Sports - Prevention
The Center for Disease Control and Prevention
has produced a number of documents and kits about brain injury and
Heads Up to Clinicians:
Concussion Training by CDC & NFL
Head Injury Prevention -
A rundown on risks and prevention of head injury in youth sports.
Is a Helmet Worth It? How Brain Injuries Affect Different Body
If you ride bicycles or motorcycles, you may have an idea of just how
much crashing hurts. Crashing or being hit while riding your
bicycle can be anything from simply embarrassing to majorly painful.
New riders may think that they’re skilled enough to never crash, but
there are many factors outside of their control, and the occasional
crash is inevitable. But while some crashes leave the rider with a
few bruises and scrapes, some leave them with broken bones and other
This is why bike safety is so important. There are so many ways
that bike injuries can linger or lead to lifelong issues that to ride
without the proper safety gear is very unwise. This is especially
true for those who live in a large city like New York City.
Because NYC has such a large population, there are many more people and
vehicles on the streets. It’s much more likely someone will run
into you or get in your way and cause a crash.
While broken bones will hurt and take time to heal, a head injury can
be even worse. Damage to the brain can be irreversible and make it
difficult to function. It can lead to vision and hearing loss,
difficulty with memory, a lack of coordination, and can even affect your
heart rate and ability to breathe. Because each section of
the brain controls different parts of the body, a brain injury can
affect just about anything.
Bicycle Injuries: Would they have been prevented with a helmet?
According to the Insurance Institute for Highway Safety, in 2009, 91%
of all bicyclists killed in an accident were not wearing a helmet. That
means out of the 628 riders who were killed that year, 573 of them
weren’t wearing a helmet. This wasn’t an abnormal year, either—the
percentage of bikers who died in accidents and were not wearing a helmet
has never been below 80% with the exception of the 2010-2012 statistics.
These statistics are actually the abnormality because, while 65 to 70%
were not wearing helmets, another 16 to 17% are listed as “unknown,”
meaning they may or may not have had some kind of protective headgear on
at the time of the accident.
The most commonly injured bicyclist is a male over 16 years old
riding without a helmet in an urban area. Out of the 601 bikers
who were killed in 2012, only 166 of them had a blood alcohol content
level above .08 percent. Most were completely sober.
What can be drawn from these statistics? While it’s hard to say
if any of the bicyclists would have survived their crash if they had
been wearing a helmet (helmets cannot prevent neck or face injuries),
it’s entirely possible some of them would have.
In many non-fatal crashes, there is a definite answer: helmets reduce
damage to the brain. According to a number of studies, head
injuries account for over 60 percent of all bicycle-related injuries.
In a study done by the Bicycle Helmet Safety Institute, medical
professionals reported that up to 88 percent of these head injuries that
resulted in brain trauma could have been prevented had the bicyclist
been wearing a helmet.
Brain Areas and Associated Functions
Damage to the brain can lead to many different difficulties and
lifelong issues. The brain controls everything about the human
body. As such, damage to the brain can affect any part of the
body, even changing a person’s behavior and abilities. The brain
can be divided into six different areas.
The brain stem is the term for the lowest part of the brain that
connects to the rest of the body. Because it connects to the neck,
the brain stem is fairly vulnerable. Damage to the brain stem can
lead to many different physical problems, including a loss of balance
and the ability to sleep. It can also cause an irregular
heartbeat, breathing problems, and difficulty with swallowing. The
brain stem controls blood pressure, body temperature, sweating, and
digestion, too, and any or all of these functions can be affected by
The cerebellum is the part of the brain that coordinates movement,
balance, equilibrium, and helps with reflexes. Those who have
damage to their cerebellum may have difficulty performing complex
actions or, in the case of major damage, basic actions like walking.
The frontal lobe is where much of our thinking occurs. It
controls things like how we perceive our environment, our emotions, our
language, and how we understand concepts and solve problems. A
head injury that affects the frontal lobe can make it very difficult to
The parietal lobe handles many of our senses, including touch
perception and our ability to manipulate objects. Damage here can
throw off how the senses work together.
The occipital lobes are concerned with one function: vision.
Damage to these lobes can lead to a loss of vision and blurred vision.
Finally, the temporal lobes handle hearing, memory, emotion, and the
processing of verbal information. Light damage can cause a
decrease in hearing or in memory, while major damage can leave someone
unable to express emotion or remember much of anything.
Parts of The Brain and Their Functions – How will brain damage
affect your functionality?
The Four Lobes – What they are and what they do.
Brain Structures and their Functions - An online resource on the
Damage to the Frontal Lobes – How an injury to the frontal lobe
affects a person.
Parts of the Brain and Their Functions – Details the different
sections of the brain.
While being injured in a bicycle crash may be
inevitable, wearing a helmet can greatly reduce the chances or severity
of brain damage. In many cases, a brain injury doesn’t just affect
one area—several parts of the brain can be damaged, leading to a number
of different problems for the bicyclist. Why risk that? A
helmet is a fairly inexpensive and easy to wear piece of equipment that
can provide a great amount of protection. It seems a risk that few
people should be willing to take, yet many people ride their bikes
without wearing a helmet. Even worse, a number of parents let
their children ride bikes without proper safety gear. No one is
too young or too old to wear a helmet.
Don’t open yourself up to brain damage from a bicycle injury.
