Sports-related concussion (also known as mild traumatic brain injury or TBI) and possible sequelae such as CTE (chronic traumatic encephalopathy) are hot topics that can be found daily in news outlets and often as story lines in movies and TV shows, EurekAlert reports.
In March, the NFL (National Football League) conceded a link between football and CTE, and The New York Times reported a connection between the NFL and earlier faulty research on concussion.
Most symptoms of concussion – headaches, confusion, dizziness, amnesia, temporary loss of consciousness etc – are mild and short lived. However, some concussions or series of concussions are accompanied by sequelae such as post-concussion syndrome (prolongation of symptoms), second impact syndrome (rapid, severe [and sometimes fatal] brain swelling brought about by a second concussion sustained before the first concussion has healed), and CTE (a neurodegenerative disease whose symptoms may not appear until years after the last injury).
Although most accounts focus on professional athletes, a far greater number of people affected by sports-related concussions are found closer to home – down the street, next door or upstairs. Heightened press interest in concussions and their sequelae has stirred worry in the parents of young athletes and suspicion in the minds of citizens who don’t know whose spin to believe. There is a lot of information and misinformation about concussion, and it is up to medical science to provide accurate reports.
The April issue of Neurosurgical Focus offers 12 articles presenting the most up-to-date knowledge of what constitutes sports-related concussion and more severe TBIs, the latest diagnostic assessment tools, the neuropathology underlying symptoms, complications that may arise, prevention, and case management strategies.
Two articles examine statistics on patients admitted to the hospital for TBIs sustained while participating in five sport categories: fall and interpersonal contact sports, skiing/snowboarding, roller skates/skateboards, equestrian sports, and aquatic sports. These articles describe the incidence of injuries associated with these sports and characterize predictors of outcomes in patients of all ages:
- “Adult sports-related traumatic brain injury in United States trauma centers” by Winkler et al.
- “Pediatric sports-related traumatic brain injury in United States trauma centers” by Yue et al.
A review article follows, providing details on the diagnosis of concussion based on symptoms and discussing the potential for neuroimaging as a diagnostic tool in the future. The authors describe associated injuries such as axonal injury, brain contusion, and intracranial hemorrhage, as well as complications such as skull fracture, cervical spine injury, and eye injury. Treatment strategies are reviewed; and current knowledge about the pathological characteristics of concussion, post-concussion syndrome, second impact syndrome, and CTE is included.
- “Sports related concussions: diagnosis, complications, and current management strategies” by Hobbs et al.
These subjects are taken up in other articles as well.
Two articles provide information on assessment tools used to diagnose concussion on the sideline during a game and in the clinical setting.
- “The Sport Concussion Assessment Tool: a systematic review” by Yengo-Kahn et al.
- “Clinical evaluation of concussion: the evolving role of oculomotor assessments” by Sussman et al.
The difficult decision of when young athletes must be advised to retire from play to prevent further injury is described. Variables indicating this eventuality are discussed and illustrative cases are provided.
- “Retirement-from-sport considerations following pediatric sports-related concussion: case illustrations and institutional approach” by Ellis et al.
Relationships between TBIs and pre-existing brain disorders as well as cervical spine injuries are discussed, based on systematic reviews and analyses of pertinent scientific literature. Although not a TBI, a cervical spine injury can also result from a hit to the head during play.
- “Sport-related structural brain injury associated with arachnoid cysts: a systematic review and quantitative analysis” by Zuckerman et al.
- “Cervical spine surgery in professional athletes: a systematic review” by Joaquim et al.
Traumatic brain injuries associated with cricket and rugby are discussed in light of helmets. Although so far no helmet has been developed to prevent concussion from occurring, developments in helmet shells and padding have prevented many more serious TBIs. Unfortunately, some players may place too much trust in helmets, leading them to play more aggressively while wearing them.
- “Craniofacial injuries in professional cricket: no more a red herring” by Tripathi et al.
- “Rugby headgear and concussion prevention; misconceptions could increase aggressive play” by Menger et al. [accompanied by a podcast]
Last, two sequelae of concussion are discussed: post-concussion syndrome and CTE. Authors found five factors in college athletes that heighten their risk of developing post-concussion syndrome. With respect to CTE, one article examines the pathology of sports-related TBI and CTE, and the potential of various neuroimaging modalities and biological markers in their diagnosis. So far, a diagnosis of CTE has only been possible at autopsy. The other article discusses common questions about CTE and proposes directions for new research.
- “Predictors of postconcussion syndrome in collegiate student-athletes,” by Zuckerman et al.
- “Sports-related brain injuries: connecting pathology to diagnosis” by Pan et al.
- “The science and questions surrounding chronic traumatic encephalopathy,” by Ban et al.
“Sports-related traumatic brain injury (TBI) is an important public health concern estimated to affect 300,000 to 3.8 million people annually in the United States. . . . Approximately 70%-90% of all TBIs are comparatively mild and frequently given the colloquial term ‘concussion’. – Winkler et al., Neurosurg Focus 40:E4, April 2016
ARTICLES AND ABSTRACTS
Richard Menger, Austin Menger and Anil Nanda
Multiple studies have illustrated that rugby headgear offers no statistically significant protection against concussions. However, there remains concern that many players believe rugby headgear in fact does prevent concussions. Further investigation was undertaken to illustrate that misconceptions about concussion prevention and rugby headgear may lead to an increase in aggressive play.
