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   Sports-Related Recurrent Brain Injuries - United States

     An estimated 300,000 sports related traumatic brain injuries, TBIs, of mild to moderate severity , most of which can be classified as concussions, (i.e., conditions of temporary 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 .  Repeated mild brain injuries occurring over an extended period (i.e., months or years can result in cumulative neurologic and cognitive deficits, but repeated mild brain injuries occurring within a short period (i.e., hours, days, 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.  This page 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.

Case Reports:

     Case 1.  During October 1991, a 17-year-old high school football player was tackled on the last day of the first half of a varsity game and struck his head on the ground.  During half-time 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 computerized tomography (CT-Scan) 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 dead 4 days later.  Autopsy  revealed diffuse brain swelling focal areas of subcortical ischemia, and a small sub dural hematoma. TBI Glossary

     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.

     Second Impact Syndrome.  The two cases described above 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 that causes vascular congestion and increased intracranial pressure, which may be difficult or impossible to control.

     The Dangers of Concussion
    " ...during the minutes to few days after concussion injury, brain cells that are not irreversibly destroyed remain alive but exist in a vulnerable state. This concept of injury-induced vulnerability has been put forth to describe the fact that patients suffering from head injury are extremely vulnerable to the consequences of even minor changes in cerebral blood flow and/or increases in intracranial pressure and apnea....

     "Experimental studies have identified metabolic dysfunction as the key  postconcussion physiologic event that produces and maintains this state of vulnerability. This period of enhanced vulnerability is characterized by both an increase in the demand for glucose (fuel) and an inexplicable reduction in cerebral blood flow (fuel delivery).58 The result is an inability of the neurovascular system to respond to increasing demands for energy to reestablish its normal chemical and ionic environments. This is dangerous because these altered environments can kill brain cells." -- 
The American Orthopaedic Society for Sports Medicine - url: http://www.intelli.com/vhosts/aossm-isite/html/main.cgi?sub=151

     Relative Risk.  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. 

    Neurologists say once a person suffers a concussion, he is as much as four times more likely to sustain a second one. Moreover, after several concussions, it takes less of a blow to cause the injury and requires more time to recover.  Troy Aikman sustained 8 concussions that he publicly admits to, the last two occurred since January 1, 2000.  According to league officials there are about 160 concussions in the N.F.L. and 70 in the NHL each year. 

Sideline Guidelines.  The American Academy of Neurology has adopted 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.  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 in 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 recommendations.

Source:  Centers for Disease Control and Prevention, Dept. of Health and Human Services, USA. 1997 

More than just a bump on the head!  Though not always visible and sometimes seemingly minor, head injury is complex. It can cause physical, cognitive, social, and vocational changes. In many cases recovery becomes a lifelong process of adjustments and accommodations for the individual and the family.

     Depending on the extent and location of the injury, impairments caused by a head injury can vary widely. The irony of mild head injuries is that often, such injuries do not even require a hospital stay, yet they result in changes so profound that lives are forever changed. 

     Some common impairments include difficulties with memory, mood, and concentration. Others include significant deficits in organizational and reasoning skills, learning, cognitive, and executive functions.

     Recovery from a head injury can be inconsistent. In many cases gains may be closely followed by setbacks and plateaus. A "plateau" is not evidence that functional improvement has ended. Typically plateaus are followed by gains.

     Changes in memory and organizational skills after a brain injury makes it difficult to function in complex environments. The resources on this page will provide answers and guidance concerning many of the most puzzling aspects of traumatic brain injury. 

     The family and friends feel the psychic repercussions of the head injury acutely as well. Caring for an injured family member can be very demanding and result in economic loss and emotional burdens. 

    It can change the very nature of their family life; the resultant emotional difficulties can affect  the cohesiveness of the family unit. Typically, the emotional damage is intense, affecting family and friends for years afterward and sometimes leading to the breakup of previously stable family units.

click here or scroll down to see additional resources

Summary of Recommendations of Management of Concussion in Sports
     A concussion is defined a head-trauma-induced alteration in mental status that may or may not involve loss of consciousness.  Concussions are graded in three categories.  Definitions and treatment recommendations for each category are presented below.
Grade 1 Concussion
Definition:  Transient Confusion, no loss of consciousness, and a duration of mental status abnormalities of less than 15 minutes.

Management:  The athlete should be removed from sports activity, examined immediately and at 5 minute intervals, and allowed to return that day to the sports activity only if post concussive symptoms resolve within 15 minutes.  Any athlete who incurs a second Grade 1 concussion on the same day should be removed from sports activity until asymptomatic for 1 week.


Grade 2 Concussion:
Definition:  Transient confusion, no loss of consciousness, and a furation of mental status abnormalities of more than 15 minutes. 

Management:  The athlete should be removed from sports activity, examined immediately and frequently to assess the evolution of symptoms, with more extensive diagnostic evaluation if the symptoms worsen or persist for more than 1 week.  The  should return to sports activity only after asymptomatic for 1full week.  Any athlete who incurs a Grade 2 concussion subsequent to a Grade 1 concussion on the same day should be removed from sports activity until asymptomatic for 2 weeks.

