Head injuries and concussions can prompt fears over the safety of persons in most contact sports. Athletes should be better informed about the overall and persistent effects of sports concussions and head injuries on mental and physical processes, so that they know about the risks associated with returning to their sport. Until now, most research on concussions and its effects are concentrated on the immediate, post-concussion period and on improving decisions about when it is safe for an athlete to return to play. Studies are now showing that there are more long term affects from head injuries and concussions. Concussions and head injuries are serious threats. There are risks of second impact syndrome, re-injury, and chronic traumatic encephalopathy associated with head injuries and concussions. There are needs for coaches, athletes, parents, medical staff, and administration to be educated on concussions and head injuries involved with youth, high school, collegiate, and professional levels to limit the risk of future injuries. Any potential long term effects of concussions or head injuries tend to be overlooked. Details concerning these injuries are discussed in the following review.
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Concussions: Second Impact Syndrome, Head Re-injury, Chronic Traumatic Encephalopathy
Four Reasons Contact Sports Affect Our Lives
Over the years sports have become increasingly popular and people are becoming exposed to them earlier and earlier. From the four year old tennis player, three year old gymnast, or the five year old football player, sports are supported by many. Sports are known to be fun, create skills, are challenging, good exercise, and they promote developmental aspects. For years now, people have been involved with sports by watching sports, participating in sports, coaching sports, and living sports. Sports are considered highly functional and a part of the everyday life. In today's populations, sports are introduced in early ages so the kids can create skills, construct friendships, and to develop in a healthy way. Sports are great for young children to be exposed to when they are used in a positive manner. According to Collins (2001), children who participate in sport build physical skills, attain exercise, form friendships, have fun, learn teamwork, learn fair play, and improve self-esteem. Sports have many pros, but with those there are negative aspects. It is common to ignore or set aside the negatives because the positives tend to outweigh and because people of today have been accustomed to having sports a part of their lives. Sports are big moneymaking businesses and are the entertainment of the world; everything from American football to bull riding or futbol. So, when we associate problems with sports at a young age, adolescent age, collegiate age, or professional status these problems are not arising from starting kids off at a young age, letting them try new things, or letting them experiment different sports. There are four main reasons why problems are arising with contact sports. One, when we get into contact sports at a young age and progress through our lives living and doing these contact sports. Two, the problem arises when we teach young kids improper skills such as the wrong way to attack an opponent or head a soccer ball. Three, problems associated with non-certified or correct gear to protect our kids, children, and adult athletes are becoming acknowledged. Finally, The lack of education on injuries, especially head injuries, is becoming apparent.
Three Main Topics Introduced
Concussions or head injuries are not a minor injury and should not be overlooked by any athlete, coach, parent, athletic trainer, or medical staff. Concussions, especially in contact sports, where athletes are experiencing more than one are becoming a serious threat. The cheerleader who has been cheering since 10 and into her college years can have anywhere between 1 and 10 concussions. The football player who started at age 7 and played professional football for 10 years could obtain so many concussions that he even lost track of how many "diagnosed" concussions he has accumulated. This is a scary thought especially since most young athletes' coaches and parents are not educated enough to understand and assess a concussion, or know when or if to refer to medical staff. It is alarming these days because most young athletes, especially at a high school level where serious injuries are just as apparent as the professional level, there are not enough athletic trainers or staff to help clarify a concussion or a serious head injury that a child may sustain. A child getting "their bell rung" may shrug it off to win the game and endanger themselves for second impact syndrome without even knowing. The purpose of the following review is to discuss second impact syndrome, re-injury, chronic traumatic encephalopathy, and measures we can take today to prevent or reduce these traumatic effects.
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For understanding concussions or head injuries there is extensive education, protocols, and parameters that need to be followed. Athletic trainers, doctors, and other medical staff have the knowledge and information to assess head injuries and decide what is best for that athlete. There are guidelines that help assess the athletes' injuries and they are becoming more apparent. The guidelines are a very good idea because they help limit head injuries and let the athlete heal properly decreasing future injuries such as second impact syndrome, but there is also a negative side to this. According to Kissick and Johnston (2005), it is controversial topic that the new guidelines are good because now there is a risk of young athletes not reporting injuries because they will be afraid they will not be able to play. The new recommendations for young athletes, published by Quinn (2009), say any athlete, 18 or younger, who may have experienced a concussion during sports should not be allowed to return to activity that same day. Sometimes, postconcussion symptoms can be deferred from hours to even days, like difficulty sleeping or concentrating, ( Guskiewicz, Bailes, Cantu, Marshall, Randolph, Jordan, 2005). So, it is very important to not let a child, collegiate athlete, or even a professional athlete return the same day after experiencing a head injury. The previous recommendation allowed the athlete to return to activity that day if cleared by a doctor or certified athletic trainer. The alteration to the guidelines is a very positive and smart change as long as the children are educated on how serious head injuries are and it is imperative to report all injuries even if they are afraid to be pulled from a game because being pulled from the activity for a week is better than being permanently damaged or even killed. Now, the NFL has even changed their guidelines which are the same as the youth's guidelines, it is stated that any athlete who sustains a head injury will be kept out of the game or practice that day even if the symptoms subside. The athlete has to go through extensive testing by a medical staff and neurologist before returning the next day or later (Goodell, 2009).
