Concussions in Sport & Athlete Safety
Sports are finally starting back up after a long shutdown with COVID. Most sports organizations, parents, and coaches will be focused on the pandemic, ensuring COVID safety measures including vaccination status and testing are in order.
But what many don’t realize is that this could be a huge year for concussion injuries.
Substantial evidence suggests that most concussions happen during the preseason, or in the first part of a sports season. This is usually when athletes are de-conditioned, out of shape, and not used to the pace of a game or competition sport.
According to a study of concussion and head impact exposure frequency published recently in JAMA Neurology, 72% of nearly 50 diagnosed concussions occurred during training. And 48% of concussions sustained, occurred during the preseason. 
These preseason concussions typically happen after only a couple of months off. What we are now dealing with is a situation where athletes have been off for a year or more because of COVID.
It’s incredibly important that parents, coaches and athletes don’t focus exclusively on COVID safety measures this preseason, but also prepare for what may be a big year for concussions.
Primary prevention refers to the measures taken to prevent injuries from occurring in the first instance. This usually means relying on protective type equipment.
But can protective equipment really stop a concussion from occurring?
How effective are mouthguards at preventing concussions or at least reducing the severity of injury? The evidence around their use remains somewhat mixed.
For instance, one study from Chisholm and colleagues at the University of Calgary found that the use of off the shelf mouthguards (the kind you get from any sporting goods store) reduced the likelihood or the odds of concussion by 69%. 
Interestingly, they also looked at dental fitted mouthguards and found that they reduced the chance of concussion by only 49%, although this was a non significant finding.
Other studies however have found mouthguards offered no protection whatsoever against concussion.
As an example, there was a meta-analysis (which is a collection of multiple studies) published in the Journal of Sports Medicine in 2019 that found whilst mouthguards reduced the risk of orofacial and dental injuries, they did little in the way of preventing concussions. 
So, we can see that the results from just these studies are quite mixed as a representation of the array of research. It is important to consider the use of mouthguards to prevent dental injuries, and there may be a small effect when it comes to concussion, but the evidence is in no way iron clad when it comes to preventing concussion.
Helmets are another common piece of protective equipment and they typically come in hard or soft shell.
Hard shell helmets were designed to prevent skull fractures and are used in team sports like hockey and American football and other high-speed sports like cycling and alpine events. There is some evidence to show that hard shell helmets can reduce brain injury severity in more severe brain injuries and reduce skull fractures. Put simply, the outer shell helps to dissipate the impact force on the skull reducing the likelihood of fracture, however the brain inside will still be getting jostled around.
Since concussion is a functional brain injury, resulting from the rapid acceleration of the brain inside the skull, a hard shell helmet is really not able to protect against this mechanism. However, this does not mean that a helmet should not be worn. As indicated above, helmets are protective against skull fractures and are absolutely important for the primary prevention of these injuries.
Soft shell helmets are things like soccer headbands, rugby head gear and Scrum caps. Do these offer any real protection against concussion?
The evidence demonstrates that they do not. For instance, a recent study following 930 participants published in the British Journal of Sports Medicine found the incidence of concussion was no different between the headgear and non-headgear wearing groups. 
If you are a coach or head of a sports organization and you are considering setting up a policy that includes mandating soft-shell helmets to ‘protect against concussion’, it’s a waste of money because they do nothing to mitigate concussion injuries.
The Q collar is what’s called a jugular compression device, and was designed specifically to reduce the chance of concussion.
What it does is wrap around the neck, applying slight pressure to the jugular veins. The idea is that when the veins are compressed, there is an increase in pressure inside the skull due to more cerebral spinal fluid and blood pooling, which causes slight swelling.
It sounds a bit scary but the science behind it makes a bit of sense. While we can’t really prevent a concussion from the outside of the skull, we can create conditions inside that may prevent the brain from being jostled around. That’s the theory anyway.
To date there is only one study that looks at the actual protective effects of Q collars. The study found that of 488 high school athletes, there was almost no difference between those who sustained a concussion whilst wearing the Q collar, and those who sustained a concussion and weren’t. 
So, while the manufacturer may claim the device protects against concussion, there is currently no data to suggest concussions will be prevented.
If you are a policy developer, or a concerned parent, most protective equipment will NOT prevent a concussion to any significant degree. They should still be worn however, as these devices can protect against other injuries, just not concussions.
If protecting the body with equipment does little to prevent concussions, how about conditioning the body? Can comprehensive athletic training help prevent concussions?
Possibly, but it’s important to discuss the specifics.
Prior to the season, some people have been told that doing a neck strengthening program will help reduce their chances of getting a concussion. Is there any truth to this?
Yes and no, it’s complicated. Here is the short answer:
Having a stiff neck can, theoretically, stops the head from moving around so much when an athlete takes a big hit. And if the head and neck don’t move as much, there is less chance for the brain to get jostled around and a concussion to occur. Remember, the mechanism for a concussion is the rapid acceleration of the brain inside the skull.
