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Sports-related concussions have been characterized as a public health epidemic in urgent need of attention. This clarion call has prompted action by a wide range of individuals and agencies. The goal of this chapter is to provide a brief discussion of the diagnosis, assessment, and epidemiology of sports-related concussion. A particular focus will be placed on the efforts that have been made to prevent this injury or mitigate the neurocognitive consequences that can arise from the injury through broad-based education programs.

There has been an exponential growth in the amount of information available on sports-related concussion in the past 10–15 years. The information has come from traditional academic and scientific research institutions; federal agencies (e.g., Centers for Disease Control [CDC]); professional sports organizations; nongovernmental sports organizations (e.g., US Soccer Federation, USA Hockey, US Lacrosse); local community groups and leagues; local, state, and federal legislators; and the media. In large measure, the increased attention on concussions has come from research and player accounts suggesting that concussions may lead to long-­term neurocognitive consequences if not evaluated and managed properly. Indeed, at the time of this writing there are thousands of retired professional players who are suing the NFL because they feel that the league did not go far enough to protect them or to share information with them about the possible long-term consequences of sports-related brain injuries. It was not long ago that some considered concussions to be comical because of players’ behavioral changes such as repeatedly asking the same question, not knowing which play had just occurred, or forgetting their field assignments. These signs and symptoms were not viewed as the result of brain injuries—these players simply had their “bell rung” or got “dinged.” Concussions were a nuisance injury that players were instructed to “play through.” Today, we know that concussions are not a laughing matter; they are brain injuries characterized by a wide range of cognitive, somatic, and psychological symptoms.

Concussion Defined

A concussion is a brain injury, often referred to as a mild traumatic brain injury (MTBI). In keeping with much of the literature (e.g., Ruff, Iverson, Barth, Bush, & Broshek, 2009), the term “concussion” will be used interchangeably with MTBI.

A concussion occurs as a result of a blow to the head or other parts of the body, causing acceleration and deceleration of the brain inside the skull. Many definitions have been put forth defining MTBI in general and concussion more specifically (Table 4.1). In 1993, the American Congress of Rehabilitation Medicine (ACRM) defined an MTBI as a traumatic disruption of brain function, manifested by at least one of the following: any loss of consciousness (LOC), any loss of memory for events immediately before or after the accident, any alteration of mental state at the time of the accident (e.g., feeling dazed, disoriented, or confused), and focal neurologic deficit(s) that may or may not be transient. Additional markers of the injury included LOC of approximately 30 minutes or less and after 30 minutes an initial Glasgow Coma Score of 13–15, and posttraumatic amnesia not greater than 24 hours (Mild Traumatic Brain Injury Committee, 1993).

Table 4.1 Concussion grading guidelines
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The American Academy of Neurology (AAN Quality Standards Subcommittee, 1997) defined concussion as follows: “Concussion is a trauma-induced alteration in mental status that may or may not involve LOC. Confusion and amnesia are the hallmarks of concussion. The confusional episode and amnesia may occur immediately after the blow to the head or several minutes later” (p. 2). Three grades of severity were assigned based on the presence or absence of specific symptoms and their duration.

According to the international consensus statement published by the Concussion in Sport group (CISG; McCrory et al., 2009), a concussion is defined as follows:

Concussion is defined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. Several common features that incorporate clinical, pathologic, and biomechanical injury constructs that may be utilized in defining the nature of a concussive head injury include:

  1. 1.

    Concussion may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head.

  2. 2.

    Concussion typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously.

  3. 3.

    Concussion may result in neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury.

  4. 4.

    Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically ­follows a sequential course; however, it is important to note that, in a small percentage of cases, post-concussive symptoms may be prolonged.

  5. 5.

    No abnormality on standard structural neuroimaging studies is seen in concussion. (p. i76–i77)

Several key factors are common across these definitions. First, LOC is not necessary for the diagnosis of concussion. Second, the injury is traumatically induced. Third, concussions are generally self-limiting, i.e., a single concussion typically resolves without complications within a relatively short period of time. However, recovery rates tend to vary by age and persistent symptoms are known to occur in a small percentage of athletes. Fourth, concussion symptoms are varied and their emergence is dynamic, with symptoms occurring immediately after the injury for some athletes while others may not show symptoms for hours or days (Echemendia & Julian, 2001).