With all these changes happening it shows that head injuries and concussions are a serious topic. There is so much research being done that stresses second impact syndrome, susceptible re-injury , and chronic traumatic encephalopathy (CTE) resulting from head injuries and concussions sustained throughout an athlete's life. In the United States, high school athletes sustain over 100,000 concussions annually (Yard, Comstock, 2009). Those 100,000 are the ones actually reported and who knows how many go unreported or diagnosed. With so many concussions happening at a young level it is essential to know the risks involved with head injuries and what can be done to help decrease these risks or limit the amount of concussions all together. Returning an athlete to play too early has many risks involved. An athlete who sustains a concussion whether it be a mild grade 1 or the severe grade 3 concussion has a great risk of re-injury (Yard, Comstock, 2009). Returning an athlete to play while experiencing symptoms or before the athlete has fully healed may result in swelling of the brain which is known as second impact syndrome. While over the years research has been done it shows that athletes with a history of concussions are more likely to sustain future concussions, which obviously puts the athlete at risk for serious injury. Finally, having multiple concussions during an athletic career is a risk factor for long term effects on the brain known as chronic traumatic encephalopathy
A concussion is caused by a direct or indirect trauma to the head. Concussions can have one or more of these symptoms: loss of consciousness, dizziness, retrograde or anterograde
amnesia, vertigo, cognitive dysfunction, blurred vision, sensitivity to light, tinnitus, lack of concentration, headache, nausea, vomiting, unbalance, fatigue, or personality changes. (Bowen, 2003) When an athlete experiences a concussion there are 3 grades.
College of Sports Medicine Guidelines For Concussions
ACSM Concussion Rating Guidelines:
None or transient retrograde amnesia. None to slight mental confusion. No loss of coordination. Transient dizziness. Rapid recovery
Retrograde amnesia. Memory may return slight to moderate mental confusion. Moderate dizziness. Transitory tinnitus. Slow recovery.
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Sustained retrograde amnesia. Anterograde is possible with intracranial hemorrhage. Severe mental confusion. Profound loss of coordination. Obvious motor impairment. Prolonged tinnitus. Delayed recovery.
Cantu Concussion Rating Guidelines:
No loss of consciousness. Concussion symptoms resolving in less than 15 minutes. Posttraumatic amnesia for less than 30 minutes
Loss of consciousness for less than 5 minutes. Posttraumatic amnesia for more than 30 minutes but less than 24 hours
Loss of consciousness for more than 5 minutes. Posttraumatic amnesia for more than 24 hours
Once the grade is determined there are guidelines to follow on when an athlete can return to play.
Return To Play Guidelines:
Evaluate return to play next day if asymptomatic
Return to play in 2 week if the athlete is asymptomatic during the previous week
Terminate season, may return to play following season if asymptomatic
Return to play after being asymptomatic 1week
Out a minimum of 1 month may return to play then if asymptomatic for 1 week consider terminating season
Terminate season, may return to play following season if asymptomatic
Out a minimum of 1 month, may then return to play if asymptomatic for 1 week
Terminate season may return to play following season if asymptomatic. Consider terminating career
Terminate career in contact sports
Second Impact Syndrome
As one can see with all the concussions that happen today in the youth level, collegiate level, into the professional level these guidelines are not followed. Especially if an athlete is having more concussions then they can count. When these guidelines are ignored, an athlete is not properly examined, or an athlete does not report a head injury that athlete is very susceptible to second impact syndrome. After an athlete has a head injury and goes back into play or activity without the symptoms resolved and experience a second head injury that athlete will experience what is called second impact syndrome. Seconds to minutes following the second injury, the athlete collapses to the ground, semicomatose, with rapid pupil dilatation, lack of eye movement, and respiratory failure (Bowen, 2003). Second impact syndrome is thought to be because the autoregulation of the brain's blood supply is disordered. This disorder of blood supply causes intracranial vascular enlargement, in turn creates intracranial pressure causing herniation of the uncus of the temporal lobe or subtentorial lobes of the cerebellar tonsils through the foramen magnum (Bowen, 2003). According to Bowen (2003), the amount of time it takes for failure of the brain from second impact syndrome is about 2 to 5 minutes. Second impact syndrome has a mortality rate close to 50% and a morbidity rate approaching 100% (Starkey, Ryan, 2002).