METHODS: Data were constructed by Internet survey solicitation among United States collegiate rugby players across 19 teams. Initial information given was related to club, age, experience, use of headgear, playing time, whether the rugger played football or wrestling in high school, and whether the player believed headgear prevented concussion. Data were then constructed as to whether wearing headgear would increase aggressive playing style secondary to a false sense of protection.
RESULTS: A total of 122 players responded. All players were male. The average player was 19.5 years old and had 2.7 years of experience. Twenty-three of 122 players (18.9%) wore protective headgear; 55.4% of players listed forward as their primary position. Overall, 45.8% (55/120) of players played 70–80 minutes per game, 44.6% (54/121) played football or wrestled in high school, 38.1% (45/118) believed headgear prevented concussions, and 42.2% (51/121) stated that if they were using headgear they would be more aggressive with their play in terms of running or tackling. Regression analysis illustrated that those who believed headgear prevented concussions were or would be more likely to engage in aggressive play (p = 0.001).
CONCLUSIONS: Nearly 40% of collegiate rugby players surveyed believed headgear helped to prevent concussions despite no scientific evidence that it does. This misconception about rugby headgear could increase aggressive play. Those who believed headgear prevented concussion were, on average, 4 times more likely to play with increased aggressive form than those who believed headgear did not prevent concussions (p = 0.001). This can place all players at increased risk without providing additional protection. Further investigation is warranted to determine if headgear increases the actual measured incidence of concussion among rugby players in the United States.
Rugby headgear and concussion prevention: Misconceptions could increase aggressive play
11- “Predictors of postconcussion syndrome in collegiate student-athletes”
Scott L. Zuckerman, Aaron M. Yengo-Kahn, Thomas A. Buckley, Gary S. Solomon, Allen K. Sills and Zachary Y. Kerr
Sport-related concussion (SRC) has emerged as a public health problem, especially among student-athletes. Whereas most concussions resolve by 2 weeks, a minority of patients experience postconcussion syndrome (PCS), in which symptoms persist for months. The objective of this study was to elucidate factors predictive of PCS among a sample of National Collegiate Athletic Association (NCAA) student-athletes in the academic years 2009–2010 to 2014–2015.
METHODS: The SRC data originated from the NCAA Injury Surveillance Program (ISP) in the 2009–2010 to 2014–2015 academic seasons. The NCAA ISP is a prospective database made up of a convenience sample of schools across all divisions. All SRCs are reported by certified athletic trainers.
The PCS group consisted of concussed student-athletes with concussion-related symptoms that lasted ≥ 4 weeks. The non-PCS group consisted of concussed student-athletes with symptom resolution in ≤ 2 weeks. Those with symptoms that resolved in the intermediate area of 2–4 weeks were excluded. Odds ratios (ORs) were estimated using logistic regression.
RESULTS: During the 2009–2010 to 2014–2015 seasons, 1507 NCAA student-athletes sustained an SRC, 112 (7.4%) of whom developed PCS (i.e., concussion-related symptoms that lasted ≥ 4 weeks). Men’s ice hockey contributed the largest proportion of concussions to the PCS group (28.6%), whereas men’s football contributed the largest proportion of concussions in the non-PCS group (38.6%).
In multivariate analysis, recurrent concussion was associated with increased odds of PCS (OR 2.08, 95% CI 1.28–3.36). Concussion symptoms that were also associated with increased odds of PCS included retrograde amnesia (OR 2.75, 95% CI 1.34–5.64), difficulty concentrating (OR 2.35, 95% CI 1.23–4.50), sensitivity to light (OR 1.97, 95% CI 1.09–3.57), and insomnia (OR 2.19, 95% CI 1.30–3.68). Contact level, sex, and loss of consciousness were not associated with PCS.
CONCLUSIONS: Postconcussion syndrome represents one of the most impactful sequelae of SRC. In this study of exclusively collegiate student-athletes, the authors found that recurrent concussions and various concussion-related symptoms were associated with PCS. The identification of initial risk factors for the development of PCS may assist sports medicine clinicians in providing timely interventions and treatments to prevent morbidity and shorten recovery time after SRC.
“Predictors of postconcussion syndrome in collegiate student-athletes”
12- “Sports-related brain injuries: connecting pathology to diagnosis”
James Pan, BS1,*, Ian D. Connolly, MS1, Sean Dangelmajer, BA2, James Kintzing, BS3, Allen L. Ho, MD1, and Gerald Grant, MD1
Brain injuries are becoming increasingly common in athletes and represent an important diagnostic challenge. Early detection and management of brain injuries in sports are of utmost importance in preventing chronic neurological and psychiatric decline. These types of injuries incurred during sports are referred to as mild traumatic brain injuries, which represent a heterogeneous spectrum of disease.The most dramatic manifestation of chronic mild traumatic brain injuries is termed chronic traumatic encephalopathy, which is associated with profound neuropsychiatric deficits.
Because chronic traumatic encephalopathy can only be diagnosed by postmortem examination, new diagnostic methodologies are needed for early detection and amelioration of disease burden. This review examines the pathology driving changes in athletes participating in high-impact sports and how this understanding can lead to innovations in neuroimaging and biomarker discovery.Sports-related brain injuries: connecting pathology to diagnosis