard plastic design in 1939 to models now made to try and address the concussion risk (See Appendix F).

Many scientists and people who work with the National Operating Committee on Standards for Athletic Equipment (NOCSAE) have stated that there would never be a concussion proof helmet (Mihoces, 2014). They have taken steps to find out the types of forces and level of impact that can cause these injuries. NOCSAE is a non-profit based out of Kansas City, who sets the testing standard for helmets. Manufacturers have a licensing agreement with NOCSAE to certify helmets based on whether they meet the standard. Each year the NFL sends a number of helmets to NOCSAE to see if the equipment meets the standard. If the piece of equipment is passed and put into use by a NFL player, the equipment must be updated over a number of years. This ethical dilemma was addressed when the NFL became aware that most of its players were still wearing older model of helmets during the peak of a concussion era.

The NFL has added new ideas to address the dilemma of how to minimize the concussion risk for its players and still remain a contact sport. They’ve had numerous talks with helmet manufacturers and NOCSAE about adding impact sensors to its helmet so that it can be scientifically assessed about the types of hits players take game by game (Fairnaru, 2015). Although the NFL cannot prevent concussions from happening in the game of football, they have ultimately done a better job of policing the issue. The NFL most recently donated $30M to the National Institute of Health (NIH) in 2012 to focus on advancing science on medical understanding of brain injuries (League, 2012). Years ago, the NFL failed to address the concussion issue, today, they’ve made it aware that it is a topic that needs to be discussed, analyzed and addressed. Making its employees and affiliates aware that changes are being made each day for this issue, shows the league’s expansion.

Conclusion

With the alarming amount of past NFL players committing suicide, the NFL has taken a more focused look into the head trauma during participation and how it is impacting each player. Football is a collision sport. A single play in football has been compared to driving a car at 35 miles per hour into a cement wall. On average, an NFL offense runs 80 plays a game. The impact of these plays is taking a concerning toll on the bodies of the players.

The NFL acknowledges the physical demands of football and has recently donated 30 million dollars to the National Institutes of Health to research sports injuries – including joint disease, chronic pain, and CTE (League, 2012). They started a youth safety initiative called the “Heads Up Program” in which the game of football is taught with better hitting techniques to protect the head. The NFL is holding clinics in which youth coaches can be taught by NFL players and coaches how to properly tackle and be tackled in order to lower the risk of injury. Along with the community outreach the NFL has changed the rules of the game to take away the “big hit” where a player cannot protect himself before contact.

NFL Commissioner Roger Goodell said in an on-air interview before the Superbowl in 2013, “Well that’s why we are investing in the research, so that we can answer the questions. What is the link? What is the cause of some of the injuries that our players are still dealing with? And we take those issues very seriously. We’re going to let the medical individuals make those points. We’re going to give them the money to advance that science. In the meantime, we need to do everything we can to advance the game and make sure it’s safe.”

Football is a contact sport and that is why society loves it so much, but with that comes risk of injury. The NFL is enhancing safety on the field by decreasing the repetitive head trauma that causes CTE through the development of a concussion management protocol, stricter return to play guidelines, and implementing new rules and regulation changes. In addition, by working closely with helmet manufacturers and donating money to fund research for technology advancements, the NFL is hoping to lessen impacts which lead to concussions. With these three areas of reform the NFL already shows from 2012 to 2014, a 36% decrease of concussions occurring in season games (League, 2015a). The NFL has a clear view of the seriousness of concussion and is doing everything in their power to ensure the safety of its players. Only time will tell if that foresight will last or if the vision of the league will become clouded after years and years of taking hits.

Introduction

A lot of people don’t exactly know what a concussion is, never mind the severity of this brain injury. Concussions are considered a mild brain injury because they are not usually life-threatening. This is correct. A concussion is usually not a life-threatening injury which is why people didn’t use to pay it much attention. However, the attitudes toward concussions have changed in the last few years because of the discoveries that medical research has uncovered. So after having said all this, what is a concussion exactly? A concussion is defined as a traumatic brain injury that is caused by a bump, blow or jolt to the head or by a hit to the body that causes the head to hit the ground or that causes the brain to bounce around or rattle within the skull. This trauma causes chemical changes in the brain and sometimes stretching and damaging brain cells. Because of people having given brain injuries more attention over the past few years, there have been many new discoveries regarding the effects of brain trauma, precisely concussions, on the brain of individuals, more specifically, athletes. Chronic Traumatic Encephalopathy, better known as CTE, is one quite important discovery. CTE is a degenerative brain disease that is found in athletes and others who have a history of repetitive brain trauma. Dr. Bennet Omalu is the medical researcher who discovered the disease when examining the brain of Mike Webster, a Hall of Fame center for the Pittsburgh Steelers, one of the greatest centers to ever play the game, who had committed suicide. This discovery was significant because it led to a clearer understanding of the implications of the disease and its effects on the athlete’s physical and emotional well-being. Therefore, this raises the question: In what way does brain trauma due to head collisions negatively impact athletes’ well-being? By thinking of the different aspects of people’s everyday lives, we can approach this question at three different angles. Upon analyzing a person’s biological, psychological and social well-being, this paper aims to illustrate to what extent brain trauma and concussions can negatively affect a person, more specifically, an athlete’s ability to function daily.

Biological Effects

The biological effects of an injury, which are better known as the physical effects, are defined as substantial physical pain or any impairment of physical condition. Athletes, especially those who play very physical contact-based sports, are exposed to the risks of suffering multiple types of injuries. Especially athletes who play sports such as football, hockey, soccer, and rugby are significantly more exposed when it comes to the risks of suffering injuries related to brain trauma, such as concussions. A concussion causes the different parts of the brain to move at different speeds, producing shearing forces that can stretch and tear nerve tissue. In Concussion by Jeanne Marie Laskas, she discusses Dr. Omalu’s assertion that “A helmet can’t keep the brain from sloshing around in that skull. If you hit your head hard enough, the brain goes bashing against the walls of the skull.”

League of Denial, by Mark Fainaru-Wada and Steve Fainaru, is a documentary that talks about the NFL and its response to concussions. In this documentary, they proceed to attempt to expose everything the NFL has been covering up about concussions and their repercussions on their players for decades. This whole scandal leads to scientific discovery, the discovery of CTE by Dr. Bennet Omalu. CTE is a degenerative brain disease in which a protein forms within your brain. Dr. Omalu discovered this disease in the brains of NFL players whom he examined after they had passed away. The protein that forms within the subject’s brain is called Tau. It accumulates and forms clumps that slowly spread throughout the brain, killing brain cells. Symptoms of CTE appear years after the head trauma. This disease causes symptoms that affect a patient’s mood and behaviour. Some common changes include impulse control problems, aggression, depression, and paranoia. In the latter stages, the patient encounters difficulties regarding thinking and memory. This includes memory loss, confusion, impaired judgement, and progressive dementia. Mike Webster was the first ever NFL player who committed suicide, to have his brain examined. Webster’s family’s decision to have Mike’s brain examined, ultimately led to him being diagnosed with CTE (Chronic Traumatic Encephalopathy). The fact that Mike Webster committed suicide leads us to question the effects of brain trauma regarding a person’s physical and psychological well being.

Psychological Effects

Since Mike Webster’s suicide brought to the forefront the correlation between head injury and psychological well-being, there has been more attention directed to this issue. In League of Denial, Pam Webster, Mike’s wife discloses the changes in Mike’s personality. She contributes to the book by stating her observations about her husband’s behaviour.

“Before Mike rarely raised his voice; now his temper was short. He became easily distracted and forgetful. He was often lethargic and indecisive. Where Webster once had approached his work with unrelenting focus, now “he couldn’t decide what to have for breakfast,” Pam said.” p 29. Her statement supports the findings of mental health professionals whose research demonstrates that head injuries and specifically CTE cause other psychological issues that need to be addressed. The issues are depression, irritability, frustration and aggression, apathy and loss of initiative as well as anxiety. Mike Webster demonstrated many of these characteristics prior to his death. But the question remains as to why these patients experience these mental health issues.

Depression is a common emotional reaction to a concussion. An athlete’s livelihood depends on the ability to perform at the highest level. After suffering an injury, such as a concussion, an athlete’s skills are directly affected, and he cannot perform at the same level as he was before. Therefore, because of a loss or diminishment of skills, those afflicted could have long term consequences because they cannot do what they were able to do prior to the concussion. Life will not be as it was before, and this can have a lasting impact on relationships. The challenges that patients with concussions must deal with result in a realization that their life will not be the same as it was before, and this is difficult for them to accept. The uncertainty that surrounds the patient leads to other mental health issues like irritability, frustration, and aggression.

Pam Webster reported that Mike was irritable and short-tempered. This is common behaviour for patients who have succumbed to a brain injury. According to Dr. Andy Tyerman, in Psychological effects of brain injury, “People with a brain injury are often impatient, intolerant of others’ mistakes, and easily irritated by interruptions, such as noise from children or machinery, which disrupt their concentration. They are frequently reported to be short-tempered, for example when things do not work out as expected or where there are differences of opinion with family or work colleagues.” (p. 10) This frustration is related to the slow recovery rate and the fact that they are injured and cannot do what they could do prior to the injury. Also, Dr. Tyerman states that patients with brain injuries cannot control their impulses and this can lead to angry outbursts and sometimes physical aggression. This proves the theory that brain trauma due to head collisions negatively impact athlete’s well-being as it demonstrates the psychological hardship that athletes must endure and how it can ultimately in some cases make them mad to the point where they throw their lives away in different ways, including suicide and/or self-harm.

Social Effects

The way people act within society is affected by their mood. People often also don’t realize how their actions can affect others that surround them. The biological and psychological effects that brain trauma, more specifically concussions, have on people’s well being, affects the social aspect of their lives in a negative way. This means that it can lead to stress on the family who are patiently waiting for recovery, while also grieving for the loss of the person that they once knew because, after the accident, they are no longer the same person. This can cause friction in the family because of the need to adjust to new roles in the family unit. Moreover, the person who has succumbed the injury can also in some cases resort to social isolation for reasons such as the shame of not being like they were before, the frustration of always having to explain why they’re not feeling well even if from the outside, they seem perfectly “normal”. In addition, there is also the horrible feeling that no one understands what the person is going through, therefore the person has the simple desire to isolate themselves to avoid situations that can trigger or worsen their symptoms. Mike Webster also experienced social isolation. In the book Concussion by Jeanne Marie Laskas, she describes Mike Webster’s erratic and incomprehensible behaviour after he retired from the NFL. “he disappeared, came back. Months at a time disappeared wandered back.’ (p.95) This behaviour was difficult for his children and for his wife to deal with because this was not who Mike was. It was whom Mike had become and the family members not only grieved the loss of the old Mike but the reality of the new Mike.

