tag:theconversation.com,2011:/ca/topics/concussions-14088/articlesConcussions – The Conversation2024-02-07T13:13:04Ztag:theconversation.com,2011:article/2223492024-02-07T13:13:04Z2024-02-07T13:13:04ZCould flag football one day leapfrog tackle football in popularity?<figure><img src="https://images.theconversation.com/files/573480/original/file-20240205-21-8bd16d.jpg?ixlib=rb-1.1.0&rect=12%2C6%2C2032%2C1355&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Youth flag football players run drills with their coach before a game in Dayton, Ohio, on Oct. 8, 2023.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/flag-football-team-beavercreek-raiders-run-drills-with-news-photo/1850858257?adppopup=true">Megan Jelinger/The Washington Post via Getty Images</a></span></figcaption></figure><p>One hundred years into the future, what if millions of people gathered every February, not to watch the Super Bowl, but to instead watch the annual world flag football championship?</p>
<p>Once a casual activity played at family reunions, the competitive sport of flag football is “<a href="https://www.usatoday.com/story/sports/2023/10/22/flag-football-why-sport-is-becoming-so-popular-with-girls-kids/71270522007/">soaring</a>,” “<a href="https://www.cnn.com/2023/10/17/sport/flag-football-nfl-olympics-cec/index.html">exploding</a>” and “<a href="https://www.cbsnews.com/news/flag-football-popularity-girls-women/">skyrocketing in popularity nationwide</a>,” according to mainstream news outlets.</p>
<p>There’s some data behind the breathless headlines: According to the <a href="https://nflflag.com/about">NFL’s official flag football program</a>, since 2015 the number of kids ages 6 to 12 who play flag football has risen by 38%, to more than 1.5 million.</p>
<p>In my recent book, “<a href="https://link.springer.com/book/10.1007/978-3-030-76457-9">Emerging Sports as Social Movements</a>,” I explore nontraditional sports like flag football and disc golf. One of my key findings is that splashy headlines about trendy sports rarely capture a sport’s true reach and staying power. </p>
<p>For every sport like pickleball that gains widespread, sustained popularity, there are several – <a href="https://www.usara.com/new-to-adventure-racing/whatisadventureracing">adventure racing</a>, paintball and wakeboarding – that remain firmly ensconced in their niche.</p>
<p>In the case of flag football, there are a handful of recent trends that truly do point to a promising future. But there are also some red flags that could end up hampering its growth.</p>
<h2>A fun, fast, safer alternative</h2>
<p>Though its rules are similar to tackle football, flag football is currently gaining attention for what makes it different. </p>
<p>It’s considered a no-contact sport. A “tackle” involves snatching one of two flags that hang from the hips of the ball carrier. While players face injury risks, they sustain <a href="https://www.cdc.gov/traumaticbraininjury/pubs/youth_football_head_impacts.html">far fewer head impacts</a> than athletes who play tackle football.</p>
<p>With the public’s concerns about brain injuries <a href="https://www.usnews.com/news/health-news/articles/2023-01-24/youth-football-participation-declining-amid-safety-concerns">on the rise</a>, many parents are opting for flag football instead of tackle for their kids.</p>
<p>Obscurity is a powerful barrier to emerging sports. But getting noticed may not be a problem for flag football.</p>
<p>The International Olympic Committee <a href="https://www.nfl.com/partners/flag-football/">announced in October 2023</a> that flag football would be headed to the Summer Games in Los Angeles in 2028. It’s not clear yet if active NFL players can compete, but if they are eligible – and if the U.S. assembles a “<a href="https://www.sportingnews.com/us/nba/news/dream-team-roster-history-usa-1992-olympics/4o78v2slilky1inrskk8h6wkb">Dream Team</a>” like the Olympic men’s basketball team of 1992 that included superstars Michael Jordan, Larry Bird and Magic Johnson – flag football could get on the radar of millions of casual sports fans in 2028.</p>
<p>The Olympic version of flag football is fast-paced.</p>
<p>Games are shorter than a typical game of tackle football. Five players compete on 50-yard fields with 10-yard end zones for two 20-minute halves. This format made its first big appearance in the <a href="https://olympics.com/en/news/flag-football-rules-players-origins-things-to-know">2022 World Games</a> in Birmingham, Alabama, where the U.S. men won gold and the women took home silver.</p>
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<figcaption><span class="caption">A short overview of how to play flag football.</span></figcaption>
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<h2>The NFL cultivates the grassroots</h2>
<p>Although it may come as a surprise, the NFL is embracing flag football and taking its growth seriously.</p>
<p>In 2021, the NFL and Nike committed <a href="https://www.wsj.com/articles/nfl-and-nike-court-a-new-football-market-girls-11612854854">US$5 million in equipment</a> to support high school flag football teams across the nation. The NFL’s <a href="https://playfootball.nfl.com/about-youth-football/find-a-league/">official flag football program</a> operates more than 1,600 local leagues and receives sponsorships from top brands like Visa, Gatorade and Subway.</p>
<p>Most NFL teams are currently supporting the grassroots of flag football with summer camps, clinics and regional tournaments.</p>
<p>During last year’s Super Bowl, an estimated 115 million viewers watched <a href="https://www.usatoday.com/videos/sports/Ad-Meter/2023/02/13/ad-meter-2023-nfl-run/11245547002/">a flag football TV commercial</a> featuring Mexican quarterback Diana Flores bobbing and spinning to evade NFL players and celebrities as they attempted to take her flag. </p>
<p>On Feb. 4, 2024, the Pro Bowl – the NFL’s annual all-star game – sidelined tackle football for the second year in a row. In its place was a 7-on-7 flag football game that aired on ESPN and ABC and streamed on ESPN+.</p>
<p>Prior to that game, on Feb. 2-3, the league also hosted the <a href="https://www.nfl.com/news/nfl-hosts-12-international-youth-flag-football-teams-at-2024-pro-bowl-games">International NFL Flag Championships</a> as part of the Pro Bowl Games, featuring young athletes from 12 countries.</p>
<h2>By the numbers</h2>
<p>Flag football may be having a moment, but the question remains: Is the sport actually experiencing a meaningful surge in participation that could extend into the future?</p>
<p>According to figures collected annually by the <a href="https://www.nfhs.org/">National Federation of High Schools</a>, 21,980 students played high school flag football in 2023. To put this number in context, however, tackle football attracted 47 times more students – roughly 1 million players – the same year. Track and field, basketball and soccer have roughly 1 million participants apiece.</p>
<p>Interest in flag football seems to be concentrated in a few regions, with roughly <a href="https://www.nfhs.org/">80% of high school players</a> living in just three states: Florida, Georgia and New York.</p>
<p>Though high school participation in flag football has <a href="https://www.nfhs.org/">increased steadily</a> since 2007, almost all the growth comes from the girls’ side.</p>
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<p>A nationwide <a href="https://sportsmarketanalytics.com/home.aspx">sports participation survey</a> finds that the number of casual players of flag football is up, but core participation is down. The study defines “casual players” as those who play fewer than 50 times per year, whereas “core players” participate 50 or more times each year.</p>
<p>The <a href="https://sportsmarketanalytics.com/home.aspx">share of Americans</a> who play casually increased by 41% between 2016 and 2022. But core participation declined by 13% during this period.</p>
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<p>For sustainable growth, nontraditional sports need to generate excitement among both core and casual players. Top-down investments and marketing strategies may attract new players, but grassroots organizing keeps them coming back.</p>
<p>Take pickleball. In recent years, the sport has generated plenty of cultural clout, with high-profile athletes like LeBron James investing in the professional circuit, and <a href="https://www.paddletek.com/blogs/news/celebrities-in-pickleball">celebrity pickleball players</a> making headlines. There has also been <a href="https://theconversation.com/pickleballs-uphill-climb-to-mainstream-success-193052">tremendous growth</a> in pickleball’s social and physical infrastructure. For these reasons, both casual and core participation in pickleball <a href="https://sportsmarketanalytics.com/home.aspx">more than doubled</a> between 2016 and 2022.</p>
<h2>Red sport, blue sport</h2>
<p>In the end, the future of flag football may hinge on the public debate over tackle football’s safety. Over the past decade, <a href="https://theconversation.com/childrens-high-impact-sports-can-be-abuse-experts-explain-why-222651">several studies</a> have found a link between repeated head impacts and the risk for serious brain injuries, <a href="https://www.bu.edu/cte/our-research/significant-research-findings/">including chronic traumatic encephalopathy</a>, or CTE.</p>
<p>Yet <a href="https://www.cbsnews.com/sanfrancisco/news/california-youth-tackle-football-ban-clears-first-legislative-hurdle-assembly-committee-ab734/">recent efforts</a> to make tackle football safer for young athletes have been met with <a href="https://doi.org/10.1353/jsm.2019.0002">fierce resistance</a> from families, fans and organizers. In many regions of the U.S., tackle football is deeply ingrained in the culture, leading to strong opposition to any changes.</p>
<p>New rules to protect NFL players have seeped into mainstream politics. For instance, in 2019, former <a href="https://www.forbes.com/sites/bobcook/2019/02/03/donald-trump-who-wants-more-violence-in-the-nfl-doesnt-want-his-son-playing-football/?sh=5ffeb68a342a">President Donald Trump</a> dubbed the NFL’s concussion protocol “soft” and said that safety measures were “ruining the game.”</p>
<p>Meanwhile, Democratic state lawmakers in New York, Illinois and California have <a href="https://www.cbsnews.com/sacramento/news/governor-newsom-says-he-wont-sign-bill-banning-tackle-football-for-young-kids/">introduced bills to ban tackle football for kids under 12</a>, often citing flag football as a suitable alternative. None of these bills, however, have passed.</p>
<figure class="align-center ">
<img alt="Two teenaged girls fight for a ball." src="https://images.theconversation.com/files/573483/original/file-20240205-27-v9xcvh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/573483/original/file-20240205-27-v9xcvh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=440&fit=crop&dpr=1 600w, https://images.theconversation.com/files/573483/original/file-20240205-27-v9xcvh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=440&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/573483/original/file-20240205-27-v9xcvh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=440&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/573483/original/file-20240205-27-v9xcvh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=553&fit=crop&dpr=1 754w, https://images.theconversation.com/files/573483/original/file-20240205-27-v9xcvh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=553&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/573483/original/file-20240205-27-v9xcvh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=553&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Flag football has become more popular among girls and women.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/long-beach-ca-lilianna-sarmiento-of-jordan-reaches-for-a-news-photo/1743556245?adppopup=true">Keith Birmingham/Pasadena Star-News via Getty Images</a></span>
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</figure>
<p>Some research shows that <a href="https://doi.org/10.1080/19406940.2018.1524784">Democrats are more likely to trust concussion science than Republicans</a>. Democrats also <a href="https://doi.org/10.3389/fspor.2021.655890">pay more attention to news about concussions</a> than Republicans. </p>
<p>As beliefs about the dangers of tackle football become polarized, the perceived benefits of flag football will likely follow suit. As I showed in a recent study of sport popularity in 207 areas of the U.S., <a href="https://doi.org/10.1080/19406940.2022.2074516">flag football is more popular in regions that tend to vote Democratic</a>, with tackle football more popular in Republican areas.</p>
<p>So in addition to going after the resources needed for sustainable growth – investment, organization, visibility, legitimacy – flag football’s advocates will also need to navigate a nation divided by politics.</p><img src="https://counter.theconversation.com/content/222349/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Josh Woods does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The NFL’s embrace of the sport points to a promising future. But gender and political divides could stand in the way.Josh Woods, Professor of Sociology, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2214032024-01-31T13:36:42Z2024-01-31T13:36:42ZSleep can give athletes an edge over competitors − but few recognize how fundamental sleep is to performance<figure><img src="https://images.theconversation.com/files/571989/original/file-20240129-15-rvkoy3.jpg?ixlib=rb-1.1.0&rect=8%2C0%2C2663%2C1778&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Sleep has been an underappreciated strategy for gaining an edge over an opponent at any level of athletic competition.</span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/ChiefsRavensFootball/47d36cdc32f2464d8b6aaed9cba32412/photo?Query=football%20playoffs&mediaType=photo,video,graphic,audio&sortBy=&dateRange=now-24h&totalCount=54&currentItemNo=44">AP Photo/Alex Brandon</a></span></figcaption></figure><p>In the adrenaline-packed world of professional sports, the power of sleep rarely gets adequate attention.</p>
<p>A healthy sleep pattern can be a stealthy game plan for athletes to gain an edge over their opponents. Only a <a href="https://www.cnbc.com/2018/12/21/lebron-james-reveals-the-nighttime-routine-that-sets-him-up-for-success.html">few top elite athletes</a> know the secret of early bedtimes for optimal performance.</p>
<p>Sleep is vital not only for keeping the mind sharp and body healthy but also for excelling in all fields in life – whether <a href="https://theconversation.com/school-start-times-and-screen-time-late-in-the-evening-exacerbate-sleep-deprivation-in-us-teenagers-179178">in the classroom</a>, on the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5158299/">battlefield</a> or in <a href="https://doi.org/10.1093/sleep/zsab051">other professional arenas</a>. </p>
<p>As a <a href="https://www.neurology.pitt.edu/people/joanna-fong-isariyawongse-md-faes-faan">neurologist specializing in sleep medicine</a> at the University of Pittsburgh, I have devoted my career to understanding and advocating for the importance of sleep health. </p>
<p>Here are some key facts to understand why sleep matters.</p>
<h2>The critical role of sleep in performance</h2>
<p>Sleep is a complex, <a href="https://www.sleepfoundation.org/stages-of-sleep#">cyclical process</a> that progresses through several stages, each with distinct characteristics and functions. Initially, it begins with light sleep, <a href="https://www.ncbi.nlm.nih.gov/books/NBK526132/#">encompassing stages 1 and 2</a>, where the body starts to relax and brain wave activity begins to slow down. </p>
<p>These stages are followed by deep sleep, also known as <a href="https://www.sleepfoundation.org/stages-of-sleep/slow-wave-sleep#:">slow-wave sleep</a>, where the body undergoes significant restorative processes. The final stage is <a href="https://my.clevelandclinic.org/health/body/12148-sleep-basics">rapid eye movement</a>, or REM sleep, characterized by vivid dreams and increased brain activity. Typically, a person cycles through these stages four to six times each night, with each cycle lasting approximately 90 minutes. </p>
<p>Sleep is when our bodies heal. Deep sleep helps repair muscles and bones through several key mechanisms, including the release of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2824213/">human growth hormone</a> – a protein produced in the pituitary gland – and various <a href="https://doi.org/10.1038/npp.2016.148">anti-inflammatory agents</a>. </p>
<p><a href="https://www.health.harvard.edu/diseases-and-conditions/growth-hormone-athletic-performance-and-aging">Human growth hormone is a key player</a> in <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2824213/">muscle development, tissue repair</a> and <a href="https://doi.org/10.1210/er.2008-0027">metabolism</a>, and is it vital for maintaining physical health. It significantly enhances the body’s capacity for self-repair, be it following an intense sports event or recovering from a sports-related injury. </p>
<p>In addition, sleep helps your brain to recalibrate through the waste-clearing <a href="https://doi.org/10.1016/j.sleep.2022.11.012">glymphatic system</a>, which is part of the central nervous system. Think of it as a dishwasher in your brain, flushing out waste products, including neurotoxic proteins such as <a href="https://doi.org/10.3389/fphar.2015.00221">amyloid-beta</a>, <a href="https://doi.org/10.1111%2Fj.1755-5949.2010.00177.x">abnormal tangles of a protein called tau</a> and <a href="https://doi.org/10.1101%2Fcshperspect.a009399">alpha-synuclein proteins</a>. </p>
<p>All three of those proteins have direct association with neurodegenerative diseases such as <a href="https://doi.org/10.1001/jamaneurol.2023.3889">Alzheimer’s dementia</a> and <a href="https://doi.org/10.1016/j.neubiorev.2017.08.016">chronic traumatic encephalopathy</a>, a disorder thought to be caused by repeated head injuries. For athletes, maintaining proper brain health and cognitive function is paramount.</p>
<p>In addition, deep sleep <a href="https://doi.org/10.1007/s00424-011-1044-0">strengthens the immune system</a> to help keep us healthy and free of illnesses.</p>
<p>REM sleep is the most active stage of sleep, the one in which we experience dreams. This contrasts with deep sleep, where the brain enters a state of synchronized slow waves, indicative of restorative rest. REM sleep is <a href="https://doi.org/10.1007/s11910-013-0430-8">essential for memory</a> and <a href="https://doi.org/10.3389/fpsyg.2019.00459">emotion processing</a>, which help with recall and reducing anxiety. </p>
<p>Athleticism by its purest definition and overall body control can often be linked to the benefits of Stage 2 sleep, which has been shown to play an instrumental role in the <a href="https://doi.org/10.1371/journal.pbio.1002429">consolidating of motor sequence memories</a> and physical skills learned during practice.</p>
<p>To fully benefit from these sleep cycles, adults need <a href="https://www.sciencedirect.com/science/article/abs/pii/S2352721815000157?via%3Dihub">seven to nine hours</a> of sleep per night. This duration ensures that they complete the necessary four to six sleep cycles, allowing their bodies and minds to fully experience the restorative effects of each sleep stage, which is essential for optimal health and performance.</p>
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<figcaption><span class="caption">Sleep is a performance enhancer, if you do it right.</span></figcaption>
</figure>
<h2>How sleep helps prevent injuries</h2>
<p>In professional sports, more training and higher pressure increase the chances of getting hurt. Research shows that collegiate athletes who sleep less than seven hours per night are <a href="https://doi.org/10.1249/JSR.0000000000000849">nearly twice as likely to get injured</a> when compared with those who sleep more than eight hours. In a game like football, where split-second decisions can lead to a touchdown or interception, a well-rested brain is the best tool for quick thinking and staying free of injury. </p>
<p>Good sleep also cuts down on the <a href="https://doi.org/10.1016/j.sleep.2019.03.008">risk of concussions</a>, which, sadly, are pretty common in sports. Up to <a href="https://doi.org/10.1097/00001199-200609000-00001">3.8 million cases</a> of concussions occur annually in the U.S. during competitive sports. Studies have shown that <a href="https://doi.org/10.1016/j.sleep.2019.03.008">sleepy athletes</a> are nearly three times more likely to suffer a concussion.</p>
<p>Sleep deficits have been linked to decreased performance in every cognitive measure, including <a href="https://doi.org/10.1093/sleep/zsab051">vigilant attention, spatial cognition</a> and tasks involving <a href="https://doi.org/10.1016/j.jadohealth.2013.12.034">inhibitory control</a>. On the sports field, this translates to sleepy athletes making more impulsive and risky decisions. </p>
<h2>Enhancing athletic performance through ample sleep</h2>
<p>Athletes of any level, even at the highest levels of competition, could gain a competitive edge by giving more attention to the value of sleep. Studies focusing on <a href="https://doi.org/10.1249/MSS.0b013e31820abc5a">sprinters</a>, <a href="https://doi.org/10.1016/j.physbeh.2013.07.002">tennis players</a> and <a href="https://doi.org/10.1249/MSS.0b013e31820abc5a">endurance athletes</a> have found that sleep can enhance the following four key abilities: </p>
<ul>
<li><p><a href="https://doi.org/10.1249/MSS.0b013e31820abc5a">Speed, strength and endurance</a>: More sleep can lead to faster sprint times, greater strength and <a href="https://doi.org/10.1007/s00421-009-1103-9">higher endurance</a>, which are crucial in sports where every second counts. Adequate sleep enhances muscle recovery and energy restoration, which are crucial for the strength and power needed in sprinting. </p></li>
<li><p>Accuracy and reaction time: One study found that tennis players who got more sleep showed better <a href="https://doi.org/10.1016/j.physbeh.2013.07.002">accuracy and faster reaction times</a>. Increased sleep enhances brain function by boosting cognitive processes such as focus, <a href="https://doi.org/10.1093/sleep/zsab051">decision-making</a> and sensory perception. Well-rested individuals also experience <a href="https://doi.org/10.1371/journal.pbio.1002429">better neuromuscular coordination</a>, essential for precise movements and quick responses. </p></li>
</ul>
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<figcaption><span class="caption">Sleep can make a critical difference when it comes to split-second decision-making.</span></figcaption>
</figure>
<ul>
<li><p>Cognitive skills and inhibitory control: Good sleep helps with <a href="https://doi.org/10.1093/sleep/zsab051">strategizing and decision-making</a> through improved recall and a clearer mind, thanks to the cleansing action of the glymphatic system. Sleep deprivation, on the other hand, can impair cognitive abilities, as evidenced in <a href="https://doi.org/10.1093/sleep/zsab051">research involving NASA recruits</a>. </p></li>
<li><p>Pain tolerance: More sleep can lead to <a href="https://doi.org/10.5665/sleep.1830">increased pain tolerance</a>, playing a vital role in the quality of life and recovery process following injuries or intense physical exertion. While the exact mechanisms are complex and involve a two-way relationship between sleep and pain, this benefit is particularly important in physically demanding sports. Improved pain tolerance can aid athletes not only in recovery but also in maintaining mental well-being, allowing them to focus on rehabilitation and training without being overly hindered by discomfort. </p></li>
