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From PEKN 1P93 Winter 2014: Group 17: Cognitive Development
 Physical Activity and Cognitive Development: Concussions
A concussion is an injury that occurs after an individual sustains a severe blow to the head, often causing a temporary loss of consciousness. This is the result of the brain slamming against the skull, with such force that the cerebrospinal fluid cannot successfully cushion the impact. The concussion usually occurs at the opposite side of the brain from where the impact occurred because when the brain experiences contact with the skull, it causes shock waves to radiate throughout the rest of the brain. Immediate symptoms following a concussion include, but are not limited to, loss of consciousness, amnesia, confusion, nausea, "ringing" in the ears, and convulsions. Concussions are commonly referred to as Mild Traumatic Brian Injuries (MTBI's). Long-term effects can include a decrease in memory retention, difficulty sleeping, irritability, headaches, difficulty concentrating (The Concussion Blog). The risk of obtaining a concussion increases successively with each one. Undergoing a first concussion, lowers the threshold for a second one to occur. This is often referred to as 'Seconds Impact Syndrome'. Studies have proven that individuals who have underwent cumulative concussions, were able to process information at a slower rate than individuals who had only sustained a single concussion (Iverson, et al.). Also, individuals with cumulative concussions, were significantly more delayed than those individuals who had avoided concussions all together (Iverson). For this reason, it is highly important to avoid concussions, especially with individuals, such as developing adolescents. With high intensity contact sports increasing in popularity (hockey, lacrosse, football etc.), concussions in athletes at a young age are also increasing. This is especially alarming, considering children are still at an early stage in terms of cognitive development, making the detrimental effects of brain injury more devastating than in an adult.
The history of concussions occurring in sport began in the Ancient Greek and Roman times, when sport was first evolving. The first known accounts of organized athletics date back to 776 BCE, significantly determined as being the year the internationally known sports competition, called the Olympics, formulated. However, there is evidence that ball sports existed before that period, allowing for the possibility of concussions to have occurred at an earlier date. Athletes during this period took part in many vigorous contact sports, such as wrestling and fist fighting (which later evolved to being presently known as the sport of boxing). These contact sports were meant to encourage injuring the other opponent, often the target area being the head, in order to be claimed the winner. At one point, the Romans even altered the proper attire of hand wrap that the boxers wore. The Roman fighters would insert metal pieces into their wrap in order to maximize the damage caused by their punch. It can be acknowledged today, that in boxing, boxers are mostly taught to punch towards the head and face area of opponents. During this time period, the risk and dangers that men experienced was significantly detrimental due to their lack of knowledge pertaining to head injuries, such as concussions. Evidential proof discovered in the form of historical art displayed on poetry and vases, portrays that the boxers would suffer severe blows to the head, and die shortly after. This represents their inability to diagnosis substantial injuries inside the head, as the only tool possessed was by simple observation. Also, little has changed since the ancient days to present, in the sport of fist fighting. With 87% of the fighters having been known to suffer a concussion at some point in their career, head injuries and cognitive development disruptions have always been commonly known to cause a detrimental impact on athletes.
Following the Ancient Greek and Roman period, a new era, called the Middle Ages, was developed. This transition of time periods initiated many changes towards the types of games that were being played. The Middle Ages were centered around games associated to war, such as jousting, fighting, and simulated duels (Salmon, 2007). While they did develop helmets to better protect athletes during times of combat and jousts, there was still an extreme amount of mild to severe brain injuries, specifically concussions, that occurred. Following this, a movement towards better identifying what a concussion is and how it can affect an individual was pursued. In the 14th century, clinicians began trying to asses concussions and reported, "the acute symptoms of concussion were described by clinicians and included the 'faltering of speech, impairing of memory, dullness of understanding and a weak judgement'" (McCrory & Berkovic, 2001). Doctors began to understand what the possible symptoms for concussions were and what they were. This enforced and encouraged the understanding and discovery of the consequences that the clinicians learnt, also could derive.
Following this time period, the "Age of Enlightenment," set in the 18th century, began. During the early part of the century, scientists began to further explore the pathophysiological mechanisms of concussions (Salmon, 2007). Clinicians proposed many different hypotheses for why concussions occurred. Some of these hypotheses involved the possibility of causes of concussions being acute compressive anemia, spinal concussion, circulatory failure, molecular vibrations, and nerve cell shock (Wrightson, 2000). They also suggested that the extreme force of a concussion could damage nerve filaments within an individual's head. This led them to propose that concussions resulted from diffuse axonal injuries, resulting in permanent brain damage (Gasquoine, 1998), and the process led to various cascades of events occurring in the metabolic levels of brain cells (Giza & Hovda, 2001). These substantial discoveries signified the detrimental effects an athlete suffering from a concussion can potentially possess.