After all this information regarding concussions in sport leaked out and gained more traction and attention within society, the way people thought about the topic also changed. Football is very popular, especially in small towns and rural areas where there are fewer opportunities and where families and students are looking for a way to pay for post-secondary education. Football is also a huge sports industry in the US. However, society has changed their way of thinking, people have changed their point of view on football. There are now fewer players as parents don’t want their kids to play, more rules and guidelines, and only certified coaches coach football teams. This huge societal change has largely taken place because there is a large risk of concussions when playing football. The same has occurred in schools where a concussion protocol has been adopted. In the NHL, the same can be stated as the NHL takes head trauma much more seriously now than it used to.

Conclusion

Bibliography

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2. Marx, Karl, and Friedrich Engels. The Communist Manifesto. New York, NY: New American Library, 1998. 96 pages. Print.
3. Orwell, George. 1984. London: Secker and Warburg, e-book, 1949.
4. Orwell, George. Animal Farm: A Fairy Story. First Mariner Edition 2009. Orlando: Houghton `Mifflin Harcourt Publishing Company, e-book, 1987.
5. Tismaneanu, Vladimir. The Devil in History: Communism, Fascism and Some Lessons of the
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7. Welch, David. Hitler: Profile of a Dictator. London, Routledge, 2001. 125 pages. Print
8. Van Vugt, Mark. “7 Steps to Becoming a Dictator.” Psychology Today. N.p., n.d. Web. 19 Dec. 2018. https://www.psychologytoday.com/us/blog/naturally-selected/201702/7-stepsbecoming-dictator

Most studies recommend rest and avoidance of exercise and symptom exacerbation until asymptomatic,4,7 causing, as a result, for prescribed rest to be one of the most frequently utilized concussion interventions.8 More recent studies, however, have instead advised a brief rest period in the acute phase (24- 48 hours) post-trauma after which patients are encouraged to become increasingly active while being sure to stay below the level of symptom exacerbation to facilitate recovery.8 Leddy et al. and others report that there is currently no conclusive research that states resting for more than 3 days is beneficial.4,9,10 Instead, the use of early exertional testing, including within the acute period of concussion recovery (aside from the initial 48 hours), has been demonstrated to provide a safe and effective biomarker for diagnosis and prognosis in concussion.11 The inclusion of sub-symptomatic exertion is especially beneficial in the event a patient’s symptoms are prolonged ( >10–14 days in adults and >4 weeks in children).8 In many instances, prolonged rest can be detrimental, rather than beneficial, to a patient’s recovery, resulting in the onset of deconditioning, fatigue, and reactive depression.12,13,14

In general, exercise can improve brain function through the process of brain neuroplasticity.15 The inclusion of exercise into the rehabilitation process following a concussion has been reported to promote various beneficial physiologic processes. This is particularly useful in the event of a concussion which has been determined to involve a physiologic insult to the brain.16 Return-to-play determination solely dependent on elimination of concussion symptoms is unreliable as physiological recovery may last longer than symptom recovery alone.17 Rather, aerobic exercise, introduced in the proper time and amount, can address the physiologic dysfunction preventing a return-to-sport because of the ability of activity to increase parasympathetic activity, reduce sympathetic activation, and improve cerebral blood flow.18,19 The various enhancements exercise can make towards brain function could be translated to brain recovery following a concussion, or other forms of traumatic brain injuries.4

The ability of exercise to facilitate recovery alongside growing support for not solely resting until fully asymptomatic4,11 highlights the importance of the Buffalo Concussion Treadmill Test (BCTT) in ushering in a new means of post-concussion rehabilitation. The discovery of a physiological component of concussion symptoms as noted above20 highlights the importance of the creation of an evaluation of such measures during the clinical determination of readiness to return to activity. The BCTT fills that role as it involves the incorporation of closely monitored submaximal exercise while ensuring the patient remains below their cognitive and physical exacerbation threshold.13 Graded exercise testing with the BCTT provides a means of establishing a safe and effective aerobic rehabilitation plan that has been used as a means of speeding up recovery times in those with post-concussion syndrome as well as reliably diagnosing physiologic dysfunction in acute concussion.4,21 The passing of the BCTT has thus been established as a method by which athletes are deemed ready to undergo the return-to-play protocol without symptom exacerbation.11,21 While the BCTT was the first to utilize a standardized training program in concussion patients, the Gapski-Goodman Test (GGT) was created to serve as an alternative physical exertion test to provide a more effective means of returning patients to sport safely and quickly. The GGT constitutes a dynamic, anaerobic, multiplanar, high-risk assessment of an athlete, all elements lacking in the BCTT. Marshall et al.11 discovered that the GGT identified 14.6% of self-reported, asymptomatic individuals after concussion who appeared ready-to-play but needed the advanced activities of the GGT to trigger symptoms.

Though the BCTT is extremely useful in providing an initial screening of an individual’s sub-symptom aerobic capacity, as noted in the Marshall study,11 the BCTT is ineffective when used alone in determining return-to-play capabilities. While the GGT mimics the sporting environment better than the BCTT, it nevertheless may not be an appropriate test for those requiring lower levels of cardiovascular fitness in their activities of daily living and thus, an alternative testing procedure is necessary.11 Physical therapists at Burke Rehabilitation Hospital outpatient clinics recognized the usefulness of the BCTT and GGT, however these tests are insufficiently thorough and generalizable to the needs of their wide-ranging clientele. The Burke Rehabilitation Hospital Post-Concussion Exertion Protocol and Assessment was developed to more thoroughly and safely guide patients from their injury to return to their sport or activity.Most studies recommend rest and avoidance of exercise and symptom exacerbation until asymptomatic,4,7 causing, as a result, for prescribed rest to be one of the most frequently utilized concussion interventions.8 More recent studies, however, have instead advised a brief rest period in the acute phase (24- 48 hours) post-trauma after which patients are encouraged to become increasingly active while being sure to stay below the level of symptom exacerbation to facilitate recovery.8 Leddy et al. and others report that there is currently no conclusive research that states resting for more than 3 days is beneficial.4,9,10 Instead, the use of early exertional testing, including within the acute period of concussion recovery (aside from the initial 48 hours), has been demonstrated to provide a safe and effective biomarker for diagnosis and prognosis in concussion.11 The inclusion of sub-symptomatic exertion is especially beneficial in the event a patient’s symptoms are prolonged ( >10–14 days in adults and >4 weeks in children).8 In many instances, prolonged rest can be detrimental, rather than beneficial, to a patient’s recovery, resulting in the onset of deconditioning, fatigue, and reactive depression.12,13,14

In general, exercise can improve brain function through the process of brain neuroplasticity.15 The inclusion of exercise into the rehabilitation process following a concussion has been reported to promote various beneficial physiologic processes. This is particularly useful in the event of a concussion which has been determined to involve a physiologic insult to the brain.16 Return-to-play determination solely dependent on elimination of concussion symptoms is unreliable as physiological recovery may last longer than symptom recovery alone.17 Rather, aerobic exercise, introduced in the proper time and amount, can address the physiologic dysfunction preventing a return-to-sport because of the ability of activity to increase parasympathetic activity, reduce sympathetic activation, and improve cerebral blood flow.18,19 The various enhancements exercise can make towards brain function could be translated to brain recovery following a concussion, or other forms of traumatic brain injuries.4

The ability of exercise to facilitate recovery alongside growing support for not solely resting until fully asymptomatic4,11 highlights the importance of the Buffalo Concussion Treadmill Test (BCTT) in ushering in a new means of post-concussion rehabilitation. The discovery of a physiological component of concussion symptoms as noted above20 highlights the importance of the creation of an evaluation of such measures during the clinical determination of readiness to return to activity. The BCTT fills that role as it involves the incorporation of closely monitored submaximal exercise while ensuring the patient remains below their cognitive and physical exacerbation threshold.13 Graded exercise testing with the BCTT provides a means of establishing a safe and effective aerobic rehabilitation plan that has been used as a means of speeding up recovery times in those with post-concussion syndrome as well as reliably diagnosing physiologic dysfunction in acute concussion.4,21 The passing of the BCTT has thus been established as a method by which athletes are deemed ready to undergo the return-to-play protocol without symptom exacerbation.11,21 While the BCTT was the first to utilize a standardized training program in concussion patients, the Gapski-Goodman Test (GGT) was created to serve as an alternative physical exertion test to provide a more effective means of returning patients to sport safely and quickly. The GGT constitutes a dynamic, anaerobic, multiplanar, high-risk assessment of an athlete, all elements lacking in the BCTT. Marshall et al.11 discovered that the GGT identified 14.6% of self-reported, asymptomatic individuals after concussion who appeared ready-to-play but needed the advanced activities of the GGT to trigger symptoms.

Though the BCTT is extremely useful in providing an initial screening of an individual’s sub-symptom aerobic capacity, as noted in the Marshall study,11 the BCTT is ineffective when used alone in determining return-to-play capabilities. While the GGT mimics the sporting environment better than the BCTT, it nevertheless may not be an appropriate test for those requiring lower levels of cardiovascular fitness in their activities of daily living and thus, an alternative testing procedure is necessary.11 Physical therapists at Burke Rehabilitation Hospital outpatient clinics recognized the usefulness of the BCTT and GGT, however these tests are insufficiently thorough and generalizable to the needs of their wide-ranging clientele. The Burke Rehabilitation Hospital Post-Concussion Exertion Protocol and Assessment was developed to more thoroughly and safely guide patients from their injury to return to their sport or activity.  

Concussions, they are a problem for every athlete that competes in a contact sport goes through, whether its reported or not. Concussions are something that cannot just be ignored. 50% of high school athletes and 70% of college athletes fail to report a concussion. Concussions can not only lead to brain damage, but also short-term or even long-term memory loss. We should be able to better understand concussions, why they’re a problem in sports and what measures are being taken to prevent them.

A concussion is often caused by a bump, blow or jolt to the head or even the body that causes the brain to move and bounce off the inside of your skull. There are an estimated of 3.8 million concussions that occur each year in the United States. In high school sports, football accounts for around 60% of the concussions. Females often receive concussions from playing soccer at a competitive level. High school athletes recovery times are often longer and more complex than college athletes recovery times. High school athletes who get a concussion the first time are often more likely to receive a second one.

Concussions can be arranged as basic or complex. Basic concussions, which are mellow and generally normal in kids and youths, bit by bit resolve inside seven days to 10 days. For whatever length of time that another head damage isn’t continued, gentle concussion as a rule don’t bring about inconveniences or long haul wellbeing dangers.

Complex concussions bring about persevering indications and can influence cerebrum work. Complex concussions increment the hazard for intricacies, for example, growing or seeping in the cerebrum, seizures, and post-concussion disorder (e.g., persevering migraine, discombobulation, or obscured vision). Extreme concussions and various concussions are described as mind boggling.

Concussions likewise can be characterized by grades. Grade 1 concussion is mellow; grade 2 is moderate; and grade 3 is serious. Grade 1 concussion doesn’t bring about lost cognizance. Individuals who support grade 1 concussion might be mistaken or disoriented for a brief span (under 15 minutes) after the damage, yet recoup totally inside 20 minutes.

Grade 2 concussion doesn’t bring about lost cognizance, yet side effects (e.g., disarray) last longer than 20 minutes. Individuals who support grade 2 concussions may not recollect the damage (called post-awful amnesia).