</ul>
<h2>Essential sleep tips for peak performance</h2>
<p>Here are some practical and effective sleep tips tailored for athletes, designed to help them harness the power of sleep for top-notch performance in their respective sports: </p>
<ul>
<li><p>Consistency and quantity: A regular sleep schedule is crucial for peak performance. Athletes should make sure they’re getting eight to 10 hours of sleep, not just the day before a big game but every day throughout the competitive season. </p></li>
<li><p>Environment: A sleep-conducive environment – dark, quiet and cool – is essential to getting a restful night’s sleep.</p></li>
<li><p>Pre-sleep routines: Relaxing activities such as reading, stretching and meditation before bed can enhance sleep quality.</p></li>
<li><p>Screen limits: <a href="https://theconversation.com/school-start-times-and-screen-time-late-in-the-evening-exacerbate-sleep-deprivation-in-us-teenagers-179178">Reducing screen time</a> before bed helps maintain natural sleep rhythms and the production of melatonin.</p></li>
<li><p><a href="https://theconversation.com/whats-the-best-diet-for-healthy-sleep-a-nutritional-epidemiologist-explains-what-food-choices-will-help-you-get-more-restful-zs-219955">Dietary considerations</a>: Avoiding caffeine, alcohol and heavy meals before sleep aids in restfulness.</p></li>
<li><p><a href="https://theconversation.com/short-naps-can-improve-memory-increase-productivity-reduce-stress-and-promote-a-healthier-heart-210449">Strategic napping</a>: Short, well-timed naps can be a valuable tool for recovery and achieving peak performance. </p></li>
<li><p>Sleep banking: To prepare for travel when you anticipate reduced sleep, consider sleeping longer beforehand. This can be achieved either through extra napping or by extending your regular nightly sleep. </p></li>
</ul>
<p>It’s important for any athlete to remember that sleep isn’t a weakness. Success as an athlete is about more than just physical training and tactical preparedness; it’s also about harnessing the power of sleep for optimal performance.</p><img src="https://counter.theconversation.com/content/221403/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Joanna Fong-Isariyawongse does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Studies show college athletes sleeping less than 7 hours per night are almost twice as likely to be injured when compared with athletes sleeping more than 8 hours.Joanna Fong-Isariyawongse, Associate Professor of Neurology, University of PittsburghLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2142162023-11-14T13:25:01Z2023-11-14T13:25:01ZBrains have a remarkable ability to rewire themselves following injury − a concussion specialist explains the science behind rehabilitation and recovery<figure><img src="https://images.theconversation.com/files/558408/original/file-20231108-15-h36ch4.jpg?ixlib=rb-1.1.0&rect=0%2C5%2C3594%2C2387&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Every brain injury is unique, as is every person's path to recovery. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/surgery-medical-team-surgical-doctor-teamwork-royalty-free-image/1218284504?phrase=concussion&adppopup=true">Chinnapong/iStock via Getty Images Plus</a></span></figcaption></figure><p>High-profile sports like football and soccer have <a href="https://theconversation.com/concussions-can-cause-disruptions-to-everyday-life-in-both-the-short-and-long-term-a-neurophysiologist-explains-what-to-watch-for-192390">brought greater attention in recent years</a> to concussions – the mildest form of <a href="https://www.cdc.gov/traumaticbraininjury/index.html">traumatic brain injury</a>. </p>
<p>Yet people often do not realize how common concussions are in everyday life, and seldom does the public hear about what happens in the aftermath of concussions – how long the road to recovery can be and what supports healing. Concussions are important to understand, not only for recovery, but also for the insights that the science of recovery can bring to brain health.</p>
<p>I am a speech language pathologist and an <a href="https://som.cuanschutz.edu/Profiles/Faculty/Profile/28113">instructor in physical medicine and rehabilitation</a>. I specialize in brain injury rehabilitation, with experience ranging from coma recovery to concussion care. </p>
<p>Treating problems tied to head injuries is complex. This is, in part, because it is not possible to directly examine the brain of a living person and because every brain injury is unique. Many aspects of health, both pre- and post-injury, affect recovery. In treating brain injuries, I work to translate this specialized science for each patient and their unique situation.</p>
<h2>Brain injury can take many forms</h2>
<p>While people commonly think of athletes when it comes to concussions, <a href="https://theconversation.com/the-risk-of-concussion-lurks-at-the-super-bowl-and-in-all-other-sports-176541">sports-related concussions</a> are just one type of mild brain injury seen in health care practice. Concussions can also result from <a href="https://ninds.nih.gov/health-information/disorders/traumatic-brain-injury-tbi">abusive head trauma, blast exposure, car accidents and falls</a>. </p>
<p>The severity of a brain injury is diagnosed based on symptoms, brain imaging and a neurologic exam. Concussions are characterized by a lack of clear tissue damage seen on <a href="https://my.clevelandclinic.org/health/diagnostics/22966-brain-mri">brain images like an MRI</a> and by the length of time that a person loses consciousness – defined as between zero to 30 minutes. </p>
<p>In addition, a significant portion of concussions <a href="https://doi.org/10.1136/bjsports-2012-091941">may not be identified or formally diagnosed at all</a>. Even if you do not lose consciousness at the time of an injury, you could still have a concussion. Confusion, sensitivity to noise and lights and even changes to sleep and mood are common symptoms. But often, these signs <a href="https://www.youtube.com/watch?v=P2wrNGrVHLk&t=11s">may be misunderstood as signs of stress or shock during traumatic events</a>, such as a car accident. Some people mistakenly assume that if they don’t lose consciousness, they haven’t experienced a concussion.</p>
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<figcaption><span class="caption">Some people mistakenly assume that if they don’t lose consciousness, they haven’t experienced a concussion.</span></figcaption>
</figure>
<p>People who don’t feel that they have returned to normal after a concussion may need further treatment. Many report chronic symptoms that linger beyond the typical three-month recovery – a condition known as <a href="https://www.mayoclinic.org/diseases-conditions/post-concussion-syndrome/symptoms-causes/syc-20353352#">post-concussive syndrome</a>. Around 10% of those who suffer a concussion experience post-concussive syndrome, although differences in how this problem is defined and recorded leads to <a href="https://doi.org/10.3171/2015.6.JNS15664">highly variable estimates across studies</a>.</p>
<p>So how does having a concussion affect the brain over time? </p>
<p>The links between concussion and dementias such as chronic traumatic encephalopathy, or, more generally, the relationship between a brain injury early in life and later brain diseases, are <a href="https://doi.org/10.1093/brain/awz286">not yet clear</a>. </p>
<p>This uncertainty should not stop people from <a href="https://doi.org/10.1002%2Fana.26566">finding a path forward</a> and taking strides to support their own brain health. </p>
<h2>The brain’s mode of repair</h2>
<p>After recovering from a brain injury, patients want to understand how to minimize further risk to their brain, which is all the more important since prior injury puts the brain at <a href="https://pubmed.ncbi.nlm.nih.gov/14625331/">greater risk for further injuries</a>.</p>
<p>Researchers and medical providers have learned that after injury the brain can change and “rewire” itself at a cellular level over the life span – a process called <a href="https://www.ncbi.nlm.nih.gov/books/NBK557811/#">neuroplasticity</a>. Brain cells, called neurons, join to form electrical pathways that power activity within the brain. In addition to other repair processes, neuroplasticity supports damaged brain areas to reconnect injured routes or find “detours” to restore brain function. This means that in recovery, the brain can literally find a new way – or make one – to regain critical abilities.</p>
<p>Neuroplasticity also offers insight into why each brain injury is unique. </p>
<p>Following a concussion, therapists focus on <a href="https://doi.org/10.46747%2Fcfp.6803175">detailed evaluations and patient interviews</a> to identify affected areas and to design an intervention. While the general map of <a href="https://www.hopkinsmedicine.org/health/conditions-and-diseases/anatomy-of-the-brain">brain regions and their associated functions is standard</a>, individual variability is common. Brain injuries from the same cause of injury, via similar force and intensity of impact and affecting the same location of the brain, can lead to very different symptoms in different people. </p>
<p>While the brain is fully developed by the time people reach their early 20s, neuroplasticity continues well beyond this point. Researchers have seen neuroplastic change during the life span in both <a href="https://theconversation.com/youve-likely-heard-of-the-brains-gray-matter-heres-why-the-white-matter-is-important-too-180945">the white</a> and <a href="https://doi.org/10.1038/nn.3045">gray matter</a> that form brain tissue. The remapping of brain pathways that occurs in <a href="https://doi.org/10.1016/j.apmr.2011.03.036">late-life injuries, such as a stroke</a>, is one strong piece of evidence to suggest there may be no specific “end date” to the brain’s capacity to restore its internal connections. </p>
<p>Importantly, fuller density of brain cells is thought to create a buffer that is protective against damage due to injury and aging. This extra “bandwidth” is referred to as <a href="https://doi.org/10.1016/j.neuropsychologia.2009.03.004">cognitive reserve</a>. Broadly speaking, higher levels of baseline cognitive reserve have been linked to <a href="https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002259">genetics, educational attainment and health factors</a>.</p>
<p>Neuroplasticity is one process that research shows is critical to maintaining these reserves throughout life.</p>
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<figcaption><span class="caption">One high-profile study found that nearly half of all people who experienced a concussion were still experiencing symptoms half a year later.</span></figcaption>
</figure>
<h2>Building and maintaining your cognitive reserves</h2>
<p>Cognitive reserve is crucial to brain health both before and after a concussion. </p>
<p>Studies show that <a href="https://doi.org/10.1016/j.apmr.2019.08.477">higher levels of cognitive reserve</a> may lessen your risk for prolonged problems after a concussion. In addition, injuries that occur <a href="https://doi.org/10.1177/1941738112473059">during childhood</a> and <a href="https://doi.org/10.1016/j.ajem.2021.11.005">late life</a> may present different challenges in recovery linked to the brain’s cognitive reserves and overall health.</p>
<p>For this reason, <a href="https://www.ncbi.nlm.nih.gov/books/NBK185341/">screening tools for concussion</a> often probe a person’s medical history prior to the event.</p>
<p>Keeping up cognitive reserves likely maintains healthy brain connections that can help us age better. <a href="https://doi.org/10.1002/hbm.25605">Bilingualism</a>, maintaining an <a href="https://www.aan.com/PressRoom/Home/PressRelease/5006">active social life</a> and even <a href="https://www.aan.com/PressRoom/Home/PressRelease/5006">going to museums</a> are linked with lower rates of dementia. These studies support that brain activity is good for brain health and it is triggered by many things, including thinking, learning and engaging with the world around us. </p>
<h2>How daily activity rewires the brain</h2>
<p>Just as there is no one-size-fits-all brain injury, there is also no single path toward brain health. </p>
<p>Advanced <a href="https://doi.org/10.3389%2Ffneur.2021.639179">brain imaging to detect concussions</a> is not available in standard clinical settings, so clinicians rarely have clear road maps for rehabilitation. But getting optimal sleep, avoiding excessive drinking or other toxic substances and leading a physically and mentally active life are core tenets of brain health. </p>
<p>Finally, the brain does not exist in isolation. Its health is connected to other parts of the body in many ways. Therefore, doctors recommend treating medical conditions that <a href="https://doi.org/10.1001/jamaneurol.2022.0976">directly affect our brain health and that reduce brain aging</a>, such as <a href="https://doi.org/10.1161/HYPERTENSIONAHA.110.163055">high blood pressure</a>,<a href="https://doi.org/10.1002/alz.057893">sleep apnea</a>,<a href="https://doi.org/10.1186/s10194-020-01166-7">migraines</a> and even <a href="https://doi.org/10.1016/S2468-2667(23)00058-0">hearing loss</a>.</p>
<p>Brain health is unique to each person, and brain injury treatment depends on your individual lifestyle and health risks. Strategies to treat <a href="https://doi.org/10.1093%2Fneuros%2Fnyz332">specific symptoms vary</a> and should be designed with the help of medical specialists. But brain health and cognitive reserve provide a common direction for everyone. Living an active lifestyle – physically, mentally and socially – can <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7586385/">drive neuroplasticity and maintain the brain</a>.</p>
<p>Studies of healthy people offer insights into how individual brains are shaped through everyday activities. For instance, research finds that <a href="https://doi.org/10.3410%2FB1-78">expert musicians</a> have denser sound-processing regions in their brains. The brains of cab drivers have <a href="https://doi.org/10.1073/pnas.070039597">greater development of spatial memory areas</a>. Even military fighter pilots have been shown to have <a href="https://doi.org/10.3389/fphys.2023.1082166">denser tissue in regions connected to strategic thinking</a>. </p>
<p>These startling discoveries teach us that what we do every day truly matters to brain health. For all of these reasons, brain researchers commonly use the phrase <a href="https://doi.org/10.1098%2Frstb.2013.0175">“neurons that fire together, wire together”</a> to describe how the brain’s connections change shape associated with repeated patterns of the electrical firing of brain activity. </p>
<p>While many questions remain to be answered, it is well established that the brain can be shaped throughout life. With this knowledge in mind, we can tend to it with greater care.</p><img src="https://counter.theconversation.com/content/214216/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Hilary works in brain rehabilitation and references her clinic in this article. The arguments provided in this article may lead readers to seek brain-related healthcare. Hilary has a professional relationship with two of the authors who works are included in cited research. </span></em></p>Concussions can teach researchers a great deal about how the brain recovers after injury and offer insights into how people can promote brain health throughout their lives.Hilary A. Diefenbach, Speech Language Pathologist and Cognitive Rehabilitation Specialist, Marcus Institute for Brain Health; Instructor, University of Colorado Anschutz Medical CampusLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2133832023-09-13T08:46:11Z2023-09-13T08:46:11ZConcussion: what it is and how sports science is making rugby safer<p><em>Two decades ago there were only two criteria used to diagnose concussion. Jon Patricios, a sport and exercise medicine physician and co-lead author of the latest international consensus statement on concussion in sport, discusses the science of head injuries and some of the protocols adopted by World Rugby to make the game safer.</em></p>
<h2>What is concussion?</h2>
<p>Concussion is a traumatic brain injury that occurs as a result of a force that’s transmitted to the brain. It manifests as a functional change in the way the brain operates. Most are transient and resolve completely if recognised and managed appropriately. </p>
<p>Usually, we don’t see structural changes in the brain in the case of a concussion. In other words the brain scans look normal. And so what we have available to us, what I call the visible wound, is the changes in brain function. </p>
<p>That’s what we as medical professionals treating concussion look for, what we assess and what we manage. </p>
<h2>What are the obvious signs of concussion?</h2>
<p>Things like loss of consciousness, or a seizure, clear disorientation, or inability to walk or poor coordination. </p>
<p>When I started working with professional rugby players in 1995 as a rugby team doctor there were only two criteria which classified you as concussed. One was a loss of consciousness, and the other was amnesia (memory loss). We now have over 20 criteria that we look for including irritability, nausea, inability to concentrate, poor balance, emotional changes and heart rate. </p>
<p>The one thing medical science still doesn’t have for concussion is what we call biomarkers – like a blood test, or a saliva test, or an appropriate brain scan. Once developed, these would be able to tell you if there’s a concussion, how bad it is and whether it’s resolving. Research in these fields is increasing exponentially and I think we will see these commercially available in the next five years.</p>
<h2>What are the less obvious signs?</h2>
<p>Much of the time the signs are subtle. Things like changes in movement. There may be symptoms which you rely on the patient reporting. We break those symptoms and signs down into what we call domains, which means we look at various aspects of brain and body function.</p>
<p>Those include physical symptoms, like headaches and nausea. They also may include changes in balance, emotional changes, anxiety, concentration – those sorts of things. </p>
<p>They often include <a href="https://www.sciencedirect.com/topics/psychology/cognitive-change">cognitive changes</a> like an inability to concentrate. Also what we call autonomic functions like heart rate, which might not be regulated properly, and blood pressure changes. </p>
<p>If one doesn’t take the athlete through a systematic approach one might miss some of the changes. </p>
<p>The other important thing is to “know the athlete” – understand what they are like before and injury. Evaluating the player before the season starts so you have a better understanding of how that player normally operates.</p>
<h2>A player is knocked out cold on the field. What are the next steps?</h2>
<p>The first thing is to treat it as you would any serious injury. And that’s to make sure the player is still <a href="https://www.physoc.org/explore-physiology/what-is-physiology/">functioning physiologically</a>: the airways are open, they are breathing and their circulation is adequate. That’s the “ABC” of emergency medicine.</p>
<p>The second thing is to see if there are any serious injuries. For example, if the player has a neck injury. So you protect the airway and you protect the neck.</p>
<p>The next important aspect is to remove the player from further danger. You get them off the field where you can better assess them and monitor recovery, in an ordered, controlled, quieter medical space. </p>
<p>From there, you will work through your systematic evaluation, and assess which areas are most likely to have been affected. </p>
<p>You will repeat that evaluation within an hour or two and then within another day to see how they are improving (or not).</p>
<h2>Often long rest periods are prescribed. Why?</h2>
<p>As with every injury, there’s a spectrum of concussions and probably every one is slightly different. </p>
<p>You might have had a more severe injury, a high impact, with a player who is highly symptomatic, and has a number of domains that manifest. Not just their physical symptoms, but their concentration, their emotions and their balance.</p>
<p>Long periods of rest might not necessarily be appropriate. So what we’ll talk about is longer periods of relative rest, where you don’t cocoon them but allow them to continue with activities of daily living and then purposefully incorporate exercise within 72 hours. We actually expose them to exercise gradually but early, but at a lower intensity. It has been shown to actually speed recovery if you introduce gradual exercise in an appropriate way, early in the recovery stage.</p>
<h2>Do the rules make the game safer now? Is it safe enough?</h2>
<p>The rules <a href="https://www.world.rugby/the-game/player-welfare">have changed</a> to improve identification of concussions and player safety.</p>
<p>In most collision sports, a player is obliged to go through a specific process before being allowed to return to the field. And these processes in the professional game have to be documented, and submitted before that player is allowed back. </p>
<p>The laws have been driven by the science behind concussion, which is encouraging. </p>
<p>Is it safe enough? Well, in collision sports you can never take concussions out of the game. Because as long as there’s a potential to be involved in a tackle or to be hit by a fist there’s the risk of injury. But safety awareness is higher than it’s ever been, and our protocols are evidence-based and more robust.</p><img src="https://counter.theconversation.com/content/213383/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jon Patricios is a Board member of the Concussion in Sport group and medical advisor to SA Rugby, World Rugby, UEFA and the NFL (all unremunerated)</span></em></p>Rugby players risk serious injury due to the game’s sheer physicality. Sports scientists have worked with international rugby bodies to improve safety.Jon Patricios, Professor of Health Sciences, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2127012023-09-06T06:27:00Z2023-09-06T06:27:00ZWe are finally moving towards a national strategy on concussions in sport. Will the government and sports bodies now act?<p>A Senate committee has tabled a long-awaited, 187-page <a href="https://parlinfo.aph.gov.au/parlInfo/download/committees/reportsen/RB000082/toc_pdf/Concussionsandrepeatedheadtraumaincontactsports.pdf">report</a> on the growing problem of concussions in sport, with 13 recommendations for action. </p>
<p>Senator Janet Rice, the committee chair, urged the government to take the report very seriously and quickly move to implement the recommendations. She said now is the time for the “Commonwealth to step up”.</p>
<p>In the past few years, we’ve heard countless <a href="https://www.news.com.au/sport/afl/family-of-nick-lowden-reveal-frightening-change-before-his-tragic-death/news-story/acaf19d16d9e98c62379b83587f787ad">heartbreaking</a> stories about Australian sports figures who have struggled with their mental health after suffering head injuries on the field. </p>
<p>Some have <a href="https://www.9news.com.au/national/inquiry-into-exrichmond-players-death-to-begin/b535df11-6344-41b1-9639-41f65d3927e7">posthumously</a> been diagnosed with chronic traumatic encephalopathy (CTE), a form of dementia.</p>