Pathophysiology of Concussion

Concussions are often frustrating to players and those who coach and treat them because the injury is largely invisible. Concussed athletes do not have visible indicators of their injuries; they do not wear casts, slings, and orthopedic boots or use crutches. By all accounts, the players look “normal.” Concussions are not only invisible to the naked eye; they also do not appear on traditional neuroimaging techniques such as CT scans or MRIs, although newer imaging techniques that focus on brain functions hold promise for clinical use in the future (Prabhu, 2011). Sports-­related concussions are not grossly “structural” injuries, although microscopic structural changes have been noted (Buki & Povlishock, 2006; Povlishock, Buki, Koiziumi, Stone, & Okonkwo, 1999; Povlishock & Pettus, 1996). Instead, ­concussions usually create a neurometabolic cascade that renders cells temporarily dysfunctional (Giza & Hovda, 2001).

Typically, within minutes of an injury there are changes inside and outside of the cell membranes consisting of an influx of calcium and efflux of potassium that creates depolarization throughout the cells (Katayama, Becker, Tamura, & Hovda, 1990; Okonkwo & Stone, 2003; Pettus, Christman, Giebel, & Povlishock, 1994). The cells then activate ion pumps, increasing the use of glucose (hyperglycolysis). Increases in lactate also occur that may cause an increased risk of secondary ischemic injury and possible predisposition for recurrent injury. As the metabolic cascade unfolds, the hyperglycolysis eventually creates a hypermetabolic state in which the brain is using vast amounts of resources to stabilize functioning (Giza & Hovda, 2001; Lee, Wong, Samii, & Hovda, 1999). Unfortunately, this hypermetabolic state is accompanied by disruptions in cerebral blood flow, which creates a mismatch between the brain’s need for glucose and the glucose available due to restrictions in cerebral blood flow (Lee et al., 1999; Yuan, Prough, Smith, & Dewitt, 1988). A “hypometabolic” state then ensues that can last for several days after the initial injury (Yoshino, Hovda, Kawamata, Katayama, & Becker, 1991). Decreased cerebral blood flow has been reported to last approximately 10 days following concussive injuries in animal models, which is consistent with the finding of an apparent 7–10 day period of increased susceptibility to recurrent injury (Guskiewicz, Echemendia, & Cantu, 2009). Eventually, cell functioning begins to stabilize and the metabolic crises resolve, returning the cells to normal levels of activity. This cellular process underscores the evolving and dynamic nature of concussions. In essence, a concussive injury is a process and not a static event.

Signs and Symptoms of Concussion

Initial signs of concussion include LOC, a dazed or vacant look, motor incoordination/balance problems (stumbles, falls, wobbly legs), and on-field confusion/disorientation (for example, forgetting plays/assignments or not knowing which bench or sideline to go to) (McCrory et al., 2009).

In contrast to signs, which are typically observable events or behaviors, symptoms are reported by the athlete. Concussion symptoms are varied and may best be grouped into four clusters: somatic, cognitive, psychological/emotional, and sleep disturbances (Lovell et al., 2006; see Fig. 4.1). Athletes who sustain a concussion often experience a state of confusion or disorientation that typically resolves within minutes. This initial state of confusion is what has been historically referred to as being “dinged” or having one’s “bell rung.” Following this initial confusion is a dynamic and evolving course of symptoms that varies player by player. Consistent with the dynamic flux in pathophysiology, symptoms may occur immediately after injury or may emerge hours or days later. It is not unusual for a player to initially report that they are feeling fine but then feel sick on the bus or car ride home. In addition, at times there may not be one identifiable blow that causes the concussion symptoms to emerge but rather a cumulative effect of several subconcussive blows.

Fig. 4.1
figure 00041

Symptoms of concussion

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Adding to the complexity of this injury is the observation that symptoms associated with MTBI are not specific to concussion. In fact, they occur frequently within the general population for individuals who have not suffered a concussion (Bailey, Samples, Broshek, Freeman, & Barth, 2010; Benge, Pastorek, & Thornton, 2009; Lannsjo, af Geijerstam, Johansson, Bring, & Borg, 2009; Luis, Vanderploeg, & Curtiss, 2003; Randolph et al., 2009). These symptoms can be seen in individuals who may have a physical illness (e.g., bad cold or flu) or a psychological condition (e.g., depression, anxiety, ADHD) or even those who did not sleep well the night before. Consequently, a key task in concussion management is determining which symptoms are due to the acute injury as opposed to those that may be premorbid or comorbid from other conditions. While comprehensive symptom assessment is critical in the evaluation of concussion, it is important to recognize that athletes are strongly motivated to return to play and may therefore minimize symptoms in order to return to the playing field. Although many associate this behavior with professional athletes who have very strong motivation to return to play, it also occurs quite frequently among college, high school, and middle school athletes.