Purchase and wear a helmet whenever you ride.
- reference: http://www.dandalaw.com/resources/is-a-helmet-worth-it/
Ohio University Online
Football - A Bloody History
Contributed by Paul Buress
Those familiar with the history of the game know that violence is
nothing new, and that in the early days death was a not-uncommon
visitor to the gridiron. In fact, over a century before President
voiced his worry over college players facing “concussions and so
forth,” President Teddy Roosevelt called a meeting of several
university football team representatives to push for safety measures
after 19 boys were killed during regulation time in 1905. Four years
later, the five-year tally was 113 dead, and finally changes began
to take shape.
Read more at:
We are all urged to exercise in order to keep fit
and to avoid getting fat. Sports seem like a fun way of burning
extra calories to lose weight, but according to a
U.S. Consumer Product
Safety Commission report, sports injuries among baby boomers
increased by 33 percent from 1991 to 1998. There were about
hospital emergency room-treated injuries to persons 35 to 54 in
1991 compared to more than 365,000 sports injuries to persons of
these ages in 1998. The number of injuries keeps increasing every
year. In 2006, the National Electronic Injury Surveillance System
(NEISS) reported over half a million injuries just for basketball.
Another two million injuries were associated with bicycling,
football, other sports.
The increase in injuries has also made doctors and
RN's much busier which has sparked an increase in the need for
CNA training across the country.
Is boxing really a sport
when the goal is to
each other senseless?
Baby boomers suffered more that 1 million sports
injuries which cost over $18.7 billion Dollars in medical expenses
in 1998. The highest numbers of sports-related injuries came from
bicycling, basketball, baseball, and running.
The largest number of deaths were associated with
head injuries while riding a bicycle. Most of these injuries
resulted from accidents with motor vehicles due to heavy traffic,
poor visibility, or failure to obey traffic regulations. Drowning
while swimming was the next most common cause of death, followed by
skiing accidents. Swimming where there is no lifeguard increases the
risk of drowning if a person should get a cramp, or have some other
serious problem. Deaths from skiing accidents occur because of the
high speeds involved and the inability to maneuver to avoid
obstacles like trees or rocks. Sonny Bono, of Sonny and Cher fame,
died of injuries after hitting a tree while skiing near Lake Tahoe,
California. His death came just days after Michael Kennedy, son of
Robert F. Kennedy, died in a similar accident.
The effect of an injury
may be felt many years later.
The prevalence of sport injuries in professional
sports can be seen by just reading the sports pages of any
newspaper, especially after the weekend games. Here is a sampling of
the Washington Post for Tuesday, March 13, 2007:
Caron Butler's value to the Washington
Wizards was made obvious late last season when the team lost
five straight games while he was out with a thumb injury
on his right (shooting) hand and again after this season's
all-star break when the team went 0-3 while he was out with
lower back spasms.
Butler said persistent stiffness
in the left knee -- the same knee that required
arthroscopic surgery in October 2003 and forced him to miss
13 games as a member of the Miami Heat season -- has robbed him
of quickness and explosiveness and led him to play with
Washington Capitals' goaltender Brent Johnson
left after the second period with a right knee injury.
Johnson hurt himself while sprawling to stop Tkachuk's shot and
was replaced by Frederic Cassivi at the start of the third
period. Johnson will be reevaluated Tuesday. The Capitals don't
play again until Thursday in Boston, where Olie Kolzig hopes to
return from a sprained left knee.
Texas Rangers outfielder Nelson Cruz was
hit in the head by a pitch and taken to a hospital during
the Rangers' 11-7 victory over the Milwaukee Brewers yesterday
Cruz was batting with the bases loaded in the
sixth inning when he was hit on the helmet near an ear by a
fastball from Yovani Gallardo.
Cruz stayed on the ground
for several minutes, then walked off on his own power. He had an
indentation on the side of his face where his helmet had
been and looked dazed as he walked to the visitor's
clubhouse. He was coherent when he got in a car and was taken to
- Yankees: Carl Pavano last pitched in
the majors on June 27, 2005, before being sidelined by
shoulder, back, buttocks, elbow, and rib injuries.
Cardinals: Jason Isringhausen is set to make his spring
training debut Thursday, right on schedule. The right-handed
closer missed the World Series after hip surgery in
- Padres: Greg Maddux was scratched from a
scheduled start against the White Sox because of a mild lower
As far as injuries are concerned, basketball is
near the top of the list. The large number of injuries is due in
part to the popularity of basketball, but the jumping and
competitive aspects of the game cause the most damage. Players
collide, hit (foul) each other, or fall and land improperly after
jumping and they get hurt. Attempts to block the ball under the
basket put the players in direct conflict without any protective
equipment. Experienced players like Kareem Abdul-Jabbar used goggles
to avoid eye injuries.
Greg Oden after breaking his kneecap
President Obama needed twelve
stitches after getting
during a basketball game in 2010
The 2009 season was particularly disastrous for
the Portland Trail Blazers who had many players sidelined with
serious injuries. Greg Oden broke his left kneecap after jumping to
block a play. The rookie Patrick Mills injured a foot during
training right after he was drafted. Nicolas Batum suffered a
shoulder injury the previous year, and then re-injured it during the
summer. When he started playing again, the cartilage in his shoulder
tore and he had to have surgery. Travis Outlaw was lost for the year
while recovering from a stress fracture in his foot. Martell Webster
had a similar injury the previous year, and he re-broke the foot
when he returned to play. Even the head coach, Nate McMillan,
ruptured his Achilles' tendon during practice when he stepped in to
fill gaps due to the shortage of players.