The 19th century was a very significant era for the evolution of athletics, making it equally as significant for acknowledging the impact of injuries to the head. Not only did the Olympic games get reinstituted, but the development of a very physical game that would account for a significant amount of concussion injuries in the future, became evident. The game was called football, and allowed for athletes to tackle each other. This reinforced the potential risk of athletes being vulnerable to suffer injuries to the head. With the start of football deriving from the 19th century, the development of helmets followed, in the 20th century. However, when considering the poor construction of helmets, and the constant physical impacts enforced throughout the game, helmets weren't particularly effective in protecting athletes from concussions (Cantu & Mueller, 2003). On October 9, 1905, in the middle of the season, President Theodore Roosevelt met with representatives from colleges such as Princeton, Harvard, and Yale, to discuss solutions towards reducing the risk of injuries, in an effort to save the sport (Salmon, 2007). This led to the formation of the NCAA, initiating the outlawing of various rules in several sports in order to protect the athletes from serious head injuries, such as concussions. Unfortunately, even with all these changes, between the years of 1931 and 1975, there was an average of 18.9 fatal injuries per year, for all levels of play (Cantu & Mueller, 2003). With the prevalence of the fatalities in the sport of football, the need for better protection for the athlete's head and more importantly organs, such as the brain, became a prominently known issue (Salmon, 2007). The development of plastic shell helmets in the 1940s was the first attempt at resolving the problem in sport and later, in the early 1950s, face masks were introduced. The National Operating Committee on Standards for Athletic Equipment (NOCSAE) was founded in 1969 in order to make competitive sports as injury free as possible. They committed to monitoring sports with special emphasis towards making equipment strong enough to protect athletes' head and brain (Pellman, Viano, Tucker, Casson & Waeckerle, 2003). NOCSAE began a new standard for the impact performance of football helmets in 1973. This led to a significant reduction in injuries as it was determined that between 1973 and 1980, youth football experienced a 51% reduction in fatal head injuries, a 35% reduction in concussions, and a 65% reduction in cranial fractures (Pellman et al., 2003). This has led to a dramatic decline in brain-related injuries amongst football players since 1975.
The 1990s, also considered the decade of the brain, brought major attention to concussions in soccer, ice hockey, U.S. football and rugby at all levels of play. Team physicians, neuropsychologists and athletic trainers were now crucial for assessing the severity of the concussion. This process pursued evaluating the immediate and long term effects, and developing valid return-to-play criteria, in order to protect athletes from further injuring themselves (Salmon, 2007). Levels of concussions were developed during this time as well. It began by the formulation of classification described as mild, moderate or severe concussions. There became a noticeable emphasis on the long-term effects of concussions, known as the 'post concussion syndrome.' These effects are composed of a variety of symptoms, such as cognitive impairments (poor concentration and attention, complex thought, memory impairments), somatic complaints (blurred vision, headache, impaired balance, sleep disturbance), and behavioural changes (emotional liability, depression, irritability). Often, patients will experience an array of these various symptoms (Benton, 1987; Wrightson, 2000). During the late 1990s, researchers developed various computer programs, specifically designed for assessing sports-related concussions (Salmon, 2007). This shortened the time it took to assess possible concussion symptoms and allowed doctors and trainers to begin treating the patient much sooner.
During present day (21st century), we face the reality of the lack of diagnosis of concussions occurring. For example, incident rates for concussions that have occurred in athletics, have generally been reported as 5-10% annually (Salmon, 2007). However, anyone who has been involved in sports is aware that this number is drastically higher. When athletes are asked if they've ever suffered from symptoms indicating a potential concussion, the incident rate proves to portray up to 70% (Salmon, 2007). It can be declared that one of the major issues in sport today is the fact that athletes are proceeding to play with a concussion and not obtaining proper medical treatment. Doctors have found that a sports-related concussion can bring on a series of personal, medical, neuropsychological and competitive problems. Neuropsychologists now believe that concussions occurring in sport, result in the shearing of axons and biochemical changes that often occur in the frontotemporal regions, as well as the subcortical (Zillmer & Spiers, 2001). While scientists, doctors, and neuropsychologists have come a long way in identifying and treating concussions in sport, there is still a major problem associated with them. Competitive sports have been increasing at such a rapid rate, that sports injuries now rank as second highest, behind motor vehicle accidents (MVA's), in percentage pertaining to the cause of brain injuries per year. It has been reported that approximately 1.3 million people suffer from some sort of mild traumatic brain injury per year in the United States alone (Salmon, 2007). With the participation in competitive sports increasing, concussions continue to become evidentially known as a severe health risk, especially with those participating in sport at a young age.
 Target Audience
Although almost everyone is susceptible to obtaining a concussion, not everyone knows the proper steps to pursue, when symptoms of a concussion occur. The proper process for the recovery of a concussion is not a common topic known throughout the population, even though it is a very serious issue. This lack of knowledge is not due to limited information, but rather towards the fact that individuals do not take on the self-inititive to seek out and discover this information for themselves. Information regarding the appropriate treatment methods for those suffering from a concussion, or ways to prevent a concussion, is readily available, but has received minimal promotion and support to allow it to be easily accessible to the public without the requirement of it being self-inititivly driven activity. It is because of this, that the target audience is athletic coaches and individuals of authority, such as teachers. Through targeting the largest influences pertaining to all sports, coaches and individuals of authority, can initiate significant change in the way their athletes develop their performance and overall long-term success in sport.