<p>Our sports leagues have begun paying greater attention to the risks associated with concussions and mild traumatic brain injuries. The primary focus has been on the elite level, with some recent action at the community level. </p>
<p>It has been nearly 30 years since the National Health and Medical Research Council, the government’s public health agency, called for precautionary action on this issue. However, governments have been slow to act on repeated calls for a national strategy to what is fundamentally a public health concern.</p>
<p>So, will the government follow through now by implementing the Senate committee’s recommendations? And how will our sports leagues respond?</p>
<h2>Conflicting approaches to concussions</h2>
<p>The Senate committee received 92 submissions and heard from 84 witnesses from a wide range of backgrounds, including athletes, families, medical experts, the leaders of sports organisations and other experts. (I also presented evidence, based on my expertise in this field.)</p>
<p>Two conflicting narratives emerged from the evidence. On the one hand, athletes, families, health care professionals and other public interest groups expressed concern that the current approach on concussions and player safety was inadequate. They argued there are too many gaps in the system and, in some cases, that sports organisations are putting self interest above player health.</p>
<p>On the other hand, the Australian Institute of Sport and other sports-affiliated parties argued the current approach, which allows sports organisations to self-regulate when it comes to handling head injuries, is fit for purpose. They also said player health and wellbeing was a primary concern.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/concussion-risks-arent-limited-to-the-afl-we-need-urgent-action-to-make-sure-our-kids-are-safe-too-155638">Concussion risks aren't limited to the AFL. We need urgent action to make sure our kids are safe, too</a>
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<p>In some respects, the report carefully toed the line between the two sides. Several recommendations set out a greater role for the Commonwealth government to play, but did not provide the level of specificity some might have expected for such an urgent and pressing public health concern.</p>
<h2>Lack of reliable data on head injuries</h2>
<p>One of the main concerns in the report was the lack of reliable and accurate data on the prevalence of concussions in sport and our general level of understanding on the health risks.</p>
<p>To address the data issue, the inquiry recommended the government establish a national sports injury database as a matter of urgency. This is greatly needed not only to enact better injury prevention policies and programs, but also so families can make decisions on sports for their children.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/australian-researchers-confirm-worlds-first-case-of-dementia-linked-to-repetitive-brain-trauma-in-a-female-athlete-208929">Australian researchers confirm world’s first case of dementia linked to repetitive brain trauma in a female athlete</a>
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<p>The report further recommends requiring professional sporting codes to collect this data on concussions and share it with the new database. Currently, only some sporting codes share this information publicly. </p>
<p>On the research front, the report recommended the government establish a new independent body (or an entity within an existing body) that would be dedicated to research into the short- and long-term effects of concussions and repeated head trauma in sport, including CTE. </p>
<p>Many of those submitting evidence cited concerns over the lack of coordination and direction in the current approach to research. As the committee pointedly said,</p>
<blockquote>
<p>There is clear evidence of a causal link between repeated head trauma and
concussions and subsequent neurodegenerative diseases such as CTE. While
important research questions remain regarding the degree of causation and the
nature of long-term impacts, these questions should not be used to undermine
the fundamental nature of that link. </p>
</blockquote>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1621649637492019202"}"></div></p>
<h2>‘High level of confusion’ on return-to-play rules</h2>
<p>Other recommendations focus on how sporting codes should change their rules or policies to mitigate the risks of head injuries. </p>
<p>Here, the committee also called for a greater role by government and medical experts in developing return-to-play protocols (as in, the amount of time a player should sit out after a head injury before returning to the field), which could be adapted for use across sports. </p>
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<em>
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Read more:
<a href="https://theconversation.com/new-study-highlights-the-brain-trauma-risks-for-young-athletes-212369">New study highlights the brain trauma risks for young athletes</a>
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<p>This is an important point. The report cited concern over the “high level of confusion” over how much time a player should sit out, which comes from the disparate rules across sporting codes.</p>
<p>And the committee noted that even with return-to-play policies in effect, compliance and enforcement remained a problem. The report again cited a greater role for government in overseeing these protocols, though it doesn’t specify how. </p>
<p>If the goal is to achieve uniformity and compliance, then a practical issue to consider is whether the sports and their networks have the required resources and capabilities to achieve this. And is legislation required to empower government to monitor compliance? </p>
<h2>Inadequate support for athletes</h2>
<p>The final sections of the report deal with the current lack of financial support for players who suffer concussions, including:</p>
<ul>
<li><p>the exclusion of athletes from workers’ compensation schemes</p></li>
<li><p>the absence of a national injury insurance scheme</p></li>
<li><p>inadequate support provided by sporting organisations</p></li>
<li><p>inadequate private insurance, and </p></li>
<li><p>barriers to legal remedies for concussion and head trauma-related claims. </p></li>
</ul>
<p>The report made clear much more could be done by sporting organisations to improve their duty of care to athletes. As a baseline, it “encourages” professional sports organisations to ensure their athletes have insurance coverage for head trauma and the removal of the exclusion of athletes from workers’ compensation regimes.</p>
<p>The goal here is to address the inequities in access to adequate support for professional athletes. But without crunching the numbers and doing a cost-benefit analysis across the various compensation options, it’s difficult to know whether athletes will be better off. </p>
<p>The lack of detail and concrete timeframes in the report make it difficult to predict what lies ahead. With sports revenue streams likely to be impacted due to the <a href="https://www.aph.gov.au/Parliamentary_Business/Committees/House/Social_Policy_and_Legal_Affairs/Onlinegamblingimpacts/Report">ban on sports gambling advertising</a>, the sports organisations will be paying close attention to the costs of these recommendations. </p>
<p>Let’s hope the government adheres to its role as “neutral umpire” when it comes to the resistance it could now face in implementing the recommendations. </p>
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<p><em>If this article has raised issues for you, or if you’re concerned about someone you know, call Lifeline on 13 11 14.</em></p><img src="https://counter.theconversation.com/content/212701/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Annette Greenhow receives funding from the Government of Canada Social Sciences and Humanities Research Council and previously received funding from Australian Catholic University and the City of Gold Coast Ambassador Program. She is affiliated with the Australia and New Zealand Sports Law Association as a board member (views are her own). Annette provided a submission and evidence at the Senate Inquiry. Her PhD findings on the topic of regulating concussion in Australian sport form the basis of a forthcoming book on the topic due for publication in the coming months. </span></em></p>In a landmark Senate report, the government was urged to take a greater role in overseeing compliance of concussion rules across sports leagues. Details, however, were in short supply.Annette Greenhow, Assistant Professor, Faculty of Law, Bond UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1923902022-11-10T13:43:24Z2022-11-10T13:43:24ZConcussions can cause disruptions to everyday life in both the short and long term – a neurophysiologist explains what to watch for<figure><img src="https://images.theconversation.com/files/494518/original/file-20221109-16873-evqs5d.jpg?ixlib=rb-1.1.0&rect=400%2C16%2C5166%2C3638&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Sleep plays a critically important role in the recovery process in the days following a concussion.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/skiing-accident-royalty-free-image/164528977?phrase=concussion&adppopup=true">nicolamargaret/E+ via Getty Images</a></span></figcaption></figure><p><em>The <a href="https://www.cnn.com/2022/10/19/sport/nfl-tua-tagovailoa-concussion-spt-intl">repeat concussions</a> suffered by Miami Dolphins quarterback Tua Tagovailoa less than a week apart in September 2022 have brought the seriousness of traumatic brain injury back into the public eye and <a href="https://www.washingtonpost.com/health/2022/09/30/tua-concussion-protocol-nfl/">triggered scrutiny</a> of the NFL’s concussion protocols. And the upcoming World Cup soccer competition, which begins Nov. 20, 2022, will likely include highly visible head injuries.</em></p>
<p><em>The Conversation asked David Howell, <a href="https://profiles.ucdenver.edu/display/15074432">director</a> of the <a href="https://medschool.cuanschutz.edu/orthopedics/research/labs/howell-concussion-lab/our-research">Colorado Concussion Research Laboratory</a> at the University of Colorado School of Medicine, to explain the latest science behind concussions and why a recently injured brain is more vulnerable to repeat injury. Howell’s work focuses on the many different areas of concussion-related dysfunction and recovery, including <a href="https://doi.org/10.3390/s20216297">movement deficits</a>, <a href="https://doi.org/10.1097/jsm.0000000000000803">sleep problems</a> and <a href="https://doi.org/10.1177/03635465211069372">rehabilitation</a>.</em></p>
<h2>How widespread are concussions?</h2>
<p>The word concussion can evoke a variety of different images for different people. While concussions are most visible during high-profile sporting events, they can also occur on the playground, during the junior varsity football team practice or on the ski slope. The effects can be just as severe for children and teens as for high-profile athletes.</p>
<p>Concussion effects range from mild to severe, from short term to long term, and can affect many different facets of life. A concussion is defined as a traumatic brain injury caused by an impact to the head, resulting in an alteration of brain function. </p>
<p>A concussion often leads to disruptions to everyday life – whether it be a job, academics, sports, physical activity or sleep. Given how unique people’s brains are and how differently they may respond to the injury, concussion recognition, diagnosis and treatment remain challenging for patients and clinicians alike. </p>
<h2>What happens to the brain during a concussion?</h2>
<p>There is a complex set of events that occur within the brain during and after a concussion occurs. </p>
<p>As a result of the trauma to the brain, brain cells – or neurons – stop functioning as they typically do when healthy. Generally there is not one specific area of the brain that is affected by a concussion. Instead, the injury can affect a widespread set of brain regions, not necessarily at the impact point. Thus, each person may experience a unique set of symptoms or functional problems following the injury. </p>
<p>One main problem that arises following a concussion is an <a href="https://doi.org/10.1016/j.csm.2020.08.001">energy crisis</a> of sorts. This occurs when the brain requires a large volume of energy, in the form of glucose delivered by blood flow to the brain, to restore the injured processes. The body also may have trouble delivering blood to the brain because of a brain blood flow disruption <a href="https://doi.org/10.3389/fneur.2018.00196">caused by the injury</a>, at the very time the brain needs extra energy to restore the injured areas. This mismatch can produce a variety of different symptoms people experience following a concussion.</p>
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<figcaption><span class="caption">Research suggests that a concussion can alter the brain’s wiring.</span></figcaption>
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<h2>What signs should you look for if you suspect a concussion?</h2>
<p>Concussions produce a wide range of signs and symptoms, such as problems with walking and balance, dizziness, mood changes, disruptions to sleep and more. </p>
<p>Some of the main signs that health care providers look for following an impact to the head or body include unsteadiness of gait, loss of consciousness, seizures or other concussion symptoms like headache, cognitive impairment or problems with vision or balance.</p>
<p>It is critical that if a concussion is suspected, individuals cease playing their sport or activity. A simple mantra of “<a href="https://sportscotland.org.uk/media/3382/concussionreport2018.pdf">If in doubt, sit them out</a>” should always be applied, regardless of the setting. </p>
<h2>Why is the injured brain more vulnerable to repeat injury?</h2>
<p>Miami Dolphins quarterback Tua Tagovailoa, who was <a href="https://www.cnn.com/2022/10/19/sport/nfl-tua-tagovailoa-concussion-spt-intl">carted off the field</a> in late September 2022 after his second head injury in less than a week, serves as an example of how vulnerable the brain can be to additional trauma following an initial concussion.</p>
<p>Research shows that the rate of second concussions is highest in the immediate <a href="https://doi.org/10.1136/bjsports-2019-100579">days following an initial concussion</a>. In addition, recent studies have found that athletes who continue to play following a concussion <a href="https://doi.org/10.1177/0363546518757984">experience longer recovery times</a> and <a href="https://doi.org/10.1007/s40279-022-01668-1">more severe symptoms</a>. </p>
<p>While athletes of all ages may want to continue competing after a concussion, relying on a person with an injured brain to determine whether their brain is healthy enough to continue playing is flawed logic. Qualified health care professionals should always make these sorts of decisions for an athlete, rather than someone with a vested interest such as the athletes themselves or their coaches.</p>
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<a href="https://images.theconversation.com/files/494481/original/file-20221109-11066-izy6xc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Football players stand in a circle looking at a teammate stretched on the ground." src="https://images.theconversation.com/files/494481/original/file-20221109-11066-izy6xc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/494481/original/file-20221109-11066-izy6xc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/494481/original/file-20221109-11066-izy6xc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/494481/original/file-20221109-11066-izy6xc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/494481/original/file-20221109-11066-izy6xc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/494481/original/file-20221109-11066-izy6xc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/494481/original/file-20221109-11066-izy6xc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Teammates gather around Miami Dolphins quarterback Tua Tagovailoa after an injury during the first half of an NFL game on Sept. 29, 2022.</span>
<span class="attribution"><a class="source" href="https://www.apimages.com/metadata/Index/Dolphins-Bengals-Football/2fc554f4223f4e0c9234f61e9f7e62da/1/0">AP Photo/Emilee Chinn/</a></span>
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<p>Given the energy crisis described above that occurs following a head injury, the brain simply cannot handle the added and cumulative stress of two injuries occurring in short succession. A second insult to the brain is often simply too much for the brain to handle, and the brain will preserve its most basic functions, such as breathing, above all else. </p>
<p>This is why it is imperative that athletes who experience a concussion be removed from the field of play and allowed to recover fully before returning to unrestricted sport participation. This often involves <a href="https://doi.org/10.1136/bjsports-2017-097699">a stepwise reintegration approach</a>, which allows for a gradual and safe reintroduction into physical activity at first, and an appropriately safe return to play under medical care.</p>
<h2>You’ve had a concussion – now what?</h2>
<p>The first step following a concussion is to stop playing sports and to rest for a day or two. Sleep is <a href="https://doi.org/10.1089/neu.2021.0295">critically important</a> in the days following a concussion. </p>
<p>A myth that continues to persist is that a person should be woken up every hour following a concussion. This is simply not supported by science. In fact, poor sleep after a concussion has been widely documented as being a <a href="https://doi.org/10.1097/jsm.0000000000000803">predictor of poor outcomes</a>, including <a href="https://doi.org/10.1177/0009922816681603">longer recovery times</a> and more severe anxiety, depression or <a href="https://doi.org/10.1089/neu.2018.6257">cognitive symptoms</a>. Waking someone up every hour applies to <a href="https://doi.org/10.1093/bja/aem128">more severe brain injuries</a> that would be ruled out by a health care provider during diagnosis.</p>
<p>In addition, <a href="https://doi.org/10.1136/bjsports-2018-100338">recent guidelines</a> and <a href="https://doi.org/10.1542/peds.2014-0966">past research</a> suggest that complete physical and cognitive rest, which is <a href="https://doi.org/10.1097/wco.0000000000000611">sometimes called cocoon therapy</a>, can actually be <a href="https://doi.org/10.3389/fneur.2019.00362">harmful to recovery</a>. </p>
<p>Therefore, it is important to keep a balanced approach in mind. Following a day or two of physical rest, people with a concussion should begin resuming <a href="https://doi.org/10.1016/j.jpeds.2020.07.049">light physical and cognitive activity</a> that does not provoke or exacerbate ongoing symptoms. </p>
<p>When a person begins to feel better following a concussion, they should gradually add in higher intensity and greater amounts and duration of exercise, dictated by whether their symptoms are not significantly provoked. Recent studies have focused on the value of an individualized aerobic exercise program in the week following a concussion. Past work suggests that performing aerobic exercise at a heart rate just below the level at which symptoms are exacerbated is <a href="https://doi.org/10.1016/s2352-4642(21)00267-4">safe and effective for recovery</a>.</p>
<p>It is important to note that the effects of a concussion may also result in secondary conditions, such as anxiety or depression due to the biological, social or psychological effects of the injury. A recent study showed that adolescents who sustained a concussion have a <a href="https://doi.org/10.1001/jamanetworkopen.2022.1235">higher risk of mental health issues</a> compared to those with an orthopedic injury.</p><img src="https://counter.theconversation.com/content/192390/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr. Howell has received research support from the Eunice Kennedy Shriver National Institute of Child Health & Human Development, the National Institute of Neurological Disorders And Stroke, the National Institute of Arthritis and Musculoskeletal and Skin Diseases, 59th Medical Wing Department of the Air Force, MINDSOURCE Brain Injury Network, the Tai Foundation, and the Colorado Clinical and Translational Sciences Institute and he serves on the Scientific/Medical Advisory Board/owns shares for Synaptek, LLC.</span></em></p>While high-profile concussions in the NFL have brought renewed attention to the gravity of head injuries, they can also occur on the playground or during junior varsity practices – with lasting effects.David Howell, Assistant Professor of Orthopedics,, University of Colorado Anschutz Medical CampusLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1832022022-06-27T18:42:03Z2022-06-27T18:42:03ZPrevention is better than cure when it comes to high concussion rates in girls’ rugby<figure><img src="https://images.theconversation.com/files/470099/original/file-20220621-14-veejfi.JPG?ixlib=rb-1.1.0&rect=0%2C0%2C3600%2C2398&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Reconsidering the rules of the game may help prevent concussions and other injuries.</span> <span class="attribution"><span class="source">(John Woods/Rugby Canada)</span>, <span class="license">Author provided</span></span></figcaption></figure><p>Popularity and participation numbers in rugby union are growing in Canada, particularly in the women’s game. It’s easy to see why — rugby is fast-paced, highly skilful and provides a hugely supportive team environment.</p>
<p>With the Canadian women’s rugby sevens team <a href="https://www.cbc.ca/sports/olympics/rio2016/rugby/canada-beats-britain-rugby-sevens-bronze-1.3712440">winning an Olympic bronze medal at the Rio 2016 Games</a>, and a women’s World Cup happening this October in New Zealand, it’s anticipated that the rise in participation numbers and overall popularity of the women’s game will continue its upward trend. </p>
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<figcaption><span class="caption">In 2016, Canada defeated Great Britain in women’s rugby sevens to take home the Olympic bronze medal.</span></figcaption>
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<p>This is all good news for the sport. But rugby’s growing popularity means that there is more to consider, especially when it comes to injuries and their prevention.</p>
<h2>Hard-hitting</h2>
<p>When you think of the most hard-hitting, high-risk sports, girls’ youth rugby probably isn’t the first thing that comes to mind. However, <a href="https://doi.org/10.1097/jsm.0000000000000993">in Canada</a> and <a href="https://doi.org/10.1055/a-1327-3009">the United Kingdom</a>, the sport is emerging as having one of the highest concussion rates across all youth sports. </p>
<p>While this is not new in the context of <a href="https://doi.org/10.1136/bjsports-2015-094978">boys rugby</a>, with the emergence of more quality data related to the girls’ game specifically, the rates in this cohort may be higher than in many other sport settings for youth.</p>