Grade 3 Concussion:
Definition:  Loss of consciousness, either brief (seconds) or prolonged (minutes or longer).

Management:  The athlete should be removed from sports activity for 1 full week without symptoms if the loss of consciousness is brief, or 2 full weeks without symptoms if the loss of consciousness is prolong.  If still unconscious, or if abnormal neurologic signs are present at the time of initial evaluation, the athlete should be transported by ambulance to the nearest hospital emergency department.  An athlete who suffers a second Grade 3 concussion should be removed from sports activity until asymptomatic for 1 month.  Any athlete with an abnormality on computed tomography or magnetic resonance imaging brain scan consistent with brain swelling, contusion, or other intracranial pathology should be removed from sports activities for the season and discouraged from future return to participation in contact sports.

Features of Concussion Frequently Observed:
1. Vacant stare (befuddled facial expression)
2. Delayed verbal and motor responses (slow to answer questions or follow instructions) 
3. Confusion and inability to focus attention (easily distracted and unable to follow through with normal activities)
4. Disorientation (walling in the wrong direction; unaware of time, date and place) 
5. Slurred or incoherent speech (making disjointed or incomprehensible statements) 
6. Gross observable incoordination (stumbling, inability to walk tandem/straight line) 
7. Emotions out of proportion to circumstances (distraught, crying for no apparent reason) 
8. Memory deficits (exhibited by the athlete repeatedly asking the same question that has already been answered, or inability to memorize and recall 3 of  3 words, or 3 of 3 objects in 5 minutes) 
9. Any period of loss of consciousness (paralytic coma, unresponsiveness to arousal)

Additional Resources:
Roberts,William, MD "Who Plays? Who Sits?", The Physician in Sports Medicine, 6/92, Vol 20, No. 6, pp. 66-72. 
Kelly, James P. "Concussion," Current Therapy in Sports Medicine.  Mosby - Year Book, Inc. 1995, pp 21 - 24. 
Saunders, R. and Harbaugh, R., "The Second Impact in Catastrophic Contact-Sports Head Trauma," Journal of American Medical Association, 6/27/84, Vol 252. No. 4, pp 538-539

Also see our Coma page

Additional Resources
Campaign Safe & Sober - Safe Driving Tips Motorcycle Helmets: The Facts of Life Safe Communities Success Stories Tribal Communities NHTSA s Kid s HomePage Contact Lists Materials Catalog Reply Card President's Letter The...url: http://www.nhtsa.dot.gov/people/outreach/safesobr/OPlanner/protection/safecomm.html
Injury Related Web Sites - National Center for Injury Prevention and Control Search NCIPC Links to organizations found at this site are provided solely as a service. url:http://www.cdc.gov/ncipc/injweb/websites.htm
SafeUSA -- Information and fact sheets for the general public and health consumers. 
url: http://www.cdc.gov/safeusa/siteindex.htm

Protective  Gear:
Plum Enterprises -- 500 Freedom View Lane, PO Box 85, Valley Forge, PA 19481-- Manufacturers of protective headgear for head protection around the house after head injury, surgery, during epileptic seizures, etc. These protective caps are  not designed for the heavy impacts seen in most sports.  Sizes available from toddlers to adults. Telephone: 800-321-PLUMB; Fax: 610-783-7577 -- url: http://www.plument.com/
email: lynn@plument.com

WIPSS Jaw-Joint Protector, a custom fit  mouthpiece that prevents jaw joint, head, and mouth injuries. Jaw Joint Injuries occur at an alarming rate  in soccer. According to Bill Whitney,  Olympic Development Soccer Coach, the primary reasons for injury are: 
getting hit in the jaw by the ball, 
the aggressive action of the opponent, 
heading the ball

 The amount of force calculated the moment a soccer ball hits the head of a player is  208 joules. Since the jaw is not attached to the skull, and knowing that every force  produces equal and opposite directional components of force, the impact causes  the lower jaw to slam against the base of the skull. These forces account for a large  percentage of the damage found in the jaw joints of soccer players. 
WIPSS Products, Inc.- email: wwhitney@voicenet.com -- URL: http://www.wipss.com/

SoccerDocs  -- During the summer of 1994 one of SoccerDocs' founders, like many soccer parents  across the nation, was enjoying his seven-year-old son Charles' soccer game. While Charles was goalkeeping an uncontested shot found its way through the defenders and and struck him directly in the forehead before Charles could put up his hands. The shot caused a concussion, resulting in headaches and dizziness. 

     This incident motivated his father to find head protection but he soon realized that no practical product existed. He was surprised to learn from a review of the scientific literature that there was a potential for long-term effects even from non-catastrophic head injuries (when the player does not lose consciousness). While concerned about his son's safety, he also knew that Charles wanted to continue to play the game he loved. This is what led him to co-found SoccerDocs. url: http://www.soccerdocs.com/
Telephones :1-877-HEADER-1 -- 1-877-432-3371 -- 612- 823-2426

Head Blast  --  The inventor of a so-called "shinguard for your head" is bracing for jeers from world-class soccer players when his product hits the market next month.Zatlin conceived the idea when his 12-year-old son Ben complained of dizziness after heading a fast-moving clearance pass back to the other side of the field. He took Ben straight to a local sporting goods store in search of protection. Zatlin, who owns a small printing press and hat-binding company, has begun production of a laminated foam headband he says softens the impact of headers by 30 to 50 percent. By design, the ball would go no farther or shorter than if it struck a player's forehead. 

