Concussions in Sport
Concussion in Sport
Nicholas Medina A.T.C.
University of New Mexico
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Concussions in Sport
Resch, J., Driscoll A., McCaffrey N., Brown C., Ferrara MS., Macciocchi S.,
Baumgartner T., Walpert K., (2013). ImPact test retest reliability: reliably unreliable?,
Jul-Aug 2013. Journal of Athletic Training 48(4) 506. This article reviews the reliability
of the computer based concussion evaluation software known as ImPact. Utilizing the
software for both baseline testing (prior to any known head trauma) and post injury at set
times following injury, the software is evaluated for the reliability to test concussion
symptoms and recovery.
McCrory, P., Meeuwisse, W., Johnston, K., Dvorak, J., Aubry, M., Molloy, M., & Cantu,
R. (2009). Consensus statement on Concussion in Sport–the 3rd International Conference
on Concussion in Sport held in Zurich, November 2008. South African Journal of Sports
Medicine, 21(2). Following the third meeting of several sanctioning bodies in different
sports, discussion of improvements for evaluation and return to activity guidelines are
established. Among the sports represented are soccer, hockey and rugby. Much of the
discussion is centered around the results of the previous recommendations gathered from
those previous attempts to objectively measure concussion.
Riemann, B. L., & Guskiewicz, K. M. (2000). Effects of mild head injury on postural
stability as measured through clinical balance testing. Journal of athletic training, 35(1),
19. The authors of this study show pretty compelling evidence that concussions can lead
to temporary impairments in coordination of the body such as posture control. Though it
may seem inconsequential, the implications can be far reaching in sports where the
inability to protect oneself can lead to catastrophic injury.
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Concussions in Sport
Macciocchi, S. N., Barth, J. T., Littlefield, L., & Cantu, R. C. (2001). Multiple
concussions and neuropsychological functioning in collegiate football players. Journal of
Athletic Training, 36(3), 303. This study is comparing the differences between the
effects of one concussion versus two concussions in football players. The study evaluates
the neuropsychological processing of athletes after one or more concussions and finds
that there is not much difference between one and two head injuries. Admitted
limitations of the study are that neurobehavioral changes were not considered and on self
evaluation most athletes reported these changes to be the most significant.
Covassin, T., Swanik, C. B., & Sachs, M. L. (2003). Sex differences and the incidence of
concussions among collegiate athletes. Journal of athletic training, 38(3), 238. This
study evaluates data submitted by NCAA schools on the incidence of concussion or mild
traumatic brain injuries in several varsity sports. The two highest incidence sports for
concussion; football an ice hockey are not evaluated likely due to these sports being male
sports and may skew data when attempting to compare male and female sports. Results
of this study show that female sports show higher rates of concussion when compared
with their male counterparts, which the authors suggest may be due to weakness in the
neck and upper body.
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Concussions in Sport
With the increased focus in the last decade on head injuries in sports and their
potential long term consequences, it is a moral obligation to those that compete to learn
as much as possible. With proper awareness of risk people engage in all sorts of
dangerous behaviors and activities but only in sport are they doing it for the profits and
entertainment of others. The decision we need to make as a collective society is whether
we will accept the risks associated with our sports as they are, or if we will try to do
better for our sons and daughters that will be the entertainers of the future. This leads us
to our first ethical dilemma when discussing concussion in sports, which is whether
athletes and their parents are truly aware of the risk associated with sports. Since we are
only starting to scratch the surface of long-term data when it comes to the effects of head
injuries the risk associated sports is not fully understood, which is our second ethical
dilemma; do we owe it to athletes to study these injuries and their long term effects? The
third dilemma I see with concussions in sports is a more technical one for the sports
medicine team, what is the proper way to assess concussion? There are multiple ways to
assess a concussion including computer software and written protocols that can give a
health professional a myriad of answers but it is often up to an Athletic Trainer or
Physician to make the final determination about an athletes playing status. Without a
universal protocol for assessment of a concussion all sports medicine personnel are
operating with huge liability and many are operating on the side of caution because of
threat of litigation. Another point of ethics that is notable is that after a concussion many
different assessment methods result in guidelines for return to activity that can be just as
varied as the assessment protocols themselves. On one concussion measuring scale an
athlete may receive one score and therefore be able to continue playing but on another
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Concussions in Sport
scale that same athlete may be held from competition and referred to a physician.
Ultimately the time it takes to return athletes back to activity safely is an ethical dilemma
itself given such varied measurement standards and varied return to play guidelines. The
last issue I wish to discuss among concussion in sport is whether we will allow the data to
give us a gender-based scale to measure concussion symptoms with. The data would
suggest that females are overall more likely to get a concussion in sports, does this mean
that we have a different measuring stick for a male with head trauma versus a female with
the same trauma?
Upon researching this topic I chose to stick with a more scientific approach
utilizing several peer reviewed journals. Each study attempted to provide a new or
unique insight into head injuries and the effects sustained after trauma. The journal
studies were located using the google scholar search engine of which many articles were
reviewed and specific ones were chosen to cover the topic of head injuries from different
approaches. Articles for “concussions and sports,” were searched as well as “concussion
assessment in sports.”