Epidemiology

It is now well established that concussions occur frequently in sports, accounting for approximately 10% of all athletic injuries. The CDC estimated that approximately 300,000 sports-related traumatic brain injuries (TBI) occur each year (Thurman, Branche, & Sniezek, 1998). This estimate only included those TBIs that had LOC and were treated by physicians. Since most concussions do not involve LOC and are not treated by physicians, the estimate was increased to 1.6–3.8 million sports-related concussions each year (Langlois, Rutland-Brown, & Wald, 2006). The marked difference in these two estimates underscores the difficulty in identifying the actual number of sports concussions that occur annually. The inability to arrive at a reliable incidence is based on differences in injury definition, players’ ability to recognize and report post-concussion symptoms, different methodologies used by studies, unwillingness on the part of the player or family to seek medical care, or players’ acceptance of concussion symptoms as being normal rather than an indication that clinical attention is needed. For example, recent studies of Canadian football and soccer players revealed significant discrepancies between the number of players who reported post-concussion symptoms and those who attributed these symptoms as signs of concussion. Specifically, at the end of one playing season, 70% of football players and 63% of soccer players reported symptoms consistent with a concussion using a traditional post-concussion symptom checklist, yet only 23% of the football players and 20% of the soccer players realized that they had suffered a concussion (Delaney, Lacroix, Gagne, & Antoniou, 2001; Delaney, Lacroix, Leclerc, & Johnston, 2000). Similarly, McCrea et al. reported that only 47.3% high school football players reported their injuries (McCrea, Hammeke, Olsen, Leo, & Guskiewicz, 2004).

Concussions are not limited to college and professional athletes. In a study of ice hockey, lacrosse, and field hockey, it was found that children aged 2–9 years sustained twice as many head and face injuries when compared to children aged 10–18. In ice hockey, bantam (13–14 years) and peewee (11–12 years) age players had a higher risk of concussion when compared to players aged 9–10 years old (Emery, Hagel, Decloe, & Carly, 2010; Emery & Meeuwisse, 2006).

Hootman, Dick, and Agel (2007) examined the frequency of concussion among college athletes using the NCAA Injury Surveillance System from 1988 through 2004. As can be seen in Table 4.2, concussions ranged from a low of 2% of game and practice injuries in women’s volleyball to a high of 18.3% of game and practice injuries in women’s ice hockey. It should be noted, however, that the data collected for women’s ice hockey only included a few seasons and may not accurately represent the true occurrence of injury in this group. Concussions accounted for 6% of injuries in football, 7.9% in men’s ice hockey, and 3.3% in wrestling.

Table 4.2 Concussion epidemiology across NCAA sports, 1988/1999–2003/2004
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Once an athlete has suffered a concussion, he or she is at risk for subsequent concussions. Studies have found that collegiate athletes are three times more likely to suffer a concussion if they had three or more previous concussions in a 7-year period and playing with two or more previous concussions required a longer time for total symptom resolution after subsequent injuries (Guskiewicz et al., 2003). Players also were at three times higher risk for subsequent concussion in the same season. Repeat concussion in the same season occurred within 10 days of the initial injury 92% of the time. Along the same lines, high school athletes with three or more concussions were at increased risk of experiencing loss of consciousness, anterograde amnesia, and confusion after subsequent concussion (Collins et al., 2002).

Cumulative Effects of Concussion

A key concern among parents, athletes, medical staffs, and sports organizations is whether there are long-term neurocognitive effects of concussions (Solomon, Ott, & Lovell, 2011). Although there has recently been intense focus on this question using a variety of assessment instruments, the findings are inconsistent. Some studies have found previously concussed athletes may take longer to recover when compared to athletes with no history of concussion (Iverson, Gaetz, Lovell, & Collins, 2004; Slobounov, Slobounov, Sebastianelli, Cao, & Newell, 2007). Others have found that athletes with a self-reported history of concussions may have persistent cognitive deficits when compared to those with no history of prior ­concussions (Collins et al., 1999; Iverson et al., 2004; Moser et al., 2007; Moser, Schatz, & Jordan, 2005; Wall et al., 2006). Yet other studies have found no significant neurocognitive effects in athletes with a history of multiple concussions (Broglio, Ferrara, Piland, Anderson, & Collie, 2006; Collie, McCrory, & Makdissi, 2006b; Iverson, Brooks, Lovell, & Collins, 2006; McCrory et al., 2005; Straume-Naesheim, Andersen, Dvorak, & Bahr, 2005).