Instead of targeting individuals who lack the motivation to teach themselves, it is in the best interest of all people, to target people of influence and ability to promote change; athletic coaches and teachers. These individuals have the motivation to learn these topics, for the better of their athletes, to in turn, be able to teach and motivate those that they supervise. Athletic coaches can use information about concussion awareness, prevention, and treatment to implement it into their sport practices. This will allow them to be able to help promote and support the healthy recovery of the athletes' cognitive development, when diagnosed with a concussion. Coaches and teachers can also motivate, encourage and even teach students and athletes to seek this information and learn more about concussion awareness, on their own. If these authority figures teach their students these practices, the younger generations will grow up with the knowledge to increase the awareness of prevention and decrease the risk of obtaining a concussion. It will be assumed that as the awareness increases, in future years, a greater portion of the population will have access to this knowledge. If these topics are taught to younger generations, then surely the number of concussions can be reduced along with the rate of recovery, while still ensuring that the athletes receive efficient and proper recovery for their cognitive development and overall health.
Silverberg and Iverson preformed a review of the literature when it comes to rest and its impact on concussion recovery. They determined that:
- Complete bed rest with no cognitive activity has not been proven to either help, nor hinder, MTBI recovery. In regards to research done focusing on this type of complete rest, along with other medical conditions, demonstrates that after as few as three days, negative psychological consequences begin to occur. In addition to these consequences, it has been shown that complete rest beyond one or two days is not helpful, and even potentially harmful.
- Whether symptomatic or not, an athlete returning to play within a week of suffering from a concussion, increases the risk of the athlete obtaining a second concussion. This discovery is also commonly known as the 'second impact syndrome' (Silverberg & Iverson, 2013).
- Within two weeks of the initial concussion, vigorous activity has been shown in several people, to delay their overall recovery time. (Silverberg & Iverson, 2013)
- Within the first few days of suffering from an injury, a gradual return to noncontact physical activity, as tolerated by the body, has been proven more likely to speed up than slow down the total time it takes to make a full recovery. (Silverberg & Iverson, 2013)
- Comorbid conditions to a MTBI cervical soft tissue injury and vesicular disorders have been proven to have success in recovery facilitated by physical mobilization. (Silverberg & Iverson, 2013)
- The likelihood of depression and anxiety occurring after a MTBI can be greatly reduced by engagement in activities valued by the person, including physical activity for athletes. (Silverberg & Iverson, 2013)
- While cognitive and/or physical exertion can potentially aggravate symptoms anywhere along the path to recovery, it has not been determined whether to possess any significant influence towards any long-term functional or neuropathlogical consequences. (Silverberg & Iverson, 2013)
These findings by Silverberg and Iverson have been significant in increasing the awareness pertaining to the severity of concussions occurring in young athletes. These statistical facts prove to promote the complexity and importance of concussions and their association with physical activity.
“Chronic Traumatic Encephalopathy (CTE) is a progressive degenerative disease of the brain found in athletes (and others) with a history of repetitive brain trauma, including symptomatic concussions as well as asymptomatic sub concussive hits to the head” (BU CTE Center). These impacts trigger degeneration of the brain progressively over time. This degeneration can include an increase in tau protein, a protein which is abnormal in the brain, influencing its loss of ability (BU CTE Center). “Everyone diagnosed with CTE upon autopsy (now over 100 cases) received extraordinary brain trauma / There are no reported cases of CTE pathology in individuals who did not receive abnormal and excessive repetitive brain trauma” (Cantu & Nowinski, 2012). CTE is associated with a variety of symptoms including “The brain degeneration is associated with memory loss, confusion, impaired judgment, impulse control problems, aggression, depression, and, eventually, progressive dementia” (BU CTE Center). The condition has reached the media of late, involving suicides of relatively young former athletes who undergo personality changes and suffer from depression. The disease has been shown to be very similar to Alzheimer’s disease when analyzing the effects it has on the brain. The similarity of the two medical impairments, have been determined through various methods of research to possess additive effects on the body (McKee, et al., 2009). McKee et al. also states that, “in athletes, by instituting and following proper guidelines for return to play after a concussion or mild traumatic brain injury, it is possible that the frequency of sports-related CTE could be dramatically reduced or perhaps, entirely prevented.”.
Concussions in youth sports, is especially of concern because, “young brain is more vulnerable to trauma than the mature brain,” which is likely due to the fact that, “the young athlete is at biomechanical disadvantages … as their head reaches 90% of full size by age 5, yet their body is only 20% of adult mass” (Cantu & Nowinski, 2012). The anatomical difference of adolescence compared to adults, is a prominent cause of increased potential in young athletes suffering from concussions. The scientific research proving the importance of achieving optimal health as an adult, is through proper growth and development. The influences associated with concussions on young athletes proves to thus be a severe and reoccurring issue in the world of sport.
Traditional protective equipment, such as facegaurds, mouth mouthguards, and other facial protection, have been analyzed to see if their absence or presence on an athlete influences their concussion rates. Benson et al. states that, “there is scientific evidence that full facial protection in ice hockey may protect athletes from more severe concussions, as measured by time loss from competition. Such findings justify the use of mouth guards and facial protection in collision sports as a means to reduce injuries, but at this time cannot be advocated specifically for concussion risk reduction” (Benson, et al., 2009). This once again proves to be a significant discovery to signify the struggle with controlling the increasing rate of individuals diagnosed with a concussion. Certain equipment has been designed to help reduce the risk of getting a concussion, however, there has been no method developed to fully prevent a concussion from occurring without altering their performance in sport.