<p>Considering how concussions occur, it is well recognized that the tackle is the event that leads to the most injuries and concussions in rugby. When focusing more specifically on which player gets injured however, we see that in the girls’ game, a greater proportion of players instigating the tackle (tackler) are injured compared with the ball carrier (the player being tackled). </p>
<p>Looking at tackles that lead to concussions, the specific mechanism of concussion in women’s and men’s games may also be different. In the men’s game, head-to-head contacts are common, however in the women’s game, early research is showing <a href="https://doi.org/10.1080/17461391.2021.1973573">head-to-ground contact and whiplash are more common mechanisms.</a>.</p>
<p>Unfortunately, this research is currently focused on adult athletes, and requires further investigation with injury surveillance, video analysis and mouthguard technologies in youth to better understand head impacts and concussion rates. </p>
<h2>Public health burden</h2>
<p>As the evidence base continues to grow and highlight the public health burden associated with the youth game, rugby faces significant opposition to its growth. In the U.K., there have been calls for <a href="http://www.sportcic.com/resources/Open%20Letter%20SportCIC%20March7%202016.pdf">removal of the tackle</a> from youth rugby.</p>
<p>Concerns were raised in Canada too when in 2019, the Nova Scotia <a href="https://www.cbc.ca/news/canada/nova-scotia/rugby-federation-cancels-games-1.5120503">high school rugby season was cancelled over safety concerns</a>. (However, the season was later reinstated.) </p>
<p>Neither the calls for a tackle ban nor the cancellation of a season have led to long-term changes in the sport. But as more evidence emerges, we are likely to see more of these concerns raised in the coming years, leading to questions surrounding the appropriate age and level of introduction of contact to the game. </p>
<p>How can these risks be mitigated for both male and female rugby players? Our research team at the <a href="https://www.ucalgary.ca/sport-injury-prevention-research-centre">Sport Injury Prevention Research Centre at the University of Calgary</a> is working on preventing these injuries from occurring in the first place. Based on previous work, we know that three key pillars for injury prevention exist. These include: <a href="http://dx.doi.org/10.1136/bjsports-2016-097452">policy or law change, training programs and protective equipment</a>.</p>
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<a href="https://images.theconversation.com/files/470122/original/file-20220621-22-hyxlyh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="a young woman tackles another standing woman in a gym as a coach watches on" src="https://images.theconversation.com/files/470122/original/file-20220621-22-hyxlyh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/470122/original/file-20220621-22-hyxlyh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/470122/original/file-20220621-22-hyxlyh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/470122/original/file-20220621-22-hyxlyh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/470122/original/file-20220621-22-hyxlyh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/470122/original/file-20220621-22-hyxlyh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/470122/original/file-20220621-22-hyxlyh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Tackle training is one of the several avenues being explored for prevention of injuries in the youth game.</span>
<span class="attribution"><span class="source">(University of Calgary)</span>, <span class="license">Author provided</span></span>
</figcaption>
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<h2>Training contexts</h2>
<p>Changing game laws and rules by governing bodies can significantly impact all levels of the game. However, easily accessible strategies such as neuromuscular training (NMT) programs — which strengthens the connection between the nervous and muscular systems — currently represent the prevention strategy with the most promising findings to date. This has been demonstrated previously in multiple other youth sports. In rugby, this work has been limited to senior and junior men’s settings. </p>
<p>The use of such programs in rugby is best exemplified in youth male rugby to date using the coach-delivered Activate NMT program which has previously been shown to reduce the risk of injury <a href="http://dx.doi.org/10.1136/bjsports-2016-097434">by 72 per cent and concussion by 59 per cent when implemented three times per week</a>, as recommended.</p>
<p>When translating these findings into the context of the Canadian youth game however, it is important to consider the contextual differences between rugby in the U.K. and Canada. In Canada, the playing season is much shorter and often players enter the game at a later age. Given this, and the somewhat unpredictable nature of the injuries that occur, our prevention efforts should be multi-factorial and may span not only one pillar of prevention, but all three.</p>
<h2>A sport for all</h2>
<p>Rugby has previously been described as a “<a href="https://www.world.rugby/news/632406/world-rugby-launches-a-global-sport-for-all-strategic-plan-2021-25-to-guide-long-term-growth?lang=en">sport for all</a>.” With the rise in interest and participation in girls’ and women’s rugby set to continue in Canada, it’s time to put prevention at the forefront of player welfare in the sport. </p>
<p>This is particularly important as many players, both male and female, return to the sport for the first time in two years following the COVID-19 pandemic. Prevention is better than cure, and nowhere does this apply more than keeping our young players safe and free to enjoy the benefits of this wonderful sport.</p><img src="https://counter.theconversation.com/content/183202/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stephen West does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Girls’ rugby is a sport with higher than expected concussion rates. As the sport grows in popularity, preventing concussions is more effective than treating them.Stephen West, Postdoctoral Research Associate, Kinesiology, University of CalgaryLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1765412022-02-10T19:10:44Z2022-02-10T19:10:44ZThe risk of concussion lurks at the Super Bowl – and in all other sports<figure><img src="https://images.theconversation.com/files/444890/original/file-20220207-66930-1gnpd0b.jpg?ixlib=rb-1.1.0&rect=14%2C0%2C4878%2C3232&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Over the past two decades, researchers have gained a great deal of insight into the risks surrounding concussions – some of which has led to sweeping policy changes.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/tom-brady-of-the-tampa-bay-buccaneers-calls-the-play-during-news-photo/1300905188?adppopup=true">Kevin C. Cox/Getty Images Sports via Getty Images</a></span></figcaption></figure><p>An estimated 90 million to 100 million Americans will tune in to watch the <a href="https://www.latimes.com/sports/story/2022-02-09/super-bowl-2022-start-time-teams-location-channel-halftime-show">Super Bowl this Sunday</a>. Unlikely to be mentioned during the festivities is this sobering but significant side note: Athletes participating in collision sports are among those <a href="https://doi.org/10.1007/s40279-021-01428-7">at highest risk for concussion</a>. </p>
<p>That risk is not limited to professional football. Researchers estimate that <a href="https://doi.org/10.1097/00001199-200609000-00001">4 million sports and recreation-related concussions</a> occur in the U.S. every year, across all sports and all levels of play and in both games and practices. They happen to athletes and kids playing basketball and soccer and weekend warriors who bicycle and ski. But thousands of concussions also result from car accidents, slips and trips or other blows to the head.</p>
<p>I’m the director of the <a href="https://concussion.umich.edu/">University of Michigan Concussion Center</a>, and <a href="https://concussion.umich.edu/leadership/steven-broglio/">I have been researching</a> brain injuries <a href="https://scholar.google.com/citations?user=DE-SIlkAAAAJ&hl=en">for nearly a quarter-century</a>. Across the globe, hundreds more researchers like me have dedicated their careers to understanding concussions and traumatic brain injuries – and, most critically, how to prevent and treat them. While tremendous progress has been made, much more remains to be done.</p>
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<figcaption><span class="caption">How dangerous are concussions? The answer is complicated.</span></figcaption>
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<h2>The backstory</h2>
<p>When I began my career, concussions were broadly viewed as “getting your bell rung.” It was not uncommon for an athlete who had been knocked out to be sent back into a game within 20 minutes of injury. </p>
<p>The devastating results of repeat concussions without appropriate treatment led to the adoption of <a href="https://www.shapeamerica.org/standards/guidelines/Concussion/state-policy.aspx">sweeping legislation</a> that specifically addressed youth sports concussions. </p>
<p>That legislation, enacted between 2009 and 2014, is law in all 50 states. Although it varies from state to state, youth athletes now receive annual education on concussions. Those suspected of having a concussion must be removed from play, and concussed athletes can’t play their sport until cleared by a medical professional. </p>
<p>In 2005, researchers discovered the first case of <a href="https://doi.org/10.1227/01.neu.0000163407.92769.ed">chronic traumatic encephalopathy</a> in a former professional football athlete. The degenerative brain disease is characterized by protein deposits that have been linked to concussions and repeated head impacts.</p>
<p>This monumental finding occurred concurrently with U.S. military involvement in Iraq and Afghanistan. For both conflicts, traumatic brain injury <a href="https://doi.org/10.1176/appi.neuropsych.16050100">became the signature injury</a> of returning veterans, and the U.S. government increased funding to study short- and long-term effects of concussion. </p>
<p>In addition, sports organizations <a href="https://www.cbssports.com/nfl/news/for-first-time-ever-nfl-admits-theres-a-link-between-cte-and-football/">reversed their prior stance</a> and acknowledged the link between concussions and long-term injury. They began supporting policies that embraced evidence-based rule changes to reduce concussion risk. </p>
<figure class="align-center ">
<img alt="Children play soccer on a grassy field." src="https://images.theconversation.com/files/445305/original/file-20220209-21-bmsr84.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/445305/original/file-20220209-21-bmsr84.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/445305/original/file-20220209-21-bmsr84.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/445305/original/file-20220209-21-bmsr84.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/445305/original/file-20220209-21-bmsr84.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/445305/original/file-20220209-21-bmsr84.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/445305/original/file-20220209-21-bmsr84.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Even young athletes can sustain concussions when playing contact sports like football, basketball and soccer.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/boys-playing-football-royalty-free-image/BC0459-001?adppopup=true">Bob Thomas/The Image Bank via Getty Images</a></span>
</figcaption>
</figure>
<h2>A golden age of concussion research</h2>
<p>Those events laid the foundation for a new generation of scientists to explore precise ways to diagnose concussions, develop novel treatment options and understand who’s most at risk for negative long-term outcomes. </p>
<p>That includes three transformative studies that are currently underway in the U.S.: <a href="https://tracktbi.ucsf.edu/transforming-research-and-clinical-knowledge-tbi">TRACK-TBI</a>, which is evaluating 3,000 patients across traumatic brain injury spectrum; <a href="https://www.childrenshospital.org/nfl-long-study/findings">NFL-LONG</a>, which tracks former NFL players; and the <a href="http://www.careconsortium.net/">CARE Consortium</a>, which has enrolled more than 55,000 military service academy members and collegiate athletes to better understand the short- and long-term effects of concussion. </p>
<p>The CARE Consortium, which I co-lead, has produced more than 100 peer-reviewed papers that have contributed to overall improvements in concussion diagnosis and management. Notably, we reported that recovery from a concussion <a href="https://doi.org/10.1007/s40279-021-01541-7">may take up to one month</a>. We also discovered that male and female athletes return to post-concussion play <a href="https://doi.org/10.1136/bjsports-2020-103316">at the same rate</a> and <a href="https://doi.org/10.1001/jamanetworkopen.2019.19771">identified blood-based markers</a> that may eventually serve as the gold standard for concussion diagnosis. </p>
<p>My colleagues and I are now starting follow-up evaluations of the CARE Consortium participants to better understand the long-term effects of injury. Those findings, along with work from other studies, will inform researchers on the risk of long-term neurodegeneration and shine a light on ways to intervene with medications and therapies. </p>
<h2>The future</h2>
<p>Concussion research is flourishing. Since the first modern case of chronic traumatic encephalopathy was identified 17 years ago, more than 13,000 papers have been published in the medical literature. Although researchers have much more to learn, the advances in concussion care over the past 20 years are clearly significant. Concussed athletes are now <a href="https://doi.org/10.1136/bjsports-2019-100579">kept off the playing field substantially longer</a>, standardized <a href="https://doi.org/10.1136/bjsports-2017-097699">assessment protocols are widespread</a> and <a href="https://doi.org/10.1001/jama.2018.14165">rules are in place</a> to reduce concussion risk.</p>
<p>Findings from these studies will never grab headlines as the Super Bowl does, and some may say that policy changes should <a href="https://www.economist.com/international/2019/01/26/few-sports-are-doing-enough-to-protect-athletes-from-brain-damage">happen faster</a>. Admittedly, the scientific process is slow, but decisions based on limited research are rarely, if ever, the right decision. But one day, this largely unheralded work will keep sports safe and its participants whole in body and mind.</p><img src="https://counter.theconversation.com/content/176541/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Steven P. Broglio has current or past research funding from the National Institutes of Health; Centers for Disease Control and Prevention; Department of Defense - USA Medical Research Acquisition Activity, National Collegiate Athletic Association; National Athletic Trainers’ Association Foundation; National Football League/Under Armour/GE; Simbex; and ElmindA. He is co-author of Biomechanics of Injury (3rd edition, Human Kinetics) and he has consulted for US Soccer (paid), US Cycling (unpaid), medico-legal litigation, and received speaker honorarium and travel reimbursements for talks given. He is co-author of “Biomechanics of Injury (3rd edition)” and has a patent pending on “Brain Metabolism Monitoring Through CCO Measurements Using All-Fiber-Integrated Super-Continuum Source” ( U.S. Application No. 17/164,490)</span></em></p>Millions of sports-related concussions occur in the US every year. Many of them happen to high school and college athletes.Steven P. Broglio, Professor of Kinesiology, Neurology, Physical Medicine and Rehabilitation, University of MichiganLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1690762021-10-29T12:38:51Z2021-10-29T12:38:51ZHow to help kids with ‘long COVID’ thrive in school<figure><img src="https://images.theconversation.com/files/428313/original/file-20211025-17-ih8cjs.jpg?ixlib=rb-1.1.0&rect=0%2C8%2C5499%2C3647&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many long COVID-19 symptoms – such as fatigue, brain fog and memory impairment – are similar to those experienced post-concussion.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/elementary-school-wear-mask-for-protect-corona-royalty-free-image/1281854942"> Cavan Images/Cavan Collection via Getty Images</a></span></figcaption></figure><p>Children who get COVID-19 typically recover quickly and will not require special support upon return to school. However, some people who contract the disease experience persistent symptoms and post-viral complications. These complications can include fatigue, shortness of breath, brain fog, changes in taste and smell, and headaches. <a href="https://theconversation.com/deciphering-the-symptoms-of-long-covid-19-is-slow-and-painstaking-for-both-sufferers-and-their-physicians-164754">This post-viral syndrome</a> is called long-haul COVID-19, more commonly referred to as “long COVID” in the <a href="https://recovercovid.org/">medical community</a>. </p>
<p>Children who experience long COVID will need support at school. Some symptoms – such as fatigue, brain fog and memory impairment – are similar to those experienced after a concussion. But because these symptoms are challenging to identify or to track, it can be difficult for teachers to know how to help. </p>
<p>We are researchers who study <a href="https://www.springerpub.com/managing-concussions-in-schools-9780826169228.html">how schools manage concussions</a> and the <a href="https://doi.org/10.1080/07448481.2021.1927053">prevalence of long COVID</a> and associated mental health outcomes. We believe strategies that schools use to <a href="https://www.cdc.gov/headsup/pdfs/schools/tbi_returning_to_school-a.pdf">support students with concussions</a> may also help those with prolonged COVID-19 symptoms. </p>
<h2>Kids and long COVID</h2>
<p>Not all physical symptoms experienced after COVID-19 illness <a href="https://www.researchsquare.com/article/rs-798316/v1">indicate long COVID</a>. When symptoms do last more than a few weeks, a thorough medical evaluation by a pediatrician with knowledge of long COVID is recommended. Pediatric post-COVID clinics are an excellent way to find such doctors. However, at this time, these clinics <a href="https://www.usnews.com/news/health-news/articles/2021-07-13/for-kids-with-long-covid-clinic-help-can-be-hard-to-find">aren’t widespread</a> in the United States.</p>
<p>Post-COVID complications have been reported frequently <a href="https://doi.org/10.1093/cid/ciab611">by adults</a>. However, research on long COVID in children is scarce, with <a href="http://www.doi.org/10.1183/13993003.01341-2021">estimates of persistent symptoms</a> <a href="https://doi.org/10.1111/apa.15870">varying widely</a>. The wide-ranging estimates likely reflect differences in how study participants were recruited, how long after having acute COVID-19 they participated in the study, the symptoms researchers assessed and other methodological differences. </p>
<h2>School accommodations</h2>
<p>Students who continue to experience symptoms after they’ve tested negative and been cleared to return to school should notify the school of persistent issues. Even if the child is not officially diagnosed with long COVID, a gradual return to school and activities, as well as academic and environmental accommodations, can support children during recovery. </p>
<p>We recommend that parents, teachers and doctors work together to support the child’s recovery. This is what’s called <a href="https://www.ama-assn.org/delivering-care/ethics/collaborative-care">collaborative care</a>. It is helpful if a school-based professional – such as a school nurse, counselor or psychologist – serves as a central communicator. This involves sharing accommodations with teachers, talking with doctors (with a signed release) and communicating progress back to the family. </p>
<p>Together, these collaborative care teams can establish temporary accommodations for the affected student, such as:</p>
<ol>
<li><p>Allow a flexible attendance schedule with rest breaks to minimize fatigue.</p></li>
<li><p>Reduce physical activity and minimize exposure to overstimulating environments to prevent fatigue and headaches.</p></li>
<li><p>Modify the workload. This might include, for example, removing high-stakes projects and nonessential work, providing alternate assignments and allowing the student to drop classes without penalty. Base grades on adjusted work so the child is not penalized for memory problems. </p></li>
<li><p>Provide extra time to complete assignments and tests so a child with brain fog can process information.</p></li>
<li><p>Develop an emotional support plan for the student to prevent anxiety and depression. This might include identifying an adult at school to talk with if the child feels overwhelmed, or providing a support group for students to discuss their experiences and recovery.</p></li>
<li><p>Encourage the student to explore alternative extracurricular activities that are nonphysical and not cognitively taxing.</p></li>
</ol>
<p>We recommend that schools front-load adjustments for a student with long COVID and gradually withdraw them as the student recovers. The symptoms, recovery rate and trajectory will vary for each student. Therefore, a gradual and monitored return to activity is important to help ensure that symptoms don’t worsen when students engage in more activity. If symptoms do get worse, then accommodations should resume. </p>
<h2>An evolving illness</h2>
<p>We have <a href="https://theconversation.com/preliminary-research-finds-that-even-mild-cases-of-covid-19-leave-a-mark-on-the-brain-but-its-not-yet-clear-how-long-it-lasts-166145">much to learn</a> about the long-term effects of COVID-19 and the prognosis for <a href="https://theconversation.com/how-many-people-get-long-covid-and-who-is-most-at-risk-154331">those who develop long COVID</a>. These guidelines are based on what is known at this time and should be considered preliminary. </p>
<p>As COVID rates and treatments evolve, it is important for parents, educators and medical providers to continue talking with one another about persistent symptoms and effective treatments.</p>
<p>[<em>Research into coronavirus and other news from science</em> <a href="https://theconversation.com/us/newsletters/science-editors-picks-71/?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=science-corona-research">Subscribe to The Conversation’s new science newsletter</a>.]</p><img src="https://counter.theconversation.com/content/169076/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>When a student suffers a concussion, their school typically offers certain accommodations – lighter workload, rest breaks, more time to complete tests. Do kids with long COVID need the same?Susan Davies, Professor, School Psychology, University of DaytonJulie Walsh-Messinger, Associate Professor of Psychology, University of DaytonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1556382021-03-19T02:33:00Z2021-03-19T02:33:00ZConcussion risks aren’t limited to the AFL. We need urgent action to make sure our kids are safe, too<p>The AFL season kicked off this week with the defending champion Richmond Tigers taking on Carlton in front of nearly 50,000 fans at the Melbourne Cricket Ground — apparently the <a href="https://twitter.com/austadiums/status/1372529594893438977">largest sport crowd</a> in Australia since the beginning of the COVID-19 pandemic. </p>