Recently, Bruce and Echemendia (2009) examined whether the contradictory findings in the literature were due to the type of neuropsychological tests being used, i.e., traditional “paper and pencil” vs. computerized. The relationship between concussion history and neuropsychological test performance was examined on three different samples of athletes using traditional neuropsychological measures, a computer-­based neuropsychological battery (ImPACT), and both ImPACT and traditional testing. Multi-sport college athletes reported their history of concussions during preseason baseline testing, and then those athletes who had no history of concussion were compared with those who had one, two, and three or more concussions. No significant differences were found across concussion history groups irrespective of the type of neuropsychological test instrument used. The authors cautioned that these findings were based on relatively young athletes for whom long-term consequences may have not yet emerged.

Though receiving a great deal of attention in the media recently, chronic traumatic encephalopathy (CTE) was first identified in boxers and termed “dementia pugilistica” (Millspaugh, 1937). The disease was described as progressive deterioration in general cognitive functioning (attention, concentration, memory), executive functioning (impulsivity, poor insight, poor judgment), physical functioning (dizziness, impaired gait, Parkinsonian-like features), and psychological functioning (depression). McKee et al. (2009) elaborated on the characteristic features of CTE, specifically the immunocytochemical abnormalities of phosphorylated tau associated with the disease. In a review of 48 cases of neuropathologically verified CTE they found that CTE is “characterized by cerebral and medial temporal lobe atrophy, ventriculomegaly, enlarged cavum septum pellucidum, and extensive tau-immunoreactive pathology throughout the neocortex, medial temporal lobe, diencephalon, brainstem and spinal cord” (p. 732). They suggested a common pathogenesis of CTE and Alzheimer’s disease (AD) due to the presence of tau-­immunoreactive neurofibrillary tangles, neuropil neuritis, and β-amyloid in both conditions. McKee et al. (2009) speculated that TBI may interact with AD “to produce a mixed pathology with greater clinical impact or synergistically by promoting pathological cascades that result in either AD or CTE” (p. 732).

A recent comprehensive review of this literature concluded that many of the studies had significant methodological flaws and there was little consistency across studies, which made direct comparisons difficult if not impossible. The authors of the review concluded that long-term neurocognitive deficits due to concussion have only been empirically demonstrated among professional boxers (Solomon et al., 2011).

Taken together, the prospect for long-term neurocognitive impairment in athletes, due to either multiple concussions or repeated subconcussive blows or some combination of the two, presents a significant public health concern that must be studied intensively using well-designed and well-controlled prospective studies.

Assessment of Concussion

The assessment and management of sports-related concussion begins with an acute evaluation on the field followed by a sideline or locker room evaluation, a formal post-acute neurocognitive assessment, graded progression of physical exertion, and finally, unrestricted return to play (see Table 4.3 for return-to-play guidelines). Each step is designed to answer a different set of clinical questions for which different instruments and techniques need to be used.

Table 4.3 Return-to-play guidelines
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A sideline or on-field clinical examination of players is a critical first step. The primary goal of the acute “on-field” assessment is to identify any life-threatening conditions (e.g., developing intracranial bleeding) and to assess for the possibility of spinal cord injury. If an athlete’s symptoms are deteriorating, especially if there is deterioration to a stuporous, semicomatose, or comatose state of consciousness, the situation must be treated as a medical emergency, and emergency transport is required (Guskiewicz et al., 2009).

