News Room

September, 2005

Although sports injuries contribute to fatalities infrequently, the leading cause of death from sports-related injuries is traumatic brain injury. Sports and recreational activities contribute to about 21 percent of all traumatic brain injuries among American children and adolescents.

Traumatic Brain Injury

A traumatic brain injury (TBI) is defined as a blow or jolt to the head or a penetrating head injury that disrupts the normal function of the brain. TBI can result when the head suddenly and violently hits an object, or when an object pierces the skull and enters brain tissue. Symptoms of a TBI can be mild, moderate, or severe, depending on the extent of damage to the brain. Mild cases may result in a brief change in mental state or consciousness, while severe cases may result in extended periods of unconsciousness, coma, or even death.

Incidence

The U.S. Consumer Product Safety Commission (CPSC) tracks product-related injuries through its National Injury Information Clearinghouse. According to the CPSC, there were an estimated 311,766 sports-related head injuries treated at U.S. hospital emergency rooms in 2004. The actual incidence of head injuries is potentially much higher, as many of these injuries are treated at physician's offices, immediate care centers, or self-treated.

Included in these statistics are not only the sports/recreational activities, but the equipment and apparel used in these activities. For example, swimming-related injuries include the activity as well as diving boards, equipment, flotation devices, pools, and water slides.

The following 20 sports/recreational activities represent the categories contributing to the highest number of estimated head injuries treated in U.S. hospital emergency rooms in 2004.

Cycling: 69,476
Powered Recreational Vehicles (ATVs, Dune Buggies, Go-Carts, Mini bikes, Off-road): 27,213
Football: 25,515
Basketball: 24,320
Baseball and Softball: 22,671
Water Sports (Diving, Scuba Diving, Surfing, Swimming, Water Polo, Water Skiing): 18,860
Winter Sports (Skiing, Sledding, Snowboarding, Snowmobiling): 18,566
Skateboards/Scooters: 15,125
Soccer: 14,465
Horseback Riding: 10,669
Health Club (Exercise, Weightlifting): 9,901
Golf: 8,049
Trampolines: 5,392
Hockey: 4,741
Ball Sports (unspecified): 4,221
Skating (In line, roller, roller hockey): 4,041
Ice Skating: 2,852
Fishing: 2,689
Wrestling: 2,268
Volleyball: 2,021

The top 10 head injury categories among children ages 14 and younger:

Cycling: 41,382
Baseball and Softball: 12,386
Basketball: 11,747
Football: 11,048
Water Sports: 10,305
Skateboards/Scooters: 9,835
Powered Recreational Vehicles: 9,018
Winter Sports: 6,558
Soccer: 5,598
Trampolines: 5,074

Additional Sports Facts

Boxing
Over time, professional boxers can suffer permanent brain damage. The force of a professional boxer's fist is equivalent to being hit with a 13 pound bowling ball traveling 20 miles per hour, or about 52 g's.

There are boxers with minimal involvement and those that are so severely affected that they require institutional care. There are some boxers with varying degrees of speech difficulty, stiffness, unsteadiness, memory loss, and inappropriate behavior. In several studies, 15-40 percent of ex-boxers have been found to have symptoms of chronic brain injury. Most of these boxers have mild symptoms. Recent studies have shown that most professional boxers (even those without symptoms) have some degree of brain damage.

Cycling
Every year, more than 500,000 people visit emergency rooms in the United States with bicycle-related injuries. Of those, more than 69,000 were head injuries in 2004. There are about 600 deaths a year, with two-thirds being attributed to TBI. It is estimated that up to 85 percent of head injuries can be prevented through proper usage of SNELL, ANSI or ASTM-approved helmets. It is essential that the helmet fit properly so that it doesn't fall off during a fall.

The following facts/statistics are from Safe Kids USA:

• Head injury is the leading cause of wheeled sports-related death and the most important determinant of permanent disability after a crash.
• Without proper protection, a fall of as little as two feet can result in a skull fracture or other TBI.
• About 52 percent of children ages 5-14 do not use a bicycle helmet, while 41 percent do, and 7 percent had one but were not wearing it.
• Children whose helmets fit poorly are twice as likely to sustain a head injury in a bicycle crash as children whose helmets fit properly.
• A helmet that is worn too far back on the head is 52 percent less effective.