The following table of injuries is based on 2006
data compiled by the U.S. Consumer Product Safety Commission's
National Electronic Injury Surveillance System (NEISS).
|Sport and Type of Injury
||Basketball - Cut hands, sprained ankles, broken
legs, eye and forehead injuries.
||Bicycling - Feet caught in spokes, head injuries
from falls, slipping while carrying bicycles, collisions
||Football - Fractured wrists, chipped teeth, neck
strains, head lacerations, dislocated hips and jammed
||ATVs, Mopeds, Minibikes - Riders of ATVs were
frequently injured when they were thrown from vehicles.
There were also fractured wrists, dislocated hands, shoulder
sprains, head cuts and lumbar strains.
||Baseball, Softball - Head injuries from bats and
balls. Ankle injuries from running bases or sliding into
||Exercise, Exercise Equipment - Twisted ankles and
cut chins from tripping on treadmills. Head injuries from
falling backward from exercise balls, ankle sprains from
||Soccer - Twisted ankles or knees after falls,
fractured arms during games.
||Swimming - Head injuries from hitting the bottom
of pools, and leg injuries from accidentally falling into
||Skiing, Snowboarding - Head injuries from
falling, cut legs and faces, sprained knees or shoulders.
||Lacrosse, Rugby, & other Ball Games - Head and
facial cuts from getting hit by balls and sticks, injured
ankles from falls.
Head Injuries can have long-term effects.
Brain damage caused by concussions may result in strokes, paralysis,
headaches or reduced concentration and mental clarity. A 2009 study
commissioned by the National Football League reported that
Alzheimer's disease or other similar memory-related diseases appear
in the league's former players at 19 times the normal rate for men
ages 30 through 49. Other studies have found that football players
who suffered concussions were more likely to suffer from depression.
In general, it is a good idea to avoid sports that expose the head
to repeated impacts, such as boxing, soccer, and football.
- Baby Boomer Sports Injuries, U.S. Consumer Product Safety
Commission, April 2000. [PDF]
National Electronic Injury Surveillance System (NEISS) On-line
Brain injuries pose risk to athletes Efforts to safeguard children on Oregon’s sports fields ramp up as our knowledge about concussions grows
Posted to Web:
8, 2009 04:31PM
Appeared in print: Sunday,
Mar 8, 2009, page
March is Brain
Injury Awareness Month, and this year’s focus is
on concussion in sports. Concussion is often
called the “silent injury,” because its effects
cannot be seen. The casual observer cannot tell
that a sullen, withdrawn teen was once a vibrant
and smiling girl prior to her concussion while
playing soccer. You don’t know that the young
man next door now struggles with basic
schoolwork after multiple concussions during
last football season.
For many years
concussions were described as “dings” or
“bell-ringers” and usually thought to be minor
injuries. In fact, a concussion is a traumatic
brain injury that interferes with the brain’s
normal function. Sadly, a small number of high
school athletes die each year from catastrophic
brain injuries. Thousands of additional athletes
suffer nonfatal, but potentially disabling,
brain injuries. These injuries garner very
little attention, but may have dramatic
The U.S. Centers
for Disease Control and Prevention estimate that
300,000 sports concussions occur among children
and adolescents each year in the United States.
Using the most conservative estimates,
approximately 1,000 high school athletes in
Oregon suffer at least one concussion each
school year. While most of these youngsters
recover within a few weeks, many suffer from
memory problems, chronic headaches, difficulty
concentrating and depression for months or even
The past decade has
seen a revolution in the management of
sports-related concussion. What was once
considered a relatively benign condition is now
recognized as a critical medical issue with
distressing and potentially permanent
We have learned
that adolescents recover more slowly and are
more prone to further injury than college and
professional athletes. We now know that an
athlete doesn’t have to be rendered unconscious
to have suffered a concussion. In fact, only
about 5 percent of all concussed athletes are
“knocked out” at the time of injury. Research
also indicates that young athletes who have a
history of a previous concussion take longer to
get better and may be three to six times more
likely to sustain an additional concussion.
Perhaps even more
surprisingly, recent studies confirm that
concussions are not just “football injuries.”
New evidence suggests that girls playing soccer
are not only more susceptible to concussions
than their male counterparts, they also take
longer to recover normal brain function after
the injury. High school girls playing soccer
sustain concussions at a rate 60 percent higher
than boys. In basketball, the concussion rate
for girls is 300 percent that of the boys.
As our knowledge of
concussions has evolved, so has our approach to
diagnosing and managing injured athletes. Key to
this understanding is that athletes who are
still having symptoms from a concussion
(headache, confusion, difficulty concentrating,
etc.) should never return to physical activity
until those symptoms have resolved and they have
been cleared by a physician. If they do return
to sports while still experiencing concussion
symptoms, they are at risk for a more severe
concussion, or even a potentially fatal
condition called Second Impact Syndrome.
safeguard high school athletes, the Oregon
School Activities Association became the
nation’s first state athletic governing body to
mandate a “no same day return to play” policy
for concussed athletes. The OSAA has also
supplied coaches and athletic directors with
materials on the
signs and symptoms of concussion. Unfortunately,
our ability to protect high school athletes does
not extend to the thousands of athletes in youth
and club sports. Parents and coaches in youth
and club leagues must be aware of the signs and
symptoms of concussion and insist that
educational programs, rules and protocols
regarding proper concussion management are
In response to
these concerns, we have formed the Oregon
Concussion Awareness and Management Program.