If the athlete is deemed medically stable but a concussion is suspected, then a comprehensive sideline assessment should be conducted. Such assessment includes a thorough history, observation of symptoms (signs), player report of symptoms, a careful assessment of the player’s recall of the events prior to and following the injury, and assessment of the cognitive and physical areas that are frequently affected by concussion, including tests of learning and memory, concentration, motor coordination, and cranial nerve functioning. Over the years there has been momentum towards using standardized, empirically derived brief screening tools to evaluate post-concussion signs and symptoms, cognitive functioning, and postural stability on the sidelines immediately after concussion (Barr & McCrea, 2001; McCrea, Kelly, Randolph, Cisler, & Berger, 2002). The Sport Concussion Assessment Tool 2 (SCAT2) is such a standardized method that can be used with athletes who are 10 years of age and older (McCrory et al., 2009). The SCAT2 contains the Glasgow Coma Scale, Standardized Assessment of Concussion (SAC, cognitive assessment), Maddocks questions, a sideline assessment of balance, and an examination of motor coordination. The SCAT2 has been adopted in various forms by a wide range of professional sports organizations (e.g., NHL, NFL, MLB). Brief measures such as the SCAT2 are useful for obtaining an initial assessment of cognitive functioning during the acute phase of the injury but are not a substitute for formal neuropsychological assessment, which is usually conducted in the subacute phase of recovery (Aubry et al., 2002; McCrea et al., 2009).

Neuropsychological Assessment

Neuropsychological evaluation has become an important component of the post-­injury or post-acute evaluation of a concussion. The current paradigm involves the use of pre-injury “baseline” testing, which is then compared to post-injury test data. A broad range of studies across several disciplines has now demonstrated that neuropsychological tests are useful in the identification of neurocognitive deficits following concussion (Echemendia, 2006; Echemendia et al., 2012; Moser et al., 2007).

As noted earlier, traditional neuropsychological test batteries consist of “paper and pencil” tests that usually require individualized face-to-face administration. The development of computerized test batteries created a paradigm shift for neuropsychological assessment in sports. These batteries allow for groups of athletes to be assessed using standardized, automated administration with immediate access to test results. Although each of these batteries is different in their composition and the number of functional domains that are assessed, all of these batteries allow for thorough assessment of simple and complex information processing speed, which has been shown to be a sensitive indicator of neurocognitive dysfunction post-injury. Computerized batteries are much more cost-efficient than their paper and pencil counterparts and have extended the use of neuropsychological measurement pre- and post-injury to a much larger number of athletes when compared to traditional batteries. Many studies have validated the use of these computerized test platforms (Bleiberg et al., 2004; Bleiberg, Garmoe, Halpern, Reeves, & Nadler, 1997; Collie, Darby, & Maruff, 2001; Collie, Makdissi, Maruff, Bennell, & McCrory, 2006a; Collie & Maruff, 2003; Collie et al., 2003; Collins et al., 2002, 2003; Covassin, Elbin, Kontos, & Larson, 2010a; Covassin, Elbin, & Nakayama, 2010b; Darby, Maruff, Collie, & McStephen, 2002; Echemendia, 2006; Erlanger et al., 2001; Guskiewicz et al., 2003; Iverson, Lovell, & Collins, 2005; Lovell, Collins, Iverson, Johnston, & Bradley, 2004).

Although computerized test batteries have significant advantages when compared to traditional testing, they are not without their drawbacks: (1) they currently do not fully assess memory functioning because they are only capable of examining recognition memory, (2) they minimize the interaction between the athlete and the neuropsychologist thereby reducing qualitative observations of performance, (3) effort and motivation are less effectively assessed and managed using group administration formats, and (4) they limit the ability to examine the process by which injured athletes solve problems and learn and remember information, which has been shown to be useful in the assessment of athletes with a concussion. These computer programs also introduce complex instrumentation error as scores may differ due to differences in timing accuracy across computer platforms, whether the test is administered via the Internet, the speed of the computer’s processor, the type of mouse being used, and so on.

A “hybrid” model has been developed that takes advantage of the strengths of both the paper and pencil tests and the computerized tests while minimizing their weaknesses (Echemendia, 2010). This hybrid approach has been adopted in the NHL and MLS as well as the US Soccer Federation and several universities. Typically, a computerized assessment is given at baseline and a battery consisting of paper and pencil tests and the computerized test is administered post-injury. This hybrid approach uses both intraindividual (baseline to post-injury) comparisons and interindividual (post-injury to normative data) comparisons. This approach has promise of yielding more accurate assessment of post-injury neurocognitive functioning than either method alone (Allen & Gfeller, 2011; Maerlender et al., 2010; Schatz & Putz, 2006).