<p>In the lead-up to the new season, however, the focus has not solely been on the footy. Much attention is also being paid to the darker side of the sport: concerns over concussions and the safety of its players. </p>
<p>Last month, the <a href="https://www.theguardian.com/sport/2021/feb/17/afl-considering-proposal-for-landmark-multimillion-dollar-concussion-trust-for-players">Guardian</a> published a report saying the AFL is considering creating a $2 billion concussion trust fund to support past, present and players. </p>
<p>Then, the <a href="https://www.coronerscourt.vic.gov.au/sites/default/files/2021-02/Finding%20D%20Frawley.pdf">coroner’s report</a> into the death of AFL legend Danny Frawley found chronic traumatic encephalopathy (CTE), a degenerative brain disease, had been “a potential contributor” to the depression he had suffered. </p>
<p>The coroner <a href="https://www.theaustralian.com.au/breaking-news/call-for-afl-players-to-donate-brains-after-danny-frawleys-tragic-death/news-story/a7b7fc7e135b914cd78b2dfe48e741f5">recommended</a> the AFL “actively encourage” players to donate their brains to the Australian Sports Brain Bank for scientific research to </p>
<blockquote>
<p>improve the safety of future generations of footballers and others engaged in contact sports. </p>
</blockquote>
<p>Last week, the AFL said it <a href="https://www.theage.com.au/national/victoria/afl-asks-for-voice-in-coronial-probe-into-richmond-player-s-death-20210309-p57926.html">wanted to be involved</a> in the investigation into the suicide of 38-year-old former player Shane Tuck, who had also suffered mental health problems. One of the brain bank researchers said Tuck had “the <a href="https://www.theage.com.au/sport/afl/shane-tuck-had-severe-cte-brain-bank-reveals-20210122-p56w3n.html?utm_medium=Social&utm_source=Twitter#Echobox=1611348821">worst case</a>” of CTE he had ever seen. </p>
<p>All of this comes months after former AFL player Shaun Smith was <a href="https://www.theguardian.com/sport/2020/sep/18/concussion-payout-to-former-afl-player-shaun-smith-reinforces-cte-link-with-contact-sport">awarded</a> a $1.4 million insurance payout for the “total and permanent disablement” he suffered as a result of concussions — the first of its kind in Australia.</p>
<p>With the AFL placing such attention on this issue, it’s important to also consider what these developments mean for other levels of the sport, especially schoolchildren. </p>
<h2>Should my child be signing up to join the footy team?</h2>
<p>This was the exact question I asked myself when I first started <a href="http://classic.austlii.edu.au/au/journals/SportsLaweJl/2011/2.pdf">researching</a> the dangers of concussions in professional sport in 2010. </p>
<p>I assumed that at the school level, our kids would be entering a sports system that was optimally safe and acknowledged the risks of contact sport. But this wasn’t necessarily the case. There was no real understanding of who was responsible for making the system safe.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/concussions-and-kids-know-the-signs-60672">Concussions and kids: know the signs</a>
</strong>
</em>
</p>
<hr>
<p>We’ve known for years that the dangers of mismanaging concussions are not just an elite-level footy concern that stops at the boundary lines of the MCG. This should, in fact, be regarded as a prominent public health issue.</p>
<p>Given this, who should ultimately take the lead on this at the school and junior level — the government (the guardians of the public’s health) or the AFL (the guardians of the sport)? The answer is a mixture of both.</p>
<h2>A prominent public health issue</h2>
<p>Unlike some countries, Australian governments have traditionally adopted a “hands off” approach when it comes to the legal regulation of sport-related concussions. </p>
<p>The federal government has taken some steps toward framing this as a public health concern in recent years by developing a Concussion in Sport Australia <a href="https://www.concussioninsport.gov.au/">information website</a>. It provides guidance for athletes, parents, coaches and teachers on everything from the early signs of a concussion to the long-term consequences. </p>
<p>Some state and territory governments have partnered with professional groups to develop their own concussion in sport <a href="https://www.sport.nsw.gov.au/sectordevelopment/concussion">protocols</a> and education workshops for community sport programs. </p>
<p>These are all positive steps in the right direction, but the approach remains patchy and inconsistent across the country. </p>
<p>Recognising the wider social context, I put out an urgent call in 2018 for a collective and <a href="https://www.heraldsun.com.au/lifestyle/health/urgent-call-for-national-sports-concussion-strategy-to-protect-brains/news-story/419bc7c81f05fdbbdab8305188d55e2b">nationally coordinated response</a>. </p>
<p>My proposal aimed to bring together state governments, sporting codes and medical and other experts to work with Sport Australia on designing a national concussion framework. What we needed was a consistent approach across sports to reduce and manage the risks associated with concussion in sport — all guided by research.</p>
<p>The idea didn’t make much headway with governments. There is still more work to be done.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1328943526273495041"}"></div></p>
<h2>How laws in other countries are helping</h2>
<p>While the data are patchy, <a href="https://bjsm.bmj.com/content/51/12/949.long">experts agree</a> that sport-related concussions among children are very common, and the effects of concussions in children are different from those in adults. Experts also agree that <a href="https://search.informit.org/doi/epdf/10.3316/informit.241612182530676">children and adolescents</a> should be subject to more conservative and careful concussion management. </p>
<p>The United States is far ahead in this effort. Youth sport concussion laws are now in place in states across the country that focus on mitigating the risk of mismanaging concussions and preventing serious complications. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"853686174128390144"}"></div></p>
<p>The laws generally focus on <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6378501/#:%7E:text=Youth%20sports%20concussion%20laws%20generally,return%20to%20play%E2%80%9D%20or%20RTP">three central principles</a>) — education, immediate removal from play and medical clearance before return. While <a href="https://www.jahonline.org/action/showPdf?pii=S1054-139X%2817%2930913-8">far from perfect</a> in terms of regulatory process, these laws have gone a long way to heighten awareness of the dangers of concussion. </p>
<p>There has been success on this front in the Canadian province of Ontario. </p>
<p>A <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-018-6232-9">government mandate</a> was issued in 2014 requiring schools to develop a concussion protocol as part of the curricula. Then, in 2018, a <a href="https://www.ontario.ca/laws/statute/s18001">new law was passed</a> that required all sport organisations to establish a concussion code of conduct and removal from sport and return-to-play protocols for children under 18.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1138779649373347840"}"></div></p>
<p>Australia does not have similar laws. The Australia Institute of Sport has <a href="https://www.sportaus.gov.au/__data/assets/pdf_file/0005/683501/February_2019_-_Concussion_Position_Statement_AC.pdf">issued a position statement</a> that reads:</p>
<blockquote>
<p>Children should not return to contact/collision activities before 14 days from complete resolution of all concussion symptoms.</p>
</blockquote>
<p>But what is clearly needed are stronger laws or collaborative governance mechanisms to ensure our kids are entering an optimally safe sports system.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/can-headband-sensors-reduce-underreported-concussions-in-kids-62676">Can headband sensors reduce underreported concussions in kids?</a>
</strong>
</em>
</p>
<hr>
<h2>What has the AFL done?</h2>
<p>The AFL does not have the same legislative mandate as government, but it wields significant influence as the guardian of the sport. </p>
<p>According to the AFL, concussion has been on its radar for <a href="http://www.aflcommunityclub.com.au/fileadmin/user_upload/Coach_AFL/Injury_Management/ResponsibleApproachConcussionintheAFL.pdf">over 25 years</a>, but most of this has been focused on the elite level of the sport. </p>
<p>The <a href="http://www.aflcommunityclub.com.au/index.php?id=66">AFL Community Club website</a> does provide guidelines on managing concussions for community football, which includes a sport concussion assessment tool for children aged five to 12.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/is-the-nrl-legally-liable-for-the-long-term-impacts-of-concussions-119880">Is the NRL legally liable for the long-term impacts of concussions?</a>
</strong>
</em>
</p>
<hr>
<p>However, some of the AFL’s affiliate networks across the country have <a href="https://aflnswact.com.au/community-football-concussion/">outdated</a> or hard-to-find information on concussion safety on their websites. Given the prominence of the issue, this inconsistency is something the AFL needs to urgently address. </p>
<p>In December, the AFL advertised for a new “<a href="https://www.theage.com.au/sport/afl/afl-to-consolidate-concussion-responses-into-a-single-role-20201213-p56n1b.html">concussion lead</a>” to coordinate its strategy on head trauma and concussion responses, which signifies just how serious this issue has become. </p>
<p>Undoubtedly, the AFL has had a lot on its plate navigating the COVID-related disruptions to the sport, but the time is right to adopt a wider lens in developing an effective concussion strategy to keep our kids safe. </p>
<hr>
<p><em>If this article has raised issues for you, or if you’re concerned about someone you know, call Lifeline on 13 11 14.</em></p><img src="https://counter.theconversation.com/content/155638/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Annette Greenhow does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Rocked by recent events on the dangers of concussion at the elite level, the AFL has a perfect opportunity to adopt a wider lens and mobilise its network to keep footy safe, especially for the kids.Annette Greenhow, Assistant Professor, Faculty of Law, Bond UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1220352019-10-10T12:46:03Z2019-10-10T12:46:03ZCould helmetless tackling training reduce football head injuries?<figure><img src="https://images.theconversation.com/files/296289/original/file-20191009-3894-1t2038e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A young football player holds his mouth guard.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/boy-putting-his-mouth-guard-131180210?src=HSe99Ku-wSt0C-t7Lt68pA-1-3">Suzanne Tucker/Shutterstock.com</a></span></figcaption></figure><p>With football season well underway, there already have been instances of helmet-to-helmet hits, concussions and yet another round of conversations about strategies to reduce head impact exposure in players. </p>
<p>This is an urgent matter for all football players, but particularly for the <a href="https://www.nytimes.com/2018/10/29/sports/football-participation.html">1.1 million high schoolers</a> who play, as well as for thousands more youngsters who play at even younger ages, hoping to one day find gridiron glory. Football is the <a href="https://rapidcityjournal.com/news/local/as-brain-injury-research-expands-football-participation-falls-in-s/article_f43a125c-ca0b-5294-9820-c4eb79d9d61e.html">most widely played</a> high school sport – and the <a href="https://news.gallup.com/poll/224864/football-americans-favorite-sport-watch.aspx">most popular spectator sport</a> in the country.</p>
<p>Because of the growing concern about concussions, many people argue that <a href="https://bioethics.georgetown.edu/2015/12/should-high-school-football-be-banned/">tackle football should be banned</a>. Opponents to this argue that tackle football is safer now, that coaches teach tackling differently. They argue that safer methods are reducing head impacts and the concussions that come with them. Yet, what are “safe” tackling techniques, and what does the data tell us about their impact on preventing concussions?</p>
<p>There is very little scientific evidence available to support claims that teaching tackling a certain way results in decreased head impacts, concussions or other injury. </p>
<p>I am <a href="https://scholar.google.com/citations?view_op=list_works&hl=en&user=ZiCI3uYAAAAJ">professor of kinesiology</a> who has studied spine injury and concussions in football throughout my career. Colleagues and I recently conducted and published a <a href="https://www.jsams.org/article/S1440-2440(18)31067-3/abstract">study</a> of high school students in an effort to see if a certain type of training can in fact protect athletes. Combined with an earlier study on the <a href="https://natajournals.org/doi/full/10.4085/1062-6050-51.1.06">college</a> level, the findings suggest that we are only beginning to answer these questions.</p>
<h2>A growing concern</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/296291/original/file-20191009-3887-yg4u8l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/296291/original/file-20191009-3887-yg4u8l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=346&fit=crop&dpr=1 600w, https://images.theconversation.com/files/296291/original/file-20191009-3887-yg4u8l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=346&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/296291/original/file-20191009-3887-yg4u8l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=346&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/296291/original/file-20191009-3887-yg4u8l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=434&fit=crop&dpr=1 754w, https://images.theconversation.com/files/296291/original/file-20191009-3887-yg4u8l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=434&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/296291/original/file-20191009-3887-yg4u8l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=434&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Football helmets have been a mainstay of the sport since its inception.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/football-player-raises-his-helmet-before-83208013?src=n47gB67rNV1p39md5hTiqA-1-51">Brocreative/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>Overall participation in high school football <a href="https://rapidcityjournal.com/news/local/as-brain-injury-research-expands-football-participation-falls-in-s/article_f43a125c-ca0b-5294-9820-c4eb79d9d61e.html">dropped 5.2%</a> last year. Some programs have even been canceled due to lower numbers that are further hampered by injury. For example, both <a href="https://www.nbcwashington.com/news/local/Maryland-High-School-Cancels-Varsity-Football-Season-for-Lack-of-Players-562021491.html">Thomas Jefferson High School</a> and <a href="https://www.nytimes.com/2019/10/09/sports/grinnell-football-season-canceled.html#click=https://t.co/EDtFIYK9ZK">Grinnell College</a> ended their seasons this October because of injuries. </p>
<p>While the use of theoretical safer tackling techniques, such as shoulder tackling, are anecdotally in widespread use, what scientific evidence is there to show they are truly safer? Do we really know, beyond chance, if a tackling technique results in the reduced concussions or the head impacts that cause them? As scientists, we just don’t know whether training tackling a specific way can truly reduce head impacts and concussion.</p>
<p>In the meantime, some of us wonder whether the answer could lie in helmetless tackling training.</p>
<p>To understand how helmetless tackling could help, it may first help to understand the concept of <a href="https://journals.lww.com/cjsportsmed/Fulltext/2004/07000/Risk_Compensation__A__Side_Effect__of_Sport_Injury.1.a">risk compensation</a>, the theory that helmetless tackling training is based on. </p>
<p>Risk compensation is a concept that goes at least as far back as when seat belts were first being mandated for drivers and passengers of cars. The thought was that adding seat belts caused a change <a href="https://www.sciencedirect.com/science/article/abs/pii/0001457594900957?via%3Dihub">in driving behavior</a>, which actually increased the frequency of motor vehicle <a href="https://link.springer.com/article/10.1007/BF00138059">accidents</a> because drivers felt safer. </p>
<p>In the case of football, the modern helmet creates a perceived reduction of risk, allowing the participant to initiate head first tackling and blocking. In other words, a football helmet – while necessary for traumatic head injury protection – contributes to an increase in risk-taking behaviors, such as head-first contact during a tackle or block. </p>
<p>A clear example of this phenomenon occurred after hard-shell helmets were introduced into football. <a href="https://www.ncbi.nlm.nih.gov/pubmed/434291">“Spear-tackling” behavior emerged</a>, leading to a spike in catastrophic head and neck injuries. </p>
<p>Rule changes in 1976 prohibited spear-tackling – the lowering of the head to make a tackle – which <a href="https://www.ncbi.nlm.nih.gov/pubmed/27432138">reduced head and spine injury</a> over 50%. However, football remains a helmet-centric sport and headfirst contact <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2707068/">continues</a>. </p>
<p>Contrast this against another sport that involves a lot of tackling: rugby. While rugby players are definitely prone to <a href="https://doi.org/10.1016/j.jemermed.2018.11.007">sustaining concussions</a>, American football is beginning to model the rugby style tackle of using their shoulders to initiate contact while avoiding head contact. </p>
<p>Based on risk compensation theory, rugby players tackle with their shoulders not only because they were taught that way, but because their heads are not protected with a helmet. Keeping the head out of the way simply develops naturally as an <a href="https://www.sciencedirect.com/science/article/pii/S0304394004006159">anticipatory reflex</a> to <a href="https://www.degruyter.com/view/j/revneuro.2004.15.5/revneuro.2004.15.5.371/revneuro.2004.15.5.371.xml">protect</a> the head. </p>
<h2>Helmetless tackling</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/296292/original/file-20191009-3917-1anqc9t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/296292/original/file-20191009-3917-1anqc9t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/296292/original/file-20191009-3917-1anqc9t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/296292/original/file-20191009-3917-1anqc9t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/296292/original/file-20191009-3917-1anqc9t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/296292/original/file-20191009-3917-1anqc9t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/296292/original/file-20191009-3917-1anqc9t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Young football players learn some of the basics of the game, without helmets.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/bakersfield-ca-june-9-coaches-teach-104775533?src=SQFvG0LqpVnOKSQ0LqvUXA-1-2">Richard Thornton/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>Our research is based on the hypothesis that a football player who regularly receives tackling and blocking training without wearing a helmet will reinforce motor behaviors for avoiding head impacts with other players. </p>
<p>Adopting and mastering this skill could counter the inclination to initiate head-first tackling and blocking when wearing a helmet. </p>
<p>Using a randomized study, we found college players assigned to a helmetless training group decreased their head impacts compared to a control group by <a href="https://doi.org/10.4085/1062-6050-51.1.06">30% at the end of the season</a>. In a larger <a href="https://natajournals.org/doi/full/10.4085/1062-6050-51.1.06">study in high school players</a>, we found subjects who participated in helmetless tackling training to have fewer head impacts in the middle of the season in two successive years, mostly during games. This difference did not hold up by the end of the season, however. </p>
<p>We also compared the subjects in our study who were freshmen separately from those who competed on the junior varsity and varsity levels. When we analyzed the data that way, the reduction in head impacts appeared to only be coming from the older, or varsity, players. This may suggest that the younger, less experienced players could need a higher frequency, or dose, of the helmetless training.</p>
<p>Clearly, researchers need to do more work to fully understand the kind of training, and how much training, is needed depending on the age and experience level of the player to get the desired results. </p>
<p>Either way, this research represents the only prospective randomized, controlled studies to our knowledge, to have explored the outcomes of a tackling training technique in football. </p>
<h2>The need for randomized controlled trials</h2>
<p>Importantly, head impacts and concussions suffered from tackling and blocking involves more than just teaching a sport skill. This is not to suggest that teaching sport skills is simple. Rather, it suggests that head impact exposure in football is a medical problem, and just like any other medical problem, needs a medical solution. </p>
<p>As with over the counter or prescription medications and medical devices, federally mandated rigorous study using randomized controlled trials are the norm for demonstrating a cause effect relationship. Given the populations involved, and number of participants playing football, rigorous research using randomized controlled trials is warranted. </p>
<p>Those of us who study this problem do not yet know whether new tackling techniques are truly safer, but we do know that players, especially young ones, deserve to know. </p>
<p>[ <em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>. ]</p><img src="https://counter.theconversation.com/content/122035/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Erik Swartz currently receives funding from The GOG Foundation. He has previously received funding from The National Football League, General Electric, and UnderArmor (NineSigma Head Health Challenge), and the National Athletic Trainers' Association. HUTT is a USPTO registered trademark of the University of New Hampshire. </span></em></p>Football participation among high schoolers continues to decline, as concern about brain injury increases. Could training without helmets make a difference?Erik Swartz, Professor of Kinesiology, UMass LowellLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1213572019-09-12T11:06:09Z2019-09-12T11:06:09ZConcussions and children returning to school – what parents need to know<figure><img src="https://images.theconversation.com/files/291860/original/file-20190910-190021-7091p2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The level of knowledge around concussions among parents and school personnel is not as high as it should be.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/adorable-cheerful-children-playing-soccer-ball-676528381?irgwc=1&utm_medium=Affiliate&utm_campaign=Pixabay%20GmbH&utm_source=44814&utm_term=https%3A%2F%2Fpixabay.com%2Fimages%2Fsearch%2Fchildren%2520playing%2F">LightField Studios/Shutterstock.com</a></span></figcaption></figure><p>“Jamal” is a 16-year-old boy who sustained a concussion in a skateboarding accident in July. He was diagnosed in the emergency room. Jamal initially had headaches, nausea and sensitivity to light and noise, but he appeared symptom-free within two weeks.</p>