Athletes of youth, high school, collegiate, or professional level who sustain a concussion are more susceptible to future concussions. In a study of more than 4,000 NCAA football players, it was determined that once a college athlete suffered their first concussion, they were three times more likely to have at least one more during the same season (Guskiewicz, 2007).To limit re-injury to the head it is imperative that athlete's gear and equipment is up to date and certified. The athlete should be fitted properly of all equipment to limit injury. The use of padding, mouth guards, shoulder pads, braces, helmets etc; are imperative to keep the athlete safe. To limit re-injury it is also important for the athlete, coaches, administration, and parents to be educated on head injuries, the risks, the symptoms and signs, and what to do. Education is very important for the athlete and all who are involved to keep the athlete safe and limit risk of re-injury. If an athlete is to sustain a head injury the athlete should provide written clearance for return to play post concussion or injury. All involved with the sport or activity should have a good understanding of concussion recognition, assessment, and management (Kissick, Johnston, 2005).
Chronic Traumatic Encephalopathy
In today's world, concussions are becoming a red alert. The word concussion is starting to show more seriousness than it used to. With advanced technology, research, and education we are finding out that the concussion from a football game can mean more than a one week suspension from play. The three, grade 1 concussions at age 15, 17, and 18 of a high school game can lead to dementia, Alzheimer's, sleep disorders, depression, or brain damage at age 40. This type of brain damage has a name: chronic traumatic encephalopathy (CTE) and it is a new awareness brought about by Chris Nowinski, who founded the Sports Legacy Institute along with Dr. Robert Cantu (Guskiewicz, 2005). The project focuses on studying the brains of former athletes who suffered several concussions. Now, the NFL research committee is taking on its own studies to find out the impact of multiple concussions or head injuries on athletes and finding stunning results showing damage to athletes' brains. The damage done to an athlete's brain by age 30 or 40 closely resembles what might be found in the brain of an 80-year-old with dementia (Guskiewicz, 2003). Many new studies have been conducted and new attention has focused on long term effects of concussions of athletes. For many years concussions or head injuries have been shrugged off as a "ding" or getting "your bell rung" so the athlete can finish the game to win. Concussions that were clinically diagnosed were also not treated as they should have been treated. Athletes returning too early or not properly giving time for the injury to heal has great prominence on future injuries.
Emphasis on winning has been widely accepted and may be to blame along with other factors. "Winning is everything" is the attitude of today's sports. Even from the 5 year olds soccer team to the NFL, winning is the object of the game. Even though it is said that we should focus on the exercising aspect, the fun, the socializing, and the skills of the athletic event winning has taken over. With such a high importance on winning these days it is essential that the athlete stay in the game. It is important for that star soccer player or the most stunning cheerleader stay in the competition so the team can win; no matter what. In professional sports and even college sports money is on the line and pressure is overbearing. It is critical to finish out a game and not pay attention to the effects of injury. So, with head injuries, specifically concussions, athletes tend to fight to get cleared quickly or the athlete does not report their injury at all. "You get a concussion, they've got to take you out of the game. So if you can hide it and conceal it as much as possible, you pay for it the next day, but you'll be able to â€¦ stay in the game." - Washington Redskins fullback Mike Sellers. "I've had times where I walked up to the line, where I know the play, but don't know what to do." - Oakland Raiders tight end Tony Stewart. These two quotes demonstrate how players try to play no matter what and that is another reason what is causing danger for these athletes. For youth sports or high school sports the athlete is not properly assessed or the education is lacking to determine an extent of a head injury or concussion and the athlete is not properly returned to play. The athlete is not educated enough or told that full blown head injuries and "dings" should not be shrugged off. The brain and body need time to recover and recover correctly to decrease future injury or permanent damage.