This program has focused upon educating
physicians, coaches, administrators, athletes,
parents and others on the signs and symptoms of
concussion, as well as management strategies,
safe return to play, and prevention. The
program also has helped make computerized
neurocognitive testing available at a discounted
rate to all high schools across the state. While
the program was created to address concussions
in high school athletes, we stand ready to
expand our efforts to encompass all young
athletes within our state.
The goals that program has set can be reached
only through the cooperation of all the parties
involved: parents, athletes, coaches, athletic
trainers, physicians, teachers and others.
Unfortunately, educating this broad group of
participants across our large state brings many
logistical and financial barriers. While the
dedicated efforts of a handful of individuals
have already shown tangible results, we will
require the help of many more. Only through
grants, state funding, private contributions and
sponsorship will we be able to make youth, club
and high school sports safer throughout Oregon.
Head Injuries Sustained during Sports and Recreation
Sports are a valued
pastime, but playing them safely is part of the game.
The most common brain injury in
sports is a concussion. According to a study released by the
Centers for Disease Control and Prevention, there are an
estimated 300,000 sports-related concussions in the United
States each year. ( 1 )
Brain injuries cause more deaths
than any other sports injury. In football for instance, brain
injury accounts for 65 to 85% of all fatalities.
( 1 )
Nearly 90 percent of professional
boxers have sustained a brain injury.
( 2 )
Because the objective of boxing is
to make one's opponent unable to fight, it is not surprising
that acute traumatic brain injury (ATBI) occurs in boxing
matches and sparring sessions. Jabs and angled blows to the head
may result in ATBI. In addition to ATBI, chronic traumatic brain
injury (CTBI) is of concern in boxing.
( 3 )
Approximately 5 percent of soccer
players sustain brain injury as a result of head-to-head
contact, falls, or being struck on the head by the ball.
( 2 )
Heading or hitting the ball with
the head is the riskiest activity; when done repeatedly, it can
cause a concussion. ( 2 )
Football injuries associated with
the brain occur at a rate of one in every 3.5 games.
( 4 )
Football is responsible for more
than 250,000 head injuries in the United States. In any given
season 10 percent of all college players and 20 percent of all
high school players sustain brain injuries.
( 5 )
Football players with brain
injuries are six times more likely to sustain new injuries.
( 5 )
A helmet helps prevent a brain
injury from occurring.
The Consumer Product Safety
Commission (CPSC) estimates that in 1997, there were 84,200
skiing injuries (including 17,500 head injuries) treated in U.S.
emergency rooms. The CPSC also estimated that 7,700 of those
head injuries, including 2,600 head injuries to children, could
be prevented or reduced in severity each year by using helmets.
About 11 skiing and snowboarding-related deaths would be
prevented annually with helmets. (
Always wear a helmet when skiing
for protection during falls and collisions.
The head is involved in more
baseball injuries than any other body part. Almost half of the
injuries involve a child’s head, face, mouth or eyes.
( 2 )
The leading cause of injury and
death is being hit by the ball, the second leading cause is
collision. ( 2 )
Always wear a helmet when batting.
In-Line Skating, Rollerskating and Skateboarding
Brain injuries occur most often
when skaters fall and hit their heads on the pavement.
Skating on roads causes a risk of
colliding with cars, bicyclists, pedestrians and pets.
Always wear a helmet for
protection from falling.
Brain injuries account for 60
percent of equestrian related fatalities, and 17 percent of all
equestrian injuries are brain injuries.
( 7 )
Always wear a helmet when riding a
In 90% of the cases, injuries to
equestrians that require hospitalization are caused from the
rider being separated from the horse while riding or the rider
falling with the horse. ( 8)
In 1999, there were an estimated
6,000 horseback riding brain injuries.
( 9 )
1. Concussion in Sports and Return to School
Issues Following Concussion, James P. Kelly, MD and Ronald C.
Savage, Brain Injury Source Pediatric Issue, Volume 3, No. 3, Summer
2. American Association of Neurological
Surgeons/Congress on Neurological Surgeons, 1998.
((February 5, 2001)
3. The Physician and Sportsmedicine - Vol 28
- No. 1 - January 2000, "Acute Traumatic Brain Injury in Amateur
(February 5, 2001)
4. Kelly JP. Concussion. LN Torg JS, Shepard
RJ (eds.) Current Therapy in Sports Medicine, Philadelphia: Mosby,
5. Diagnosis and Management of Concussion in
Sports, James P. Kelly, MD and Jay H. Rosenberg, MD
6. Centers for Disease Control, SafeUSA:
Winter Sports Injury Prevention - Safety on the Slopes.
http://www.cdc.gov/safeusa/slopes.htm (January 26,
7. National Electronic Injury Surveillance
8. American Medial Equestrian Association,
9. National Electronic Injury Surveillance
This fact sheet was
developed by the Brain Injury Association of America (April 2001)
School Sports and Brain Injury
Do you play sports? Perhaps you are on
a basketball team? Do you play soccer or football? Volleyball?