Grade 3 concussion is the most extreme sort. An individual who supports a55t grade 3 concussion loses awareness (for the most part for a concise timeframe) and regularly doesn’t recollect what happened just previously or soon after the damage.

Changes in the guidelines for athletic challenge have diminished the quantity of games related concussions. After the National Collegiate Athletic Association utilized the head while handling unlawful in 1976, the yearly number of head and neck wounds in football declined by about half. The necessary utilization of protective helmets in many physical games, just as advances in helmet configuration, has additionally brought about less head wounds. Improved molding of youthful competitors, particularly reinforcing of neck muscles, may likewise avert concussions.

On the off chance that a kid continues a concussions, guardians should look for fitting therapeutic consideration. They should demand a portrayal of side effects demonstrative of intensifying mind damage and of regular post-concussive indications, just as rules for come back to play and for therapeutic development. For competitors who experience diligent challenges after a concussions, for example, cerebral pains, trouble concentrating, fractiousness, rest unsettling influences, or dropping evaluations, a viable treatment plan will regularly join instruction, intellectual recovery, mental help, and at times prescription.

During recuperation the player must be as inactive as could reasonably be expected. Running, cycling or some other strenuous movement must be dodged. Extraordinary scholarly movement ought to be untouchable also. Studies have demonstrated that focusing on the body in any of these spaces will really restrain the recuperation procedure. The mind needs all the body’s assets to recuperate quicker and appropriately. The lively stroll to clear the brain and that second language class you were going to are in a lower priority status for in any event a couple of days if not longer. From a nourishment consumption outlook, liquor must be stayed away from completely. Liquor diminishes the oxygen accessible to the cerebrum, and mind recuperation from damage requires a bounty of oxygen.

Concussions are a test from numerous points of view. They jump out at players everything being equal and all degrees of play. All may appear to be well with the concussed competitor, however disregard could have annihilating outcomes. Guardians, mentors and players should all be aware of concussions. Testosterone in the cheap seats and win no matter what demeanors have no spot in game. We are managing fragile living creature and blood and dark issue as well. Be cautioned, be shrewd, and know. 

Introduction

Concussion is a form of a traumatic brain injury that is considered to be of a mild form. Traumatic brain injuries are forms of sudden injuries on the head that penetrates and cause damage to the brain. This paper seeks to discuss concussions and physical activities. The paper will look into the origin of concussions, their symptoms and treatment, physical aspects as well as its psychological aspects.

History of Concussions

Concussion is an element of traumatic brain injury and has been in existence for a long time. Reference to traumatic brain injury is made to periods of as early as the nineteenth century. Brain injuries have been identified and medical measures developed to help people who incur such injuries.

Knowledge about traumatic brain injury has been in development since the nineteenth century when there were increased cases of injuries that were associated with the brain. Measures such as pathophysiology have been developed and were being offered to those who suffered from such injuries. Developments of antiseptics that penetrated into the brain were the only available remedy for such injuries (David et al. 1).

Causes of concussion

Injuries caused to the brain occur following a violent impact that “causes the brain to collide with the inside of the skull” (Traumatic 1) which results in disruptions in the operations of the brain (Traumatic 1). Major identified causes of concussion include accidents, falls and sports activities that involve violent physical impacts among players such as football, rugby among others (Traumatic 1).

Another cause of traumatic brain injury is the motor vehicle accidents. Motor vehicle accidents result in sudden motions and impacts that can cause brain injuries. During an accident, a person’s head can be “stricken, suddenly jerked, or penetrated by a foreign object” (Brain 1). If such effects pass to the brain, then a traumatic brain injury may occur. The injury may be mild or severe depending on the degree of fatality of the accident. Mild injuries may be temporary with inflicted short time unconsciousness while a severe traumatic brain injury causes prolonged and more extreme effects to the injured person.

Motor vehicle accidents cause a significantly large percent of total traumatic brain injuries recorded. A research conducted by Atlanta Nation Center for injury prevention and control conducted in the year 2006 indicated that at least twenty percent of the recorded traumatic brain injuries were due to motor vehicle accidents. In the research, over a million cases of traumatic injuries were realized to have been reported in America out of which almost three hundred thousand were caused by motor vehicle accidents.

Brain injuries encountered in these accidents constituted the most severe category of traumatic brain injuries. This can be attributed to the fact that most of these accidents lead to high level impacts that exert a lot of physical pressure on the skull and thus the brain (Brain 1).

The effect of the motor vehicle accidents that leads to traumatic brain injuries results from biological properties of the brain that demands coordination among its cells. One of the essential elements of this coordination is the nerve system. In an event of an accident, this system may be strained due to pressure from sudden movement of the head or even collision of the head with objects in the vehicle or outside the vehicle in the process of the accident.

The brain then loses coordination resulting in the injury. Another significant cause of traumatic brain injuries is falls. Though its effects are occasionally less severe, falls cause more cases of traumatic brain injuries as compared to motor vehicle accidents. While motor vehicle accidents cause about twenty percent of brain injuries in America, falls cause close to thirty percent.

Falls can occur when a person slips or flips from a high level off the ground. It can also occur as a result of a violent encounter between people in a fight or in social activities such as games. Falls account for a higher percentage of the injuries because they can occur even in domestic environments in the form of minor accidents. The extent of a brain injury as a result of a fall also varies depending on the nature of the falls. Injuries due to falls are, however, considered to be milder than those due to motor vehicle accidents (Brain 1).

Diagnosis and treatment of concussion

Diagnosis of concussion and traumatic brain injuries at large is accounted for if its symptoms are significantly realized in a patient. Some of the symptoms of brain injuries are similar to those of other complications and thus care should be taken before diagnosis to avoid confusing brain damage with other medical complications. One of the key characteristics of traumatic brain injury is “confusion and disorientation” of the victim (CDC 8). Unconsciousness that lasts for a long period of time is a feature that is associated with concussions.

The interference of the nerve systems in the brain causes lapses that send the victim into long durations of unconsciousness that can last to about half an hour. Higher susceptibility to coma is also an indicator that can lead to concussion being considered. Though all states of coma are not indicators of the brain damage, higher scales, normally rated at thirteen and above, have been associated with traumatic brain injury.

Experiences such as “amnesia and neurological problems” (CDC 8) also points to possibility of brain injury (CDC 8). Other symptoms such as “headaches, dizziness, insomnia, fatigue, nausea, blurred vision, seizures” (CDC 8) together with changes in a person’s behavior such as “irritability, depression, anxiety, sleep disturbance” (CDC 8) among other characteristic symptoms are indicators of the presence of concussion (CDC 8).

Care should however be taken before conclusive diagnosis into traumatic brain injury is pronounced because most of these symptoms are, independently or in some cases jointly, experienced in other complications (CDC 8).

Developments have not yet been made into a specific treatment of concussions. Damages caused by head injury to people vary to a great extent and a range of care is therefore necessary for the victims subject to specific brain damages. With no availability of treatment, victims are left to the possibility of recovery if their injuries do not cause death. Mild injuries are recognized to respond to recovery care and this has led to a large percentage of victims regaining their complete health after suffering mild concussions.

It has been established that more than half of victims of mild to moderate concussions recover under counseling on how to deal with the injuries. Medical services are however available for controlling and treating other aspects of external injuries suffered in order to minimize brain injuries. Measures of preventing further damage to the brain such as treating the injured part of the head are normally undertaken to control the extent of brain injury (National Institute 1).

Medical care that is available to victims of concussions is therefore control measure to help in reducing the degree of damage as well as associated impacts of the injury (National Institute 1). Preventive measures are therefore the only sure alternative for controlling traumatic brain injury.

Taking precautions to avoid or reduce accidents as well as their impacts is an effective measure in controlling concussions (CDC 1). In an event of a mild case of concussion leading to “bad headache, a feeling of being confused (dazed), or unconsciousness” (New York Times 1), a patient is supposed to be examined by a medical practitioner who can then determine when the patient can return to sports or any other exposure to causes of concussion (New York Times 1).

Physical aspects of concussion

Aspects of concussion can be discussed from two perspectives: its physical perspectives and its psychological perspectives. Physical aspects are those elements that are related to the body structure and not to the mental capacity. Concussion, in its occurrence exhibits a lot of features that are related to the physical properties of the body. The causes of concussion are, for example, entirely physical. It has been established that brain injuries are caused by a physical mechanism in which the brain encounters a bombardment with the skull.

That movement of the brain relative to the skull, which results into the collision, is a pure physical process. Contrary to biological locomotive processes like involuntary muscular movements such as that encountered in inhalation and exhalation, the brain and skull movement that leads to the injury is an externally instigated mechanism.

From the cause of the injury that could be collision between players in a game, falls or even involvement in an accident, the bombardment of the head with an object or a sudden movement of the head that leads to disturbance remains to be a physical process. The effect of these disturbances is equally transmitted into the brain in a physical manner. The cause of concussion is therefore an entirely physical process (Traumatic 1).

Concussion is also characterized by quiet a number of physical impacts on its victims. A person who suffers from concussion is, for example, identifiable with a problem of slow response during conversations as well as comprehension and response to directives given to the victim. This is a change that is realized after someone has suffered from a concussion. The change in response is normally significant and can be realized as the victim of concussion will take a longer time than previously or normally taken.

The same lapse in response to directives will be realized in these victims as they tend to take a longer time to coordinate messages being passed to them before they can respond. A footballer or any other player who plays after suffering from concussion, and prior to recovery, might for example delay in response, fail to take a timely play thereby giving opponents an attacking advantage (Medicine 1).

Poor concentration has also been an identifiable factor in victims of concussion. A person who suffers from the mild brain injury shows some tendencies of being diverted from subject objectives at particular times. Cases of a person failing to identify an occurrence like speech directed to him or her have been common with victims of concussion.

Characteristics of absent mindedness and application of a lot of strain as the victim tries to engage in interactions are reported. These effects caused by inefficient coordination of activities of the brain are as a result of the damage that the brain suffers during the impacts that leads to the concussion.

A victim of concussion may also experience a change in his or her speech which may be significantly different from how the person communicated before suffering from brain injury. A characteristically slower speech is normally associated with concussion: “emotional liability and personality changes” (Medicine 1) are also some of the physical aspects that are associated with concussion (Medicine 1). Headaches and nausea have similarly been reported among victims of minor traumatic brain injuries (IOL 1).

The injury to the brain which has been medically identified to be functional rather than being on the brain structure is reported to have impacts on the head in the form of headaches. Feelings of discomfort in the stomach have also been reflected by people who suffer from brain injuries (Larkin 1).

Physical aspects of concussion are as well realized in its prevention measures. Being a physical process in terms of how it is acquired, measures of controlling or eliminating concussion primarily depends on physical strategies. Steps such as educating sportsmen and women on how best to avoid concussions are an important component of controlling the types of injuries such as those caused in sports. Sufficient care being taken can prevent, to a great extent, violent collisions in some sports.

