Concussions in sport

Last updated

Concussions, a type of traumatic brain injury, are a frequent concern for those playing sports, from children and teenagers to professional athletes. Repeated concussions are a known cause of various neurological disorders, most notably chronic traumatic encephalopathy (CTE), which in professional athletes has led to premature retirement, erratic behavior and even suicide. In the context of sports-related concussions (SRC), an SRC is currently defined as a "complex pathophysiological process affecting the brain, induced by biomechanical forces". [1] Because concussions cannot be seen on X-rays or CT scans, attempts to prevent concussions have been difficult. [2]

Concussion Type of traumatic brain injury

Concussion, also known as mild traumatic brain injury (mTBI), is typically defined as a head injury that temporarily affects brain functioning. Symptoms may include loss of consciousness (LOC); memory loss; headaches; difficulty with thinking, concentration or balance; nausea; blurred vision; sleep disturbances; and mood changes. Any of these symptoms may begin immediately, or appear days after the injury, and it is not unusual for symptoms to last four weeks. Fewer than 10% of sports-related concussions among children are associated with loss of consciousness.

Traumatic brain injury condition caused by an external force which has traumatically injured the brain

Traumatic brain injury (TBI), also known as intracranial injury, occurs when an external force injures the brain. TBI can be classified based on severity, mechanism, or other features. Head injury is a broader category that may involve damage to other structures such as the scalp and skull. TBI can result in physical, cognitive, social, emotional, and behavioral symptoms, and outcome can range from complete recovery to permanent disability or death.

Sport Forms of competitive activity, usually physical

Sport includes all forms of competitive physical activity or games which, through casual or organised participation, aim to use, maintain or improve physical ability and skills while providing enjoyment to participants, and in some cases, entertainment for spectators. Hundreds of sports exist, from those between single contestants, through to those with hundreds of simultaneous participants, either in teams or competing as individuals. In certain sports such as racing, many contestants may compete, simultaneously or consecutively, with one winner; in others, the contest is between two sides, each attempting to exceed the other. Some sports allow a "tie" or "draw", in which there is no single winner; others provide tie-breaking methods to ensure one winner and one loser. A number of contests may be arranged in a tournament producing a champion. Many sports leagues make an annual champion by arranging games in a regular sports season, followed in some cases by playoffs.

Contents

The dangers of repeated concussions have long been known for boxers and wrestlers; a form of CTE common in these two sports, dementia pugilistica (DP), was first described in 1928. An awareness of the risks of concussions in other sports began to grow in the 1990s, and especially in the mid-2000s, in both the medical and the professional sports communities, as a result of studies of the brains of prematurely deceased American football players, who showed extremely high incidences of CTE (see concussions in American football).

Boxing combat sport

Boxing is a combat sport in which two people, usually wearing protective gloves, throw punches at each other for a predetermined amount of time in a boxing ring.

Wrestling form of combat sport involving grappling type techniques

Wrestling is a combat sport involving grappling-type techniques such as clinch fighting, throws and takedowns, joint locks, pins and other grappling holds. The sport can either be theatrical for entertainment, or genuinely competitive. A wrestling bout is a physical competition, between two competitors or sparring partners, who attempt to gain and maintain a superior position. There are a wide range of styles with varying rules with both traditional historic and modern styles. Wrestling techniques have been incorporated into other martial arts as well as military hand-to-hand combat systems.

American football Team field sport

American football, referred to as football in the United States and Canada and also known as gridiron, is a team sport played by two teams of eleven players on a rectangular field with goalposts at each end. The offense, the team with possession of the oval-shaped football, attempts to advance down the field by running with the ball or passing it, while the defense, the team without possession of the ball, aims to stop the offense's advance and to take control of the ball for themselves. The offense must advance at least ten yards in four downs or plays; if they fail, they turn over the football to the defense, but if they succeed, they are given a new set of four downs to continue the drive. Points are scored primarily by advancing the ball into the opposing team's end zone for a touchdown or kicking the ball through the opponent's goalposts for a field goal. The team with the most points at the end of a game wins.

As of 2012, the four major professional sports leagues in the United States and Canada have concussion policies. [3] Sports-related concussions are generally analyzed by athletic training or medical staff on the sidelines using an evaluation tool for cognitive function known as the Sport Concussion Assessment Tool (SCAT), a symptom severity checklist, and a balance test. [4]

Major professional sports leagues in the United States and Canada Informal group of sports leagues

The major professional sports leagues in the United States and Canada are the highest professional competitions of team sports in those countries. The four leagues universally included in the definition are Major League Baseball (MLB), the National Basketball Association (NBA), the National Football League (NFL), and the National Hockey League (NHL). Other prominent leagues include Major League Soccer (MLS) and the Canadian Football League (CFL).

Balance (ability) ability to maintain the line of gravity of a body within the base of support with minimal postural sway

In biomechanics, balance is an ability to maintain the line of gravity of a body within the base of support with minimal postural sway. Sway is the horizontal movement of the centre of gravity even when a person is standing still. A certain amount of sway is essential and inevitable due to small perturbations within the body or from external triggers. An increase in sway is not necessarily an indicator of dysfunctional balance so much as it is an indicator of decreased sensorimotor control.

Dangers

Concussion symptoms can last for an undetermined amount of time depending on the player and the severity of the concussion. A concussion will affect the way a person's brain works. [5]

There is the potential of post-concussion syndrome, defined as a set of symptoms that may continue after a concussion is sustained. [6] Post-concussion symptoms can be classified into physical, cognitive, emotional, and sleep symptoms. [6] Physical symptoms include a headache, nausea, and vomiting. [6] Athletes may experience cognitive symptoms that include speaking slowly, difficulty remembering and concentrating. [6] Emotional and sleep symptoms include irritability, sadness, drowsiness, and trouble falling asleep. [6]

Along with the classification of post-concussion symptoms, the symptoms can also be described as immediate and delayed. [7] The immediate symptoms are experienced immediately after a concussion such as: memory loss, disorientation, and poor balance. [7] Delayed symptoms are experienced in the later stages and include sleeping disorders and behavioral changes. Both immediate and delayed symptoms can continue for long periods of time and have a negative impact on recovery. [7] According to research, 20-25% of individuals who have sustained a concussion experienced chronic, delayed symptoms. [7]

Playing through concussion makes people more vulnerable to getting hit again, and that is why most sports have test that trainers will perform to prevent getting hit a second time. A second blow can cause a rare condition known as second-impact syndrome, which can result in severe injury or death. [8] Second-impact syndrome is when an athlete suffers a second head injury before the brain has adequate time to heal in between concussions. [9]