Football
The National Center for Catastrophic Sport Injury Research tracks a number of head injury statistics related to football annually:

• There were 44 head injury-related deaths from 1995-2004.
• High school players sustained 43 head injuries from 1995-2004 in which there was incomplete recovery.
• College players sustained five head injuries from 1995-2004 in which there was incomplete recovery.
• According to league officials there are about 160 concussions in the National Football League every year.

Horseback Riding
Head injuries comprise about 18 percent of all horseback riding injuries, although they are the number one reason for hospital admissions and the leading cause of death. Three of every five equestrian accident deaths are due to head injuries.

Soccer
Protection against head injuries in soccer is complicated by the fact that heading is an established part of the game, and any attempt to protect against head injuries must allow the game to be played without modification. Several head guards have been developed to reduce the risk of head injuries in soccer. One independent research study found that none of the products on the market provided substantial benefits against minor impacts, such as heading with a soccer ball.

A McGill University study found that more than 60 percent of college-level soccer players reported symptoms of concussion during a single season. Although the percentage at other levels of play may be different, these data indicate that head injuries in soccer are more frequent than most presume.

According to CPSC statistics, 40 percent of soccer concussions are attributed to head to player contact; 10.3 percent are head to ground, goal post, wall, etc.; 12.6 percent are head to soccer ball, including accidents; and 37 percent are not specified.

Types of Head Injuries

Concussions

Cerebral concussions frequently affect athletes in both contact and non-contact sports. Cerebral concussions are considered diffuse brain injuries and can be defined as traumatically induced alterations of mental status. A concussion results from shaking the brain within the skull and, if severe can cause shearing injuries to nerve fibers and neurons.

Grading the concussion is a helpful tool in the management of the injury (see Cantu below) and depends on: 1) Presence or absence of loss of consciousness, 2) Duration of loss of consciousness, 3) Duration of posttraumatic memory loss, and 4) Persistence of symptoms, including headache, dizziness, lack of concentration, etc.

Some team physicians and trainers evaluate an athlete's mental status by using a five-minute series of questions and physical exercises known as the Standardized Assessment of Concussion (SAC). This method, however, may not be comprehensive enough to pick up subtle changes

According to the Cantu Guidelines, Grade I concussions are not associated with loss of consciousness, and posttraumatic amnesia is absent or is less than 30 minutes in duration. Athletes may return to play if no symptoms are present for one week.

Players who sustain a Grade II concussion lose consciousness for less than five minutes or exhibit posttraumatic amnesia between 30 minutes and 24 hours in duration. They may also return to play after one week of being asymptomatic.

Grade III concussions involve posttraumatic amnesia for more than 24 hours or unconsciousness for more than five minutes. Players who sustain this grade of brain injury should be sidelined for at least one month, after which they can return to play if they are asymptomatic for one week.

Following repeated concussions, a player should be sidelined for longer periods of time and possibly not allowed to play for the remainder of the season.

Second-impact syndrome results from acute, often fatal brain swelling that occurs when a second concussion is sustained before complete recovery from a previous concussion. This is thought to cause vascular congestion and increased intracranial pressure, which can occur very rapidly and which may be difficult or impossible to control. The risk of second-impact syndrome is higher in sports such as boxing, football, ice or roller hockey, soccer, baseball, basketball, and snow skiing.

According to the Cantu Guidelines, Grade I concussions usually are not associated with loss of consciousness and athletes may return to play if no symptoms appear for one week.

Players who sustain a Grade II concussion usually lose consciousness for less than five minutes, and may return to play after one week of being asymptomatic.

Grade III concussions usually involve memory loss for more than 24 hours and unconsciousness for more than five minutes. Players who sustain this grade of brain injury should be sidelined for at least one month.

Following repeated concussions, a player should be sidelined for longer periods of time and possibly not allowed to play for the remainder of the season.