This can specifically be helpful in sports such as football and hokey in which uttermost care can highly prevent injuries obtained through rough tackles from opponent players or instruments used in the games. Taking care, for instance, by avoiding collisions of heads or hitting of opponents’ heads can also help in controlling concussions. Provisions of protective devices to players while inside the pitch can also help in reducing effects of impacts during games (Hagemann 1).

When intensity of impacts of collisions is reduced, the effect that is transmitted into the head is also controlled hence reducing the chances of a player being injured in the head. Such protective devices also reduce the extent to which injuries can be suffered by a player.

Development of techniques used in sports can also play a significant role in controlling the number and frequency of brain injuries encountered in sports. Initiatives by coaches and trainers to impact players with newly developed techniques which are safe are another solution to the danger that has been facing participants in sports.

An initiative to reduce these injuries together with its supervision and management has equally been identified as a step towards prevention and reduction of the number of reported cases of concussion. Physical measures, if effectively put into consideration and subsequently implemented can play a very crucial role in controlling concussion as well as other traumatic brain injuries (Powel 1).

The process of treating or dealing with concussion has also been given a physical approach. Measures that include a complete rest of the victim by avoiding any source of a significant distraction or strain are recognized to help patients in the process of healing after suffering from a head injury.

Refraining victims from exposing themselves to activities that can cause head injuries is also another measure used to ensure an uninterrupted healing process. Legislations have even been considered to restrict sportsmen and women who suffer from traumatic brain injuries to only return to participation in sports subject to approval by a certified health practitioner. In general, concussion has a significant physical aspect in its cause, symptoms, prevention as well as its treatment (Sports 1).

Psychological aspects of concussion

Psychology has been developed and integrated in sports to help in the development of player’s participation in any given professional sport. In Canada for example, the acculturation of psychology in sports has been recognized and even made to be part of “Kinesiology and physical education programs” (McGill 1).

Involvement of psychology in sports has been adopted to help players “understand psychological and social factors on an individual’s behavioral outcomes” (McGill 1) as well as to “understand how participation in sports and exercise influence psychological and social developments, health and well being” (McGill 1).

There should be an integration of psychology in sports (McGill 1). It has been established and agreed upon among psychologists that knowledge and skills that individuals poses play a significant role in how they respond to issues as well as how they succeed in handling issues.

Impacting players with information on how they can solve, handle or even cope up with straining issues that face them in their sporting careers will therefore play a crucial role in how they can deal with setbacks that include injuries such as traumatic brain injuries (Traumatic 1).

There being no established or specific cure for concussion, a victim relies on his or her ability to have patience with the recovery process as well as being psychologically prepared to deal with any impact that concussion may cause. A psychologically informed and prepared person will, for example, be calm and wait for a full recovery process before any exposure to a possible threat of an injury.

Psychological preparedness can also help an individual in copping up with disabilities that can be caused by concussion. Cases of psychological immaturity can lead to players loosing hope in life if they are barred from playing when they have undergone concussions. Psychology therefore plays an important role in the lives of players especially in the cases where the players are victims of concussions (Barker 1).

Once an athlete is injured and diagnosed with concussion, the first step is the elimination of the player from sports. Even though the withdrawal of a player from participation in sports is on medical grounds to offer the player time for recovery, the victims normally suffer from isolation from their respective teams (Sports 1). A person who is, for example, hospitalized or put under rehabilitation facilities will most likely be isolated from team mates and friends who would at the same time be engaged in their daily lives’ activities.

This isolation has an impact of psychologically which will likely have a torturing effect on the patient. Some of the symptoms of concussions are also regarded to be psychological. Reactions by a victim of concussion such as “anger, denial, depression, distress, shock and guilt” (Bloom et al. 1) are psychological. Concussion therefore induces psychological reactions to its victims just as it does in inducing physical reactions (Bloom et al. 1).

The effects of players’ psychological attitudes again play an important element in the overall health of a player who has suffered from concussion. A player who is only focused on returning to the field would for example lie that symptoms of concussion have disappeared when the player is actually not yet recovered. This mostly occurs if a player is not psychologically mature enough to accept the injury and take enough rest to recovery (Kontos et al. 225).

Recommendations

Following the psychological aspects of concussion, a practitioner faced with a challenge of an athlete who wants to engage in a physical activity prior to recovery should refer the athlete for psychological counseling to help the athlete understand the situation and dangers involved.

Conclusion

Concussion is a form of a minor traumatic brain injury. Its cause is basically physical though its symptoms and impacts together with its control exhibit both physical and psychological factors. It is advisable that concussions are avoided at all costs but in case they are incurred then it is very significant that enough rest is observed before one return to active sports.

Works Cited

Barker, J. Mental matters almost as much as physical in elite sports. National Post, 2009. Web.

Bloom et al. Sport psychology and concussion. New impacts to explore, 2004. Web.

Brain. Motor vehicle induced brain injury. Brain Spinal Cord, 2011. Web.

CDC. Facts for physician about traumatic brain injury. Center for Disease Control. Web.

David et al. The history and evolution of traumatic brain injury, rehabilitation in military service members and veterans. The History of Traumatic Brain Injury, 2010. Web.

Hagemann, G. Rugby, concussions and myths. Lifestyles, 2011. Web.

Kontos et al. An introduction to sports concussion for the sport psychology consultant. News Letter, 2004. Web.

Larkin, S. Crow Steve not quitting. Craig, 2011. Web.

McGill, J. What is sport and exercise psychology? Sports Psych. Web.

Medicine. Brain concussion. Medicine Net, 2010. Web.

National Institute. Traumatic brain injury. Disorders, 2011. Web.

New York Times. Concussion. New York Times, 2011. Web.

Powel, J. Cerebral concussion. NCBI, 2010. Web.

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Abstract

Sport-related concussion is a serious neurodegenerative condition with a complex pathophysiology, which is not well understood. Rising cases of concussion have resulted in attempts to manage the condition after the injury. Neuropsychological testing has been widely applied to assist injured athletes during cognitive disorder assessment and recovery management. While the tests are now popular, their validity and reliability have not been ascertained. Consequently, further research is necessary to develop reliable tools for neuropsychological tests for sport-related concussion.

Sport-related Concussion: A Brief Overview

Much attention has been directed to contact sports in the recent past. Specifically, the source of concern has been the immediate and long-term outcomes of sport-related concussion (SRC). Chronic traumatic encephalopathy (CTE), which is a progressive neurodegenerative disease caused by repetitive head trauma, is now studied to determine long-term effects of contact sports (Saulle & Greenwald, 2012; Yi, Padalino, Chin, Montenegro, & Cantu, 2013). Football, the prestigious National Football League (NFL), now faces lawsuits and criticism regarding player management and safety following cases of mild traumatic brain injuries.

More strikingly, most cases have originated from a majority of retired players. Understandably, the sport is based on toughness, powerful impacts, full contact and the ability to overcome attackers. To date, many researchers have presented studies on concussion and contact sports players. Concussion refers to traumatically prompted transient disruption of brain functions and constitutes an intricate pathophysiological process (Sisodia & Kumar, 2013). Sport-related concussion is not only restricted to football, but is also reported in boxing (the first known identified cases), soccer, hockey, and professional wrestling. Although neurological outcomes of sport-related concussion are well documented, neuropsychological tests and their relevance to concussion are not yet fully understood. This essay focuses on the reliability of neuropsychological tests following sport-related concussion.

Management of Sports-related Concussion

Medical management of sport-related concussion can be viewed as having two different elements. The first aspect of management encompasses acute care management of injuries suffered immediately after the contact with the goal of identifying and treating any possible neurological outcomes, such as cerebral haemorrhage. This form of intervention is usually not necessary since most sport-related concussions entail mild concussions that may not result in acute neurological crises. Medical personnel consider the second aspect of management vital. It requires observing various symptoms associated with concussion over time with the aim of noting the progress for return-to-play decisions. In instances of extremely mild concussions, absolute recovery is often noted after few minutes, allowing players to resume sports and usually eliminating the need for any additional workup.

Sports-related concussions are normally linked to more than a single symptom, reduced balance, and cognitive insufficiencies (Echemendia et al., 2013). Balance assessment, symptom scales, and neurocognitive testing are available to assess these issues. According to Echemendia et al. (2013), these assessment modalities can be used to observe any changes within the first few days after an insult. Symptoms presentation and the rate of recovery normally differ, which indicate the importance of evaluating all the three factors as components of a thorough sport concussion management.

Neuropsychological Testing

Neuropsychological evaluation of concussion is considered a vital aspect of management. Today, concussion management efforts that rely on neuropsychological assessment to help in clinical decision-making have been widely adopted across sport institutions, including professional sports and schools (Echemendia et al., 2013). Cognitive insufficiencies linked to concussion are generally elusive and could be found in multiple domains, implying that it is difficult to assess concussions. As a result, the diagnosis of concussion is based on clinical decisions depending on the evaluation of a wide range of domains with related symptoms, such as headache, loss of consciousness, cognitive deficiency and neurobehavioral changes, including irritability (Makdissi, Davis, & McCrory, 2014). Players often find it difficult to process information, and they display impaired memory and are slow to react. The application of neuropsychological tests in handling concussion is seen as an opportunity to overcome the dependence on subjective symptoms, which are also associated with other neurodegenerative conditions, such as Alzheimer’s disease, and are poorly recognized and reported differently (Gavett, Stern, & McKee, 2011). Moreover, such symptoms have also been associated with other outcomes, which do not necessarily reflect specific symptoms associated with concussion.

According to Sisodia and Kumar (2013), neuropsychological testing offers an objective means of evaluating sport-related concussion, as well as linking outcomes to specific individual-related factors, such as gender, age, and history past concussion. Based on neuropsychological results in sport-related concussion, patients have often displayed the above-mentioned symptoms. Notably, neuropsychological testing has undergone significant changes from the use of paper and pencil, balance field tests and now to the more commonly used computer-based test batteries (Sisodia & Kumar, 2013). Currently, multiple computerized neuropsychological test batteries are available in the mainstream markets, and they are marketed to athlete intervention programs across different institutions.

For cognitive function, formal neuropsychological testing is recognized as the clinical standard for evaluating cognitive impairment. Such a test is commended in any situations in which chances of recovery remain unclear or cases are difficult, specifically in prolonged recovery. Screening neuropsychological tests have been applied to evaluate cognitive recovery following the injury. Preferably, test results should be gauged against a person’s own pre-injury baseline results. In instances where no such baseline results are available, which is usually the case, normative data should be used. These standardized or formal neuropsychological tests are used as short measurement tools, formulated for the sideline evaluation of athletes following concussion in order to quantify the severity of the injury.

They are also used alongside other clinical data to determine suitability for return to play decisions. In this respect, the Standardized Assessment of Concussion (SAC) has gained significant recognition, and its reliability, sensitivity, and change-score analyses have been sufficiently studied. It, therefore, has been observed that baseline testing can be vital for assessing cognitive limitations after injury and for evaluating recovery (Iverson & Schatz, 2015). Additionally, many screening neuropsychological tests have been authenticated for management of concussion in athletes and are easily accessible. For instance, ImPACT or Axon Sports are computerized options for concussion management. The basic paper and pencil cognitive evaluations have been used to determine or estimate cognitive impairment, but they require other conservative return-to-play strategies and cautious observation of symptoms as athletes recover to play (Makdissi et al., 2014).