In addition, returning to sports with impaired sensorimotor function after experiencing a sports-related concussion (SRC) increases the risk of sustaining musculoskeletal (MSK). [10] In addition, athletes that expereienced a concussion are two times more likely to sustain an MSK injury compared to non-concussed athletes. [11]

Repeated concussions have been linked to a variety of neurological disorders among athletes, including CTE, Alzheimer's Disease, Parkinsonism and Amyotrophic lateral sclerosis (ALS). [12] [13]

Repeated concussions or mild-to-moderate traumatic brain injuries (TBI) have also been established to have effects on the motor dysfunction and movement disorders, however a systematic review has concluded that more investigation is needed to fully understand the long term effects of concussions and TBIs. [14]

Incidence

It is estimated that as many as 1.6-3.8 million concussions occur in the US per year in competitive sports and recreational activities; this is a rough estimate, since as many as 50% of concussions go unreported. [15] Concussions occur in all sports with the highest incidence in American football, ice hockey, rugby, soccer, and basketball. [4] In addition to concussions caused by a single severe impact, multiple minor impacts may also cause brain injury. [16] Less than 10% of cases experience a loss of consciousness, and many typical symptoms appear after the initial concussion evaluation. [17] The overall incidence risk of concussion is higher in adults than in youth, as the injury rate per 1,000 athletic exposures for youth is 0.23, compared to 0.28 in collegiate athletes. [18]

Injury rate (all types) per exposure based on sport in collegiate athletes from 1998 to 2004 [19]
SportInjury rate per 1,000 athletic exposures
Women's ice hockey0.91
Men's spring football (American)0.54
Men's ice hockey0.41
Women's soccer0.41
Men's football (American)0.40
Men's soccer0.28
Men's lacrosse0.25
Women's lacrosse0.25
Men's wrestling0.25
Women's basketball0.22
Women's field hockey0.18
Men's basketball0.16
Women's gymnastics0.16
Women's softball0.14
Women's volleyball0.09
Men's baseball0.07
All sports0.28

Policies

Major League Baseball

Major League Baseball's (MLB) policy was first started in 2007, and injured players are examined by a team athletic trainer on the field. [20] On March 29, 2011, MLB and the Major League Baseball Players Association announced that they have created various protocols for the league's concussion policy. The new policy includes four primary components: [21]

National Basketball Association

The National Basketball Association (NBA) does not have a policy, and team procedures after concussions vary by team. [20] The NBA has a meeting to educate the players each year about concussions. Players also go through a neurological and cognitive assessment after each season. [24]

National Football League

The National Football League's (NFL) policy was first started in 2007, and injured players are examined on field by the medical team. [20] The league's policy included the "NFL Sidelines Concussion Exam", which requires players who have taken hits to the head to perform tests concerning concentration, thinking and balance. [27] In 2011, the league introduced an assessment test, which combines a symptoms checklist, a limited neurological examination, a cognitive evaluation, and a balance assessment. For a player to be allowed to return, he must be asymptomatic. [28]

If a player is cleared by the Unaffiliated Neurotrauma Consultant (UNC), then they will be allowed to play but will be monitored closely throughout the game. If a player is diagnosed with a concussion, then that player is not allowed back in the game. A return to play process is issued, which includes five steps, “1. Rest and recovery 2. Light aerobic exercise 3. Continued aerobic exercise/strength training 4. Football specific activities 5. Full football activity/clearance” [29]

Almost every team has experienced a player who will “keep playing, then manage to stumble off the field, unnoticed by the coaches, cameras or press. He might take a breather for a series or two. But he can walk, so he wants to play. He gets back in the game and back to his teammates.” [30]

According to Johns Hopkins University, a study took place which “researchers recruited nine former NFL players who retired decades ago and who ranged in age from 57 to 74. The men had played a variety of positions and self-reported a wide range of concussions, varying from none for a running back to 40 for a defensive tackle." [31]

National Hockey League

The National Hockey League's (NHL) concussion policy began in 1997, and players who sustain concussions are evaluated by a team doctor in a quiet room. [20] In March 2011, the NHL adopted guidelines for the league's concussion policy. Before the adoptions, examinations on the bench for concussions was the minimum requirement, but the new guidelines make it mandatory for players showing concussion-like symptoms to be examined by a doctor in the locker room. [32]

Dr. Paul Echlin and Dr. Martha Shenton of Brigham and Women’s Hospital and other researchers, conducted a study where “Forty-five male and female Canadian university hockey players were observed by independent physicians during the 2011-12 season. All 45 players were given M.R.I. scans before and after the season. The 11 who received a concussion diagnosis during the season were given additional scans within 72 hours, two weeks and two months of the incident. The scans found microscopic white matter and inflammatory changes in the brains of individuals who had sustained a clinically diagnosed concussion during the period of the study.” [33]

"We celebrate the big hit, we don't like the big head hit. There is an important distinction because we celebrate body-checking." [32]

NHL Commissioner Gary Bettman

Youth sports

Many children and teenagers participate in sports and extracurricular activities that create a risk of a head injury or concussion, including basketball, cheerleading, soccer, and football. [34] As a consequence, schools and youth sports groups should implement programs to reduce the risk of concussion, ensure prompt diagnosis [35] and provision of medical care, and that young participants are not endangered by a premature return to sports. [36] [37]

In 2010, more high school soccer players suffered concussions than basketball, baseball, wrestling, and softball players combined, according to the Center for Injury Research and Policy. [38] According to a study in the JAMA Pediatrics medical journal, many girls do not get necessary care and prevention regarding concussions, and 56 percent of players (or their families) reporting concussion symptoms never sought treatment. [39]

A growing topic is concussions in girls' soccer, predominantly among high-school girls. Studies show that girls are reporting nearly twice as many concussions as boys in the sports that they both play. The number of girls suffering concussions in soccer accounts for the second largest amount of all concussions reported by young athletes. [40]

According to a 2012 study published by ScienceDirect, soccer has the highest injury rate per athlete-exposure among 7- to 13-year-old children. [41]

This study was performed to compare the clinical recovery patterns after sport-related concussions for high school and collegiate athletes. It was important for them that these findings help us get a better understanding of how developmental factors influence the response to and recovery after different levels of play. Determining if college or professional athletes are more resilient to concussive injury on average than more heterogeneous high school samples.