Baseball or Softball? A study published on September 8, 1999
(Journal of the American Medical Association, Vol. 282, pp. 958-963,
1999) has documented the incidence of traumatic brain injury in high
school athletes who play these and other sports. The results may
246 athletic trainers in
235 high schools in the United States were asked to keep track of
the injuries associated with 10 different sports teams (5 boys'
teams and 5 girls' teams). Of the 23,566 injuries reported over the
1995-1997 seasons, 1,219 were classified as mild traumatic brain
injuries (MTBIs). From these data, it was estimated that in the US
there are 62,816 MTBIs each year in these ten sports. Most people
will think of an MTBI as a "concussion": a change in mental status,
such as confusion or disorientation, caused by an impact to the
head. Such a head injury does NOT have to cause a person to lose
The sports included in the study were:
* Field Hockey
Below are the sports had the most (#1)
and fewest (#5) MTBIs? Make your predictions then move your mouse
over the two boxes below to see which of these sports had the most
(#1) and the fewest (#5) MTBIs.
Here are some details about the
injuries associated with each of the sports.
* 63.4% of all reported MTBIs were
related to football.
* Players did not return to play
for an average of three days.
* The number of MTBIs during games
was 11 times higher than during practices.
* Most injuries were associated
with tackling or being tackled.
* 14.3% of the MTBIs occurred in
linebackers; 14.0% in running backs; 13.4% in offensive linemen.
* Of the 693 different players who
suffered an MTBI, 621 players (89.6%) had only 1 MTBI; 65 players
(9.4%) had 2 MTBIs; 6 players (0.9%) had 3 MTBIs and 1 player (0.2%)
had 4 MTBIs.
* No deaths were reported.
* 10.5% of all reported MTBIs
were related to wrestling.
* The number of MTBIs during
matches was 3.1 times higher than during practice.
* Most MTBIs were suffered during
takedowns or attempted takedowns.
* Wrestlers did not return to the
sport for an average of 2 days after an MTBI.
* 4.2% of all reported MTBIs were
related to boys' basketball and 5.2% were related to girls'
* MTBIs occurred more often during
games than practice: 4.9 times more often in boys' games compared to
practice; 6.1 times more often in girls' games compared to practice.
* Collisions between players
accounted for most MTBIs. MTBIs were also suffered by many girls
* Most game-related MTBIs in boys
and girls were suffered by guards. In practice, most MTBIs occurred
* Players did not return to play
for an average of 2 days.
* 5.7% of all reported MTBIs were
related to boys' soccer and 6.2% were related to girls' soccer.
* In boys' soccer, the injury rate
was 16.2 times higher during games than during practices; in girls'
soccer, it was 14.4 times higher during games than during practices.
* Forwards and halfbacks suffered
most of the MTBIs.
* Most MTBIs occurred while
heading the ball. However, it is unclear if player-to-player,
player-to-ball or player-to-ground collisions caused the MTBIs.
* Players did not return to play
for an average of 3 days.
* 1.2% of all reported MTBIs were
related to boys' baseball; 2.1% were related to girls' softball.
* Most baseball and softball
related MTBIs occurred when players collided with other players,
although MTBIs were also sustained by players from collisions with a
bat, during sliding and from being hit by a pitch.
* Baseball players did not return
to play for an average of 3 days; softball players did not return to
play for an average of 2 days.
* 1.1% of all reported MTBIs were
related to girls' field hockey.
* Games had MTBI rates 14.4 times
higher than practices.
* MTBIs occurred from being hit
with a hockey stick, hit with a ball and collsions with other
* Players did not return to play
for an average of 3 days.
* 0.5% of all reported MTBIs were
related to girls' volleyball.
* MTBIs occurred from being hit
with a ball, collisions with other players, and during digging.
* Players did not return to play
for an average of 1 day.
These data show that many high school
sports have a significant risk for brain injury. It is especially
important to monitor and treat people who suffer MTBIs because
injuries to the head may have lasting effects on memory and
To prevent injuries:
* Know the rules of the game.
* Know the proper technique to
play the game.
* Wear protective safety
* Seek immediate medical help if
you are injured.
JUST DO IT!
(but do it safely)
Did you know?
In 1904, US President
Theodore Roosevelt threatened to outlaw football after 19 college
football players were killed or paralyzed from brain or spinal cord
injuries. (Statistic from Maroon et al., Neurosurgery, 47:659-672,
References and further information:
1. Powell, J.W. and Barber-Foss,
K.M. Traumatic brain injury in high school athletes, J. American
Medical Association, 282:958-963, 1999.
2. Soccer and the Brain
http://faculty.washington.edu/chudler/sports.html; September 20,
Sports-Related Head Injury
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
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.
The U.S. Consumer Product Safety Commission (CPSC) tracks
product-related injuries through its National Electronic Injury
Surveillance System (NEISS). According to the CPSC, there were an
estimated 313,726 sports-related head injuries treated at U.S.
hospital emergency rooms in 2007. The actual incidence of head
injuries may potentially be much higher for two primary reasons. 1).
In the 2007 report, the CPSC excluded estimates for product
categories that yielded 1,200 injuries or less, those that had very
small sample counts, or those that were limited to a small
geographic area of the country; 2). Many less severe head injuries
are treated at physician’s offices, immediate care centers, or
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
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 2007.