Although there has been considerable excitement regarding the use of neuropsychological tests in the evaluation of sports-related concussion, there are also those who have been critical of the field (Kirkwood, Randolph, & Yeates, 2009; Randolph & Kirkwood, 2009; Randolph, McCrea, & Barr, 2005). The criticisms set forth areas that are in need of further research and questions that need to be answered more completely. One area of concern is the widespread use of baseline testing. Although widely adopted, there are no studies that have established whether baseline testing adds greater precision to the detection of post-injury cognitive deficits when compared to post-injury evaluations alone (Echemendia, 2010). Although the use of baseline testing appears attractive and even logical, it does not come without costs because it introduces significant complexity into the interpretation of post-­injury test data. Specifically, not only is there error surrounding the post-injury tests, there is also error around the baseline tests as well as the error associated with comparing tests at two different time intervals, particularly in light of poor temporal stability found among some of these tests (Barr, 2003; Broglio, Macciocchi, & Ferrara, 2007; Mayers & Redick, 2012; Schatz, 2010).

The widespread use of computerized testing has created the perception that little or no formal training is needed to administer and interpret these tests, which leads to the basic question, “Who should administer and interpret neuropsychological tests?” Many programs, perhaps most programs, have adopted a model where tests are administered and interpreted without consultation of a qualified neuropsychologist. The CISG (McCrory et al., 2009) concluded, “Neuropsychologists are in the best position to interpret neuropsychological tests by virtue of their background and training.” Echemendia, Herring, and Bailes (2009) examined this question at length and concluded, “The interpretation of neuropsychological tests requires comprehensive knowledge of the tests, their characteristics given a specific population (for example, team, sport), the athlete and his or her specific situation, psychological variables, and many others. For these reasons we conclude that neuropsychological tests may be administered under the guidance of a neuropsychologist but that the interpretation of neuropsychological test data is best managed by a clinical neuropsychologist.”

Prevention Strategies

Given the frequency that sports-related concussions occur at all levels of play and across all age groups, it would seem to be important to attempt to prevent these injuries as much as possible. Unfortunately, the prevention of sports-related concussions is complicated by a number of factors. First, concussions are acceleration/deceleration injuries caused by forces applied to the body. Consequently, athletes playing any contact or collision sport are inherently at risk for concussion due to the contact forces involved in the game. Even sports not traditionally viewed as contact or collision sports are at risk. For example, cheerleading has a very high rate of concussions due to the use of “pyramids” with “flyers” and the “bases” that catch them (or fail to). Removing concussions from these sports would require fundamental and dramatic changes to the sport. Although concussions may not be eliminated from these sports, it is possible to reduce the number of concussions that occur and to improve the management of the injury in order to lessen any possible long-term neurocognitive and psychological consequences.

A key focus on prevention has come in the form of education. Effective concussion education programs require a multifaceted approach that provides education to players, their families, coaches, game officials, league officials, teachers, school officials, and governmental bodies. These educational approaches may take many forms ranging from formal educational forums such as seminars and lectures, print media, video recordings, television programs, public service announcements, and congressional hearings. A wide range of individuals including medical experts, clinicians, and organization officials can deliver the message of prevention. Perhaps the most effective “messengers” are the players themselves. It can be very moving and persuasive to hear a 15-year-old describe his or her struggle with post-­concussion symptoms. Similarly, hearing from a professional sports idol, who has dealt with concussion and its aftermath, that young players must learn to identify their symptoms, report them, and be removed quickly from play can help motivate a young athlete to “sit it out” when in doubt.

Importantly, successful education prevention programs are increasingly available. Table 4.4 indicates various Internet-based resources in this regard. For example, the CDC have taken a leadership role by developing and disseminating materials at no cost through their website and other venues. The materials include “Heads Up Concussion” kits for coaches, parents, schools, physicians, nurses, and athletes of all ages. The materials are generally available in both English and Spanish. Professional sports leagues as well as national sports organizing bodies have also provided important information. For example, the National Football League has launched a detailed education website as have several youth sports organizations such as USA Hockey, US Soccer Federation, and US Lacrosse. Concussion awareness programs have also led to cooperative arrangements among several organizations to provide public education. As one example, the National Academy of Neuropsychology joined forces with the National Athletic Trainers’ Association to produce sports-specific educational videos for the National Hockey League and NHL Players’ Association and the National Football League. These videos are available for free as downloads. At the college level the National Collegiate Athletic Association (NCAA) has taken an active role in educating their member schools, players, and coaches through the development of comprehensive concussion evaluation and management model strategies and programs, print and media educational materials, as well as nationally broadcast webinars/podcasts.