The study was performed with Division 1, 2, and 3 football players at 15 universities across the United States. Then there was project sideline that followed football, hockey, and soccer players in Milwaukee, Wisconsin. They also looked at male and female high school and collegiate athletes mostly in southeaster United States. For every athlete they did a preseason baseline testing to see if anyone had a concussion already. They conducted these tests in the athletes’ schools in classrooms or other quiet indoor settings. All the athletes were individually proctored by the trained research assistants.

From this study they concluded that the collegiate athletes were older, taller, and heavier and have played their sport for more years then the high school athletes have. The high school group had more concussions and a higher proportion of females then the collegiate or control samples did. They had a total of 621 concussed athletes and 150 non-injured controls. They found little evidence that there were different rates of clinical recovery from the concussions between the high school students and the collegiate athletes. They saw that for the collegiate players that the elevated symptoms through day 5 of post-injury resolved by day 7. The high school athletes took 1–2 days longer to recover, but they both showed rapid recovery within the few days of the injury. The high school athletes did have more severe concussions though.

The information that the authors give are relevant to only people who play sports at the high school or college level. This information would not benefit someone who does not play sports or does not get concussions often. They were testing to see what the effect of the concussions had on these athletes and how they recovered from them. This information could also be good for coaches and parents to know as well.

Limitations they could have had for this experiment would be if the majority of the team’s players were injured or if none of them have ever had concussions or no one got concussions from their sports. I don’t think there was any data missing that they didn’t tell us about in their report. Other limitations that may have existed in this study was if a player already had a concussion and continued to play contact sports and did not let it heal that would be disrupting their data that they are looking for.

[42]

Table

LeagueYear policy first introducedYear baseline testing occurredYear current policy became effectiveFirst step after injuryPerson who approves/denies player to returnPerson who decides player return
NFL 2007 2008 2009 Evaluation by medical teamMedical staffMedical staff/Consultant
MLB 2007 2011 2007Evaluation by an athletic trainer using National Association GuidelinesMedical staffHead physician/Medical director
NBANeverNeverNeverDepends on teamDepends on teamDepends on team
NHL 1997 1997 2011 Neuropsychological evaluation by team doctor off rinkTeam doctorTeam doctor
MLS 2011 2003 2011Evaluation by medical teamTeam physicianTeam physician/Neuropsychologist
NASCAR 2003 20032003Ambulance to infield care centerNASCARNASCAR

Concussions in other sports

American football

American football causes 250,000 concussions annually, and 20% of high-school football players experience a concussion every year. [43] [44] In 2000, researchers from the Sports Medicine Research Laboratory at the University of North Carolina at Chapel Hill analyzed 17,549 players from 242 different schools. 888 (5.1%) of the players analyzed have at least one concussion a season, and 131 (14.7%) of them have had another concussion the year later. Division III and high-school players have a higher tendency to sustain a concussion than Division II and Division I players. [45] In 2001, the National Football League Players Association partnered with the UNC to determine whether professional football players suffer any health effects after any injuries, although the findings were criticized by the NFL for being unreliable due to being based on self-reporting by the players. [46]

Association football

Association football— also known as soccer— is a major source of sports-related concussions around the world. Even though 50-80% of injuries in football are directed to the legs, head injuries have been shown to account for between 4 and 22% of football injuries. There is the possibility that heading the ball could damage the head, as the ball can travel at 100 km/hour; although most professional footballers have reported that they experienced head injuries from colliding with other players and the ground. [47] [48] A multi-year study by the University of Colorado published in JAMA Pediatrics confirmed that athlete-to-athlete collisions that occur during heading, not impact with the ball itself, is generally the cause for concussion. [49]

A Norwegian study consisting of current and former players of the Norway national football team found out that 3% of the active and 30% of the former players had persistent symptoms of concussions, and that 35% of the active and 32% of that former players had abnormal electroencephalogram (EEG) readings. [50]

During the 2006-07 English Premier League season, Czech goalkeeper Petr Čech suffered from a severe concussion in a match between his club Chelsea and Reading. During the match, Reading midfielder Stephen Hunt hit Čech's head with his right knee, knocking the keeper out. [51] Čech underwent surgery for a depressed skull fracture and was told that he would miss a year of playing football. Čech resumed his goalkeeper duties on January 20, 2007 in a match against Liverpool, now wearing a rugby helmet to protect his weakened skull.

According to Downs DS and D Abwender in their article Neuropsychological Impairment in Soccer Athletes, “participation in soccer may be associated with poorer neuropsychological performance, although the observed pattern of findings does not specifically implicate heading as the cause”. [52]

On November 2, 2013 in a match between Tottenham and Everton, Tottenham goal keeper Hugo Lloris sustained a blow to the head by on -coming player Romelu Lukaku's knee. The blow left Lloris knocked out on the ground. Reluctantly manager Andre Villas Boas decided to leave the player on after regaining consciousness and having passed a medical assessment. This broke the rules of the PFA, which state that any player who has lost consciousness must be substituted. [53]

There has been a widespread debate on protective head gear in soccer. Known as a sport associated with intricate footwork, speed, and well-timed passes, soccer also is classified as a high- to moderate-intensity contact/collision sport, with rates of head injury and concussion similar to those seen in football, ice hockey, lacrosse, and rugby. While the benefits of helmets and other head protection are more obvious in the latter sports, the role of headgear in soccer is still unclear. [54]

There are clear rules from FIFA regarding what to do when a player gets a concussion. FIFA's guidelines say that a player who has been knocked unconscious should not play again that day. The rules do however allow for "a transient alteration of conscious level" following a head injury, which says that a player can return to play following assessment by medical staff. The rules also state that a player who is injured with head damage is not to be played for five days. [53]

Auto racing

The death of Dale Earnhardt at the 2001 Daytona 500, along with those of Kenny Irwin, Adam Petty and Tony Roper in 2000, and serious injuries sustained by Steve Park in a wreck in September 2001 at Darlington, led to NASCAR establishing numerous policies to assist in driver safety, such as the introduction of the Car of Tomorrow. Drivers were eventually instructed to wear both head and neck restraints, and SAFER barriers have been installed on racetrack walls, with foam-padded supports on each side of the helmet that would allow a driver's head to move in the event of a crash. Despite this, 29 identified concussions occurred between 2004 and 2012. [55]

In 2012, when Dale Earnhardt, Jr. suffered a concussion after being involved in a crash at the end of the Good Sam Roadside Assistance 500 at Talladega, NASCAR expressed consideration in adding baseline testing to its concussion policies. NASCAR was one of few motorsport organizations that do not have baseline testing, [56] though that ended in 2014, as baseline testing started being performed at the start of the seasons. [57]