Headers in the sport of soccer have been scrutantized for their impact on causing concussions for athletes. However, it has been demonstrated that heading the ball is the “least common cause of soccer concussions” (Rudnik, 2013). Rudnik states that, “there is now also evidence [which can be seen here that shows that while intentionally heading of a soccer ball may not cause a concussion, the repetition of heading a ball may lead to concussion-like damage of brain cells. Researchers at Albert Einstein College of Medicine believe that the threshold for having evidence of brain damage appears to be between 1,000 and 1,500 headers per year—only a few headers per day” (Rudnik, 2013). Headgears may be worn by players to attempt to reduce the impact of these blows, and has been proven to do just that (Broglio, et al., 2003). Studies undertaken on soccer players (aged 12-17) have shown that players wearing headgear had a concussion rate over the course of the season of 26.9, which rose to 52.8 percent for those who did not wear any headgear (Delaney,et al., 2008). Once again, equipment has been an essential factor in helping to reduce the risk of obtaining a concussion. However it must be taken into consideration that it cannot be guaranteed that every athlete will commit to wearing, or even have accessibility to such apparel. Attempts to prevent concussions are effective, yet do not represent a complete solution to the issue of ensuring optimal health in young athletes.
 Existing Physical Activity Programs
One main return to play program that has become established by medical personal and athletic programs, is one that is promoted by thinkfirst.ca. To view this document, click on here. After the initial period of rest, the program is designed by incorporating light exercise routines that are formulated based on the athletes' ability and reaction to the physical movements. This is pursued routinely until the concussed person is cleared by a medical professional and able to return to play (Thinkfirst.ca). If at any point during this period of increasing physical activity, symptoms return, the concussed person must proceed to the initial resting period of concussion recovery. These steps in the process of recovery is to be monitored by a sports injury doctor at least once, preferably multiple times, throughout the recovery procedure (Thinkfirst.ca). This system has also been adapted from the Consensus statement on concussion in sport: the 3rd international conference on concussion in sport held in Zurich, November 2008 for the graduated increase is physical activity (McCrory, Meeuwisse, Johnston, Dvorak, Aubry, Molloy & Cantu, 2009) as the monitoring system for the recovery of an athlete suffering from a concussion. This program incorporates physical activity as a guideline, to determine an individual athlete's appropriate plan and procedure they must pursue to achieve a successful recovery. This program is commonly known, currently in the sporting community, used by many programs and sports institutions, such as Brock University Varsity Sports (Kenny, J., Clinic, Jan.20, 2014).
The NFL has established a distinct protocol for its players and teams to use when dealing with concussions. The document can be seen  here. The NFL protocol uses the SCAT3 (Standardized Concussion Assessment Tool), proposed by the international Concussion in Sport Group (NFL). This tool is tested on every player to determine a baseline score. This score is then compared to the results of the test when a concussion is suspected. A player must meet their baseline score to be cleared from having a concussion and free to return to play. If they score lower than their baseline score, then the player is diagnosed with a concussion and must follow NFL protocol for recovery in order to be able to return to play (NFL). These tests are recommended by the NFL to be serial (for example every 20 min for an hour,) to allow for a concussion that displays symptoms that cannot immediately be identified. Team officials are dedicated to officially diagnose concussions in NFL (NFL). However, an unaffiliated Neurotrama Consultant is assigned to every team to be prepared at the sideline for every game played. This unidentified Neurotrama Consultant’s job is committed to identify a potentially concussed player, and to help administer the NFL SCAT test on these possibly concussed players (NFL). A ‘Booth ATC’ is an athletic therapist in the booth of each game to watch video replays of possible injuries and provide any information which might help assessment, treatment, or recovery from an injury, including concussions. Any player diagnosed with a concussion must be taken to the locker room for the remainder of the game and is not allowed to speak with the media until he is cleared for return to play and fully recovered (NFL). This is mandatory in order to provide and allow the athlete to receive a measure of cognitive rest. This allows for the player to have less distractions in this environment and prevent initiation of stress caused by the worry associated to speaking with the media. Return to play procedure for the NFL must be followed by every team, for every player (NFL). First, a player must rest until they return to their baseline level of achievement on the NFL SCAT test. Once this is achieved a player may begin a graduated exercise, similar to the thinkfirst.ca system found here. The player must then be evaluated and cleared by both the team doctor and Independent Neurological Consultant. If it is professionally diagnosed and determined that they have passed the return to play guidelines, the are now concussion free and free to continue playing (NFL).
The NHL, similarly to the NFL, has a concussion protocol in place for its teams and players. The document can be seen here. If an athlete is suspected of having a concussion in the NHL, they must be removed from play until they are symptom free. They have to prove to show full recovery of symptoms, both during strenuous activity and at rest, as well as their test results must portray their normal cognitive baselines (NHL, 2010). The NHL has no standardized test for rink-side evaluations during gameplay, but recommendations involve using the SCAT2. This demands for baseline tests to be mandatory for all athletes within the NHL for the SCAT2 test to be most efficient and successful amongst athletes (NHL, 2010). After a player is symptom-free, during exertion and at rest, they are referred to the team neuropsychologist who will administer the imPACT test to determine if they have re-established their baseline score (NHL, 2010). The return to play decision is solely determined by the team physician, under regulations of policy set by the NHL.