Limitations of Neuropsychological Testing

Researchers have observed that athletic trainers and other sports medicine personnel generally lack adequate knowledge on psychometrics to make informed choices on the use of such tools (Randolph, McCrea, & Barr, 2005). Moreover, currently available guidelines are not peer reviewed on the use of these assessment tools (Randolph et al., 2005). While neuropsychologists can use psychometric criteria required for the implementation of a specific tool for the purpose of clinical evaluation, trainers may not get services provided by neuropsychological consultants to assist in decision-making processes. In addition, it has been observed that neuropsychological tests to assess recovery following concussion have some unique features in terms of reliability and validity, which underscore the need for further reviews and studies (Randolph et al., 2005).

Neuropsychological tests, however, face some critical drawbacks related to assessment tools, which generally focus on reliability (Sisodia & Kumar, 2013). According to results of a study conducted by Randolph et al. (2005), no available traditional or computerized neuropsychological batteries adopted for use in the evaluation and management of sport-related concussion have satisfied all the standards required to permit regular clinical use. As such, fundamental issues concerning the reliability, validity, and clinical application of these tools remain largely unresolved. In this regard, it has been shown that test-retest data from these neuropsychological tests could be difficult to interpret, and any possible interpretation is better off as a function of clinical judgment instead of statistical algorithms (Randolph et al., 2005). It also appears that the field has made abysmal achievements in improving both traditional and computerized neuropsychological tests because some recent studies have demonstrated a lack of sufficient evidence to support a widespread regular use of baseline neuropsychological tests (Echemendia et al., 2013). Nevertheless, these tests are still recognized as extremely important in the assessment and management of concussion (Echemendia et al., 2013).

Some studies have also suggested that different factors, such as psychological state, may also complicate and extend recovery from concussion in athletes (Maroon et al., 2015). In addition, age is seen as a possible major factor that may accelerate recovery in young players because of increased brain plasticity, but the same may not apply to older retired athletes. Echemendia et al. (2013) further point out that age-appropriate testing may not be available or is not well researched to be used.

Given these facts on limitations of neuropsychological testing, further research is obviously required before these assessment tools can be declared effective for regular evaluation and management of sport-related concussion. Nevertheless, the relevance of baseline testing for quantifying cognitive impairment after insults and for evaluating recovery remains important for management and decision-making purposes. Many researchers have decried the lack of sufficient evidence to ascertain the importance of baseline test results and their validity (Iverson & Schatz, 2015; Yengo-Kahn, Johnson, Zuckerman, & Solomon, 2016). Invalid test results may be detected in some instances, but validity indicators cannot expressly show specific causes of errors during testing. Thus, such outcomes explain why Yengo-Kahn et al. (2016) insist that the scientific community and the public must treat such data with caution. Interpretation of results, therefore, requires advanced psychometric systems to help with accuracy of documentation of cognitive insults and regular management of recovery.

Conclusion

The past few decades have recorded a fast increase in the application of neuropsychological tests to manage athletes after concussive insults. Neuropsychological testing is now widely recognized across various sporting institutions globally, as well as by sports medicine physicians who apply it as a component of clinical management of brain injuries. It is generally observed that neuropsychological evaluation in the management of sport-related concussion is important because of supporting empirical evidence. However, reliability and validity of these assessment tools remain unclear, as most studies have demonstrated. Therefore, further research is necessary to advance neuropsychological testing in sport-related concussion to encourage their use.

References

Echemendia, R. J., Iverson, G. L., McCrea, M., Macciocchi, S. N., Gioia, G. A., Putukian, M., & Comper, P. (2013). Advances in neuropsychological assessment of sport-related concussion. British Journal of Sports Medicine, 47(5), 294-298. Web.

Gavett, B. E., Stern, R. A., & McKee, A. C. (2011). Chronic traumatic encephalopathy: a potential late effect of sport-related concussive and subconcussive head trauma. Clinics in Sports Medicine, 30(1), 179–xi. Web.

Iverson, L. G., & Schatz, P. (2015). Advanced topics in neuropsychological assessment following sport-related concussion. Brain Injury, 29(2), 263-75. Web.

Makdissi, M., Davis, G., & McCrory, P. (2014). Updated guidelines for the management of sports-related concussion in general practice. Australian Family Physician, 43(3), 94-99.

Maroon, J. C., Winkelman, R., Bost, J., Amos, A., Mathyssek, C., & Miele, V. (2015). Chronic traumatic encephalopathy in contact sports: a systematic review of all reported pathological cases. PLoS ONE, 10(2), e0117338. Web.

Randolph, C., McCrea, M., & Barr, W. B. (2005). Is neuropsychological testing useful in the management of sport-related concussion? Journal of Athletic Training, 40(3), 139–154.

Saulle, M., & Greenwald, B. D. (2012). Chronic traumatic encephalopathy: a review. Rehabilitation Research and Practice, 2012, 1-9. Web.

Sisodia, V., & Kumar, S. P. (2013). Sport-related Concussion and neuropsychological testing: Shaken or stirred? Journal of Sports Medicine & Doping Studies, 3, e138. doi: 10.4172/2161-0673.1000e138.

Yengo-Kahn, A. M., Johnson, D. J., Zuckerman, S. L., & Solomon, G. S. (2016). Concussions in the National Football League: A current concepts review. American Journal of Sports Medicine, 44(3), 801-11. Web.

Yi, J., Padalino, D. J., Chin, L. S., Montenegro, P., & Cantu, R. C. (2013). Chronic traumatic encephalopathy. Current Sports Medicine Reports, 12(1), 28-32.

Problem Statement

Much of what is known today about long-term consequences of constant head injuries, specifically noted in sports, has only gained important public awareness and interest recently. Specifically, media have concentrated on chronic traumatic encephalopathy (CTE). CTE is defined as a progressive neurodegenerative disease caused by repetitive head trauma (Saulle & Greenwald, 2012; Yi, Padalino, Chin, Montenegro, & Cantu, 2013).

Notably, CTE has gained wider recognition and discourse because of its association with sports, such as football, boxing, soccer, hockey, and professional wrestling. Most affected athletes, mainly retired, tend to suffer from depression, anger, drug abuse, motor/memory disorders, and suicide. Further, postmortem analyses from the affected athletes have demonstrated a relationship between CTE and these cognitive, emotional, and physical disorders (Saulle & Greenwald, 2012).

The evidence available on CTE has created public awareness about the long-term negative effects of concussions and subconcussive brain trauma associated with sports. As previously noted, the conclusive diagnosis of CTE depends on an autopsy analysis, and much effort is now directed toward in vivo confirmatory diagnostic examination that could assist in identifying athletes at greatest risk of experiencing CTE and ascertaining CTE in early stages.

The review, therefore, aims to draw a conclusion on a link between CTE and concussion in retired American footballers, national football league (NFL) players. By identifying athletes with possible CTE, effective intervention strategies could develop earlier to manage the burden of the condition. While research has indicated a link between neurological conditions and constant exposure to mild traumatic brain insults, a clear relationship between long-term effects that are linked to CTE and how and why concussions cause chronic traumatic encephalopathy in retired NFL players remains unclear.

The purpose of this literature review is to examine how and why constant hits to the head or concussions cause chronic traumatic encephalopathy in retired NFL players. Recent literature on CTE specifically referring to NFL retired players has been included in this research to address the research question. The literature review covers progress made in CTE research, clinical symptoms, neuropathology, and clinical implications.

Research Question

This research paper seeks to explore the question of how and why concussions cause chronic traumatic encephalopathy in retired NFL players.

Literature Review

For decades now, it has been claimed that involvement in some contact sporting activities may enhance athletes’ risks of developing a neurodegenerative disease after retirement (Gavett, Stern, & McKee, 2011; Saulle & Greenwald, 2012).

Earlier evidence had established such a relation in boxers, athletes who often sustained multiple hard blows on their heads during sporting activities. Harrison Martland first described the case in 1928 as a clinical spectrum of abnormalities common in boxers who had participated in the game long enough. Later in the 1960s, the term CTE was introduced to replace dementia pugilistica used in the 1920s to refer to conditions of fighters (Korngold, Farrell, & Fozdar, 2013).

The NFL culture promotes toughness and resistance to adversity. In the recent past, however, the majority of the retired NFL players have filed lawsuits based on negligence claims and now require monetary compensations (Abreu, Cromartie, & Spradley, 2016). These claims are based on findings that link repeated concussions to psychological problems and concerns about the neurodegenerative disease, CTE that ultimately impairs cognition, behavior, and movement (Korngold et al., 2013).

Clinical Features

Nearly all studies on CTE have covered clinical manifestations since the 1920s. Martland first used the term ‘punch drunk’ to refer to such signs and symptoms identified in boxers after substantial head trauma. Further, dementia pugilistica was later used to reflect motor deficits and confusion. The CTE was adopted to capture neurologic deterioration that originated after multiple traumatic brain injuries (Yi et al., 2013). Today, it is observed that clinical manifestation of the condition appears similar to other neurodegenerative conditions.

It is shown that concussion and post-concussion symptoms demonstrate momentary conditions of neuronal and axonal instability because CTE is known to take several years or decades after the recovery from acute or post-acute impacts of head trauma (Gavett et al., 2011). Current evidence suggests that the exact association between CTE and concussion is not completely understood (Maroon et al., 2015; Gavett et al., 2011).

Hence, it is vital to define the timeline of how CTE symptoms develop to differentiate it from concussive or post-concussive syndrome (PCS) (Saulle & Greenwald, 2012). Usually, concussion symptoms are headache, amnesia, blurred vision, slurred speech, and fatigue, which disappear in days or weeks if effectively managed. For CTE, it is observed that sustained axonal perturbation could start a series of metabolic, membrane, ionic, and cytoskeletal disorientation, resulting in a pathological reaction that eventually leads to CTE in susceptible athletes.

According to Gavett et al. (2011), CTE is often noted in mid-life after the retirement of athletes. Behavior is affected mostly in individuals with neuropathological susceptibility who become angry, irritable, show shorter rage, and apathetic while suicidal tendencies are observed as a prominent symptom of the condition (Korngold et al., 2013; Korngold et al., 2013). Further, some individuals also present cases of cognitive difficulties and poor memory as elements of cognitive dysfunction (Saulle & Greenwald, 2012).

Later stages of the disease are characterized by speech, movement (Parkinsonism), and ocular degeneration as cognition deteriorates. A smaller percentage of individuals with neuropathologically-documented CTE normally suffer dementia before deaths. On this note, Gavett et al. (2011) note that dementia is relatively less common because majorities with CTE usually die from suicide, accidents, or drug overdose relatively at an early age. In addition, Saulle and Greenwald (2012) have noted that CTE does not have a clear stage of progression, for instance, from PCS to CTE.