Basketball

In the 2005 high school basketball year, 3.6% of reported injuries were concussions, with 30.5% of concussions occurring during rebounds. [58] Incidence rates for concussions in NCAA men's basketball is lower than NCAA women's basketball, at 0.16 concussion per 1,000 athletes compared to 0.22 per 1,000 athletes respectively. The difference is found mainly in competition activity compared to practice. [59]

Boxing

Despite boxing's violent nature, a National Safety Council report in 1996 ranked amateur boxing as the safest contact sport in America. [60] However, concussions are one of the most serious injuries that can occur from boxing, and in an 80-year span from 1918 to 1998, there were 659 boxers who died from brain injury. [61] Incidence rates for concussion in boxing may frequently be miscalculated due to the fact that concussions do not always result from a knockout blow. [62] Olympic boxers deliver punches with high impact velocity but lower HIC and translational acceleration than in football impacts because of a lower effective punch mass. They cause proportionately more rotational acceleration than in football. Modeling shows that the greatest strain is in the midbrain late in the exposure, after the primary impact acceleration in boxing and football.[ citation needed ]

Muhammad Ali, possibly the most famous boxer of all time, was “diagnosed with 'a cluster of symptoms that resemble Parkinson's disease,' known as Parkinson's syndrome, which his doctor believed were caused by numerous blows to the head,” which led to his death in 2016. [63]

Gymnastics

As many skills as gymnastics involve flipping or a blind landing, incidence of head injury increases. A 15-year study found an incidence of 1.7% for concussion and closed head injury for high school gymnasts.:) [59]

Ice hockey

Ice hockey has also been known to have concussions inflict numerous players. Because of this, the NHL made hockey helmets mandatory in the 1979–80 NHL season. [64] According to a data release by the National Academy of Neuropsychology's Sports Concussion Symposium, from 2006 to 2011, 765 NHL players were diagnosed with a concussion. [65] At the Mayo Clinic Sports Medicine Center Ice Hockey Summit: Action on Concussion conference in 2010, a panel made a recommendation that blows to the head are to be prohibited, and to outlaw body checking by 11- and 12-year-olds. For the 2010–11 NHL season, the NHL prohibited blindside hits to the head, but did not ban hits to the face. The conference also urged the NHL and its minor entities to join the International Ice Hockey Federation, the NCAA and the Ontario Hockey League in banning any contact to the head. [66]

The NHL has been criticized for allowing team doctors to determine whether an injured player can return to the ice, instead of independent doctors. [67]

Rugby union

Concussions are also a significant factor in rugby union, another full-contact sport. In 2011, the sport's world governing body, World Rugby (then known as the International Rugby Board, or IRB), issued a highly detailed policy for dealing with injured players with suspected concussions. Under the policy, a player suffering from a suspected concussion is not allowed to return to play in that game. Players are not cleared to play after the injury for a minimum of 21 days, unless they are being supervised in their recovery by a medical practitioner. Even when medical advice is present, players must complete a multi-step monitoring process before being cleared to play again; this process requires a minimum of six days. [68] In 2012, the IRB modified the policy, instituting a Pitchside Suspected Concussion Assessment (PSCA), under which players suspected of having suffered concussions are to leave the field for 5 minutes while doctors assess their condition via a series of questions. Players who pass the PSCA are allowed to return to play. [69]

However, an incident during the third Test of the 2013 Lions tour of Australia led to criticism of the current protocols. During that match, Australian George Smith clashed heads with the Lions' Richard Hibbard and was sent to pitchside. According to ESPN's UK channel, "despite looking dazed and confused, Smith passed the PSCA and was back on the field minutes later." [69]

In 2013, former Scotland international Rory Lamont charged that the current concussion protocols can easily be manipulated. A key part of the current protocols is the "Cogsport" test (also known as COG), a computer-based test of cognitive function. Each player undergoes the test before the start of a new season, and is then tested again on it after a head injury, and the results compared, to determine possible impairment. According to Lamont, some players deliberately do poorly on the pre-season test, so that they will be more likely to match or beat their previous results during play. [70]

Lamont was also critical of the PSCA, noting:

The Concussion bin was replaced by the head bin in 2012 with the players assessment taking 10 minutes. [71] If concussed the player must then recover by first returning to general activities in life, then progressing back to playing. Returning to play, the player must follow the Graduated Return to Play (GRTP) protocol, by having clearance from a medical professional, and no symptoms of concussion.

Female sports

Numerous reports have indicated that female athletes suffer more concussions than male athletes. [72] A December 2008 report states that 29,167 female high school soccer players in the United States suffered from concussions in 2005, compared to 20,929 male players. In high school basketball, 12,923 girls suffered from concussions while only 3,823 boys did. Girls also sustained more concussions in softball, compared to boys in baseball. [73] Female athletes also had longer recovery times than males, and also had lower scores on visual memory tests. Girls also have longer recovery times for concussions, which may be due to a greater rate of blood flow in the brain. [74]

Women's ice hockey was reported as one of the most dangerous sports in the NCAA, with a concussion rate of 2.72 per 1,000 player hours. Even though men's ice hockey allows body checking, while women's ice hockey does not, the rate of concussions for men is 46% lower, at 1.47 per 1,000 player hours. College football also has lower concussion rates than women's hockey, with a rate of 2.34 per 1,000. [75]

Women’s basketball is one of the women’s sports with the highest risks of getting a concussion. Women have a greater risk of getting a concussion by dribbling/ball handling rather than defending. Also it was found that female college basketball players typically receive concussions during games rather than practices. [76]

Prevention efforts and technology

There have been numerous attempts at preventing concussions, such as the establishment of the PACE (Protecting Athletes Through Concussion Education) program, [77] which works with the imPACT system, which is currently used by every NFL and some NHL teams. [78] In 2008, the Arena Football League tested an impact monitor created by Schutt Sports called the "Shockometer", which is a triangular device attached to the back of football helmets that has a light on the device that turns red when a concussion occurs. [79] Riddell has also created the Head Impact Telemetry System (HITS) and Sideline Response System (SRS) to record the frequency and severity of player hits during practices and games. On every helmet with the system, MX Encoders are implemented, which can automatically record every hit. [80] Eight NFL teams had originally planned to use the system in the 2010 season, but the NFL Players Association ultimately blocked its use. [81] Other impact-detection devices include CheckLight, by Reebok and MC10., [82] and the online test providers ImPACT Test, BrainCheck, and XLNTbrain which establish cognitive function baselines against which the athlete is monitored over time. The CCAT online tool developed by Axon Sports is another test to assist doctors in assessing concussion.