Sports Legacy Institute (SLI) has launched the Hit Count Initiative as of February 2012 (Nowinski, 2013). The goal of this initiative program is to reduce the number of blows to the head taken by athletes in youth sports (Sports Legacy Institute, 2013). Some of the main concerns giving rise to the program can be seen in their infograph here. The concerns outlined in the info-graph are regarding the high number of hits taken by youth players in soccer and football in the USA. This hit count occurs with the use of sensors to detect impacts at a threshold of 20g’s. This level is high enough to not capture any normal activity movements, but instead targets impacts low enough to be triggered by any blows that would cause a typical concussion (Cantu, Giola, Guskiewicz, Hoshizaki, Hovda, McKee, Nowinski, Meehan & Sarmiento, 2013). These hits would include sub-concussive blows. Sub-concussive blows, impacts that report to have detection of any clinical concussion symptoms, have “evidence [that] is accumulating that sub-concussive impacts, … may still be damaging to the brain, both in the short- and long-term” (Cantu & Nowinski, 2012). Players who suffer these blows “…still had functional MRI changes that mimicked concussion players” (Cantu & Nowinski, 2012). “Hit Count® is also incorporated into the SLI Advanced Concussion Training (ACT) program” (Sports Legacy Institute, 2013). ACTS can be held upon invitation anywhere in North America (Sports Legacy Institute, 2013). This program is a training program developed for “coaches, parents, administrators, health professionals, athletes, and concerned citizens” so they can be properly informed and aware of concussions and their consequences (Sports Legacy Institute, 2013). The curriculum of the ACTS inlcude: basics, recognition, response, return to play, return to school, technologies, and CTE (Sports Legacy Institute, 2013).
Testing using a variety a sensor systems and helmet variables has been undertaken in the football community as an attempt to reduce concussion rates. “College football programs at Virginia Tech, Dartmouth, Brown, North Carolina, and Oklahoma have started using the Head Impact Telemetry System. This program on average costs around $50,000 to $60,000. "For high school and college programs, this system can make a significant difference, especially if the school’s authorities choose to tackle the tricky question of how many severe hits are too many for a player” (Nowinski, 2013). This Head Impact Telemetry System (HITS) is used to sensor the impact of hits, identifying their potential to be concussive. A study was undertaken at Virginia Tech, under the direction of Stephan Duma, to rank the best available football helmets for concussion prevention, including processes determining which helmets they would not recommend for purchase (Nystrom, 2011). This test was performed in 2011. Since 2011, the technology by helmet producers has developed and improved (to see some examples please see the external links section of this page). The differences in helmet construction, can provide a largely reduced concussion rate amongst athletes. A study comparing two differently constructed helmets has proven to reduce potential rate of concussions by 54% (hokiesports.com, 2014). As helmet technology continues to advance, the new helmets should be accepted and put into use by programs around the world to help provide these potential reductions immediately to ensure increased safety for involved athletes.
A partnership between 5 major Canadian sport institutions has led to the creation of a program aimed to increase education and awareness about concussions across the country. “The Canadian Football League [CFL], CFL players Association, CFL Alumni Association, Football Canada, Canadian Interuniversity Sport [CIS] and the Canadian School Sport Federation” (Masters, 2011) teamed together to create and distribute (electronically and on paper) “‘concussion flyers and posters’”. These flyers and posters will be sent to 52 universities, 3,200 high schools and more than 100,000 minor football players (Masters, 2011). The goal of the project is for these posters to be distributed in athletic facilities of the institutions and easily accessible to every player and parent of football across Canada. This document includes sections for: “(1) Signs and symptoms, (2) Management and rehabilitation, (3) Guidelines for coaches, players, parents and officials, and (4) Steps to be followed before returning to play” (Masters, 2011). The formation of powerful programs is a positive step in promoting the serious consequences associated with concussions in the world of youth sport. Through promotion and education, these designed programs can enforce the severity of concussions and their resulting effects on the cognitive development in adolescents.
