Traumatic Brain Injuries in Sports
It is estimated that there are 300,000 sports related traumatic brain injuries (TBI’s) occur in the United States each year. Most of which are mild to severe concussions. They can be caused by both repeated blows and/or one significant blow to the skull. The proportion of these concussions that are repeat injuries is unknown; however, there is an increased risk for subsequent TBI among persons who have had at least one previous TBI. Death can occur if left untreated or sent back into competition before ready.
Concussions themselves, especially in sport, are hard to avoid, but proper diagnosis and treatment can save an athlete’s life. I am writing this paper to spread the knowledge of the seriousness of this injury and how proper diagnosis and/or treatment can not only save the career of an athlete, but save their life.
Traumatic brain injuries (TBI) are common in contacts sports (Football, Hockey, Boxing, MMA, and Rugby), however they can also appear in other sports like Nascar, Baseball, and so on. A jerky motion that snaps a head forward or backwards can cause the brain to shift inside the skull (Contrecoup). TBI is a serious condition that can create significant symptoms if not treated. Repeated brain injuries that occur over an extended period (i.e., months or years can result in cumulative cognitive and neurological deficits, but repeated mild brain injuries occurring within a short period (i.e., hours, days, weeks) can be catastrophic or fatal.
Second impact syndrome; a syndrome that is results from acute, usually fatal, brain swelling that occurs when a second concussion is sustained before complete recovery from a previous concussion that causes vascular congestion and increased intracranial pressure, which may be difficult or impossible to control. Second impact syndrome has been reported more frequently since it was first characterized in 1984 and is common in sports that do not have proper medical staff available. Neurologists say once a person suffers a concussion, he/she is as much as four times more likely to sustain a second one.
After several concussions, it takes less of a blow to cause the injury and requires more time to recover. Troy Aikman sustained eight concussions in the NFL, the last two occurred since January 1, 2000. According to league officials there are about 160 concussions in the N.F.L. and 70 in the NHL each year.
Symptoms of TBI can range depending on the severity and the condition in which the athlete has. One of the most common symptom is a mild to moderate constant headache. If this symptom is followed by a blow to the skull, motor and cognitive tests are needed to rule-in or rule-out a diagnosis of TBI. If the athlete performs poorly in motor skill a trip to the hospital is necessary for a CT (computed Tomography) scan. A CT scan will help with a diagnosis of TBI and will show swelling or intracranial pressure within the skull.
In recent years a new sport has been on the rise, MMA (Mixed Martial Arts). This sport has been on the rise for some 15 years now and has evolved into a legitimate sport. In the early days it was bare-knuckles brawl with out many rules; only two were (1) no biting and (2) no Eye-gouging). However now athletes use 3.5 oz gloves and most are well trained in boxing/kickboxing and grappling (Brazilian Jiu-Jitsu or Wrestling) and a lot of rules have been implemented. It is rare to watch a full pay-per-view on TV and not see a brutal knockout, however even with so many knockouts in the 15 year history there has been only one reported death. One athlete was not properly cleared by medical staff in a lower-budget fight organization and developed a Berry Aneurysm after his fight and passed away in the hospital 3 days later. The aneurysm was pre-existing and should not have been cleared to fight. This is just to show that many serious ailments from TBI (i.e. death, neurological & cognitive disorders) can be avoided, even in the most extreme cases.
The following is the Sideline Guideline for Head Injury
Grade 1 Concussion
Definition: Transient Confusion, no loss of consciousness, and duration of mental status abnormalities of less than 15 minutes.
Management: The athlete should be removed from sports activity, examined immediately and at 5 minute intervals, and allowed to return that day to the sports activity only if post concussive symptoms resolve within 15 minutes. Any athlete who incurs a second Grade 1 concussion on the same day should be removed from sports activity until asymptomatic for 1 week.
Grade 2 Concussion
Definition: Transient confusion, no loss of consciousness, and a furation of mental status abnormalities of more than 15 minutes.
Management: The athlete should be removed from sports activity, examined immediately and frequently to assess the evolution of symptoms, with more extensive diagnostic evaluation if the symptoms worsen or persist for more than 1 week. The should return to sports activity only after asymptomatic for 1full week. Any athlete who incurs a Grade 2 concussion subsequent to a Grade 1 concussion on the same day should be removed from sports activity until asymptomatic for 2 weeks.
Grade 3 Concussion
Definition: Loss of consciousness, either brief (seconds) or prolonged (minutes or longer).
Management: The athlete should be removed from sports activity for 1 full week without symptoms if the loss of consciousness is brief, or 2 full weeks without symptoms if the loss of consciousness is prolong. If still unconscious, or if abnormal neurologic signs are present at the time of initial evaluation, the athlete should be transported by ambulance to the nearest hospital emergency department. An athlete who suffers a second Grade 3 concussion should be removed from sports activity until asymptomatic for 1 month. Any athlete with an abnormality on computed tomography or magnetic resonance imaging brain scan consistent with brain swelling, contusion, or other intracranial pathology should be removed from sports activities for the season and discouraged from future return to participation in contact sports.
Features of Concussion Frequently Observed
1. Vacant stare (befuddled facial expression)
2. Delayed verbal and motor responses (slow to answer questions or follow instructions)
3. Confusion and inability to focus attention (easily distracted and unable to follow through with normal activities)
4. Disorientation (walling in the wrong direction; unaware of time, date and place)
5. Slurred or incoherent speech (making disjointed or incomprehensible statements)
6. Gross observable incoordination (stumbling, inability to walk tandem/straight line)
7. Emotions out of proportion to circumstances (distraught, crying for no apparent reason)
8. Memory deficits (exhibited by the athlete repeatedly asking the same question that has already been answered, or inability to memorize and recall 3 of 3 words, or 3 of 3 objects in 5 minutes)
9. Any period of loss of consciousness (paralytic coma, unresponsiveness to arousal)
It is difficult to predict how well someone who has had a brain injury will recover, partly because there is no test a doctor can use to predict recovery. The Glasgow Coma Scale is used to determine the initial severity of a brain injury (usually done at the scene of the accident or in the emergency room). This scale uses eye movements and ability to speak and move other parts of the body to determine the seriousness of the injury. The prognosis of the injury will vary due to the severity of the injury, the type of injury, and what parts of the brain have been affected. Prompt diagnosis and treatment is the most important and will help with the recovery.
The recovery process is different for everyone, the patient and the family. No two brain injuries are alike, recovery is typically lengthy; from months to years; because the brain takes a long time to heal. After following a brain injury it is not safe to drive a car or even ride a bike, or return to activity, due to the increase risk of re-injury. Rehabilitation can help get the athlete back to sport or back to normal daily activities. The goal of rehabilitation is to help the athlete function independently and help heal and assist the brain in relearning so the athlete can recover more quickly.
The most serious case of TBI, as stated above, is Second Impact Syndrome. Luckily this can be avoided if the first concussion is diagnosed early and clearly. With proper care and diagnosis, sporting events can be a lot safer for our youth. The reason that deaths due to TBI still occur in our youth sports is due to improper diagnosis. Hopefully this paper will be useful in aiding one to a proper diagnosis, or helping someone become more aware of the severity of concussions and not send their athlete back into the game too quickly.
Centers for Disease Control and Prevention, Dept. of Health and Human Services, USA. 1997
Kelly, James P. “Concussion,” Current Therapy in Sports Medicine. Mosby - Year Book, Inc. 1995, pp 21 – 24