In addition to force impact sensors used to assess traumatic brain injury, studies have been conducted to assess levels of biological markers for the presence of brain concussion. A variety of concurrently researched biomarkers have been associated with concussions, including S100B, Tau protein and glial fibrillary acid protein (GFAP) [83] . In 2018, the FDA approved Banyan Biomarkers Inc. to market devices involving the use of blood samples to evaluate concussions in adults [84] . Banyan BTI (Brain Trauma Indicator) is a blood sample product that the FDA permitted for use before the decision to further assess head injury with CT scanning.

Efforts to manage concussion risk in youth and high school sports include online informational resources designed for coaches and parents. For example, the US Centre for Disease Control and Prevention created the HEADS UP program, a free online informational tool. It was first launched in 2007, with aims to improve concussion identification and management [85] . The online tool is available on CDC’s website and has been used by 2 million individuals to date [86] . The online resource was updated in 2016 and an interventional study conducted an assessment of the efficacy of the updated version [85] . In the study conducted by Daugherty et al., 180 000 youth and high school coaches were assessed for their knowledge about concussions before and after HEADS UP training. HEADS UP accounted for an increased understanding of proper return-to-play head trauma protocol in 25.3% of coaches after using it [85] .


Media coverage

In 2012, film producer Steve James created the documentary film Head Games , interviewing former NHL player Keith Primeau, and the parents of Owen Thomas, who hanged himself after sustaining brain damage during his football career at Penn. [87] The documentary also interviewed former athletes Christopher Nowinski, Cindy Parlow, and New York Times reporter Alan Schwarz, among other athletes, journalists, and medical researchers. [88]

League of Denial was a 2013 book by sports reporters Mark Fainaru-Wada and Steve Fainaru about concussions within the NFL. The American documentary series Frontline covered the topic in two episodes, one based on the book and also called "League of Denial", [89] and the other called "Football High" [90] Political sports journalist Dave Zirin has also covered the topic in detail. [91]

See also

Related Research Articles

Football player Sport person who plays football

A football player or footballer is a sport person who plays one of the different types of football. The main types of football are association football, American football, Canadian football, Australian rules football, Gaelic football, rugby league and rugby union.

Christopher Nowinski American professional wrestler

Christopher John Nowinski is an American author, co-founder and executive director of the Concussion Legacy Foundation; as well as a former professional wrestler with World Wrestling Entertainment (WWE). Nowinski was WWE's first Harvard alumnus, as he graduated with a BA in sociology. Nowinski also played college football at Harvard, where he was an All-Ivy defensive tackle. He is also recognized as the youngest Hardcore Champion in WWE history. Following his wrestling career, he wrote Head Games: Football's Concussion Crisis, which examined the long-term effects of head trauma among athletes, and also became a documentary.

Health issues in American football

Health issues in American football comprise a large number of health risks associated with participating in the sport. Injuries are relatively common in American football, due to its nature as a full-contact game. Injuries occur during both practice and games. Several factors can affect the frequency of injuries: epidemiological studies have shown older players can be at a greater risk, while equipment and experienced coaches can reduce the risk of injury. Common injuries include strains, sprains, fractures, dislocations, and concussions. Concussions have become a concern, as they increase the risk of mental illnesses like dementia and chronic traumatic encephalopathy (CTE). In individual leagues like the National Football League (NFL) and National Collegiate Athletic Association (NCAA), a public injury report is published containing all injured players on a team, their injury and the game-day status of each player.

Chronic traumatic encephalopathy Neurodegenerative disease caused by repeated head injuries

Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease caused by repeated head injuries. Symptoms may include behavioral problems, mood problems, and problems with thinking. Symptoms typically do not begin until years after the injuries. CTE often gets worse over time and can result in dementia. It is unclear if the risk of suicide is altered.

Fred Willis is a retired American football running back who played six seasons in the National Football League for the Cincinnati Bengals and Houston Oilers.

Second-impact syndrome (SIS) occurs when the brain swells rapidly, and catastrophically, after a person suffers a second concussion before symptoms from an earlier one have subsided. This second blow may occur minutes, days or weeks after an initial concussion, and even the mildest grade of concussion can lead to SIS. The condition is often fatal, and almost everyone who is not killed is severely disabled. The cause of SIS is uncertain, but it is thought that the brain's arterioles lose their ability to regulate their diameter, and therefore lose control over cerebral blood flow, causing massive cerebral edema.

Concussion grading systems are sets of criteria used in sports medicine to determine the severity, or grade, of a concussion, the mildest form of traumatic brain injury. At least 16 such systems exist, and there is little agreement among professionals about which is the best to use. Several of the systems use loss of consciousness and amnesia as the primary determinants of the severity of the concussion.

The fencing response is a peculiar position of the arms following a concussion. Immediately after moderate forces have been applied to the brainstem, the forearms are held flexed or extended for a period lasting up to several seconds after the impact. The fencing response is often observed during athletic competition involving contact, such as American football, hockey, rugby union, rugby league, Australian rules football and combat sports. It is used as an overt indicator of injury force magnitude and midbrain localization to aid in injury identification and classification for events including on-field and/or bystander observations of sports-related head injuries.

Pittsburgh Penguins Foundation organization

The Pittsburgh Penguins Foundation is a non-profit organization located in Pittsburgh, Pennsylvania. The Foundation began in July 20, 2010 with the support of the National Hockey League (NHL)'s Pittsburgh Penguins ownership group. The foundation offers preventative wellness and developmental programs, charity assist programs, promotes activity among youth and families while teaching life skills.

Health issues in youth sports

The health issues of youth sports are concerns regarding the health and wellbeing of young people between the ages of 6 and 18 who participate in an organized sport. Given that these athletes are physically and mentally underdeveloped, they are particularly susceptible to heat illness, eating disorders and injury; sufficiently severe conditions can result in death. Awareness and prevention are key factors in preventing many health issues in youth sports.

Helmet-to-helmet collision

Helmet-to-helmet collisions are occurrences in gridiron football when two players' helmets make head-to-head contact with a high degree of force. Intentionally causing a helmet-to-helmet collision is a penalty in most football leagues, including many high school leagues.

Prevention of mild traumatic brain injury involves taking general measures to prevent traumatic brain injury, such as wearing seat belts and using airbags in cars. Older people are encouraged to try to prevent falls, for example by keeping floors free of clutter and wearing thin, flat, shoes with hard soles that do not interfere with balance.

Concussions and other types of repetitive play-related head blows in American football have been shown to be the cause of chronic traumatic encephalopathy (CTE), which has led to player deaths and other debilitating symptoms after retirement, including memory loss, depression, anxiety, headaches, and sleep disturbances.