Baseball and Softball: 25,079
Powered Recreational Vehicles (ATVs, Dune Buggies, Go-Carts, Mini
bikes, Off-road): 24,090
Skateboards/Scooters (Powered): 18,542
Winter Sports (Skiing, Sledding, Snowboarding, Snowmobiling): 16,120
Water Sports (Diving, Scuba Diving, Surfing, Swimming, Water Polo,
Water Skiing): 12,096
Horseback Riding: 11,759
Health Club (Exercise, Weightlifting): 11,550
Ice Skating: 3,703
The top 10 head injury categories among children ages 14 and
Baseball and Softball: 13,508
Skateboards/Scooters (Powered): 11,848
Winter Sports: 7.546
Powered Recreational Vehicles: 7,460
Water Sports: 6,498
Winter Sports: 4,874
Additional Sports Facts
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
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.
Every year, more than 500,000 people visit emergency rooms in the
United States with bicycle-related injuries. Of those, nearly 65,000
were head injuries in 2007. 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, American National Standards Institute (ANSI) or American
Society for Testing and Materials (ASTM)-approved helmets. It is
essential that the helmet fit properly so that it doesn’t fall off
while riding or if you take 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
- 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
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.
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.
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
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
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, 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.
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
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
- 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)
- Horseback Riding
- Powered Recreational Vehicles
Head gear is recommended by many sports safety experts for:
- Bull riding
- Martial Arts
- Pole Vaulting
- Vintage Motor Sports
- 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 12 feet deep or in
- 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
- 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
- Perform regular safety checks of sports fields, playgrounds
- Discard and replace sporting equipment or protective gear
that is damaged.
Rule Changes in Contact Sports to Prevent Head and Neck
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
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
Susceptibility to Brain Injury in Sports:
A Role for Genetic Testing
Barry D. Jordan MD, MPH
PHYSICIAN AND SPORTSMEDICINE
- VOL 26 - NO. 2 - FEBRUARY 98
advances in molecular biology during the next millennium may cause
an explosion of genetic information about athletes' predisposition
to illness and injury. Recent discoveries about a possible genetic
predisposition to brain injury in boxers may be the tip of the
iceberg, with far-reaching implications for members of the sports
Evidence for Inherited
Chronic traumatic brain
injury (CTBI), which occurs primarily among retired boxers after
long exposure to the sport, is also known as dementia pugilistica,
chronic traumatic encephalopathy, or "punch-drunk" syndrome. The
condition represents the cumulative long-term neurologic consequence
of repetitive concussive and subconcussive blows to the head. A
milder form of CTBI can occur in American football, ice hockey,
rugby, soccer, or any sport associated with traumatic brain injury.
Clinically, CTBI is characterized by slurred speech, gait ataxia,
memory impairment, behavior and/or personality changes,
parkinsonism, and/or incoordination (1-6). On postmortem
examination, CTBI shares several neuropathologic features with
Alzheimer's disease (7-11).
Recent evidence suggests
that apolipoprotein E epsilon-4 (apo E-e4), a susceptibility gene
for late-onset familial and sporadic Alzheimer's disease (12,13),
may also be associated with an increased risk of CTBI in boxers
(14). In a survey of 30 boxers, those who harbored an apolipoprotein
E epsilon-4 allele and had high exposure to the sport (more than 12
professional bouts) exhibited greater neurologic dysfunction than
those without an apolipoprotein E epsilon-4 allele. In addition, all
the boxers who were severely impaired possessed an apolipoprotein E
Also supporting the
hypothesis of a genetic predisposition to the neurologic effects of
boxing, Teasdale et al (15) have since reported a significant
association between apolipoprotein E epsilon-4 polymorphism and
outcomes following acute traumatic brain injury in a nonboxing
population. In a prospective evaluation of 89 patients admitted to a
neurosurgical unit, 17 (57%) of 30 patients who had the
apolipoprotein E epsilon-4 allele experienced an unfavorable outcome
(death, a vegetative state, or severe disability). The same was true
of only 16 (27%) of 59 patients who did not have an apolipoprotein E
Weighty Decisions Ahead
Our recent finding of
this genetic predisposition to brain injury has implications not
only for the medical regulation of boxing and other contact sports
but also for our awareness of a need to better understand the
interaction between genetic susceptibility and environmental
triggers. With future advances we may be able to identify genes that
predispose athletes to other sports-related injuries. For example,
we may be able to identify those who are at increased risk of
rupture of the anterior cruciate ligament. With such possibilities
in mind, the medical community is confronted with new possibilities
for helping patients as well as with serious ethical and moral
concerns about the role of genetic testing.
There are certain
advantages to knowing of a genetic susceptibility to injury.
Identifying athletes who are susceptible to a specific injury would
give physicians the opportunity to advise them of the potential
risk. Such an athlete could elect to participate in a different
sport. Other options might include modification of training or
playing techniques, use of specialized safety equipment, rule
changes, or more rigorous medical surveillance and health status
monitoring. Furthermore, the identification of genes for sports
injury susceptibility may also provide a basis for novel treatment
strategies, such as gene therapy.