Second Impact Syndrome results from acute, sometimes fatal brain swelling that occurs when a second concussion is sustained before complete recovery from a previous concussion. This causes vascular congestion and increased intracranial pressure, which may be difficult or impossible to control. The risk for second impact syndrome is higher for sports such as boxing, football, ice or roller hockey, soccer, baseball, basketball, and snow skiing.

Coma

The word coma refers to a state of unconsciousness. The unconscious state has variability and may be very deep, where no amount of stimulation will cause the person to respond or, in other cases, a person who is in a coma may move, make noise, or respond to pain but is unable to obey simple, one-step commands, such as "hold up two fingers," or "stick out your tongue." The process of recovery from coma is a continuum along which a person gradually regains consciousness.

For people who sustain severe injury to the brain and are comatose, recovery is variable. The more severe the injury, the more likely the result will include permanent impairment.

The Glasgow Coma Scale is usually administered upon admission to establish a base line of level of consciousness, motor function and eye findings. Frequent evaluations of the patient are imperative to help assess neurologic improvement or deterioration.

Brain imaging technologies, particularly computerized axial tomography (CT or CAT scan) can offer important immediate information about a person's status. The purpose of performing an emergency CT scan is to rule out a large mass lesion (hematoma) compressing the brain that requires immediate surgical removal. Magnetic Resonance Imaging (MRI) is used in a more elective setting to image subtle changes that are not picked up by CT.

Brain Injury Symptoms

• Pain: Constant or recurring headache
• Motor Dysfunction: Inability to control or coordinate motor functions, or disturbance with balance
• Sensory: Changes in ability to hear, taste or see; dizziness; hypersensitivity to light or sound
• Cognitive: Shortened attention span; easily distracted; overstimulated by environment; difficulty staying focused on a task, following directions or understanding information; feeling of disorientation and confusion and other neuropsychological deficiencies.
• Speech: Difficulty finding the "right" word; difficulty expressing words or thoughts; dysarthric speech.

Head Injury Prevention Tips

Buy and use helmets or protective head gear approved by the ASTM for specific sports 100 percent of the time. The ASTM has vigorous standards for testing helmets for many sports-helmets approved by the ASTM bear a sticker stating this. Helmets and head gear come in many sizes and styles for many sports and must properly fit to provide maximum protection against head injuries. In addition to other safety apparel or gear, helmets or head gear should be worn at all times for:

• Baseball and Softball (when batting)
• Cycling
• Football
• Hockey
• Horseback Riding
• Powered Recreational Vehicles
• Skateboards/Scooters
• Skiing
• Wrestling

Head gear is recommended by many sports safety experts for:

• Martial Arts
• Pole Vaulting
• Soccer

General Tips

• Supervise younger children at all times and do not let them use sporting equipment or play sports unsuitable for their age
• Do not dive in water less than 9 feet deep or in above-ground pools.
• Follow all rules at water parks and swimming pools
• Wear appropriate clothing for the sport
• Do not wear any clothing that can interfere with your vision
• Do not participate in sports when you are ill or very tired
• Obey all traffic signals and be aware of drivers when cycling or skateboarding
• Avoid uneven or unpaved surfaces when cycling or skateboarding
• Perform regular safety checks of sports fields, playgrounds and equipment.
• Discard and replace sporting equipment or protective gear that is damaged

Rule Changes in Contact Sports to Prevent Head and Neck Injuries

The National Athletic Trainers' Association and the American Football Coaches Association (NATA/AFCA) Task Force, headed by Ron Courson, director of sports medicine for the University of Georgia, focused on two primary problems this year with head contact.

• Head-down contact still occurs frequently in intercollegiate football
• Helmet-contact penalties are not adequately enforced.

Rule changes implemented by the NCAA related to head-down contact and spearing in collegiate football have been distributed to all coaches and officials throughout the country. The objective is to eliminate injuries resulting from a player using his helmet in an attempt to punish an opponent.

With the rule changes and more diligent enforcement of the rules, there is hope that a significant reduction in head and neck injuries will result.