 Best Practice Activity Suggestions
Exercises formulated to strengthen the neck muscles are valuable in preventing concussions. Eckner has determined that, “in male and female athletes across the age spectrum, greater neck strength and anticipatory cervical muscle activation (“bracing for impact”) can reduce the magnitude of the head’s kinematic response” (Eckner, Oh, Joshi, Richardson & Ashton-Miller , 2014). The neck moves in six directions: tilt left, tilt right, rotate right, rotate left, extension and flexion, which can be seen in this video: A difference in neck muscles' strength can be noted between genetically different make-up of sexes. Gessel et al., stated that, “females had 26% less total mass in their head and neck than males. [And that] …females demonstrated greater angular acceleration and displacement of the head and neck,” during impact (Gessel, Fields, Collins, Dick & Comstock, 2007). The relationship between neck muscle strength, its genetically determined structure and the effects it has on the likeliness of vulnerability towards concussions, would suggest that females are more likely to suffer a concussion when receiving an equal amount of physical impact to that of a male athlete. See the external links section of this page for links to some of the many potential neck strengthening and stretching activities you can perform. One way to reduce concussions in young athletes is through the use of tracking hit counts. Hit counts can be used in the same manner as pitch counts, portraying to be widely implemented. These counts are used to limit the amount of impact on the children’s bodies. The impact of hit count prevention methods can lessen the prevalence of concussions in contact sports (like football, hockey etc.) the same way that pitch counts lessen ulnar collateral ligament “wear and tear” (Nowinski, 2013). Youth sport typically employs more contact practices than their respective pro leagues, when considering that athletes such as NFL players, only practice with pads, one day per week. The majority of youth sporting leagues place no such limits on their teams. Those which do expose their players to much less potentially concussive hits, prove to equate to about only one half (Nowinski, 2013). By reducing the amount of hits a player can take, can limit the likelihood of a concussion occurring and overall, positively encourage the success in the prevention of concussions for young athletes.
The incorporation of physical contact introduced in youth sports would be raised to a post pubescent age. Age limits in many youth organizations have already been raised to a higher age so that children and young athlete bodies are more fully developed before they undergo potentially concussive hits (Nowinski, 2013). Some leagues have even extended the minimal age for physical contact occurring, past the ‘normal’ biological maturity to allow the body to develop before these impacts can occur. The higher the age where these contacts can first occur, decrease the amount of time for, and risk of, a MTBI occurring in the young athlete (Nowinski, 2013).
According to Nowinski (2013), “sensors in helmets, headbands, skullcaps, mouthpieces, and chinstraps will soon become widely available and inexpensive." These sensors have been able to identify and assess the potential concussive blow an athlete can experience, in order to optimize proper analytical procedure for a physician. These technologies reduce the potential likelihood of suffering from a concussion and prove to be successful, considering that athletes wearing the sensor will have greater opportunity to receive faster results of diagnosis. Many teams, programs, and leagues have already attempted to start implementation of these devices when monetarily feasible. One example is the University of Arkansas’s football program, which has introduced a new helmet by Riddell, specifically designed to help reduce the risk of concussions amongst their players (Leigh, 2014). You can see the helmet here. For other examples pertaining to concussion reducing equipment, such as helmets, see the external links section of this page.
Management and recovery treatment of a concussion should be focused towards keeping both cognitive and physical rest in mind. There is a lack of understanding surrounding cognitive rest in the field of sport (Sullivan, Alla, Lee, Schneiders, Ahmed & McCrory, 2012). As such, these misconceptions involving concussions, need to be addressed by and understood by those who are recovering from a MTBI. The athlete should possess knowledge in keeping both their cognitive and physical attributes at rest, while analyzing the recovery portion of their MTBI. Most of the literature on the subject is focused on the physical rest aspect and the cognitive aspect is often overlooked. It would prove to be great success to advocate the severity associated with cognitive development and the negative effects derived from concussions that occur in young athletes.
As suggested by Silverberg, complete rest, or minimal physical activity, is the best way to recover from a MTBI (Silverberg & Iverson, 2013). It is also suggested that moderate amounts of physical activity is essential and effective in several treatment plans for athletes diagnosed with a MTBI. This moderate amount of rest is also encouraged by Schneider et al,. who states that for athletes, “If their normal activities are restricted for extended periods of time, they are at risk for secondary problems such as physical deconditioning, anxiety and stress, mild depression, and irritability” [and that] “some of the benefits of exercise that have been reported, include facilitation of molecular markers of neuroplasticity and neurogenesis, improved cognitive functioning, greater bilateral hippocampal volumes and better performance on a memory test in children with greater fitness levels, changes in neurotransmitter systems, higher ratings of self-esteem and improved sleep quality. Exercise has also been reported to be an effective adjunctive treatment in adults for depression and anxiety, chronic fatigue and migraines.” (Schneider, Iverson, Emery, McCrory, Herring & Meeuwisse, 2013). It is most beneficial to formulate a recovery plan that is specifically designed to the athletes' severity of head trauma experienced. The greater the number of individuals involved in sport that possess knowledge on proper treatment of concussions, the more unlikely it will be for athletes to severely effect their overall health.
 Future Directions
Due to the fact that the most beneficial audience regarding information involving concussions is coaches and teachers (specifically athletic coaches), the overall goal is to direct these individuals towards enforcing concussion safe, sensitive, and sound sports and play. Children typically start engaging in physical activity between ages 2-5 and begin organized sports between the ages of 6-9. Since children start engaging in physical activity at such a young age, it is advisable to keep a supervisor who is trained in all aspects of medical care. Young children can be uncoordinated, reckless, and accident-prone, so it is during this age, when introduced to the concept of physical activity, that their supervisors should be trained in educational concussion safe programs. Though some might argue that young children wouldn’t require supervisors to know such practices, it would only be beneficial to the children in preventing injury and promoting safe play, that they could transfer into everyday activities throughout their development.