Despite these potential
benefits, identifying athletes who have a genetic predisposition to
injury in sports raises important ethical and legal issues. First,
the knowledge must be kept confidential. Public knowledge of an
athlete's genetic risk could compromise his or her well-being and
livelihood. For example, knowledge of a predisposition to disease
could limit an athlete's negotiating power and/or limit the ability
to obtain medical or disability insurance. Furthermore, an athlete's
own knowledge of this predisposition could impose a significant
psychological and emotional burden. Complicating all of this is
uncertainty about the reliability of genetic testing in sports: It
may be very difficult to determine the positive predictive value of
a genetic test and to quantify the amount of athletic exposure that
will trigger a pathobiologic response.
A Future for Genetic
Advances in molecular
biology will undoubtedly expand our understanding of the
interactions between inherited disease susceptibility and
environmental precipitants. Any future application of such
scientific knowledge in the domain of sports medicine must be
accompanied by scientific validation, ethical responsibility, moral
integrity, and appropriate regulatory policies. Genetic testing may
be the wave of the future, but because of uncertainty about genetic
and environmental interactions, its role remains to be delineated.
Jordan BD: Chronic
neurologic injuries in boxing, in Jordan BD (ed): Medical
Aspects of Boxing. Boca Raton, Fla, CRC Press, 1993, pp 177-185
Mendez MF: The neuropsychiatric
aspects of boxing. Int J Psychiatry Med 1995;25(3):249-262
Roberts AH: Brain Damage in
Boxers: A Study of the Prevalence of Traumatic Encephalopathy
Among Ex-professional Boxers. London, Pittman, 1969
Neurologic injuries in boxing, in Jordan BD, Tsairis P, Warren
RE (eds): Sports Neurology, ed 2. Philadelphia,
Lippincott-Raven, to be published
Jordan BD: Dementia
pulgilistica, in Folstein MF (ed): Neurobiology of Primary
Dementia. Washington, DC, Association for Research in Nervous
and Mental Disease: American Psychiatric Press, to be published
Critchley M: Medical aspects of
boxing, particularly from a neurological standpoint. BMJ
Corsellis JA, Bruton CJ,
Freeman-Browne D: The aftermath of boxing. Psychol Med
Roberts GW, Allsop D, Bruton C:
The occult aftermath of boxing. J Neurol Neurosurg Psychiatry
Uhl GR, McKinney M, Hedreen JC, et
al: Dementia pugilistica: loss of basal forebrain cholinergic
neurons and cortical cholinergic markers, abstracted. Ann Neurol
Tokuda T, Ikeda S, Yanagesawa N,
et al: Re-examination of ex-boxers' brains using
immunohistochemistry with antibodies to amyloid beta-protein and
tau protein. Acta Neuropathol (Berl) 1991;82(4):280-285
Dale GE, Leigh PN, Luthert P, et
al: Neurofibrillary tangles in dementia pugilistica are
ubiquitinated. J Neurol Neurosurg Psychiatry 1991;54(2):116-118
Saunders AM, Strittmatter WJ,
Schmechel D, et al: Association of apolipoprotein E allele
epsilon 4 with late-onset familial and sporadic Alzheimer's
disease. Neurology 1993;43(8):1467-1472
Corder EH, Saunders AM,
Strittmatter WJ, et al: Gene dose of apolipoprotein E type 4
allele and the risk of Alzheimer's disease in late onset
families. Science 1993; 261(5123):921-923
Jordan BD, Relkin NR, Ravdin LD,
et al: Apolipoprotein E epsilon4 associated with chronic
traumatic brain injury in boxing. JAMA 1997;278(2):136-140
Teasdale GM, Nicoll JAR, Murray G,
et al: Association of apolipoprotein E polymorphism with outcome
after head injury. Lancet 1997:350(9084):1069-1071
Dr. Jordan is adjunct
associate professor of psychistry at the Charles R. Drew University
of Medicine and an instructor of neurology at the Uersity of
California at Los Angeles (UCLA) School of Medicine. Address
correspondence to Barry D. Jordan, MD, Charles R. Drew University of
Medicine, 1621 E 120th St, MP-19B, Los Angeles, CA 90059, e-mail to
Sports-Related Recurrent Brain Injuries --
Source: MMWR Weekly;
March 14, 1997 / 46(10);224-227
An estimated 300,000
sports-related traumatic brain injuries (TBIs) of mild to moderate
severity (1), most of which can be classified as concussions (i.e.,
conditions of temporarily altered mental status as a result of head
trauma), occur in the United States each year. The proportion of
these concussions that are repeat injuries is unknown; however,
there is an increased risk for subsequent TBI among persons who have
had at least one previous TBI (2,3). Repeated mild brain injuries
occurring over an extended period (i.e., months or years) can result
in cumulative neurologic and cognitive deficits (4,5), but repeated
mild brain injuries occurring within a short period (i.e., hours,
days, or weeks) can be catastrophic or fatal. The latter phenomenon,
termed "second impact syndrome," has been reported more frequently
since it was first characterized in 1984 (6-8). This report
describes two cases of second impact syndrome and presents
recommendations developed by the American Academy of Neurology to
prevent recurrent brain injuries in sports and their adverse
consequences (9). Case Reports
Case 1. During October
1991, a 17-year-old high school football player was tackled on the
last play of the first half of a varsity game and struck his head on
the ground. During halftime intermission, he told a teammate that he
felt ill and had a headache; he did not tell his coach. He played
again during the third quarter and received several routine blows to
his helmet during blocks and tackles. He then collapsed on the field
and was taken to a local hospital in a coma. A computed tomography
(CT) brain scan revealed diffuse swelling of the brain and a small
subdural hematoma. He was transferred to a regional trauma center,
where attempts to reduce elevated intracranial pressure were
unsuccessful, and he was pronounced brain dead 4 days later. Autopsy
revealed diffuse brain swelling, focal areas of subcortical
ischemia, and a small subdural hematoma.