Neuropathology of CTE

Gross pathological results in CTE have been identified as atrophy, enlargement of the lateral and third ventricles, fenestrations of the anterior cavum septum pellucidum, and scarring with neuronal loss of the cerebellar tonsils (Yi et al, 2013; Gavett et al, 2011). These findings are observed as consistent in retired athletes who suffered repeated mild head insults, and they are distinctive results for CTE.

A gross assessment often reveals anterior cavum septum pellucidum and posterior fenestrations, which are thought to be caused by the power of the head impact directed via the ventricular system, thereby distressing functional integrity of nearby or intervening tissues (Yi et al., 2013). The lateral and third ventricles enlargement is also identified as a widely notable feature in CTE. The enlargement makes the third ventricle excessively larger.

Further, atrophy is observed in frontal and temporal cortices and medial temporal lobe, hypothalamic floor diminishing is observed, as well as contraction of the mammillary features, pallor of the substantia nigra, and hippocampal sclerosis (Gavett et al., 2011). Atrophy is usually associated with low brain mass. It is noted that the above-mentioned findings of CTE were first identified in NFL players and described by Omalu in 2002 (Saulle & Greenwald, 2012). They closely resemble some traits identified in most cases of tau deposits with few neurofibrillary tangles (NFTs) and Alzheimer’s disease.

When tau is considered, microscopic neuropathology reveals that CTE is reflected by numerous neurofibrillary inclusions, such as “neurofibrillary tangles (NFTs), neuropil threads (NTs), and glial tangles (GTs)” (Gavett et al., 2011, p. 179). NFT consists of the microtubule-related protein tau. Although CTE may have similar microscopic traits as Alzheimer’s disease and other neurodegenerative diseases, its major differentiating features include tau pathology common in superficial cortical laminae (II and III). It is imperative to note that the exact pathological processes that relate repeated mild head insults to NFT development are not clearly understood.

Some studies have also established that beta-amyloid (Aβ) deposits associated with CTE are observed in 40% to 45% of patients (Gavett et al., 2011; Yi et al., 2013; Saulle & Greenwald, 2012). This is opposed to the extensive presence of Aβ deposits in patients with Alzheimer’s disease. In addition, recent findings have also established prevalent TDP-43 proteinopathy in more than 80% of cases of CTE (Gavett et al., 2011). Additionally, it was also observed that athletes who experienced a progressive motor neuron disease many years before their deaths had prevalent TDP-43 immunoreactive inclusions in the anterior horns of the spinal cord (Gavett et al., 2011).

Clinical Implications

According to an estimate from the Centers for Disease Control and Prevention (CDC), about 3.8 million sports-related concussions occur in the US every year (Kerr et al., 2014). Thus, CTE presents opportunities for clinical implications. CTE has been recognized as having clinical symptoms that can only be identified later in life, normally after athletes have retired from the game. Moreover, just like other neurodegenerative diseases that result in dementia, CTE is also characterized by gradual and harmful onset, as well as progression.

Age plays a critical role in the onset of CTE. According to Gavett et al. (2011), athletes usually experience the condition at an average age of 42.8 years and eight years after retirement, but a small number of athletes experience symptoms immediately after retirement.

Presently, the clinical diagnosis of CTE is challenging. There are no agreements on the current diagnostic criteria or any large studies to support any diagnostic approaches. However, it is noteworthy that the currently used definitive diagnosis of CTE depends on an autopsy examination. Further, research in vivo confirmatory diagnostic is underway to identify persons at greatest risks and development of effective management strategies (Yi et al., 2013; Maroon et al., 2015).

The most important consideration is the differential diagnosis of CTE, which should account for Alzheimer’s disease and frontotemporal dementia (FTD) based on the presenting situation and age of onset (Gavett et al., 2011). For instance, older persons who have conditions of memory deficiencies may seem to have Alzheimer’s disease and CTE neuropathologically. Further, in earlier instances, when the patient is aged between 40 and 50 years old, then FTD should be considered.

It is also imperative to recognize that the history of head trauma may not necessarily reflect the presence of CTE because it has been previously associated with Alzheimer’s disease, Parkinson’s disease, and other neurodegenerative conditions. This implies that it could be difficult to deliver CTE clinical diagnosis with relatively high confidence levels (Maroon et al., 2015; Gavett et al., 2011).

For risk and protective factors, one must appreciate that CTE research is still emerging, and more research will be required to advance knowledge on diagnosis using various tools. Nevertheless, current evidence provides implications for all stakeholders, including NFL players, athlete trainers, medical professionals, government agencies, and other related associations.

Notably, all studies reviewed have confirmed that repeated head trauma is responsible for CTE as neurodegenerative dementia. It remains unknown whether one hit to the head is enough to start the metabolic cascade that comes before clinical and neuropathological alterations associated with CTE – all known cases have been linked to several head insults. As such, the most possible means to prevent CTE is, at least in theory, to avoid multiple head insults (Maroon et al., 2015; Yi et al., 2013; Gavett et al., 2011).

However, one must observe that this intervention is impossible to realize because collisions and hard hits are expected in contact sports like American football. With the preventive treatment, it would be difficult to attain meaningful outcomes among NFL players. Currently, only symptoms of CTE may be managed because no known treatments are available. With more studies, expectantly, treatments may be found. Meanwhile, the use of protective gear and stringent rules could help in reducing the impacts and frequencies of collisions (Saulle & Greenwald, 2012).

Age is also a critical factor for NFL players because it affects possible CTE risk. Younger players are more susceptible to brain insults (Gavett et al., 2011). Conversely, such players also have enhanced brain plasticity and, thus, it can better compensate for certain injuries. Maroon et al. (2015) found out that the age of death ranged from 17 years to 98 years. In addition, most deaths were related to natural causes, accidents, and suicides. For natural deaths, cardiac disease, respiratory failure, end-stage dementia, and malignancy were common causes, but accidental deaths were linked to severe TBI insults and drug overdose (Maroon et al., 2015).

Genetic differences are also thought to play a critical role in influencing head insults, altered cognition, neuropathological changes, and individual behaviors. The specific gene believed to moderate CTE risk is the apolipoprotein E (APOE) gene, which has been found in patients with Alzheimer’s disease, and it could increase CTE risks (Gavett, 2011). Genetic testing established a significant percentage of persons with confirmed CTE possessed APOE ε4 allele. Conversely, Yi et al. (2013) and Maroon et al. (2015) noted some studies involving genetic testing did not determine how apolipoprotein (ApoE D4) could influence and play a role in increasing CTE risk.

Conclusion

All studies have now confirmed that CTE is a neurodegenerative condition that results from multiple head insults. It mainly affects athletes after retirement with observable symptoms. The definitive diagnosis of CTE is done after death, but significant research is being conducted in vivo to improve diagnostic testing. Current literature still lacks clarity on neuropathological findings. Further studies should focus on clear diagnostic criteria because of CTE shares some symptoms with other known neurodegenerative diseases. New findings would help to improve the diagnosis of the disease. It is imperative to recognize that current treatment is purely preventive, but symptoms can be managed. Still, for NFL players, it would be difficult to reduce cases of blows and hard hits.

References

Abreu, M. A., Cromartie, F. J., & Spradley, B. D. (2016). Chronic Traumatic Encephalopathy (CTE) and former National Football League player suicides. The Sport Journal. Web.

Gavett, B. E., Stern, R. A., & McKee, A. C. (2011). Chronic traumatic encephalopathy: a potential late effect of sport-related concussive and subconcussive head trauma. Clinics in Sports Medicine, 30(1), 179–xi. Web.

Kerr, Z. Y., Evenson, K. R., Rosamond, W. D., Mihalik, J. P., Guskiewicz, K. M., & Marshall, S. W. (2014). Association between concussion and mental health in former collegiate athletes. Injury Epidemiology, 1(1), 28. Web.

Korngold, C., Farrell, H. M., & Fozdar, M. (2013). The National Football League and chronic traumatic encephalopathy: legal implications. Journal of the American Academy of Psychiatry and the Law, 41(3), 430-436.

Maroon, J. C., Winkelman, R., Bost, J., Amos, A., Mathyssek, C., & Miele, V. (2015). Chronic traumatic encephalopathy in contact sports: a systematic review of all reported pathological cases. PLoS ONE, 10(2), e0117338. Web.

Saulle, M., & Greenwald, B. D. (2012). Chronic traumatic encephalopathy: a review. Rehabilitation Research and Practice, 2012, 1-9. Web.

Yi, J., Padalino, D. J., Chin, L. S., Montenegro, P., & Cantu, R. C. (2013). Chronic traumatic encephalopathy. Current Sports Medicine Reports, 12(1), 28-32.

Traumatic brain injuries are a common occurrence in medical practice. Frequently, they carry a set of long-lasting symptoms that sometimes can be classified as a standalone disorder. The most common is the post-concussion syndrome, known as PCS, which affects up to 10% of patients with a history of a single concussion (as cited in “What is PCS?”, n.d.). This paper aims to shed light on the cause of the disease, as well as its treatment and prevention methods.

A concussion is a mild traumatic brain injury that arises from vehicle collisions, sports injuries, and falls, impacting perception, memory, thinking, and mood. The symptoms include the difficulty of orientation in space, impaired vision, temporary trouble remembering, and slowed thinking, and they become classified as PCS when they last for three or more months. According to Ponsford et al. (2019), the probability of PCS occurring increases with a patient’s history of psychological issues, as well as losing consciousness. Current treatment methods, as new research shows, can use some improvement.

When a concussion occurs, patients are instructed to rest physically and mentally. However, Leddy, Baker, and Willer (2016) suggest that timely implementation of aerobic exercise can lead to better recovery, which in turn would minimize the risk of PCS occurrence. Also, the avoidance of a second concussion, as well as maintaining consciousness in the moment of injury and timely notification of the ambulance staff, are the research-advised preventative methods for the development of the PCS (Ponsford et al., 2019). These steps, alongside being attentive to one’s surroundings as well as taking active steps to prevent a head injury while playing potentially dangerous sports, can decrease the possibility of a concussion, thereby lowering the chances of PCS.

References

Leddy, J. J., Baker, J. G., & Willer, B. (2016). Active rehabilitation of concussion and post-concussion syndrome. Physical Medicine and Rehabilitation Clinics, 27(2), 437-454.

Ponsford J., Nguyen S, Downing M., Bosch M., McKenzie J. E., Turner S., … Green S. (2019). Factors associated with persistent post-concussion symptoms following mild traumatic brain injury in adults. Journal of Rehabilitation Medicine, 51(1), 32-39. doi: 10.2340/16501977-2492.

What is PCS? Concussion Legacy Foundation. n.d. Web.

Abstract

The problem of concussion among athletes is not new due to its high prevalence. Still, concussion among high school athletes is of particular interest due to certain reasons. First of all, there is a reporting problem because many students fail to inform a coach or another adult about trauma due to the fear of exclusion from the sport. Secondly, recovery time in case of late reporting takes more time and leads to complications. Thirdly, athletes with multiple concussions are likely to demonstrate worse outcomes than those with a single concussion. The purpose of this research is to analyze recovery periods of high school athletes and compare recovery times of individuals with a single concussion to those with multiple concussions.