Table 4.4 Online concussion-related resources
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Legislative Agenda

A crucial component to enhancing prevention methods for youth athletes has been the introduction and passage of concussion awareness legislation at the state level. Modeled after the Zackery Lystedt legislation that was signed into law in Washington State, these legislative efforts have largely contained three primary provisions:

  1. 1.

    Education of parents, athletes, coaches, and school officials about the signs and symptoms of concussion as well as appropriate evaluation and management techniques.

  2. 2.

    Immediate removal from play if a concussion is suspected.

  3. 3.

    Player cannot return to play unless cleared in writing by an appropriately trained health professional.

At the time of this writing, 38 states plus the District of Columbia have concussion laws in place. Several states have laws that are pending or working their way through legislative bodies.

Protective Equipment

There has been a significant amount of attention focused on the role of protective equipment in the prevention of sports-related concussion. Although advances have been made in the technology of protective equipment, most experts in the field have concluded that there is no reliable research to demonstrate that protective equipment reduces the rate of concussions (McCrory et al., 2009). For example, one of the most studied and technologically advanced items of protective equipment is the football helmet. The modern football helmet was designed to protect against skull fracture and not concussion. Indeed, the standards under which these helmets are tested were developed in the 1970s and have not changed much since that time. In a review of the literature, McIntosh and McCrory (2005) conclude, “Helmets and other devices have been shown to reduce the risk of serious head and facial injury, but current designs appear to make little difference to concussion” (p. 317). Mouth guards have also received a fair amount of attention with similar conclusions. Although mouth guards are very good at protecting against dental injury, there is little evidence that they reduce the rate of concussions (Daneshvar et al., 2011; Winters, 2001).

Rule Changes/Enhanced Monitoring

One of the most obvious areas for the prevention of sports concussion is the proper enforcement of the rules of the game. Often, concussions occur because of overly aggressive play, poor technique, improper coaching, or inappropriate calls from parents or spectators to play more aggressively. Vigilant officiating and willingness on the part of game officials to enforce the rules of the game will go a long way towards taking control of a game and preventing unnecessary injury. A novel and effective approach called “Fair Play” has been used to effectively curb violence in youth hockey. This program rewards teams and individual players with fewer penalties and punishes those with high penalties. The Fair Play points are included in the compilation of team standings. Teams that were not awarded Fair Play points found themselves at the bottom of the standings at the end of this season. Introduction of this novel approach has led to a decrease in fights, penalty minutes, and subsequently injuries (Roberts, Brust, Leonard, & Herbert, 1996).

In addition to enforcing those rules that are already in the rule books, additional modifications can be made to the game by the creation of new rules or the modification of techniques. In professional ice hockey, the NHL introduced rule 48 during the 2011 season. This rule was put in place in order to protect players from blindside hits to the head such that they were unable to protect themselves from the oncoming blow. The introduction of this rule led to a reduction in the number of concussions occurring from blindside hits. At the youth level, several hockey organizations have moved towards increasing the age at which body checking is allowed, i.e., 14 years of age. Towards this end, excellent approaches have been taken in youth hockey by ThinkFirst Canada Foundation. In soccer, some programs have reduced the amount of time spent in “heading” practice and/or have minimized the role of heading until players are older. In football, modifications are being made to practice schedules, the type of hitting that occurs in practices, the number of hits that a lineman can sustain in a practice or game, and the elimination of the three-point stance.

Conclusion

Sports provide a powerful and important framework for physical, emotional, and psychological development. They also provide a mechanism by which injuries occur. An all too common injury in sports is a concussion: a brain injury that can lead to serious long-term neurocognitive deficits if not evaluated and managed appropriately. Identifying and treating concussions correctly is a significant challenge for the sports medicine team. What is not complex is the very basic message that can help to prevent negative consequences: If a player is suspected of having a concussion, remove them from play! There should be no equivocating, particularly with youth athletes. Once they are removed from play they are not to return to competition until they are symptom free at rest, symptom free upon exertion, have returned to baseline neurocognitive functioning, and have been cleared by a health care professional trained in the evaluation and management of concussion.

The key to prevention is the education of all of the stakeholders: parents, players, coaches, game officials, league officials, school administrators, medical personnel, and legislators. Included in this message of prevention is an attempt to change the culture of some sports from the glorification of aggression to valuing respect for other players and the institution of Fair Play policies, from “playing through pain” to “when in doubt, sit out!” It is through this process of education and culture change that we will most effectively improve the cognitive health and safety at all levels of play and across all age groups.