Sustaining concussions over and over has a damaging effect for an athlete's future and athlete's long term effects in life. In a clinical study, 2552 retired professional football players with an average age of about 54 and average football career of 7 years took a general health questionnaire and memory questionnaire. 61% of those had at least one concussion and 24% had three or more in their career. Data collected from the study showed a relationship between recurrent concussions and mild cognitive impairment. The retired players who sustained three or more concussions had a five-fold prevalence of mild cognitive impairment diagnosis and a three-fold of significant memory problems compared with retired players without a history of concussion. Although there was not an association between recurrent concussion and Alzheimer's disease, the study found earlier onset of Alzheimer's disease in the football retirees than in the general American male population. The study concluded that the onset of dementia related syndromes may be connected to repetitive concussions (Guskiewicz, 2005).
Another study done by the NFL and Center for the Study of Traumatic Encephalopathy (CSTE) 2009, at the Boston University School of Medicine, has been focusing their attention on dead football players' brains. The study was first started by Chris Nowinski and Robert Cantu. The study started off small and now that it is recognized and is published it has taken big notice by the media. More and more brains are being donated to the study for research. The study is focused on dead football players who suffered multiple concussions. Six out of six NFL players' brains have shown effects of chronic traumatic encephalopathy, CTE (Guskiewicz 2007). Not only have they found CTE in 45 year old NFL players brains, but as young as an 18 year old athlete who sustained multiple concussions (Cantu, 2009). The study states that CTE is a progressive disease that kills brain cells. The damage done to the brain mostly controls emotion, anger, and hypersexuality. Many of the players associated with CTE suffer from headaches, depression, memory disability, and disruption of speech or cognitive function. The study concentrates on the brain and what they are seeing are brown spots covering parts of the brain called neurofibrillary tangles and neuropil threads (Guskiewicz, 2007). These tangles and threads are abnormal protein and they impair the normal functioning of the brain and eventually kill brain cells. The damage is not only superficial damage, but deep damage of the brain.
All in all, these athletes who are exposed to multiple head injuries may seem okay for now, but as time creeps the athlete will be affected greatly and fast. The brains are resembling 80 year old persons with dementia (Guskiewicz, 2005). In another clinical study, it was found that concussions from sports result in long term motor system dysfunctions (De Beaumont, 2007). Not only have studies shown problems with NFL players and exhibiting problems with their brains and having disabilities, but also boxing and wrestling where athletes are experiencing repeated concussions and blows to the head or neck. In De Beaumont study (2007), it showed that the effects of sports concussions in early adulthood persist beyond 30 years post-concussion and that it can cause cognitive and motor function disability as the athletes age. Which is what the NFL study is confirming and that these athletes are suffering negative effects as they age. But the effects are showing at a young age, 30s and 40s, and they are having major problems that a normal healthy nonconcussed athlete would not be experiencing until late 80s or not at all. The athletes are experiencing depression that could drive them to suicide and many more problems that they would not be experiencing if they did not sustain so many head injuries.
In conclusion, it is extremely important for concussions to be taken seriously. Athletes who are at risk of head injury or concussions are highly susceptible to second impact syndrome, re-injury, and chronic traumatic encephalopathy. That is why it is imperative if we introduce sports, especially contact sports, to children at a young age we need to teach them the correct mechanics of sport. We need to teach our children the safety of a sport to limit injury. It is highly important to educate coaches, athletes, parents, administration, and medical staff the proper guidelines in treating head injuries and concussions to prevent serious or permanent damage or even damage that could progress over time. For all athletes, it is needed to ensure that equipment and protective gear is up to date, certified, and properly fitted. Since sports are highly accepted and loved by many we cannot diminish sport. We need to simply educate and speak out about how head injuries and concussions are serious and need to be taken very critically. Sport ages range from 3-40s+ and as a population it is substantial to make sure the future of the athletes after sport are progressive in a good way. With all the new technology, research, and education we can see that sports have dangers involved, but we also need to go the distance to make sure the athletes are safe. Limiting head injuries or concussions will decrease second impact syndrome, possible re-injury, and chronic traumatic encephalopathy. 50% of college athletes have had a history of concussion, 1 in 10 high school athletes involved in contact sports sustains a concussion each year, and according to the NFL, about 175 concussions occur league wide each season and many more probably undiagnosed or reported from each of those categories (Guskiewicz, 2005). The statistics show that concussions and head injuries do happen. It is now our responsibility to educate the populations, accommodate equipment and protective gear, and, assess, diagnose, and treat concussions and head injuries properly to maintain the safety of athletes. In the light of things, some rules have been altered or enforced such as helmet to helmet hits in football and some guidelines have changed such as the return to play guideline to accommodate head injuries and establish their seriousness. Maybe with time we can still have our sports, but also a safer atmosphere and less alarming statistics on head injuries or concussions.