For many athletes and parents the risks associated with sports are not always the
primary focus of participation, many parents and athletes focus on the benefits of sports
but often neglect the obvious problems that can result. Today many parents and athletes
are having to be educated on the signs and symptoms of concussion and the likelihood
that they may have to deal with concussion injuries. Though the risks are just starting to
become common knowledge among people many are not aware of the long-term risks
that can occur from concussion. Already well documented in the literature are the short
term effects of concussion, among those Riemann (2000) found that even small motor
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Concussions in Sport
effects such as postural stability can be effected after head injury. Many people know
that there are mild to severe effects of concussion but many people also assume that those
effects are temporary and heal on their own. What anecdotal evidence is showing
however is that the initial concussion symptoms may dissipate but an entirely new set of
symptoms may replace them long after the concussion was received. The scientific
community is only now starting to study the long-term impacts of concussion due in part
to the lawsuits being filed by former professional athletes. With the huge amount of
concussion injuries returning home from war as well it has become a priority for the
medical establishment to weigh in on some very critical questions and the research for
those decisions is failing miserably. Macciocchi (2001) performed a study in which one
concussion was compared to two concussions and neuropsychological measurements
were taken but what is lacking is the repetition those tests over many years instead of
days or weeks. What is quite interesting to note in the study is that Macciocchi (2001)
was able to see from feedback of the athletes themselves that the most persistent
complaint involved neurobehavioral changes. Though they were measuring
neuropsychological impairment what they found was that people reported changes in
their own personalities. Knowing that your son or daughter could receive not only
headaches and dizziness but possible personality changes would you now wish to sign the
release of liability that the school hands you prior to participation?
Now that your child has begged and pleaded to play and you have agreed to let
them, you think to yourself “well there is a trainer at the school in case anything
happens.” I am that Athletic Trainer and I can say that the staff is only as good as the
tools they use and given the many different concussion assessment tools available a
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Concussions in Sport
prudent professional can be overwhelmed having to choose the right one. McCrory
(2013) and the International Conference on Concussion in Sport have just released a
series of recommendations for assessment of concussion and guidelines for return to
activity after a concussion is sustained. The concussion symptom measurement tool they
developed and advocate is called SCAT3, but one thing you may notice from the research
article is that the organizations that represent American football, baseball and wrestling
do not attend the conference and do not follow those guidelines. Professional baseball
and many NCAA schools have implemented the use of a computer based measurement
tool known as IMPACT which attempts to measure a persons reaction speed as a way of
measuring concussion symptoms. This system takes out the neuropsychological
component of concussion evaluation and bases its entire determination on a person’s
motor reaction responses, however Resch (2013) found that even baseline testing (a
person’s score prior to injury) is hugely unreliable. Depending on a person’s motivation
and attentiveness to the system a person’s baseline score can vary dramatically which
doesn’t bode well for someone after concussion.
Lastly as a parent myself who may grapple with these decisions another thing that
no one is mentioning to you when you sign up your child to play sports is the fact that it
is much more common for female athletes to receive a concussion than males. Is this in
part due to weaknesses in the evaluation techniques used or the gender biases that a
health professional might have upon evaluation? Covassin (2003) was able to show that
in regard to NCAA athletes that female athletes are more likely to sustain a concussion
but stops short of attributing any particular cause other than perhaps females have more
weakness in cervical musculature. As a society we may give our male athletes more
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Concussions in Sport
leniency when they tell us that they are ok to keep playing and not make a formal write
up of the injury versus a female who makes the same claim. I would suspect that this
societal preference may skew the data that Covassin (2003) and many other sports
medicine professionals helped to compile for that particular research article.
Though these and many other issues can be dissected regarding the issue of
concussion in sport, the main issue is that of making people fully aware of the risks that
sports pose. Though an ankle or knee injury may impact a person for a while, generally it
is not life altering. Concussion on the other hand can be much more impacting to a
person and sadly we do not know the full effect that a concussion or multiple concussions
may have on someone. It is a moral imperative that we do the research into this area so
that people can make a better decision about the acceptance of the risk that is posed.
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Concussions in Sport
References
Resch, J., Driscoll A., McCaffrey N., Brown C., Ferrara MS., Macciocchi S.,
Baumgartner T., Walpert K., (2013).
ImPact test retest reliability: reliably unreliable?, Jul-Aug 2013. Journal of
Athletic Training 48(4) 506.
McCrory, P., Meeuwisse, W., Johnston, K., Dvorak, J., Aubry, M., Molloy, M., & Cantu,
R. (2009).
Consensus statement on Concussion in Sport–the 3rd International Conference on
Concussion in Sport held in Zurich, November 2008. South African Journal of
Sports Medicine, 21(2).
Riemann, B. L., & Guskiewicz, K. M. (2000).
Effects of mild head injury on postural stability as measured through clinical
balance testing. Journal of athletic training, 35(1), 19.
Macciocchi, S. N., Barth, J. T., Littlefield, L., & Cantu, R. C. (2001).
Multiple concussions and neuropsychological functioning in collegiate football
players. Journal of Athletic Training, 36(3), 303.
Covassin, T., Swanik, C. B., & Sachs, M. L. (2003).
Sex differences and the incidence of concussions among collegiate athletes.
Journal of athletic training, 38(3), 238.
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