The problem is that neck strength is not the same thing as neck stiffness. Because in order to have neck stiffness, you have to not only have good neck strength, but also be under active contraction of the muscles. And THAT requires that an athlete be AWARE that a hit is coming.
Awareness requires a large field of vision. You can have a really strong neck, but if you don’t have a great field of vision and don’t see the hit coming, you won’t have the opportunity to stiffen your neck in preparation. As a result, your head and neck will experience a lot of movement causing acceleration and deceleration of your brain.
Most concussions happen when the person is unaware that they are about to take a hit, and in this situation neck strength won’t make a difference.
Field of Vision Training
There is some preliminary evidence that doing a preseason training program for vision therapy using a light board can help to establish and broaden an athlete’s peripheral vision.
Of all the methods of prevention we’ve looked at so far, field of vision training may have some merit when it comes to preventing concussions.
The theory would be that if you could combine vision training and game awareness with neck strength and have the time to react and contract your neck prior to an impact, then strength may play a part. However, if there is no time to react then strength wouldn’t make a difference.
The absolute best way to prevent concussions is not through training and it’s not through protective gear, it’s by reducing contact to begin with. As an example, minor hockey in Canada eliminated body contact in some of the younger age groups. And the result has been a massive reduction in concussions.
Similarly, there’s a big push in the United States to outlaw tackle football for anyone under the age of 14. This makes sense, because young, developing brains can experience long lasting cognitive effects from concussion injuries.
So, to reduce the chance of concussion in the young and most vulnerable groups, we shouldn’t rely on helmets or mouthguards but instead limit contact.
A study published in the British Journal Sports Medicine found that removing body contact in hockey reduced the risk of concussion by as much as 70%. 
It seems the greatest impact on concussion for primary prevention methods is not the use of protective equipment, and not even training, but instead limiting contact; especially in younger age groups.
Secondary and Tertiary Prevention
To reiterate, a lot of people try to set their concussion policies without giving any consideration to changing the rules of the game. They look for better helmets or mouthguards, but as we’ve seen, those do little to nothing to stop concussions from happening.
In order to actually reduce concussions, if that’s your goal, you’ve got to make changes in how the game is played. And if that is not an option, you need to look towards secondary and tertiary prevention methods. That means ensuring proper management when the injuries actually occur.
Realistically, ensuring that proper concussion management strategies are in place is really the most important thing that a sports organization, a parent, and an athlete can do. When you have solid management strategies, you know that, should a concussion occur, everything will be done the right way and your athletes won’t return to sport too soon.
In reality, it’s not the original concussion we really need to worry about, it’s the secondary concussion that happens when an athlete gets back on the field, track, road, ice rink or hill before they have fully healed.
Is it possible to train coaches and athletes to recognize concussion injuries better? Can we educate them to report injuries when they happen? Theoretically, yes.
Yes, we can teach coaches, parents and athletes to recognize the symptoms of a concussion. But does this necessarily translate into better reporting behaviors or the intention to report?
Sadly, no. And this really comes down to the culture of sport and the need for a culture shift.
The Culture of Sport
Athletes tend to be tough guys and gals. There is definitely a level of macho around sport culture and it’s what makes players “walk it off” when they get hurt. They don’t want to show weakness in front of their team mates, they don’t want to show weakness in front of their coach. And therefore, they continue to play or compete. Playing injured is almost like a badge of honor or rite of passage among athletes.
Education is good and fine, but a whole culture shift needs to occur in order to effect a meaningful change and really keep athletes safe.
The best line of defense against serious concussion injury is to ensure all teams have a comprehensive concussion management strategy in place. In addition, there needs to be a shift in the culture of sport, as athletes typically see playing and competing while injured as a badge of honor.
There is a lot of confusion around baseline testing. Most people think a baseline test is ‘just’ a computer test. But a proper baseline tests all elements that are potentially impacted by concussion injuries. This includes balance, reaction time, visual tracking, processing speed, executive function, memory (both auditory and visual), and auditory and visual concentration.
A baseline test should be a series of tests that look at multiple aspects of brain function. An athlete needs to be tested at the start of the season to have something comprehensive to compare down the road in the event of a concussion occurring.
But here’s where most people go wrong. They think baseline testing is to help with the diagnosis of concussion. And in some cases, it can be helpful with diagnosis. But most of the time diagnosis is a clinical diagnosis based on symptoms and a mechanism of injury. For example, you have an acceleration or deceleration to the head, neck or body, followed by any one of the 22 concussion symptoms like memory issues or visual disturbances, and that’s all you really need to diagnose a concussion.
What baseline testing is mostly used for is return to play clearance. The athlete sustains a concussion, they have symptoms indicative of concussion injury, a concussion is diagnosed, and they go through all the stages of return to sport.