     Dr. David Janda, director of the Institute for Preventative Sports Medicine, said he plans to test Zatlin's headband at his Ann Arbor, Mich., lab. But he expressed concern it would protect children only from the headers they do correctly, leaving the most tender spot at the top of the head exposed. 

       "When you watch kids learn to head the ball, they'll hit it off the front of their head, the back of their head, the side of the head, their shoulder -- they're all over the map," Janda said. "A headband type of approach still leaves the head vulnerable." telephone: 314- 652-2700 -- url: http://www.headblast.com/

Bicycle Helmet Safety Institute --  A helmet advocacy program of the Washington, DC Area Bicyclist Association. They are a  small, active, non-profit consumer-funded program acting as a clearinghouse and a technical resource for bicycle helmet information. Their volunteers serve on the ASTM and ANSI bicycle helmet standard committees and are active in commenting on actions of  the Consumer Product Safety Commission. They provide a documentation service and a number of helmet publications.
url: http://www.helmets.org -- email: webmaster@helmets.org
National Safe Kids Campaign --1301 Pennsylvania Ave NW, Ste 1000, Washington, DC 20004-1707
Telephone:  202-662-0600; Fax:   202-393-2072 -- url:  http://www.safekids.org/ email:
International  Inline Skating Association -- 201 N. Front St. #306, Wilmington, NC 28401 
Telephone: 910-762-7004 -- email: director@iisa.org
American National  Standards Institute  ANSI -- 11 W 42 Street, 13th fl, NY 10036, 
Telephone: (212) 642-4900; Fax: 212- 302-1286 -- url: http://www.ansi.org 
U.S. Consumer Product Safety Commission - CPSC -- Washington, DC 20207
Telephone: 301-504-0424; Fax: 301-504-0124 -- url: www.cpsc.gov -- email: info@cpsc.gov 
American  Society For Testing And Materials  - ASTM -- 100 Barr Harbor Drive
Conshohocken, PA 19428-2959 -- Telephone: 610-832-9500; Fax:  610- 832-9555 
World Health Organization  - WHO -- Helmet Initiative and Helmet Resource Center -- Look at what people are doing worldwide to reduce injuries and deaths through the use of helmets. Included is a link to "Headlines", the quarterly newsletter of the WHO Helmet Initiative. url: http://www.sph.emory.edu/Helmets
World Health Orgainzation - WHO - OMS --  Department of Health Promotion (HPR), 1211 Geneva 27
Switzerland -- Fax:  41-22-791-4186 -- url: http://www.who.org/ -- email: mainesa@who.org
Snell Memorial Foundation -- 3628 Madison Ave, Ste 11-- North Highlands, CA 95660 --  A not-for-profit organization dedicated to research, education, testing and development of  helmet safety standards. Since its founding in 1957, Snell has been a leader in the frontier of helmet safety in the United States and around the world. Telephone: 916- 331-5073; Fax:  916-331-0359 -- 
url http://www.smf.org/ -- email: info@smf.org
Centers for Disease Control -- Washington, DC  -- url: http://www.cdc.gov
Bureau of Transportation Statistics -- This DOT site links to transportation data from government and other public sources. url:  http://www.bts.gov

Sports Organizations
US Youth Soccer
Women's Nationa Basketball Assoc. - WNBA  http://www.wnba.com
Nat'l Soccer Coaches Assoc of America
Women's Boxing


International Rugby Football Board
Dublin Ireland
Telephone: 3531-662-5444
email: irb@irb.ie
Sports Illustrated for Women


League of American Bicyclists
1612 K Street NW,  Ste 401
Washington, DC 20006-2082

Telephone:  202-822-1333 
Fax:  202-822-1334 
URL:  http://www.bikeleague.org 
email: bikeleague@bikeleague.org 

Special Olympics Inc.
1325 G Street, NW / Suite 500 
Washington, DC 20005 

Telephone:  202-628-3630 
Fax:  202-824-0200 
URL:  http://www.specialolympics.org/
email:  webmasteso@aol.com

Ride Safe Home Page

email:  rsdkl@ix.netcom.com
URL:  http://ridesafeinc.com 

Womens Sports Foundation
305-315 Hither Green Lane 
Lewisham, London, SE13 6TJ 
Tel/fax: 0181-697 5370
URL:  http://www.wsf.org.uk/
Email:  info@wsf.u-net.com
Global Cycling Network

URL:  http://www.cycling.org

The International Olympic Committee Women and Sport Working Group


3359 Bryan Avenue
Simi Valley, CA  93063
Phone (805) 583-5890
Fax (805) 306-1663

For more information concerning the Management of Consciousness in Sports Public Education Campaign. please contact: Head Injury Hotline -- http://www.headinjury.com - email: brain@headinjury.com

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