Besides promoting supervisors of children with this type of practice, another future direction would be to implement the same practices into the coaching of both competitive and recreational sports leagues. Concussions indicate to be the result of a very serious brain injury, no matter what skill level or sport the individual is associated with. This suggests that the type of league of sport being played, should not dictate whether coaches should be educated on the topic of concussions or not. This is applicable to all ages of athletes within a broad variety of sports. All athletes are at risk of concussions, thus encouraging the idea that optimal endurance of safety for the athletes can be achieved, if the coaches knew how to handle situations involving concussions and developed concussion safe, sensitive, and sound sports and play. Physical activities need to be concussion-limited in order to prevent injury, concussion sensitive to help efficiently rehabilitate an injured person, and concussion sound to develop a structure and possible program pertaining to concussion prevention and awareness.
As of right now, the National Coaching Certification Program in Canada (NCCP), which is an association designed to develop proper coaching strategies, does not have a mandated concussion program for all coaches. Instead, it simply has a concussion awareness section on their website and elearning modules which cost $14.95 each to take(coach.ca, 2014). The main future direction of this informational wiki, would be to develop a mandatory concussion awareness certification workshop for coaches of all sports teams. The ideal workshop would train coaches in how to prevent and even help rehabilitate concussions, including a certificate to be rewarded to the coach upon completion of the course. This program would ensure coaches have a deeper understanding of the topic, and would increase the safety of the athletes that they supervise, ensuring that all athletes receive equal opportunity to a coach educated on helping them to prevent obtaining injuries, such as concussions.
Click on the following link to view our submission to the changemakers group to help prevent concussions in youth http://www.changemakers.com/project/youth-concussion-prevention .
 External Links
Guidelines have been established for the health care field in Canada for those who undergo persistant postconcussive symptoms (PPCS) (Marshall, Bayley, McCullagh, Velikonja & Berrigan, 2012). The list of the best practice recommendations can be found here were developed by the Ontario Neurotrama Foundation at a conference for their expert consensus group.
The NCAA holds a major influence of young athletes in the USA and Canada and have taken a role attempting to reduce concussion rates, especially those which go unreported. “the NCAA has concussion posters for men and women to be posted in training facilities and locker rooms as well as a video for athlete awareness” (Rudnik, 2013). A NCAA produced video for players encouraging them “Don't Hide It, Report It, Take Time to Recover” in regards to concussions can be seen here . The NCAA official document for sports medicine handbook for the NCAA (which includes a detailed section section regarding concussions, concussion rates per sports, protocol and laws on page 56-66) can be seen here.
There are many potential excersices and stretches to help stregethn the neck muscles, some of these can be seen in these videos:
There are many helmets under construction for a variety of sports to help lessen the number of concussions in their respective sports. Some examples can be seen here for a new football helmet, here for the new MLB padded cap for pitchers, You can watch a video showing an animation for a padded cap to fit over a football helmet: (here for an explanation of their implementation to University of South Carolina football practices), here to see a new hockey helmet designed to prevent concussions, and herefor a leading soccer protective headband.
For more information on the Hit Count system and how to use it in your program, please see here.
You can view the Sports Legacy Institute paper of the research going into the Hit Count initiative here.
You can view the Coaching Association of Canada’s Concussion awareness modules here.
 Notes and References
- Benson, B., Hamilton, G., Meeuwisse, W., McCrory, P., & Dvorak, J. (2009). Is protective equipment useful in preventing concussion? a systematic review of the literature. British Journal of Sports Medicine, 43, i56-i67. doi: 10.1136/bjsm.2009.058271
- Broglio, S., Ju, Y., Broglio, M., & Sell, T. (2003). The efficacy of soccer headgear. Journal of Athletic Training, 38(3), 220-224. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC233175/
- BU CTE Center. (n.d.). What is cte?. Retrieved from http://www.bu.edu/cte/about/what-is-cte/
- Cantu, R., Giola, G., Guskiewicz, K., Hoshizaki, B., Hovda, D., McKee, A., Nowinski, C., Meehan, W., & Sarmiento, K. (2013). Hit count threshold white paper. Retrieved from http://hitcount.org/wp-content/uploads/2014/01/Threshold-White-Paper-012714.pdf
- Cantu, R., & Mueller, F. (2003). Brain injury-related fatalities in American football, 1945-1999. Neurosurgery, 52, 846-853.
- Cantu, R., & Nowinski, C. (2012, February 3). Sports legacy institute “hit count™” white paper. Retrieved from http://www.sportslegacy.org/wp-content/uploads/2012/07/Hit-Count-White-Paper-072512.pdf
- coach.ca. (2014). Making head way concussion elearning series. Retrieved from http://www.coach.ca/making-head-way-concussion-elearning-series-p153487
- Delaney, J., Al-Kashmiri, A., Drummond, R., & Correa, J. (2008). The effect of protective headgear on head injuries and concussions in adolescent football (soccer) players. British Journal of Sports Medicine, 42(2), 110-115. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/17615173
- Eckner, J., Oh, Y., Joshi, M., Richardson, J., & Ashton-Miller , J. (2014). Effect of neck muscle strength and anticipatory cervical muscle activation on the kinematic response of the head to impulsive loads.American Journal of Sports Medicine, 42(3), 566-576. doi: 10.1177/0363546513517869
- Fink, D. (n.d.). The concussion blog: What is a concussion?. Retrieved from http://theconcussionblog.com/what-is-a-concussion/
- Gasquoine, P. G. (1998). Historical perspectives on postconcussion symptoms. The Clinical Neuropsychologist, 12, 315-324.