<p>When Jamal returned to school in late August, he had difficulty waking up in the morning, paying attention in class and managing his assignments. His headaches returned. </p>
<p>But neither Jamal nor his parents traced these issues back to Jamal’s concussion, so no one told the school about his accident. His teachers – who did not know Jamal prior to the accident – saw him as unmotivated and moody. Jamal ended the first quarter with low grades, which his parents attributed to the more challenging curriculum. </p>
<p>This poor outcome could have been avoided with a few changes to the story and with better knowledge about concussions among school personnel and parents. Many policies and educational initiatives have helped target student athletes, but children who sustain concussions for other reasons – including accidents and overall play – may go unnoticed and untreated.</p>
<p>As a researcher in school psychology, <a href="https://udayton.edu/directory/education/edc/davies_susan.php">I</a> study how to help students thrive in school. I am particularly interested in the care they receive after concussions, and I have found this care to be inconsistent among both educators and medical personnel. While some injured student-athletes receive treatment in a sports clinic and are monitored by an athletic trainer, others receive little guidance on how to safely return to their normal activities. This lack of guidance sometimes causes parents to under- or over-restrict their child’s activity, both of which can prolong recovery. </p>
<h2>Collaborating with the school</h2>
<p><a href="https://www.cdc.gov/traumaticbraininjury/get_the_facts.html">Falls account for almost half</a> of the brain injury-related hospitalizations among children under 18. Preschool-age children are particularly prone to fall-related emergency department visits. <a href="https://www.cdc.gov/traumaticbraininjury/get_the_facts.html">Adolescents are also at relatively high risk</a> for brain injury-related hospitalizations, largely due to motor vehicle accidents. </p>
<p>Concussions can result in an array of symptoms with varying degrees of severity. Symptoms can be <a href="https://www.cdc.gov/traumaticbraininjury/symptoms.html">physical, cognitive, social-emotional and sleep-related</a>. While symptoms generally resolve within a few weeks, some may persist for months – or longer. Difficulties with headaches, concentration, memory and frustration are among the most common and persistent symptoms. </p>
<p>While doctors recommend that children who have sustained a concussion <a href="https://www.cdc.gov/traumaticbraininjury/symptoms.html">refrain from athletics</a> until they no longer have symptoms and have been cleared by a medical professional, they can <a href="https://www.cdc.gov/headsup/pdfs/schools/tbi_returning_to_school-a.pdf">return to school</a> as long as school personnel know how to manage their symptoms. This is not unlike a child returning to school with a broken arm. The teacher wouldn’t put the student in gym class or require them to write a lengthy essay, but they can still attend class and participate to the degree that the injury allows. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/291861/original/file-20190910-190026-1qwzda5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/291861/original/file-20190910-190026-1qwzda5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/291861/original/file-20190910-190026-1qwzda5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=956&fit=crop&dpr=1 600w, https://images.theconversation.com/files/291861/original/file-20190910-190026-1qwzda5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=956&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/291861/original/file-20190910-190026-1qwzda5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=956&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/291861/original/file-20190910-190026-1qwzda5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1202&fit=crop&dpr=1 754w, https://images.theconversation.com/files/291861/original/file-20190910-190026-1qwzda5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1202&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/291861/original/file-20190910-190026-1qwzda5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1202&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Parents can coordinate with a person at school to track the progress of children at school after a concussion injury.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/thomashawk/2202278266/in/faves-41182236@N00/">Thomas Hawk/flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span>
</figcaption>
</figure>
<p>Some schools have incorporated a <a href="https://concussions.brainsteps.net/about/brainsteps">team-based model</a> – including teachers, school nurses, school psychologists, athletic personnel and families – to help students return to the classroom safely after a concussion. Such teams typically assign a concussion team leader who serves as a care coordinator to facilitate communication among medical professionals, school personnel and families. This model can help ensure that all students are monitored upon return to school. </p>
<p>However, this type of coordinated care is not universal. Many <a href="https://ir.lib.uwo.ca/eei/vol26/iss1/1/">educators receive little or no training</a> on brain injuries, so teachers often miss students’ symptoms. And sometimes, the symptoms are not apparent until the child is faced with the demands of school. Returning to school is particularly difficult for children who were injured during the summer months and continue to suffer from symptoms well into the school year. </p>
<p>Generally speaking, parents need to become more familiar with concussion symptoms, including the fact that <a href="https://www.cdc.gov/headsup/pdfs/providers/facts_about_concussion_tbi-a.pdf">symptoms can return</a> with a change in activity. They can also facilitate their child’s transition back to school by signing a release of information so school personnel, such as the school nurse or school psychologist, can communicate directly with medical care providers. It’s also helpful to request that one person at the school serve as a care coordinator to make sure teachers, medical professionals, parents, the student and athletic personnel (if applicable) are all informed about a child’s ongoing symptoms and recovery strategies. </p>
<h2>Treating the invisible injury</h2>
<p>Because a concussion is an invisible injury, it can be difficult for teachers and parents – and even students themselves – to remember that environmental and academic adjustments are necessary during recovery. Further, the rate of recovery and the type of adjustments needed differ from child to child depending on <a href="https://bjsm.bmj.com/content/51/12/941">a variety of factors</a>, such as intensity of injury, the child’s age and preexisting issues. </p>
<p>Of key importance is the child’s <a href="https://www.pmr.theclinics.com/article/S1047-9651(11)00079-9/abstract">gradual and monitored return to activity</a>. This means that children recovering from concussions can return to school and some social activities, but should avoid physical or mental activities that may worsen symptoms. For example, use of technology – including computers, phones (for texting), video games, television and headphones (for listening to music) – can worsen symptoms and should be minimized when possible. </p>
<p><a href="http://orcas-sportsconc2.s3.amazonaws.com/files/e_academic_adjustments.pdf">Environmental and academic adjustments</a> should be put in place according to the child’s symptoms but should not be prolonged unnecessarily. For example, a child who is easily fatigued might take rest breaks in the nurse’s office; a child who no longer is sensitive to light does not need to wear sunglasses at school. Activity can gradually be increased as long as it does not cause symptoms to flare. </p>
<p>In addition to working with the school and medical professionals to implement appropriate accommodations, it is important that parents maintain documentation of the injury. The concussion should be reported on future medical forms, including those related to athletic participation. Since <a href="https://www.mayoclinic.org/diseases-conditions/concussion/symptoms-causes/syc-20355594">previous concussion is a risk factor</a> for future injury, a child needs to know about this risk factor and include his concussion history in self-reports of medical history. </p>
<p>[ <em>You’re smart and curious about the world. So are The Conversation’s authors and editors.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=youresmart">You can read us daily by subscribing to our newsletter</a>. ]</p><img src="https://counter.theconversation.com/content/121357/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Susan Davies currently receives no external funding. Over the past five years, she has received funding through internal summer research grants from the University of Dayton, the Ohio Department of Public Safety (EMS Division), the Ohio Department of Health, and the Child Injury Action Group (Ohio). </span></em></p>Many educators receive little or no training in how to spot brain injuries resulting from a concussion. There are ways to improve collaboration.Susan Davies, Professor, School Psychology, University of DaytonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1198802019-07-08T20:11:20Z2019-07-08T20:11:20ZIs the NRL legally liable for the long-term impacts of concussions?<figure><img src="https://images.theconversation.com/files/283014/original/file-20190708-51273-ukutny.jpg?ixlib=rb-1.1.0&rect=815%2C819%2C1749%2C1209&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Protocols are now in place to treat suspected concussions during NRL matches, but this wasn't always the case in the league. </span> <span class="attribution"><span class="source">Dan Himbrechts/AAP</span></span></figcaption></figure><p>In the not too distant past, players who suffered head injuries in professional contact sports quickly returned to the field of play, sometimes in the same game, seemingly able to shake off any concussion concerns. </p>
<p>Australian professional sports leagues likewise <a href="https://www.theage.com.au/sport/nrl/league-and-american-football-not-concussion-cousins-says-medic-20120516-1yrbp.html">were unconvinced of</a> the long-term effects of head injuries – and specifically the US-based research suggesting a <a href="https://www.abc.net.au/4corners/hard-knocks/4011996">connection between head injuries and chronic traumatic encephalopathy, or CTE</a> - preferring instead to wait for Australian scientific evidence to lead the way. </p>
<p>Last month, however, a <a href="https://actaneurocomms.biomedcentral.com/articles/10.1186/s40478-019-0751-1">report</a> was released by researchers from the University of Sydney and the Royal Prince Alfred Hospital finding scientific evidence of CTE in the brains of two middle-aged, former National Rugby League (NRL) players who had each played more than 150 games over many years. </p>
<p>The report, published as a “letter to the editor” in a medical journal, is the <a href="https://www.abc.net.au/news/2019-06-27/rugby-league-players-found-to-have-deadly-brain-disease/11254032">first time</a> CTE has been identified in rugby league players anywhere in the world. </p>
<p><a href="https://concussionfoundation.org/CTE-resources/what-is-CTE">Medical experts have</a> described CTE as </p>
<blockquote>
<p>a degenerative brain disease found in athletes, military veterans, and others with a history of repetitive brain trauma.</p>
</blockquote>
<p>The Sydney researchers acknowledge that their report is limited by a lack of clinical information collected during the lifetimes of the two NRL players and note that</p>
<blockquote>
<p>it is difficult to assess whether these two CTE cases are serendipitous findings, or emblematic of a more common issue with Rugby League and other Australian football codes. </p>
</blockquote>
<p>Nonetheless, in the face of this discovery, a legal question has arisen in the rugby league world: who should be responsible for brain injuries suffered by former players? The answer is likely to be determined in Australian courts if a <a href="https://www.theguardian.com/sport/2019/jul/03/rugby-league-players-consider-class-action-over-nrls-treatment-of-concussions">threatened class action lawsuit</a> is brought by former NRL players against the league and its clubs. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/what-does-concussion-do-to-the-brain-53224">What does concussion do to the brain?</a>
</strong>
</em>
</p>
<hr>
<h2>The key questions for a class action lawsuit</h2>
<p>According to media reports, several former, but as yet unnamed, NRL players <a href="https://www.smh.com.au/sport/nrl/three-law-firms-announce-nrl-concussion-class-actions-within-24-hours-20190703-p523th.html">have expressed interest</a> in joining a proposed class action suit, claiming the league and its clubs failed to provide a safe workplace. </p>
<p>Without full details of the complaints, media reports have suggested the case will revolve around whether the league and clubs did enough to protect players from the long-term effects of repetitive concussive and subconcussive injuries and whether they knew or ought to have known about the risks associated with mismanaging such injuries. </p>
<p>Central to the case will be whether the players can demonstrate they were owed a duty of care by the league and whether that duty was breached. Another critical question will be whether players can prove that any breach of duty caused or contributed to the players’ long-term injuries.</p>
<p>A key challenge in <a href="http://classic.austlii.edu.au/au/legis/cth/consol_act/fcoaa1976249/s33c.html">any class action suit</a> is to first establish that the claims of several parties are against the same person or organisation, and arise from the “same, similar or related circumstances” involving a substantial common issue of law or fact. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/who-should-be-responsible-for-brain-injuries-in-sport-62285">Who should be responsible for brain injuries in sport?</a>
</strong>
</em>
</p>
<hr>
<p>Like most professional sports leagues, the NRL has adopted its own <a href="https://www.nrl.com/operations/the-players/management-of-concussion/">concussion protocols</a> over the years to properly manage how and when players can return to the sport following a head injury. As NRL chief executive Todd Greenberg <a href="https://10daily.com.au/news/sport/a190708hpsbc/nrl-spending-enormous-amount-on-concussion-research-20190708">says</a>: </p>
<blockquote>
<p>We have made huge changes going back to 2014 and I’m very confident those rules are in place for the primary reason for the care of our players.</p>
</blockquote>
<p>A key question in the proposed class action, therefore, is how this was handled in the past, before the current protocols were put in place. Were players returning to competition too soon after a head injury? And were the concussion protocols properly implemented and enforced? </p>
<p>These questions rely on first establishing whether the NRL, as the sport’s governing body, owed a legal duty to provide and invest in a safe workplace to prevent or reduce the risk of mismanaging head injuries. </p>
<p>Another important question is the level of scientific understanding of the risks associated with mismanaging concussions at the time the players were injured. Was the sport following best practices based on the scientific understanding at the time? </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1146431347717791745"}"></div></p>
<h2>Who is legally responsible for players’ safety?</h2>
<p>A professional sportsperson can legally be classified as an employee, with the right to expect a safe working environment. In professional team sport, this includes an obligation to remove a player from a game or training when they are believed to have suffered a concussion.</p>
<p>In 2000, the High Court in <a href="https://www.austlii.edu.au/cgi-bin/viewdoc/au/cases/cth/HCA/2000/41.html">Agar v Hyde</a> established that the governing body of a sport does not owe a duty to voluntary, amateur participants to amend the rules of the game to make it safer. One of the reasons for this decision was a finding that a sport governing body lacked any real or effective control over recreational or amateur participants. </p>
<p>However, the court left open the possibility of re-examining whether professional athletes who are classified as employees and injured at work fall within a different category. </p>
<p>Since the Agar v Hyde case, this question has not been determined in any Australian case, so it is likely to arise in a rugby league class action suit, should it proceed to trial.</p>
<h2>How cases have been handled elsewhere</h2>
<p>The heightened awareness around CTE in Australia follows the 2011 class action lawsuit filed in the United States by former football players against the National Football League. The case involved allegations the league knew about the dangers associated with repetitive concussive and subconcussive injuries but, among other things, fraudulently concealed this information and failed in its duty of care to ensure the safety of players.</p>
<p>The NFL case <a href="https://www.nflconcussionsettlement.com/">settled for US$1 billion</a> before going to trial, so these allegations were not tested in court. The NFL case did, however, bring into sharp focus the role of a sport’s governing body and who is ultimately responsible for the long-term health of players. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/concussions-and-cte-more-complicated-than-even-the-experts-know-81794">Concussions and CTE: More complicated than even the experts know</a>
</strong>
</em>
</p>
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<p>In a culture known for its litigation appetite, <a href="http://nflconcussionlitigation.com/">hundreds of legal cases</a> have since been filed in US courts – against clubs, schools, colleges, doctors, coaches, hospitals and insurers, to name a few. The National Hockey League has also been sued by former players, but the case was <a href="https://www.nytimes.com/2018/11/12/sports/hockey/hockey-concussion-settlement.html">settled</a> last year. </p>
<p>But the US and Australian sports and court systems are different, and any Australian case will need to be based on Australian law in accordance with the federal or state-based civil procedures. </p>
<p>The long-term impact of such lawsuits also remains to be seen. In the US, there are <a href="https://www.reuters.com/article/us-health-kids-tackle-football/fewer-u-s-high-school-athletes-play-football-amid-concussion-fears-idUSKCN1GO2LY">fewer high school students playing football</a> due to concerns over the long-term effects of brain injuries. Whether the links between CTE and rugby league players will have the same effect on participation rates in Australia is another issue worth further study.</p><img src="https://counter.theconversation.com/content/119880/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Annette Greenhow does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>After a report found evidence of CTE in the brains of two former NRL players, the league is facing the possibility of a class-action lawsuit. Here’s what former players would need to prove.Annette Greenhow, Assistant Professor, Faculty of Law, Bond UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1052462018-11-07T11:38:41Z2018-11-07T11:38:41ZConcussion prevention: Sorting through the science to see what’s sound<figure><img src="https://images.theconversation.com/files/242329/original/file-20181025-71020-b58g5h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Linebacker Luke Kuechly of the Carolina Panthers in a game against the Philadelphia Eagles in Philadelphia Oct. 21, 2018.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Panthers-Eagles-Football/0d641105e8dd44498d6c236a37244bfb/1/0">Matt Rourke/AP Photo</a></span></figcaption></figure><p>As his helmet collided violently with his opponent’s shoulder, <a href="https://www.youtube.com/watch?v=9bncaVseJS4">Luke Kuechly looked like a life-size bobblehead doll</a>. In an instant, the Carolina Panthers star linebacker suffered yet another concussion. His season, and perhaps career, was in jeopardy. </p>
<p>A few weeks earlier, Kuechly began wearing an <a href="http://www.espn.com/blog/carolina-panthers/post/_/id/27367/how-a-200-device-is-providing-hope-in-reducing-brain-injury">experimental collar around his neck</a> designed to protect his brain from within. The device, known as the Q-Collar and <a href="https://www.neuroshield.ca/en/">previously sold as NeuroShield</a>, is designed to mimic the <a href="http://nautil.us/issue/39/sport/how-woodpeckers-will-save-football">woodpecker’s method of injury protection</a> by keeping more blood inside the skull to create a “bubble wrap” effect around the brain. </p>
<p>So, why didn’t this nature-inspired safety equipment avert Luke Kuechly’s 2017 concussion, which apparently he <a href="https://www.panthers.com/video/luke-kuechly-third-down-stop">still wears</a>? </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"896764812474142721"}"></div></p>
<p>As a physiologist and sports medicine researcher, I study how the body responds to exercise and other stressors. I also study ways to prevent and treat sports injuries. As the public learns more about the potential long-term <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3600860/">dangers of contact sports, including chronic traumatic encephalopathy (CTE)</a>, parents, athletes and sports organizations are desperate to find a quick fix to the concussion crisis. Unfortunately, I do not think there is an easy solution to make inherently high-risk sports safe.</p>
<h2>The high altitude argument</h2>
<p>Back in 2014, a friend told me about a study which reported that NFL players were 20-30 percent less likely to sustain a concussion in <a href="https://www.jospt.org/doi/abs/10.2519/jospt.2014.5298">games played at “higher” altitudes</a>. The researchers theorized that higher altitude caused a slight swelling in the brain, and consequently increased brain volume. </p>
<p>This “tighter fit” inside the skull would reduce brain “slosh” during impacts to reduce the likelihood of concussions. Since higher altitude seemed to protect the brain, they argued, it would be beneficial to replicate this “tighter fit.” The authors proposed this could be achieved by applying slight pressure on the neck’s jugular veins to trap a bit more blood inside the brain. A few years earlier, a member of their research team <a href="https://patents.google.com/patent/US8985120">filed a patent for such a device</a> – a jugular compression collar. </p>
<p>While those less familiar with physiology may have been persuaded by this fascinating-sounding explanation, my fellow researcher, <a href="https://theconversation.com/profiles/gerald-zavorsky-272790/articles">Gerald Zavorsky</a>, and I thought this idea was scientifically implausible. Most importantly, the study defined “higher altitude” as anything above a meager 600 feet above sea level – <a href="https://www.physiology.org/doi/abs/10.1152/japplphysiol.00661.2016">way too low to have any effect on brain volume</a>.