A sports-related traumatic brain injury is a serious accident which may lead to significant morbidity or mortality. Traumatic brain injury (TBI) in sports are usually a result of physical contact with another person or stationary object, these sports may include boxing, football, field/ice hockey, lacrosse, martial arts, rugby, soccer, wrestling, auto racing, cycling, equestrian, roller blading, skateboarding, skiing, or snowboarding.

A traumatic brain injury (TBI) is a blow, jolt or penetration to the head that disrupts the function of the brain. Most TBIs are caused by falls, jumps, motor vehicle traffic crashes, being struck by a person or a blunt object, and assault. Student-athletes may be put at risk in school sports, creating concern about concussions and brain injury. A concussion can be caused by

Concussions in Australian sport

Head injuries in sports of any level are the most dangerous and sickening kind of injuries that can occur in sport, and are becoming more common in Australian sport. Concussions are the most common side effect of a head injury and are defined as "temporary unconsciousness or confusion and other symptoms caused by a blow to the head." A concussion also falls under the category of Traumatic Brain Injury (TBI). Especially in contact sports like Australian rules football and Rugby issues with concussions are prevalent, and methods to deal with, prevent and treat concussions are continuously being updated and researched to deal with the issue. Concussions pose a serious threat to the patients’ mental and physical health, as well as their playing career, and can result in lasting brain damage especially if left untreated. The signs that a player may have a concussion are: loss of consciousness or non-responsiveness, balance problems, a dazed, blank or vacant look and/or confusion and unawareness of their surroundings. Of course the signs are relevant only after the player experiences a blow to the head.

Concussions in rugby union

Concussions in England's professional rugby union are the most common injury received. Concussion can occur where an individual experiences an impact to the head. Commonly occurring in high contact sporting activities; American football, boxing, and rugby. It can also occur in recreational activities like horse riding, jumping, cycling, and skiing. The reason being that it doesn't have to be something to strike you in the proximity of your brain, but can also be caused by rapid change of movement, giving the skull not enough time to move with your body, causing your brain to press against your skull. With rugby being such a contact and fast moving sport, it is no wonder why there is concussion and other head injuries occurring. With the development of equipment and training methods, these will help benefit the players on the field know what could happen and how they can help with preventing it.

Mark John Aubry is a Canadian physician and sports medicine specialist. He is the team physician for the Ottawa Senators, and serves as the Chief Medical Officer of both the International Ice Hockey Federation, and Hockey Canada. He researches and lectures on concussions, plays a leadership role for safety in sport, and is an injury prevention activist in minor ice hockey. He is a recipient of the Paul Loicq Award for his international work, and the Dr. Tom Pashby sports safety award for Canada.

Most documented cases of chronic traumatic encephalopathy have occurred in athletes involved in contact sports such as boxing, American football, wrestling, ice hockey, rugby and soccer. Other risk factors include being in the military, prior domestic violence, and repeated banging of the head. The exact amount of trauma required for the condition to occur is unknown. Below is a list of notable cases of CTE in sports.