- Gessel, M., Fields, S., Collins, C., Dick, R., & Comstock, D. (2007). Concussions among united states high school and collegiate athletes. Journal of Athletic Training, 42(4), 495-503. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2140075/
- Grant L. Iverson, Michael Gaetz, Mark L. Lovell, Michael W. Collins. Cumulative effects of concussion in amateur athletes. Brain Injury, 18, 433-443, 2004.
- hokiesports.com. (2014, January 31). New study finds differences in concussion risk between football helmets. Retrieved from http://www.hokiesports.com/football/recaps/20140131aaa.html
- Leigh, B. (2014, Mar 21). New arkansas helmets designed to prevent concussions. Retrieved from http://bleacherreport.com/articles/2001442-new-arkansas-helmets-designed-to-prevent-concussions?utm_source=newsletter&utm_medium=newsletter&utm_campaign=sec-football
- NFL. (n.d.). Nfl's head neck and spine commitee's protocols regarding diagnosis and management of concussion. Retrieved from http://images.nflplayers.com/mediaResources/lyris/pdfs/NFL_Diagnosis_Mgmt_Concussion.pdf
- NHL. (2010, January 8). Memorandum: Concussion evaluation and management protocol. Retrieved from http://sportsdocuments.com/nhl-protocol-for-concussion-evaluation-and-management/
- Nowinski, C. (2013). Hit parade: The future of the sports concussion crisis. Cerebrum, Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3600860/
- Nystrom, L. (2011, May 10). Virginia tech announces football helmet ratings for reducing concussion risk. Retrieved from https://www.vtnews.vt.edu/articles/2011/05/051011-engineering-helmetratings.html
- Marshall, S., Bayley, M., McCullagh, S., Velikonja, D., & Berrigan, L. (2012). Clinical practice guidelines for mild traumatic brain injury and persistent symptoms.Canadian Family Physician, 58(3), 257-267. Retrieved from http://www.cfp.ca/content/58/3/257.full?sid=1df91e58-bfa5-435b-9665-259f1893197b
- Masters, M. (2011, May 3). Nationwide concussion awareness campaign launched. National Post. Retrieved from http://sports.nationalpost.com/2011/05/03/nationwide-concussion-awareness-campaign-launched/
- McCrory, P., & Berkovic, S. (2001). Concussion: The history of clinical and pathophysiological concepts and misconceptions. Neurology, 57, 2283-2289.
- 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. British Journal of Sports Medicine, 43(76-84), doi: 10.1136/bjsm.2009.058248
- McKee, A., Cantu, R., Nowinski, C., Hedley-White, T., Gavertt, B., Budson, A., Santini, V., Lee, H., Kubilus, C., & Stern, R. (2009). Chronic traumatic encephalopathy in athletes: Progressive tauopathy following repetitive head injury. Journal of Neuropathology & Experimental Neurology, 68(7), 709-735. doi: 10.1097/NEN.0b013e3181a9d503
- Rudnik, J. (2013). Soccer concussions stress value of headgear. (Master's thesis)Retrieved from http://redlineproject.org/sportsconcussionsrudnik.php
- Salmon, Paul. "Sports Neuropsychology: Assessment and Management of Traumatic Brain Injury." Developmental Neuropsychology 31.2 (2007): 243-45. Web.
- Schneider, K., Iverson, G., Emery, C., McCrory, P., Herring, S., & Meeuwisse, W. (2013). The effects of rest and treatment following sport-related concussion: a systematic review of the literature.British Journal of Sports Medicine, 47, 304-307. doi: 10.1136/bjsports-2013-092190
- Silverberg, N., & Iverson, G. (2013). Is rest after concussion “the best medicine?”: Recommendations for activity resumption following concussion in athletes, civilians, and military service members.Journal of Head Trauma Rehabilitation, 28(4), 250-259. doi: 10.1097/HTR.0b013e31825ad658
- Sullivan, S., Alla, S., Lee, H., Schneiders, A., Ahmed, O., & McCrory, P. (2012). The understanding of the concept of ‘rest’ in the management of a sports concussion by physical therapy students: A descriptive study. Physical Therapy in Sport,13(4), 209-213. doi: doi: 10.1016/j.ptsp.2011.10.004
- Sports Legacy Institute. (2013). About hit count. Retrieved from http://www.sportslegacy.org/policy/hit-count/
- Sports Legacy Institute. (2013). Advanced concussion training (act). Retrieved from http://www.sportslegacy.org/education/advanced-concussion-training/
- Thinkfirst.ca. (n.d.). Return to play guidelines. Retrieved from http://www.thinkfirst.ca/programs/documents/TF_Concussion_RTP_E_2012.pdf
- Zillmer, E. A., & Spiers M. V. (2001). Principles of neuropsychology. Belmont, CA: Wadsworth.