Essentially, our brain volume stays <a href="https://www.physiology.org/doi/abs/10.1152/japplphysiol.00661.2016">remarkably constant</a> at high altitude, even when we may feel short of breath or lightheaded. In the “Mile High City” of Denver, which houses the highest NFL stadium in the country at 5,280 feet above sea level, you would be hard-pressed to experience even a miniscule swelling in the brain. However, at much higher elevations, there is actually an increased likelihood for brain swelling <a href="https://www.wemjournal.org/article/S1080-6032(99)70851-3/pdf">which causes a life-threatening emergency called high altitude cerebral edema</a>.</p>
<h2>A game of chance</h2>
<p>If altitude does not cause a protective increase in brain volume, then why were concussions reduced in NFL games played at greater than 600 feet above sea level? To answer this question, we examined the same <a href="http://apps.frontline.org/concussion-watch/#players_2015">publicly available NFL data set</a>. The original study looked at data from two combined seasons (2012 and 2013), but we analyzed a few additional years. We confirmed that concussion rate was indeed statistically reduced at “higher” altitudes during the 2013 season, but not in the 2012 season. We dug deeper and found no connection between altitude and concussions in the 2014 or 2015 seasons. A separate study in college athletes showed concussions were <a href="https://www.ncbi.nlm.nih.gov/pubmed/26755407">even more likely at “higher” altitude</a>.</p>
<p>Since the effect wasn’t consistent <a href="https://www.nature.com/collections/prbfkwmwvz">and repeatability is a major problem in all of science</a>, we suspected the original linkages were due to random chance – a mathematical artifact of using a huge data set of nearly 1500 gridiron giants literally butting heads with one another on a weekly basis. If that was the case, we might expect that something completely arbitrary to also be associated with a reduced risk of concussion. And, indeed <a href="https://journals.lww.com/epidem/Abstract/2017/09000/Team_Logo_Predicts_Concussion_Risk__Lessons_in.17.aspx">our analysis demonstrated that is true</a>. It turns out that NFL teams with animal logos, such as the Miami Dolphins, also had a 20-30 percent reduced risk of concussion compared to teams without animal logos, such as the Pittsburgh Steelers, regardless of game altitude. </p>
<p>Based on our analysis, we concluded that random chance, not physiological response, explains why concussions were less likely at altitudes above 600 feet. Thus, an altitude-mimicking collar seems unjustified for preventing concussions.</p>
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<h2>The woodpecker theory</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/242362/original/file-20181025-71026-1sr7a2d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/242362/original/file-20181025-71026-1sr7a2d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/242362/original/file-20181025-71026-1sr7a2d.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/242362/original/file-20181025-71026-1sr7a2d.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/242362/original/file-20181025-71026-1sr7a2d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/242362/original/file-20181025-71026-1sr7a2d.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/242362/original/file-20181025-71026-1sr7a2d.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A collar based on how woodpeckers keep from hurting their brains is being used by some football players.</span>
<span class="attribution"><a class="source" href="https://theconversation.com/drafts/105480/edit">Piotr Krzeslak/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>Supposedly, the Q-Collar also replicates how woodpeckers naturally protect themselves from headaches. According to company information, woodpeckers compress their jugular vein using their <a href="http://q30innovations.com/2015/11/24/addressing-mtbi-from-the-inside-2/">neck muscles to induce “tighter fit” and reduce brain “slosh.”</a> While this amazing-sounding mechanism is <a href="http://q30innovations.com/q-collar/">often presented as a fact</a>, it does not seem to be mentioned anywhere in over a century of scientific studies examining woodpeckers. </p>
<p>I thoroughly examined all of the woodpecker papers I could find, and then tracked down all of their references, and repeated the process. I discovered <a href="https://www.jstor.org/stable/103096">ornithology papers from the 1700s</a> through <a href="https://www.tandfonline.com/doi/full/10.1080/10255842.2017.1378648">cutting-edge engineering models of woodpecker biomechanics</a>, but none mentioned jugular compression. Thus, it is not surprising that the company does not cite any scientific references to woodpecker literature.</p>
<p>Even if this mechanism does exist and has been somehow overlooked by woodpecker researchers, evolution gave the woodpecker numerous unique protective adaptations. I teamed up with a woodpecker researcher and <a href="https://bjsm.bmj.com/content/early/2018/10/26/bjsports-2018-099594">published a summary of these mechanisms in October 2018</a>. These include a specialized skull bone structure and a shock-absorbing beak. Woodpeckers even use very specific postures and movements to brace themselves, which helps to dissipate force away from their brains. We concluded that these multiple protective mechanisms work in harmony, which cannot be replicated by simply pushing on one’s jugular vein.</p>
<p>New research suggests that woodpeckers <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0191526">may indeed experience brain injuries similar to those seen in humans</a>. Regardless, <a href="https://www.thelancet.com/journals/laneur/article/PIIS1474-4422(18)30157-1/fulltext">the physics of woodpecker drumming are quite different than that of sports concussions</a>, which generally happen with unpredictable timing, and involve considerable head rotation. Despite its intuitive appeal, I believe that a woodpecker-mimicking collar is more pseudoscience than innovation.</p>
<h2>Beyond sports concussions</h2>
<p>As my colleagues and I have been debunking the scientific rationale for the Q-Collar, research examining the Q-Collar seems to have shifted from <a href="https://clinicaltrials.gov/ct2/show/NCT02271451?cond=concussion&draw=11">reducing the risk of concussions</a>, or distinct events following a single hit, to a less tangible goal of reducing brain damage from repeated subconcussive impacts. </p>
<p>New research claims evidence of benefit, based on MRI data. As one article stated in 2016, the collar “<a href="http://dx.doi.org/10.1136/bjsports-2016-096134">may have provided a protective effect</a> against brain microstructural changes after repetitive head impacts.” An article published in October 2018 from a small study showed that the brains of female soccer players who wore collars for a season <a href="https://bjsm.bmj.com/content/early/2018/09/30/bjsports-2018-099571">seemingly showed no brain damage</a>. Those who did not wear the collar did show small changes in some areas of their brain.</p>
<p>However, some other researchers have expressed concerns over the <a href="https://www.mcgill.ca/oss/article/technology-health-and-nutrition-quackery/neuroshield-can-woodpeckers-help-protect-your-brain">small numbers of subjects and the high dropout rates</a> in similar studies about the collar. Some physicians have concluded that <a href="https://www.uslaxmagazine.com/fuel/industry/ring-around-the-collar">this evidence is not enough to suggest that it does protect the brain from injury and current promotional campaigns are “potentially misleading.”</a> I also remain skeptical of these findings, since the <a href="https://link.springer.com/article/10.1007/s11682-017-9708-9">clinical utility of this particular type of MRI data remains unclear, especially in relation to long-term health</a>.</p>
<p>As the company <a href="http://q30innovations.com/wp-content/uploads/2015/07/CCHMC-LTR-Q-Collar-Risk-Determination.pdf">aims for FDA approval</a> and <a href="https://gizmodo.com/this-woodpecker-inspired-collar-could-protect-athletes-1782249329">looks beyond sports applications</a>, I fear that long-term brain health is being placed in equipment justified by misunderstandings of physiology, coincidental relationships, and yes, even what I’ve concluded are <a href="https://www.nytimes.com/2014/01/03/opinion/can-animals-help-limit-concussions.html">incorrect claims about woodpeckers and other animals</a>. </p>
<p>Some may argue that even if it does not work, there is no harm in adding an extra layer of protection. However, I believe this is a dangerous attitude. When athletes feel they are more protected, they have a false sense of extra safety and play more aggressively. <a href="https://journals.lww.com/cjsportsmed/Fulltext/2004/07000/Risk_Compensation__A__Side_Effect__of_Sport_Injury.1.a">This may actually increase risk of injury</a>. </p>
<p>As Luke Kuechly and others can attest, even innovative-sounding equipment cannot stop concussions in contact sports. Unfortunately, we may not know if long-term brain damage can actually be limited by new technologies until it is too late.</p><img src="https://counter.theconversation.com/content/105246/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>James Smoliga does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The sports world is understandably eager to prevent concussions, but some of the products on the market are not helping and may even hurt, by leading people to feel protected when they are not.James Smoliga, Professor of Physiology, Department of Physical Therapy, High Point University Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/913582018-02-06T18:23:42Z2018-02-06T18:23:42ZIf football is so deadly, why did 103 million people watch the Super Bowl?<figure><img src="https://images.theconversation.com/files/205131/original/file-20180206-88772-mtdke7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A hit from Malcom Jenkins sidelined the Patriots' Brandin Cooks for the night.</span> <span class="attribution"><span class="source">AP Photo/Tony Gutierrez</span></span></figcaption></figure><p>During the second quarter of Super Bowl LII, the party stopped, if just for a second.</p>
<p>Tom Brady found Patriots wide receiver Brandin Cooks downfield with a 23-yard completion. Cooks spun around then got laid out by the Eagles’ Malcolm Jenkins, who was going full speed, leading with his shoulder.</p>
<p>Right in the middle of football’s biggest game, there it was: another reminder of the NFL’s <a href="https://www.pbs.org/wgbh/frontline/film/league-of-denial/">concussion crisis</a>. NBC commentators Cris Collinsworth and Al Michaels seemed to struggle with the fact that the play was legal. </p>
<p>That’s where we are these days. No one knew quite what to say as Cooks looked like he had been knocked out by an absolutely routine part of the game, which sidelined him for the night.</p>
<p>For all that, I doubt the uncomfortable few minutes while he was treated on the field – viewers had no idea how badly he was hurt – caused more than a few fans to turn away. Based on my experience as a sports editor, my hunch is most of the tens of millions who watched had already come to terms with the game’s violence. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/205155/original/file-20180206-88795-1x2rjud.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/205155/original/file-20180206-88795-1x2rjud.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=442&fit=crop&dpr=1 600w, https://images.theconversation.com/files/205155/original/file-20180206-88795-1x2rjud.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=442&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/205155/original/file-20180206-88795-1x2rjud.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=442&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/205155/original/file-20180206-88795-1x2rjud.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=556&fit=crop&dpr=1 754w, https://images.theconversation.com/files/205155/original/file-20180206-88795-1x2rjud.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=556&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/205155/original/file-20180206-88795-1x2rjud.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=556&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Will Smith’s portrayal of forensic neuropathologist Dr. Bennet Omalu (pictured) in the film ‘Concussion’ helped bring the issue of CTE to national attention.</span>
<span class="attribution"><span class="source">Photo by Chris Pizzello/Invision/AP)</span></span>
</figcaption>
</figure>
<h2>Concussions and football</h2>
<p>The problem of head injuries in football has gotten widespread attention over the last decade. </p>
<p>In 2015, for example, Will Smith’s “<a href="https://www.youtube.com/watch?v=Io6hPdC41RM">Concussion</a>” chronicled the work of Dr. Bennet Omalu, who identified the prevalence of chronic traumatic encephalopathy, or CTE, in football players. A Newsweek headline at the time asked: “Can a Will Smith movie change the way America views football?” </p>
<p>The answer then was no, in part because the <a href="http://www.indiewire.com/2016/01/concussion-adds-to-will-smiths-growing-list-of-recent-box-office-disappointments-whats-going-on-160185/">movie’s box-office performance</a> was meh. </p>
<p>If fans and commentators ask a similar question today – can the concussion problem put football out of business? – the answer would still be no, but a qualified one. The health risks of the game aren’t enough on their own to kill the sport.</p>
<h2>Americans still (mostly) love football</h2>
<p>There are two reasons why football won’t go out of existence, despite a consistent flow of head injuries.</p>
<p>The first is popularity and the financial strength it yields.</p>
<p>While <a href="http://abcnews.go.com/Entertainment/wireStory/nielsen-1034-million-watch-super-bowl-52856810">Super Bowl ratings</a> were down, Philadelphia’s thrilling 41-33 upset of New England still drew 103.4 million American viewers. That makes it the <a href="http://variety.com/2018/tv/news/super-bowl-lii-ratings-1202687239/">10th most watched event</a> in television history, behind eight other Super Bowls and the final episode of “M.A.S.H.”</p>
<p>Not only that, the NFL <a href="http://tvbythenumbers.zap2it.com/more-tv-news/the-100-most-watched-tv-programs-of-2017-super-bowl-li-laps-the-field/">dominates</a> TV ratings all year. Little wonder league revenue has almost doubled this decade, <a href="https://www.sportsbusinessdaily.com/Journal/Issues/2017/03/06/Leagues-and-Governing-Bodies/NFL-revenue.aspx">to roughly $14 billion</a>. The NFL is shooting for $25 billion by 2027.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/205157/original/file-20180206-88769-1gmyuir.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/205157/original/file-20180206-88769-1gmyuir.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=379&fit=crop&dpr=1 600w, https://images.theconversation.com/files/205157/original/file-20180206-88769-1gmyuir.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=379&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/205157/original/file-20180206-88769-1gmyuir.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=379&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/205157/original/file-20180206-88769-1gmyuir.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=476&fit=crop&dpr=1 754w, https://images.theconversation.com/files/205157/original/file-20180206-88769-1gmyuir.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=476&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/205157/original/file-20180206-88769-1gmyuir.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=476&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Motor racing is more dangerous than football and has resulted in many fatalities over the years, yet the sport remains popular.</span>
<span class="attribution"><span class="source">AP Photo/Greg Huey</span></span>
</figcaption>
</figure>
<h2>Smoking, drunk driving and … football?</h2>
<p>That leads to the second point.</p>
<p>The implication of that Newsweek headline is an argument that goes like this: “If fans only understood the dangers of concussions, they would turn against football, as they did against smoking or drunk driving.”</p>
<p>But the issue is not about awareness. The New York Times reported powerfully on it as early as 2007, and a Frontline documentary in 2013 sparked a national discussion. While there is definite concern, <a href="https://www.washingtonpost.com/sports/poll-nfl-remains-as-popular-as-ever-despite-head-injuries-other-concerns/2017/09/06/238bef8a-9265-11e7-8754-d478688d23b4_story.html?utm_term=.6bbfea7bd97b">as polling data show</a>, most fans haven’t been ready to pull the plug – at least not for that reason.</p>
<p>It’s the same for players. The Associated Press interviewed 100 a couple of seasons ago and <a href="http://www.myajc.com/news/sports/ap-survey-concussions-not-most-nfl-players-chief-c/nqJGM/">found only 39</a> were more worried about the long-term effects of concussions than other injuries. </p>
<p>Maybe it’s this simple: We’ve always known football was risky, and now we know more about what that means. But if everyone knows the risks involved, then everyone should be free to do and watch what they like. There are other examples of sports and activities in a similar vein – motor racing, hockey and boxing, to name a few.</p>
<h2>Behind the decline</h2>
<p>Still, <a href="https://www.si.com/tech-media/2018/01/04/nfl-tv-ratings-decline-ten-percent-colin-kaepernick-thursday-night-football">the NFL has undeniably suffered</a> a ratings decline. </p>
<p>There are several reasons for this, from the erosion of cable television, to controversies such as what <a href="http://www.nfl.com/news/story/0ap3000000911869/article/roger-goodell-concerned-about-nfl-catch-rule">constitutes a catch</a>, to the National Anthem protests that <a href="http://www.independent.co.uk/sport/us-sport/national-football-league/donald-trump-nfl-players-protests-racial-inequality-kneel-anthem-colin-kaepernick-a8006806.html">prompted the president to attack</a> the NFL. I asked a class of 15 students recently if they knew someone who stopped watching because of players taking a knee. Five raised their hands, <a href="https://theundefeated.com/features/nfl-viewership-down-and-study-suggests-its-over-protests/">something confirmed</a> by national surveys.</p>
<p>The bottom line: Head injuries don’t appear to be behind the ratings drop. And it could reverse in an instant, perhaps by a <a href="https://www.huffingtonpost.com/entry/supreme-court-sports-gambling_us_5a25ffa8e4b07324e84022a5">Supreme Court decision</a> legalizing sports betting. That’s all it might take to
boost fan interest and <a href="https://sports.yahoo.com/gambling-nfls-boogeyman-league-got-3b-despised-thursday-night-football-013900476.html">the league’s bottom line</a> – with $25 billion around the corner.</p><img src="https://counter.theconversation.com/content/91358/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>John Affleck does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>What happened after Brandin Cooks took a massive blow during Super Bowl LII helps explain why NFL’s concussion crisis isn’t killing the sport’s popularity.John Affleck, Knight Chair in Sports Journalism and Society, Penn StateLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/879862017-11-22T23:54:54Z2017-11-22T23:54:54ZGrey Cup haunted by brain injury risk — but doesn’t have to be<p>When the Toronto Argonauts and Calgary Stampeders square off in Ottawa for the 105th Grey Cup on Sunday, it will be under dark clouds — not necessarily of weather, but rather the risk of concussions and their devastating long-term effect on players’ brains.</p>
<p>A growing body of evidence — including groundbreaking research examining the brains of living former Canadian Football League football players — suggests that the way the sport is played and the subsequent health of athletes are grave and connected problems.</p>
<p>We have long been suspicious about what football injuries were doing to the brains of some players, but even we were shocked when we brought 22 former CFL players into <a href="http://www.humanities.mcmaster.ca/%7Elmblab/">our lab at McMaster University</a> and studied their brain activity and structure. </p>
<p>Some former players showed readings similar to those one would find in a coma patient. It was astounding to us that the most deeply affected men were still standing, let alone able to carry on everyday conversations. </p>
<p>We discovered this in a two-year research project — <a href="https://www.thespec.com/hamilton-topics/7521250-collision-course/">Collision Course</a> — conducted in collaboration with Hamilton Spectator reporter Steve Buist, comparing former players to other people in a control group.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/195962/original/file-20171122-6044-mp70sx.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/195962/original/file-20171122-6044-mp70sx.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=247&fit=crop&dpr=1 600w, https://images.theconversation.com/files/195962/original/file-20171122-6044-mp70sx.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=247&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/195962/original/file-20171122-6044-mp70sx.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=247&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/195962/original/file-20171122-6044-mp70sx.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=311&fit=crop&dpr=1 754w, https://images.theconversation.com/files/195962/original/file-20171122-6044-mp70sx.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=311&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/195962/original/file-20171122-6044-mp70sx.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=311&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The brain of a normal control subject, left, shows significant difference compared to the brain of a former CFL player.</span>
<span class="attribution"><span class="source">(Handout)</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<h2>Brain shrinkage, memory problems</h2>
<p>The results and the stories of those players were stark, and often sad.</p>
<p>On average, the retired athletes, ranging from 44 to 66 years old, had lost 20 per cent of the mass of the cerebral cortex. This controls movement and cognitive functions including attention, speech and memory. </p>
<p>Of the 22 former players, 16 reported memory problems, compared to just two of the 20 healthy control subjects.</p>
<p>Brain images from some retired players in their 40s looked like images from men twice their age. </p>
<p>It’s not news that concussions from fast-moving, hard-hitting contact sports such as football and hockey have been coming under closer scrutiny. Before our project, there already had been plenty of evidence — most of it derived after athletes’ deaths — that <a href="https://thewalrus.ca/inside-the-controversial-concussion-lab-that-could-save-football/">head injuries from football had significantly damaged the brain structure of veteran players</a>. </p>
<p>Our goal was to take a comprehensive and non-invasive look at the brains of living former players, so we used the tools at our disposal, including magnetic resonance imaging (MRI) and electroencephalography (EEG). </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/195965/original/file-20171122-6061-1phv0sk.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/195965/original/file-20171122-6061-1phv0sk.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=235&fit=crop&dpr=1 600w, https://images.theconversation.com/files/195965/original/file-20171122-6061-1phv0sk.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=235&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/195965/original/file-20171122-6061-1phv0sk.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=235&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/195965/original/file-20171122-6061-1phv0sk.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=296&fit=crop&dpr=1 754w, https://images.theconversation.com/files/195965/original/file-20171122-6061-1phv0sk.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=296&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/195965/original/file-20171122-6061-1phv0sk.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=296&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Left and right images of the cerebral cortex show in blue areas where retired CFL players had significant thinning compared to people in the control group. Lighter areas represent more significant thinning. About two-thirds of the area was thinner in athletes.</span>
<span class="attribution"><span class="source">(Handout)</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>We measured the physical structures of our subjects’ brains, and gauged the neurophysiological activity going on in those same brains. These are two very different methods — revealing physical brain structures and activity — yet the results were grimly consistent.</p>
<p>The damage was not universal, to be sure. There was one player who showed no damage on either test, for example. But on balance, it was clear there is a strong and disturbing correlation between football and permanent brain injury.