Now they’re feeling better, and we can retest them on all of the functional markers in their baseline, to make sure that everything is back to normal, back to their full function. Baseline testing makes sure the reaction time, memory, visual tracking and more is back to normal.
Why is this so important?
We know from the evidence that the physiologic concussion injury outlasts the symptom recovery from concussion. So, an athlete may sustain a concussion and eventually feel better, even though they have not yet fully healed. Their symptoms may have gone away, but brain dysfunction still lingers. And this is dangerous because at this point their brain is still vulnerable to a secondary injury, which can be additive and cumulative.
The bottom line is, when people don’t fully recover, they can sustain additional brain injuries which become additive, and this is where the long-term neurodegenerative effects start to take hold.
So, baseline testing is not really to diagnose a concussion, though it can add insights. What baseline testing is really used for is to assist in making better return to sport decisions.
If you’re looking for a baseline test, visit our website to find a clinic near you that can perform a comprehensive baseline test.
When it comes to getting concussion ready, the most important thing a parent, athlete or sports organization can do is get a comprehensive baseline test done before the season starts, especially when involved in high risk sports. While it won’t necessarily help diagnose a concussion, it will help to ensure an athlete is fully recovered prior to returning to sport.
It’s important that sports organizations incorporate policy development and legislation into their management protocols. And this means from a legal standpoint, you must be familiar with what your duties are.
In our experience, knowing your legal responsibilities is only the tip of the iceberg. As a coach, your ‘duty of care’ also includes providing the best guidelines to your team and their family members to ensure their safety.
Things that should be included in your concussion policies are:
Who reports the injuries? Is it from a coach? Is it from a trainer? Is it from the parents themselves? Do they have to self report?
What is the training protocol for the staff, referees, coaches, and trainers? What type of concussion knowledge should they have?
How are you laying out your recovery or concussion recovery stages? What type of process do your athletes need to go through in order to return? Do they simply need a doctor’s letter? Can they come back in one day? Do they need to have a certain amount of time off? All of these answers need to be considered and included within your policy.
Final Clearance Decisions
What is the process for clearance to return to sport? When can non-contact sport resume? When can contact sport be resumed? And, when can full return to sport be resumed?
It’s not the concussion that you should be afraid of, it’s the improper management of those concussions that can cause trouble. It’s the too soon to return to play, the improper medical clearance where the athlete comes back because their neighbor is a doctor or they have shopped around, and they just got a sign off letter.
These are the kind of things that are questionable, and where your liability can come into play. Because if that athlete gets another concussion, and your policy wasn’t up to scratch or your protocols were not followed, there’s an issue.
If you need help developing your concussion policy, we can help you build them. That’s what we do, connect with our team today.
Concussion reporting can be an absolute pain in the neck. But it’s super important. Because unless you know where these injuries are happening, how long they’re taking to recover, how frequently they’re happening, and what age groups they are happening in, you can’t really make any good decisions.
Though we live in a technological age, so many people are still reporting by hand. And because it’s such a pain, we don’t always get the comprehensive data needed to make significant positive changes.
Complete Concussion Management has an app for this problem, and you can download it for free from the Google Play and Apple App stores. If you’re a coach, this app will allow you to input all of your players. If you’re a player, you can do your own baseline testing right on there. There is now a validated free neurocognitive test included in the app. So, you can at least do that portion of it and schedule a time with one of our trained clinics to have the remainder of your functional testing completed.
The CCMI Concussion Tracker app offers a ton of valuable resources. Athletes have access to diet plans and portals to submit concussion symptoms on an ongoing basis and suggestions for how to have a full recovery.
If you’re a parent or a coach, our app walks you through signs to look for and red flags; it provides a guided sideline assessment including a neurocognitive test where you give the athlete the phone, and we have reaction time testing right in the app. The app then compares the sideline assessment with the baseline test for real time comparison.
And perhaps the best function is that after you save the test results, the app will send a copy of the results to the athlete and their family as well as to the league office and any other coaches the athlete may be associated with.
The app essentially facilitates a whole communication circle of care. This means better health outcomes for the athlete who has been injured and no legal headaches for coaches and sports organizations.
Getting concussion ready does not necessarily mean preventing concussions. Because as we saw from the previous studies, most protective equipment and preseason training doesn’t actually prevent concussions.
The best thing you can do is to ensure your association or team have a robust concussion management policy in place, including a focus on recognition, proper return to activity protocols, and proper concussion reporting and data collection.
In other words, proper management of the injury is the most effective way that a sports organization, a parent, an athlete, and anyone else involved can actually reduce the impact of concussions, reduce long-term neurodegenerative effects, and reduce the chance of having subsequent injuries and more serious complications. All of this comes down to management.
Are you concussion ready?
Complete Concussion Management is here to help you keep your athletes safe. Head to our website to find a clinic near you.
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