The study will use a survey for obtaining factual information about participants. Data for analysis will be extracted from medical records of participants. Statistical analysis will allow analyzing variables and compare outcomes for two research groups. Research is expected to reveal disparities between recovery time of athletes with a single concussion contrasted to multiple concussions. The study findings will contribute to further research in the field of high school athletes’ trauma and recovery.

Introduction

A concussion is a highly prevalent form of traumatic brain injury and a frequent cause of referring to an emergency department (ED). For example, in 2013, there were nearly 2.8 million TBI-related ED visits, hospitalizations, and deaths registered in the United States (Taylor, Bell, Breiding, & Xu, 2017). For the period of six years from 2007 to 2013, rate the s of TBI-related ED visits grew up by 47% (Taylor et al., 2017).

During 2012, 329,290 children aged 19 or younger need treatment for sports and recreation-related injuries, which comprised a diagnosis of concussion or TBI (Coronado et al., 2015). The situation is threatening because from 2001 to 2012, the rate of ED visits of young patients aged 19 other younger for sports and recreation-related injuries with a diagnosis of concussion or TBI increased more than twice (Coronado et al., 2015).

One of the possible reasons for this tendency is that athletes are monitored more closely than they have been in the past (Register-Mihalik et al., 2013). One of the peculiarities of concussions is the recovery time, which is different for each student-athlete and depends on a variety of factors such as post-concussion return to play or multiple concussions (Marar, McIlvain, & Fields, 2013). Thus, student-athletes who receive multiple concussions are expected to have longer recovery time than those students who have only suffered one concussion and the side effects such as post-traumatic headaches are likely to affect those patients more frequently.

Discussion

A concussion is defined as “a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces” (Lezak, Howieson, Bigler, & Tranel, 2012, p. 1089). It is one of traumatic brain injury (TBI) types, which is usually caused by a direct blow to the head, face, or neck. Also, concussion leads to short-lived impairment of neurologic function or may result in neuropathologic changes (Lezak et al., 2012).

There are many studies investigating concussion among student-athletes and diverse aspects of this problem. One of the popular issues is that of recovery after concussion. Findings in this area contribute to the theoretical background of the proposed research. For example, Beauchamp et al. (2013) investigate predictors of neuropsychological outcomes after a concussion in childhood and conclude that each student who suffers from a concussion is affected differently and their recovery time also has peculiarities. Each athlete’s recovery time depends on following the doctor’s directions (Nelson et al., 2016).

Despite the supposition that recovery can last longer depending on an athlete’s age, there are no clinically significant age differences in recovery after sport-related concussion (Nelson et al., 2016). Concussion has some adverse effects that influence different spheres of life. For example, there is evidence that concussion and severe post-concussion symptoms result in an increase in school-related problems as well as worse academic effects (Ransom et al., 2015). Also, Kerr, Thomas, Simon, McCrea, and Guskiewicz (2018) claim that multiple concussions lead to adverse health outcomes among former collegiate football players. Thus, the prevalence of disorders such as depression or alcohol dependence was higher among the respondents with three or more concussion cases.

After the concussion occurs, the medical professional who is monitoring the athlete that sustained the injury uses multiple different assessment tools, one of the tools are called the Sports Concussion Assessment Tool (SCAT-3), Glasgow Coma Scale, Maddocks Score, Post-Concussion Symptom Scale, the Standardized Assessment of Concussion (Begasse de Dhaem, Barr, Balcer, Galetta, & Minen, 2017).

These assessment tools help to determine the baseline for the patient’s level of trauma. These assessment tools evaluate the level of pain in which the patient is in and how the recovery is progressing (Begasse de Dhaem et al., 2017). Utilization of more than one assessment tool gives the medical professional a better idea on the pain level the patient is experiencing. After the recovery period, if the patient is not responding as expected, the assessment tools guide the medical provider with a path that helps in the aid of recovery (Begasse de Dhaem et al., 2017).

A concussion is a mild form of TBI (Hall & Ketchman, 2017). Therefore, they share a common side effect such as headaches. The headache factor for most of these patients with a concussion was not part of their daily lives until they sustained a TBI. About 89% of patients who sustained a TBI suffer from post-traumatic headaches (Begasse de Dhaem, et al., 2017). Lucas, Hoffman, Bell, and Dikmen (2013) in their research reveal that 90% of individuals experience headaches after TBI while only 18% had a problem with headaches before the injury.

Post-concussion symptoms and their measurement are one of the concerns related to concussion among children. The evaluation of these patients uses, in addition to SCAT-3, such testing tools as the Post-Concussion Symptom Inventory (PCSI) and Standardized Assessment of Concussion (SAC) (Beauchamp et al., 2018). The results obtained through these tools will also allow evaluating the recovery process for each patient. Moreover, such tools provide data about a variety in the recovery process of different patients and their return to the normal daily routine as well as changes in a person’s attitudes and personality (Beauchamp et al., 2018).

A preliminary study by Register-Mihalik et al. (2013) surveyed high school athletes who were not medically diagnosed with a concussion since they did not report their injury to an adult. The research is focused on revealing the fears related to injury reporting and involves the analysis of change in attitudes and influence on playing capabilities. High school students in six different sports were asked specific questions in a survey relating to the recognition of concussion-like symptoms. Some students may not realize that they received a concussion until the second or third time they are injured (Register-Mihalik et al., 2013).

The more injuries they obtain to the head/, the slower their reaction time will be to recover immediately following the injury. The students may not be aware of the injury due to the lack of knowledge about its symptoms (Register-Mihalik et al., 2013). Therefore, there is a need in providing young athletes with information to help them learn how to better recognize a concussion or other injury and how they should report it to a coach or a medical professional (Register-Mihalik et al., 2013).

As it was mentioned, one of the problems with young athletes with traumas such as concussion is the lack of reporting regularly (Asken et al., 2016). The athletes do not want to report themselves as injured, especially with a head trauma because of the factors of missing out on their activity. Still, such behavior leads to prolonged recovery due to the high vulnerability of an individual after concussion in case of not delivering medical aid. Moreover, not reporting multiple concussions can cause more serious side effects and result in a complicated and less effective recovery.

The recovery period is crucial for an athlete because the success of recovery predetermines further career opportunities in sports and has an impact on the health of an individual on the whole. It was already mentioned that the process of recovery can be monitored with the help of specialized tools applied during regular visits to a healthcare facility (Begasse de Dhaem et al., 2017). In addition to this strategy, the student-athlete is expected to follow the caregivers’ plan of recovery since it is a significant factor for the recovery time.

The patient must follow the period of limited screen time, including cell phones, video games and the time they spend watching television, altering their school schedule if they have a hard time focusing or getting tired extremely easy and it is also important they get their sleep (Begasse de Dhaem et al., 2017).

It is hard to measure and compare different athletes because every trauma has a specific character. Still, it is possible for the athletes and their recovery time by the number of concussions they have had or are currently experiencing. Thus, the research problem is the discovery of differences in recovery time among high school athletes depending on several concussions. This problem is of great significance for student sport because a recovery plan for athletes with a concussion should consider peculiarities of trauma depending on its single or multiple characters.

The purpose of this study is to analyze recovery periods of high school athletes and compare recovery times of high school athletes with a single concussion to those with multiple concussions. The hypothesis is as follows: Do high school athletes with a single concussion need less time to recover than those experiencing multiple concussions. The hypothesis will be tested using a quantitative study design with the application of statistical tools.

The independent variable for this study is the number of concussions diagnosed in life. The dependent variable is recovery time, and it is the key outcome addressed in this research. The utilizationothesis is likely to be true because previous studies prove that athletes with multiple concussions have more adverse effects, which can lead to a longer recovery time to manage all the symptoms. The hypothesis as well as the selected design allows discovering the existing differences in recovery time, which is related to the research problem since it focuses on recovery time disparities depending on several concussions.

On the whole, the number of concussions the athlete has had can also affect their remaining time in the sport. A patient can only sustain so much head trauma before the injury or side effects become permanent. The side effects such as traumatic headaches can become a lifetime obstacle for that patient and in the long-term effect their long-term education goals and even their long terms goals in their career. Head traumas can be very frustrating for an athlete.

They must understand what has happened to the brain when they sustained the injury. This would also allow them to cooperate more with the plan of recovery and help them understand why simple things such as screen time should be limited. Despite significant attention to the issue of concussion among student-athletes, there is no recent research that compares the recovery time depending on the number of concussions experienced by an athlete.

Nevertheless, the results of such research can contribute to the stimulation of trauma reporting in case there is evidence that multiple concussions and those without proper treatment in particular result in longer recovery that a single concussion. Thus, the primary focus of this research is to reveal disparities between the recovery time of athletes with a single concussion contrasted to multiple concussions.

Conclusion

Summarizing, it should be mentioned that the problem of trauma in sport is diverse and actively researched. The aspect of concussion among high school athletes is of great significance in the context of student sport because concussion as a form of traumatic brain injury can have adverse effects that have an impact on the career of athletes, their academic performance, and health condition in general.

Therefore, the issue of recovery after concussion demands careful investigation because well-planned recovery has the potential of minimizing adverse effects and providing an athlete with an opportunity to continue both education and sports activities. This research is expected to discover the differences in recovery time experienced by high school athletes with a single concussion and multiple concussions. The study findings will contribute to research in the field of sport-related trauma as a whole and the problem of post-concussion recovery in particular.

References

Asken, B., McCrea, M., Clugston, J., Snyder, A., Houck, Z., & Bauer, R. (2016). “Playing through it”: Delayed reporting and removal from athletic activity after concussion predicts prolonged recovery. Journal of Athletic Training, 51(4), 329-335. Web.

Beauchamp, M. H., Aglipay, M., Yeates, K. O., Désiré, N., Keightley, M., Anderson, P., &… Zemek, R. (2018). Predictors of neuropsychological outcome after pediatric concussion. Neuropsychology, 32(4), 495-508. Web.

Begasse de Dhaem, O., Barr, W. B., Balcer, L. J., Galetta, S. L., & Minen, M. T. (2017). Post-traumatic headache: The use of the sport concussion assessment tool (SCAT-3) as a predictor of post-concussion recovery. The Journal of Headache and Pain, 18(1), 60-68. Web.

Coronado, V. G., Haileyesus, T., Cheng, T. A., Bell, J. M., Haarbauer-Krupa, J., Lionbarger, M. R., … Gilchrist, J.(2015). Trends in sports- and recreation-related traumatic brain injuries treated in US emergency departments: The National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP) 2001-2012. Journal of Head Trauma Rehabilitation, 30(3), 185–197. Web.

Hall, E. E., & Ketcham, C. J. (2017). Concussions in athletics: Assessment, management and emerging issues. New York, NY: Nova Science Publishers, Inc.

Kerr, Z., Thomas, L., Simon, J., McCrea, M., & Guskiewicz, K. (2018). Association between history of multiple concussions and health outcomes among former college football players: 15-year follow-up from the NCAA concussion study (1999-2001). The American Journal of Sports Medicine, 46(7), 1733-1741. Web.