References

  1. McCrory, P.; Feddermann-Demont, P.; Dvořák, J.; al, et (2017). "What is the definition of sports-related concussion: a systematic review". British Journal of Sports Medicine. 51: 877–887. doi:10.1136/bjsports-2016-097393.
  2. Mayo Clinic Staff. "Concussion Tests and diagnosis".
  3. "Concussions in sports - NFL Topics - ESPN". Espn.go.com. Retrieved 2012-06-30.
  4. 1 2 Harmon K. G.; Drezner J. A.; Gammons M.; Guskiewicz K. M.; Halstead M.; Herring S. A.; Roberts W. O. (2013). "American Medical Society for Sports Medicine position statement: concussion in sport". British Journal of Sports Medicine. 47 (1): 15–26. doi:10.1136/bjsports-2012-091941. PMID   23243113.
  5. Wedro, Benjamin. "Concussion". MedicineNet. Retrieved October 30, 2013.
  6. 1 2 3 4 5 Ganti, Latha; Khalid, Hussain; Patel, Pratik Shashikant; Daneshvar, Yasamin; Bodhit, Aakash N; Peters, Keith R (2014). "Who gets post-concussion syndrome? An emergency department-based prospective analysis". International Journal of Emergency Medicine. 7. doi:10.1186/s12245-014-0031-6. PMC   4306054 .
  7. 1 2 3 4 Livingston, Scott C (2011). "The Neurophysiology Behind Concussion Signs and Symptoms". International Journal of Athletic Therapy and Training. 16 (5): 5–9. doi:10.1123/ijatt.16.5.5.
  8. Bey, T; Ostick, B (2009). "Second impact syndrome". The western journal of emergency medicine. 10 (1): 6–10. PMC   2672291 . PMID   19561758.
  9. Edwards, Jonathan C; Bodle, Jeffrey D (2014). "Causes and Consequences of Sports Concussion". The Journal of Law, Medicine & Ethics. 42 (2): 128–32. doi:10.1111/jlme.12126. PMID   25040374.
  10. McPherson, April L.; Nagai, Takashi; Webster, Kate E.; Hewett, Timothy E. (2019). "Musculoskeletal Injury Risk After Sport-Related Concussion: A Systematic Review and Meta-analysis". The American Journal of Sports Medicine. 47 (7): 1754–1762. doi:10.1177/0363546518785901.
  11. McPherson, April L.; Nagai, Takashi; Webster, Kate E.; Hewett, Timothy E. (2019-06-01). "Musculoskeletal Injury Risk After Sport-Related Concussion: A Systematic Review and Meta-analysis". The American Journal of Sports Medicine. 47 (7): 1754–1762. doi:10.1177/0363546518785901. ISSN   0363-5465.
  12. Cantu RC (2007). "Chronic traumatic encephalopathy in the National Football League". Neurosurgery. 61 (2): 223–5. doi:10.1227/01.NEU.0000255514.73967.90. PMID   17762733.
  13. Pellman, E. J; Viano, D. C; Withnall, C; Shewchenko, N; Bir, C. A; Halstead, P. D (2006). "Concussion in professional football: Helmet testing to assess impact performance--part 11". Neurosurgery. 58 (1): 78–96, discussion 78–96. doi:10.1227/01.neu.0000196265.35238.7c. PMID   16385332.
  14. Ozolins, Bede; Aimers, Nicole; Parrington, Lucy; Pearce, Alan J. (2016). "Movement disorders and motor impairments following repeated head trauma: A systematic review of the literature 1990–2015". Brain Injury. 30 (8): 937–947. doi:10.3109/02699052.2016.1147080.
  15. Harmon, Kimberly G; Drezner, Jonathan A; Gammons, Matthew; Guskiewicz, Kevin M; Halstead, Mark; Herring, Stanley A; Kutcher, Jeffrey S; Pana, Andrea; Putukian, Margot; Roberts, William O (2013). "American Medical Society for Sports Medicine position statement: Concussion in sport". British Journal of Sports Medicine. 47 (1): 15–26. doi:10.1136/bjsports-2012-091941. PMID   23243113.
  16. Rivara, G R (2014). "Sports-Related Concussions in Youth: Improving the Science, Changing the Culture". Institute of Medicine; National Research Council. Retrieved 12 November 2014.
  17. "Sports-Related Concussion". www.reliasmedia.com. Retrieved 2019-11-03.
  18. Pfister, Ted; Pfister, Ken; Hagel, Brent; Ghali, William A.; Ronksley, Paul E. (2016-03-01). "The incidence of concussion in youth sports: a systematic review and meta-analysis". British Journal of Sports Medicine. 50 (5): 292–297. doi:10.1136/bjsports-2015-094978. ISSN   0306-3674. PMID   26626271.
  19. Hootman, J. M; Dick, R; Agel, J (2007). "Epidemiology of collegiate injuries for 15 sports: Summary and recommendations for injury prevention initiatives". Journal of Athletic Training. 42 (2): 311–9. PMC   1941297 . PMID   17710181.
  20. 1 2 3 4 Brady, Erik; Falgoust, J. Michael (2011-10-25). "Concussions now a hot issue as leagues toughen policies". Usatoday.Com. Retrieved 2012-06-30.
  21. Stephania BellFantasy SportsFollowArchive (2011-04-01). "7-day DL, return-to-play protocols part of MLB's new concussion policy - Fantasy Baseball - ESPN". Sports.espn.go.com. Retrieved 2012-06-30.
  22. "Baseball establishes seven-day DL in concussion policy". Content.usatoday.com. 2011-03-30. Retrieved 2012-06-30.
  23. "2017-2021 Basic Agreement" (PDF). Major League Baseball Players. Major League Baseball Players Association. Retrieved 28 April 2019.
  24. http://www.nba.com/official/concussion_policy_summary.html%5B%5D
  25. 1 2 "NBA concussion protocol explained". FanSided. 2016-06-06. Retrieved 2019-04-26.
  26. http://www.foxsports.com/nba/video?vid=699539523883%5B%5D
  27. "NFL to require sideline test after head blows – - CNN.com Blogs". Thechart.blogs.cnn.com. 2011-02-25. Retrieved 2012-06-30.
  28. Mayer, Larry (2012-11-12). "Cutler on mend after suffering concussion". Chicago Bears . Retrieved 2012-11-12.
  29. "How does the NFL's concussion protocol work?". SBNation.com. Retrieved 2018-03-20.
  30. 1958-, McClafferty, Carla Killough. Fourth down and inches : concussions and football's make-or-break moment. Minneapolis. ISBN   9781467710671. OCLC   828775853.
  31. "Johns Hopkins study of retired NFL players sheds light on concussion-related brain damage". The Hub. 2015-01-26. Retrieved 2018-04-19.
  32. 1 2 "NHL commissioner Gary Bettman pleased with league's concussion protocol - ESPN". Sports.espn.go.com. 2011-04-23. Retrieved 2012-06-30.
  33. Klein, Jeff Z. (2014-02-04). "Study Finds Changes in Brains of Hockey Players Who Had Concussions". The New York Times. ISSN   0362-4331 . Retrieved 2018-04-19.
  34. Kerr, Z. Y; Cortes, N; Caswell, A. M; Ambegaonkar, J. P; Hallsmith, K. R; Milbert, A. F; Caswell, S. V (2017). "Concussion Rates in U.S. Middle School Athletes, 2015-2016 School Year". American Journal of Preventive Medicine. 53: 914–918. doi:10.1016/j.amepre.2017.05.017. PMID   28739314.
  35. "Sport Concussion Assessment Tool – 3rd edition" (PDF). Sports Concussion Institute. 2013. Retrieved 28 September 2017.
  36. Larson, Aaron (24 March 2016). "Liability for Concussions in Youth Sports". ExpertLaw. Retrieved 28 September 2017.
  37. "Graduated Return to Play Protocol" (PDF). Sports Concussion Institute. 2008. Retrieved 28 September 2017.
  38. Cantu, Robert C., and Mark Hyman. "Soccer." Concussions and Our Kids: America's Leading Expert on How to Protect Young Athletes and Keep Sports Safe. Boston: Houghton Mifflin Harcourt, 2012. 40+. Print.