Case 2. During August
1993, a 19-year-old college football player reported headache to
family members after a full-contact practice during summer training.
During practice the following day, he collapsed on the field
approximately 2 minutes after engaging in a tackle. He was
transported to a nearby trauma center, where a CT scan of the head
showed diffuse brain swelling and a thin subdural hematoma. Attempts
to control the elevated intracranial pressure failed, and he was
pronounced brain dead 3 days later. Autopsy revealed the brain to be
diffusely swollen with evidence of cerebrovascular congestion and
features of temporal lobe herniation.
Summary of Related Data
The true incidence of
second impact syndrome is unknown. During 1984-1991, four cases were
described, and during 1992-1995, a total of 17 cases were described;
most cases have involved male adolescents or young adults and
involved participation in boxing, football, ice hockey, and snow
skiing (8). Combined data from four states (Colorado, Missouri,
Oklahoma, and Utah) during 1990-1993 indicated an annual rate of 2.6
cases per 100,000 population of sports-related TBI that resulted in
hospitalization or death; the proportion attributable to second
impact syndrome is unknown.
Reported by: J Kelly, MD,
Brain Injury Program, Rehabilitation Institute of Chicago, Illinois.
Quality Standards Subcommittee and Task Force on Preventive
Neurology, American Academy of Neurology, Minneapolis, Minnesota.
Div of Acute Care, Rehabilitation Research, and Disability
Prevention, and Div of Unintentional Injury Prevention, National
Center for Injury Prevention and Control, CDC.
Editorial Note: The two
cases described in this report involved repeated head trauma with
probable concussions that separately might be considered mild but in
additive effect were fatal. The risk for catastrophic effects from
successive, seemingly mild concussions sustained within a short
period is not yet widely recognized. Second impact syndrome results
from acute, usually fatal, brain swelling that occurs when a second
concussion is sustained before complete recovery from a previous
concussion. Brain swelling apparently results from a failure of
autoregulation of cerebral circulation that causes vascular
congestion and increased intracranial pressure, which may be
difficult or impossible to control (7).
Population-based data are
needed to define the incidence of this condition, describe causes,
and identify populations at highest risk. CDC is developing a
multi-state system for TBI surveillance (10). Based on this
surveillance system, CDC, in collaboration with participating
states, is developing methods to conduct surveillance for
sports-related second impact syndrome.
The risk for second
impact syndrome should be considered in a variety of sports
associated with likelihood of blows to the head, including boxing,
football, ice or roller hockey, soccer, baseball, basketball, and
snow skiing. The American Academy of Neurology has proposed
recommendations for the management of concussion in sports that are
designed to prevent second impact syndrome and to reduce the
frequency of other cumulative brain injuries related to sports (9)
(see box (Table_1)).
These recommendations define symptoms and signs of concussion of
varying severity and indicate intervals during which athletes should
refrain from sports activity following a concussion. Following head
impact, athletes with any alteration of mental status, including
transient confusion or amnesia with or without loss of
consciousness, should not return to activity until examined by a
health-care provider familiar with these guidelines.
The popularity of contact
sports in the United States exposes a large number of participants
to risk for brain injury. Recurrent brain injuries can be serious or
fatal and may not respond to medical treatment. However, recurrent
brain injuries and second impact syndrome are highly preventable.
Physicians, health and physical education instructors, athletic
coaches and trainers, parents of children participating in contact
sports, and the general public should become familiar with these
Sosin DM, Sniezek JE, Thurman DJ.
Incidence of mild and moderate brain injury in the United States,
1991. Brain Inj 1996;10:47-54.
Salcido R, Costich JF. Recurrent traumatic
brain injury. Brain Inj 1992;6:293-8.
Annegers JF, Grabow JD, Kurland LT, Laws
ER Jr. The incidence, causes, and secular trends of head trauma in
Olmsted County, Minnesota, 1935-1974. Neurology 1980;30:912-9.
Jordan BD, Zimmerman RD. Computed
tomography and magnetic resonance imaging comparisons in boxers.
Gronwall D, Wrightson P. Cumulative effect
of concussion. Lancet 1975;2:995-7.
Saunders RL, Harbaugh RE. The second
impact in catastrophic contact-sports head trauma. JAMA
Kelly JP, Nichols JS, Filley CM, Lillehei
KO, Rubinstein D, Kleinschmidt-DeMasters BK. Concussion in sports:
guidelines for the prevention of catastrophic outcome. JAMA
Cantu RC, Voy R. Second impact syndrome: a
risk in any contact sport. Physician and Medicine 1995;23:27-34.
Quality Standards Subcommittee, American
Academy of Neurology. Practice parameter: the management of
concussion in sports. Neurology 1997;48:581-5.
CDC. Traumatic brain injuries -- Colorado,
Missouri, Oklahoma, and Utah, 1990-1993. MMWR 1997;46:8-11.