Lezak, M. D., Howieson, D. B., Bigler, E. D., & Tranel, D. (2012). Neuropsychological assessment (5th ed.). New York, NY: Oxford University Press.

Lucas, S., Hoffman, J., Bell, K., & Dikmen, S. (2013). A prospective study of prevalence and characterization of headache following mild traumatic brain injury. Cephalalgia, 34(2), 93-102. Web.

Marar, M., McIlvain, N. M., & Fields, S. K. (2013). Epidemiology of concussions among United States high school athletes in 20 sports. The American Journal of Sports Medicine, 40(4), 747-755. Web.

Nelson, L., Guskiewicz, K., Barr, W., Hammeke, T., Randolph, C., Ahn, K., … McCrea, M. A. (2016). Age differences in recovery after sport-related concussion: A comparison of high school and collegiate athletes. Journal of Athletic Training, 51(2), 142-152. Web.

Ransom, D., Vaughan, C., Pratson, L., Sady, M., McGill, C., & Gioia, G. (2015). Academic effects of concussion in children and adolescents. Pediatrics, 135(6), 1043-1050. Web.

Register-Mihalik, J. K., Guskiewicz, K. M., McLeod, T. C. V., Linnan, L. A., Mueller, F. O., & Marshall, S. W. (2013). Knowledge, attitude, and concussion-reporting behaviors among high school athletes: A preliminary study. Journal of Athletic Training, 48(5), 645–653. Web.

Taylor, C.A., Bell, J. M., Breiding, M. J., & Xu, L. (2017). Traumatic brain injury–related emergency department visits, hospitalizations, and deaths — United States, 2007 and 2013. MMWR Surveillance Summary, 66(SS-9), 1–16. Web.

Research Topic

Recovery time among high-school athletes

Methods

Participants

The choice of sample size depends on multiple factors, including research designs, goals, and objectives, as well as the availability of eligible participants (Clark, Berger, & Mansmann, 2013). The sufficient sample size for the study will be 100 participants, of which half will be first-time concussion patients, and the other half will be those who had a concussion before. The present research focuses on high school athletes, and thus the two key inclusion criteria are current enrolment in a high school and participation in sports. To ensure that potential participants fit the chosen criteria, the researcher will ask them to fill in a short survey.

The survey will contain questions about the participants’ age, school name, sports affiliation, and the number of concussions suffered in life. This information will help to establish the independent variable for each participant. Another essential inclusion criterion is that the suitable participants need to have an established diagnosis of concussion. The exclusion criteria for the present research are severe injuries besides a concussion, critical chronic diseases, or autoimmune conditions that could affect their recovery time. Participants who take drugs affecting brain function or sports performance will also be excluded from the sample to avoid inconsistency in the results.

The recruitment will take place in hospitals or emergency departments where high school athletes with head trauma are admitted. In this case, all teenage students admitted to the facility because of a head injury will be considered potential participants for the study, but only those diagnosed with a concussion will be included. Each potential participant will then fill in a survey to determine if they fit other inclusion criteria.

Probability sampling, such as simple random or stratified sampling, would be the ideal option for this research (Jacobsen, 2017). However, given that the number of available would probably be limited, convenience sampling should also be considered. If convenience sampling is used, all the available participants would be involved in the study, thus increasing the sample size. Based on the notes above, the sampling method should be as follows.

The researcher will first collect data on every available participant who fits the criteria for inclusion. If the number of participants exceeds 150 by the time the preliminary stage of the research, stratified sampling will be applied. The available subjects will be separated into two groups depending on the number of concussions suffered, and then 50 subjects from each group will be chosen at random. This method will allow ensuring a sufficient number of participants without affecting the validity and reliability of data.

Materials

Survey

A short survey will be distributed to all potential subjects to make sure that they fit the criteria specified above. The survey will ask the following questions:

1. What is your age?
2. Are you currently a high school student?
3. Do you take part in school sports? If so, which sport(s) do you participate in?
4. Have you ever been diagnosed with a concussion before?

The survey will serve the purpose of obtaining factual information about the potential participants, and thus its validity and reliability will largely depend on whether or not the participants are responding truthfully. The survey can be checked for validity and reliability by comparing the participants’ responses with information in their hospital records. An example of this survey can be found in the Appendix.

Statistical tools

To perform a successful data analysis, it will be necessary to use statistical software. Excel could be a helpful tool for performing correlation and regression analyses. However, using a professional statistical analysis program, such as SPSS, will help to complete the analyses quicker and more accurately. Thus, SPSS or a similar statistical software will be required for the study.

Computers

Computers are the only required hardware for the study, as they are needed to produce a statistical analysis of data and prepare the report for publication. A computer can also be used to create tables or graphs necessary to represent the results correctly. The chosen computer must support the software selected for the study (e.g., SPSS or Excel) and allow for sufficient data protection (e.g., protected by a password or data encryption).

Procedure

To fulfill the purpose of the present research, a quantitative design would be most appropriate. On the one hand, it would enable the researcher to include large amounts of numerical data to determine the correlation between the number of concussions suffered in life and the recovery time (Salvador, 2016). On the other hand, it would allow including more participants, providing an opportunity to generalize findings to other populations. The procedure of quantitative research design comprises the preparation for research, data collection, and data analysis. All of these steps will be explained in the present section.

To prepare for the study, it is critical to acquire support from hospitals and clinics where school athletes with head injury are diagnosed and treated. The researcher will submit a research proposal and obtain permission from hospital employees to survey the participants and access their medical information, including diagnosis and recovery time. If more than one institution is included, it is also necessary to ensure that the formats of their records match, and that the recovery time is calculated by the same method.

Thus, the researcher will ask institutions to provide information about the electronic health record software used in the facility and the possibility of data sharing. The researcher will also send printed copies of the survey to all institutions to obtain approval. If the research uses any outside resources, such as grants, they will have to be obtained during the preparation stage.

The second step of the study is the data collection process, which will be separated into three stages. First of all, all potential participants will be approached in person and will be asked to fill in an informed consent form and a survey to determine their eligibility. This will be a one-time meeting and there will be no need to visit the participants in person again. Secondly, for eligible participants, information about past concussions will be accessed through their medical records. Based on this information, the participants will be separated into two groups. The first group will include first time concussion patients, whereas the second group will include patients who had suffered more than one concussion in life. Thirdly, the recovery time for eligible participants will be recorded based on hospital medical records.

In determining the recovery time, the study will rely on the physician’s use of relevant tools, such as the Sport Concussion Assessment Tool (SCAT) or the Standardized Assessment of Concussion (SAC) tool. Physicians will be asked to record the participants’ recovery progress in the hospital’s medical records, which will be accessed to determine the recovery time of each patient. These three steps will be repeated for all new patients that fit the age and diagnostic criteria for the duration of the study.

Once the data collection period ends and the sufficient sample size is reached, the researcher will begin data analysis. The information on the two research variables will be included in one file, with patient names replaced with consecutive numbers to ensure confidentiality. The first set of data will include the number of concussions suffered in life, and the second set of data will be the participants’ recovery time as recorded by their physician. The data will then be analyzed using statistical software, such as SPSS.

Correlation analysis, regression analysis, and descriptive statistics results will be obtained for the two sets of data. The p-value will be set at 0.05, which is a standard significance level in health research studies (Jacobsen, 2017). The central hypothesis to be tested is that the recovery time of high school athletes who had suffered more than one concussion in life will be longer than of those suffering their first concussion.

The null hypothesis is that the recovery time of high school athletes who had suffered more than one concussion in life will be the same as of those suffering their first concussion. Thus, the p-value at or above 0.05 will support the central hypothesis and reject the null hypothesis. On the contrary, if the p-value resulting from the analysis will be less than 0.05, the null hypothesis will be confirmed. Descriptive statistics will be used to determine the mean recovery time among patients in each study group and the standard deviation.

Measures

The first variable for the present research will be the number of concussions diagnosed in life. The choice of the variable is based on research hypotheses, as well as the possibility of operationalizing the variable. The number of concussions diagnosed in life can be represented in numerical form, which suits the purpose of the present research. The second variable is recovery time, as it is the main outcome addressed in research hypotheses. The recovery time will be measured in the number of days passed from the date of injury and the date of recovery. Thus, the independent variable can also be operationalized and analyzed using quantitative research methods.

The validity and reliability of the measures will be addressed as part of the research to ensure a high quality of the study. With respect to validity, content and construct validity of both variables will be assessed based on their coverage and homogeneity. As Heale and Twycross (2015) explain, coverage and homogeneity of variables depend on whether or not the variable measures the concept correctly. For instance, the independent variable has good content and construct validity if it covers one concept comprehensively.

The reliability of the chosen variables will be evaluated through inter-rater reliability. Inter-rater reliability test is a process of determining whether or not the variables have the same numerical value if assessed by two or more different observers (Heale & Twycross, 2015). As part of the test, the medical information of the participants will be given to two independent observers, who will have to determine the dependent and independent variable scores. The results will then be compared to ensure equivalence.

Ethical Considerations

There are three sections of American Psychological Association’s ethical guidelines that apply to the proposed research. First of all, Section 8 of the APA Ethical Principles of Psychologists and Code of Conduct (APA, 2017) stresses the importance of institutional approval and informed consent. In order to ensure compliance with this section of the guidelines, institutional approval will be received prior to beginning research.

In addition, each potential participant will receive an informed consent form containing all relevant details about the study. If the participant is a minor, their parent or guardian will sign the informed consent form. Participants who refuse to sign the informed consent form, as well as minors whose parents or guardians refuse to provide consent to their participation, will be excluded from the study, and no information about them will be recorded. These steps will help to assure that the subjects are aware of the goals of and procedures involved in the study and participate in the study willingly.

Another important consideration is the need for protecting the participants’ privacy and confidentiality. In accordance with APA (2017) guidelines, the researcher will seek to protect the participant’s privacy and confidentiality by not recording identifying information of the patients. Identifying information includes names, addresses, school affiliation, and other details that can be used to distinguish a participant from people of similar age and gender.

Instead of names, the researcher will use consecutive numbers to differentiate between participants in all data reports and documents. The medical information obtained from doctors’ records will be stored on the researcher’s computer in a separate document protected by a password. The procedures specified above will ensure sufficient protection of privacy and confidentiality, preventing data leaks or unwanted disclosure of personal information.

References

American Psychological Association (APA). (2017). Ethical principles of psychologists and Code of Conduct. Web.

Clark, T., Berger, U., & Mansmann, U. (2013). Sample size determinations in original research protocols for randomised clinical trials submitted to UK research ethics committees. BMJ, 346(f1135), 1-10.

Heale, R., & Twycross, A. (2015). Validity and reliability in quantitative studies. Evidence-Based Nursing, 18(3), 66-67.

Jacobsen, K. H. (2017). Introduction to health research methods: A practical guide (2nd ed.). Burlington, MA: Jones & Bartlett Learning.

Salvador, J. T. (2016). Exploring quantitative and qualitative methodologies: A guide to novice nursing researchers. European Scientific Journal, 12(18), 107-122.