  39. Cook, Bob. "Study Reveals Many Girls Soccer Players Stay On Field Despite Concussions." Forbes. Forbes Magazine, 21 Jan. 2014. Web. 06 May 2014.
  40. Snow, Kate, Sarah Koch, Deirdre Cohen, and Jessica Hopper. "Concussion Crisis Growing in Girls' Soccer." NBC News. NBC, 9 May 2012. Web. 16 Feb. 2014.
  41. Levy, Michael L., Aimen S. Kasasbeh, Lissa C. Baird, Chiazo Amene, Jeff Skeen, and Larry Marshall. "Concussions in Soccer: A Current Understanding." Science Direct, Nov. 2012. Web. 12 Feb. 2014.
  42. Nelson, D. L., Guskiewicz, M. K.,…. & McCrea A. M., (2016). Age differences in recovery after sport-related concussion: a comparison of high school and collegiate athletes. Journal of Athletic Training, 51 (2), 142-152. doi: 10.4085/1062-6050-51.4.04
  43. McKeag, Douglas; Moeller, James L. (2007-01-01). ACSM's Primary Care Sports Medicine. Lippincott Williams & Wilkins. ISBN   9780781770286.
  44. SMH. "Sport-Related Concussion". Hughston.com. Archived from the original on 2013-02-06. Retrieved 2012-07-01.
  45. "Neuroscience for Kids - Football Concussions". Faculty.washington.edu. Retrieved 2012-07-01.
  46. Hadhazy, Adam (2008-09-02). "Concussions Exact Toll on Football Players Long After They Retire". Scientific American. Retrieved 2012-07-01.
  47. "Neuroscience for Kids - Soccer". Faculty.washington.edu. Retrieved 2012-07-04.
  48. Mozes, Alan. "Banning Soccer 'Headers' Won't Solve Concussion Problem: Study". U.S. News & World Report . Retrieved 13 July 2015.
  49. Seaman, Andrew (13 July 2015). "'Heading' bans in soccer may not be enough to stop concussions". Reuters . Retrieved 13 July 2015.
  50. Tysvaer, Alf Thorvald (1992). "Head and Neck Injuries in Soccer". Sports Medicine. 14 (3): 200–13. doi:10.2165/00007256-199214030-00006. PMID   1439395.
  51. "Mourinho angry as keepers injured". BBC Sport . 14 October 2006. Retrieved 16 October 2006.
  52. Downs, DS and D Abwender (2002). "Neuropsychological Impairment in Soccer Athletes.".
  53. 1 2 Gibson, Owen (November 4, 2013). "Concussion Rules under Spotlight in Wake of Hugo Lloris Row". The Guardian . Retrieved March 21, 2016.
  54. Malonie, Jamie, Linda Nield, and Matthew Livley. "Can Headgear Halt Soccer Concussions?" Consultant For Paediatricians, July 2013. Web. 04 Mar. 2014
  55. "NASCAR drivers have concussion concerns - Racing - SI.com". Sportsillustrated.cnn.com. 2012-02-21. Retrieved 2012-07-01.
  56. Bandoim, Lana. "NASCAR May Be Considering Changes to Its Concussion Policies: Fan View". Yahoo! Sports . Retrieved 2012-10-21.
  57. Gluck, Jeff (2013-10-24). "NASCAR will mandate baseline concussion testing in 2014". USA Today . Retrieved 2013-10-24.
  58. "Concussions becoming a concern in basketball | basketball, becoming, concern - Sports - Colorado Springs Gazette, CO". Gazette.com. Retrieved 2012-07-04.
  59. 1 2 Daneshvar, Daniel H; Nowinski, Christopher J; McKee, Ann C; Cantu, Robert C (2011). "The Epidemiology of Sport-Related Concussion". Clinics in Sports Medicine. 30 (1): 1–17, vii. doi:10.1016/j.csm.2010.08.006. PMC   2987636 . PMID   21074078.
  60. "Concussions in Boxing | iSport.com". Boxing.isport.com. Retrieved 2012-07-01.
  61. "–". Usatoday.com. 2011-08-29. Retrieved 2012-07-04.
  62. Koh, Jae O; Cassidy, J. David; Watkinson, E. Jane (2009). "Incidence of concussion in contact sports: A systematic review of the evidence". Brain Injury. 17 (10): 901–17. doi:10.1080/0269905031000088869. PMID   12963556.
  63. "Boxing Great Muhammad Ali's 'Sad Decline' from Brain Damage Explored in New Biography". PEOPLE.com. Retrieved 2018-04-19.
  64. Stubbs, Dave (2012-06-19). "Dave Stubbs: Max Pacioretty richly deserves Masterton trophy". Montrealgazette.com. Retrieved 2012-07-14.
  65. "Bigger Hockey Players Causing More Concussions". LiveScience. 2008-11-10. Retrieved 2012-07-04.
  66. Klein, Jeff (2010-10-20). "Hockey Urged to Ban All Blows to Head by Concussions Panel". The New York Times.
  67. Proteau, Adam. "NHL Can Do More To Prevent Concussions". The Hockey News. Retrieved October 30, 2013.
  68. "IRB Concussion Guidelines". International Rugby Board. 2011-05-24. Retrieved 2013-02-16.
  69. 1 2 "Lamont: Players are cheating concussion tests". ESPN Scrum. 27 July 2013. Retrieved 26 December 2013.
  70. 1 2 Lamont, Rory (19 December 2013). "'Players are deliberately cheating concussion tests'". ESPN Scrum. Retrieved 26 December 2013.
  71. "Rugby is still holding the concussion bomb with tongs in spite of warnings". Irish Independent . Retrieved 13 September 2016.
  72. "Girls, sports and concussions" . Retrieved 2015-10-07.
  73. "High school headaches: Girls' concussions outnumber boys' in most sports". News.medill.northwestern.edu. Archived from the original on 2013-12-14. Retrieved 2012-07-04.
  74. "Concussions: Girls Have Longer Recovery Time". Webmd.com. 2012-05-11. Retrieved 2012-07-04.
  75. Klein, Jeff Z. (2010-10-19). "Women's Hockey, a Most Dangerous Game - NYTimes.com". Slapshot.blogs.nytimes.com. Retrieved 2012-07-04.
  76. "The Epidemiology of Sport-Related Concussion." Clin Sports Med, 1 Jan. 2012. Web. 8 Feb. 2013.
  77. PACE program website Archived 2012-07-05 at the Wayback Machine
  78. "Drew Brees Teams Up Against Concussions in School Sports - ABC News". Abcnews.go.com. 2012-06-26. Retrieved 2012-07-04.
  79. "AFL-Test-Drives-Schutt'S-Shockometer / News". NFLPlayers.com. 2008-05-22. Retrieved 2012-07-04.
  80. "HITS™ Technology". Riddell. Archived from the original on 2012-06-23. Retrieved 2012-06-26.
  81. "Failure to use HIT system exposes league to future concussion liability | ProFootballTalk". Profootballtalk.nbcsports.com. Retrieved 2012-06-26.
  82. https://www.bostonglobe.com/business/2013/07/14/reebok-introduce-concussion-sensor-for-sports/s7L509zIM5lBrHXb0ylDDM/story.html
  83. Papa, Linda. "Potential Blood-Based Biomarkers for Concussion". Sports Medicine and Anthroscopy Review. 24 (3): 108-115. doi:10.1097/JSA.0000000000000117. PMID   27482776 . Retrieved 3 November 2019.
  84. "FDA authorizes marketing of first blood test to aid in the evaluation of concussion in adults". U.S. Food and Drug Administration. FDA. Retrieved 3 November 2019.
  85. 1 2 3 Daugherty, Jill (May 6 2019). "Effectiveness of the US Centers for Disease Control and Prevention HEADS UP coaches' online training as an educational intervention". Heatlh Education Journal. 78 (7): 784-797. doi:10.1177/0017896919846185 . Retrieved 6 May 2019.Check date values in: |date= (help)
  86. "HEADS UP to Youth Sports". Centers for Disease Control and Prevention. CDC. Retrieved 3 November 2019.
  87. "'Head Games' Film Focuses on Concussions, Asks If Enough is Being Done". Athleticbusiness.com. Retrieved 2012-07-14.
  88. "Head Games: The People". Headgamesthefilm.com. Retrieved 2012-07-14.
  89. League of Denial
  90. Football High
  91. The Collision of Sports and Politics