Brain EEG shows <a href="https://www.thespec.com/news-story/7525066-collision-course-a-spectator-report-on-the-science-of-hard-head-knocks/">a difference in automatic attention that does not involve conscious awareness</a>, and also difference in voluntary attention that is usually controlled by awareness.</p>
<h2>Sports, science and risk</h2>
<p>As Canada approaches the Grey Cup on Sunday, one might expect researchers who have seen what we have to be marching outside the game with placards, calling for a stop to the carnage.</p>
<p>Far from it. Both of us will be watching — and enjoying — the action.
Football and hockey are simply great sports, packed with action and surprises, making them tremendously entertaining. Between the two of us, we have played years of both sports — one of us on the field, the other on the ice.</p>
<p>But unlike some, we won’t be cheering on Grey Cup Sunday when players get dumped on their heads, or when they get slammed to the ground and their helmets bounce off the turf. When we watch a game, we can see when a head-injured player is having a seizure after a tough hit, or when a player has lost consciousness even before hitting the turf. </p>
<p>Still, collisions are part of football and hockey, and that’s not going to change, nor should it. <a href="https://theconversation.com/how-to-avoid-recognize-and-treat-concussion-in-sports-83204">Players nowadays are more aware of the risks</a>, and that those risks increase with the number of years they play and the blows they take.</p>
<p>But those risks can certainly be diminished, if there is a will among sports leagues, owners, players and fans to adopt some small changes that can make football and hockey much more sustainable. </p>
<h2>Technology to protect players’ heads</h2>
<p>Improved rules to end hockey fighting, to better protect quarterbacks in the pocket, and to crack down much harder on illegal, high-risk blows in both sports, together with much stricter enforcement, would make football and hockey safer.</p>
<p>More cautious protocols around possible head injuries would go a long way to reducing repetitive concussion damage that echoes through decades. Today, we do more to protect players’ knees than their heads, and that has to change.</p>
<p>One way to go at it might be to use objective, evidence-based standards for blows to the head. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/LPhNbs20p7k?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Technology to detect a potential brain injury is used by Liberty Christian High School in Dallas-Fort Worth, Texas.</span></figcaption>
</figure>
<p><a href="http://www.cnn.com/2014/06/09/tech/innovation/smart-football-helmet-concussions/index.html">Technology exists today</a> that can slip easily into a <a href="https://www.sbnation.com/college-football/2017/5/12/15629572/texas-longhorns-helmet-technology-riddell-insite-monitor-hits">helmet to measure the force and torque of a blow to the head</a> and transmit it to coaches and medical staff on the sidelines. It could be made mandatory for someone who gets hit too hard to be pulled out of play for examination, regardless of the apparent symptoms.</p>
<h2>Surviving the game</h2>
<p>It’s clear that even without tougher rules, some players are ready for changes that will protect them from debilitating brain injuries. It’s already hard enough for a player to survive in a game where any play could be his last.</p>
<p>We understand that dialling back the extreme blows that lead to head injuries might make games slightly less exciting. On the other hand, they might also make them more exciting, as strategy and agility would become more important and integral to winning.</p>
<p>Owners may worry about losing money if the game is perceived as softer — but they will definitely lose money if <a href="http://ottawacitizen.com/sports/local-sports/legal-battle-over-cfl-players-benefits-moving-upfield-inch-by-inch">badly injured players sue</a> them for not taking better care of their brains and win.</p>
<p><a href="https://www.fastcodesign.com/1671752/why-nfl-helmets-will-never-be-concussion-proof">There will always be injuries, and there will always be risk</a>. Players accept that.
Surely, we don’t need to see their heads pounded so badly that their already short careers in professional sports leave them permanently and catastrophically injured.</p><img src="https://counter.theconversation.com/content/87986/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>John Connolly conducted the EEG/ERP research using equipment purchased with funds from the Canada Foundation for Innovation. He is also the CSO of a pre-revenue start-up called VoxNeuro, Inc. that is involved in neurocognitive assessment. His work in the CFL research did not involve VoxNeuro, however. The CFL research described in this article received support from The Hamilton Spectator. </span></em></p><p class="fine-print"><em><span>Michael Noseworthy receives funding from: Natural Sciences and Engineering Research Council (NSERC) of Canada. MRI scanning was done using equipment purchased with funds provided through the Canada Foundation for Innovation (CFI). The CFL work described received support from the Hamilton Spectator.</span></em></p>Concussions in football and other contact sports correlate with severe, long-term brain damage — but science shows it doesn’t have to be that way.John F. Connolly, Professor and Senator Wm. McMaster Chair; Director, ARiEAL Research Centre; and co-director of Language, Memory & Brain Laboratories, McMaster UniversityMichael D. Noseworthy, Professor, Electrical and Computer Engineering, McMaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/832042017-09-06T00:00:09Z2017-09-06T00:00:09ZHow to avoid, recognize and treat concussion in sports<figure><img src="https://images.theconversation.com/files/184776/original/file-20170905-10416-uxwbyn.jpg?ixlib=rb-1.1.0&rect=142%2C150%2C1479%2C1114&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">There are benefits to sport participation, and it is important for parents to be aware of concussion risks, how to avoid them, and the signs when they may have occurred.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/success?src=O7-G38HI5gMwFUYyWdNuPw-1-27">(Shutterstock)</a></span></figcaption></figure><p>Recognize, remove, rest and recover before returning to sport. Those are key points about sport-related concussion stated in the <a href="http://bjsm.bmj.com/content/51/11/838">5th International Consensus Statement on Concussion in Sport</a>. </p>
<p>The <a href="http://www.parachutecanada.org/injury-topics/item/canadian-guideline-on-concussion-in-sport">Canadian Guidelines on Concussion in Sport</a> have been developed based on this statement and were recently released by <a href="http://www.parachutecanada.org/">Parachute Canada</a>, a charitable organization focused on injury prevention, and its expert advisory group.</p>
<p>The good news is that most people who suffer a concussion will recover in the initial days and weeks following injury. However, some will have ongoing symptoms. While concussions may occur in sport, there are many benefits to physical activity and sport participation for both youth and adults.</p>
<p>I am a physiotherapist and researcher (assistant professor and clinician scientist) at the <a href="https://www.ucalgary.ca/siprc/">Sport Injury Prevention Research Centre</a>, Faculty of Kinesiology, University of Calgary. <a href="https://ucalgary.ca/siprc/node/131">My research</a> focuses on the prevention and treatment of sport-related concussion in children, youth and adults, with special emphasis on the role of the neck and balance systems.</p>
<p>A concussion is a type of a brain injury that occurs following a trauma to the head or body. Symptoms can come on immediately or may take hours to gradually evolve. The most common symptom following concussion is a headache. However, a number of other symptoms such as dizziness, nausea, fatigue, difficulty with concentration, neck pain and other complaints may also occur. Lying motionless, clutching the head, being slow to get up, wobbling and appearing dazed are some of the observable signs.</p>
<p>In the event that a concussion may have occurred, it is important that the player is removed from the activity and has follow-up medical evaluation as soon as possible. A tool called the <a href="http://bjsm.bmj.com/content/51/11/872">Concussion Recognition Tool 5 (CRT5)</a> has been developed by the Concussion in Sport Group and is meant to help coaches, officials, parents and players recognize the signs of concussion.</p>
<h2>How are concussions treated?</h2>
<p>All individuals with a suspected concussion should see a health care professional with knowledge of concussion. The typical treatment is a short period of rest (24 to 48 hours, both mental and physical) followed by a gradual return to the typical activities that are done throughout the day.</p>
<p>Following this, individuals may slowly increase their activity level using a graduated return-to-school strategy and return-to-sport strategy. </p>
<p>The return-to-school strategy includes steps to gradually increase the amount of mental activity prior to returning to school. </p>
<p>The return-to-sport strategy includes a series of steps that are performed sequentially, with each step taking a minimum of 24 hours. These include light aerobic exercise, sport-specific exercises, non-contact training drills and full practice prior to returning to play or sport. </p>
<p>These two strategies can be performed simultaneously under the supervision of a health care professional. They take approximately one week to complete as long as the person with the concussion does not have any recurrence of symptoms. It is recommended that individuals return to school prior to returning to sport. Medical clearance should be obtained prior to returning to sport.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/185317/original/file-20170908-32308-3wz6nn.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/185317/original/file-20170908-32308-3wz6nn.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=430&fit=crop&dpr=1 600w, https://images.theconversation.com/files/185317/original/file-20170908-32308-3wz6nn.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=430&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/185317/original/file-20170908-32308-3wz6nn.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=430&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/185317/original/file-20170908-32308-3wz6nn.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=540&fit=crop&dpr=1 754w, https://images.theconversation.com/files/185317/original/file-20170908-32308-3wz6nn.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=540&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/185317/original/file-20170908-32308-3wz6nn.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=540&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Dr. Kathryn Schneider examines a girl for concussion.</span>
<span class="attribution"><span class="source">(Riley Brandt/University of Calgary)</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>Most people get better in the initial days to weeks following a concussion. However, for those who have ongoing symptoms and difficulties, there are some treatments that have been shown to help.</p>
<p><a href="https://www.ucalgary.ca/siprc/">My research</a> has found that people with ongoing headaches, neck pain and/or dizziness and balance problems who are treated with physiotherapy techniques aimed at treating the neck and balance systems are more likely to be medically cleared to return to sport in eight weeks. </p>
<p>There is also some research that low-level aerobic exercise may be beneficial following a concussion. Our research in this area is ongoing and we currently have a number of studies that are evaluating different types of treatments to help with recovery.</p>
<h2>Is there any way to prevent a concussion?</h2>
<p>The best way to minimize the impact of concussions is to prevent them. To do this, we first need to understand who is at the greatest risk. </p>
<p>Research has shown that individuals who have had a previous concussion, who play games (as opposed to practice) and engage in contact sports all increase the risk of concussion. </p>
<p>Many different sport associations are working to use research to inform rule changes to decrease the risk of concussion, including rules to disallow bodychecking in youth ice hockey nationally, in leagues for 11-to-12-year-olds (based on <a href="https://ucalgary.ca/siprc/node/125">research led by Carolyn Emery</a>). </p>
<p>Another focus of my research program is to evaluate different pre-training strategies that may be used to prevent concussions.</p>
<p>Concussions in sport are an area of much discussion. It is imperative that individuals with a suspected concussion are removed from play until they can be medically evaluated and do not return until they are cleared to do so. </p>
<p>At this time, the relationship between exposure to head trauma and neurodegenerative diseases is unknown, as research in this area is inconsistent and incomplete. Chronic traumatic encephalopathy (CTE), a neurodegenerative disease, has been reported in some athletes. However, in many other athletes, CTE is not present. Moreover, studies suggest that former athletes are not at increased risk of suicide, and previous high school football players do not have a greater chance of developing diseases such as CTE later in life. </p>
<p>More research is required to better understand how common CTE is in the general population and if the rate is higher in athletes exposed to head trauma. Additional research to understand factors that increase the risk of or protect against neurodegenerative disease (such as genetics, exposure to different types of lifestyles and sport factors) is also required. These are critical questions that will require further research to answer.</p>
<p>The good news is that most people recover well following a concussion when managed appropriately. Awareness of the signs and symptoms of concussion, and appropriate initial management when a concussion may have occurred, are of utmost importance.</p><img src="https://counter.theconversation.com/content/83204/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kathryn Schneider is affiliated with
Scientific Committee and Expert Panel for the 5th International Consensus Conference on Concussion in Sport
</span></em></p>As students return to school and prepare to join sports teams, here’s what they and their parents need to know about concussions.Kathryn Schneider, Assistant Professor, Clinician Scientist (Physiotherapist), Faculty of Kinesiology, University of CalgaryLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/817942017-08-01T00:16:35Z2017-08-01T00:16:35ZConcussions and CTE: More complicated than even the experts know<figure><img src="https://images.theconversation.com/files/180246/original/file-20170728-23754-13wbuam.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Youngsters leave a football field in 2015 after playing at halftime at a game between the Buffalo Bills and the Carolina Panthers. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Banning-Tackle-Football/6000c666116049f0875924b3292a818a/13/0">AP Photo/Bill Wippert</a></span></figcaption></figure><p>For many, American football is a beautiful game that is simple to enjoy but complex to master. Choreographed with a mixture of artistry and brutality, it features the occasional “big hit” or bone-jarring tackle, forcing a fumble and turning the tide of the game. </p>
<p>But with this part of football comes justified concern about the long-term health effects of engaging in this type of activity over time, concerns that abound in practically every high-impact contact sport. It is possible that effects of continued involvement may accumulate quietly in the background until they show themselves, later in life. </p>
<p>A recent study appeared to give a “big hit” to the game of football itself, with findings that <a href="http://www.npr.org/2017/07/25/539198429/study-cte-found-in-nearly-all-donated-nfl-player-brains">nearly all the brains of 111 deceased NFL players </a> studied showed signs of <a href="https://concussionfoundation.org/CTE-resources/what-is-CTE">chronic traumatic encephalopathy</a>, or CTE. </p>
<p>At the University of Florida, our interdisciplinary team has studied brain injuries in athletes, military veterans and civilians for many years. A <a>study of which we were co-authors</a>, published in September, 2017, in JAMA Neurology, concluded that there are many gaps in knowledge. While repetitive brain trauma is the biggest risk factor for CTE, our findings suggested that there are many associated issues of neurodegenerative disease to consider as we develop ways to keep our athletes, both young and old, safe.</p>
<h2>The concussion ‘explosion’</h2>
<p><a href="https://www.cdc.gov/headsup/basics/concussion_whatis.html">Concussions</a> result from mechanical impact to the brain that produces transient changes in awareness or consciousness and a range of other symptoms. A 2016 study reported that between <a href="https://theconversation.com/concussions-and-kids-know-the-signs-60672">1.1 million and 1.9 million concussions</a> occur each year in children.</p>
<p>Although diagnosed concussions have been the primary focus, they are not the only, or maybe even the main, problem. There is also rising concern about<a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5264430/"> subconcussive impacts</a>, repetitive blows that may not be severe enough to cause clinical symptoms. There may be hundreds of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4346237/">subconcussive impacts</a> per player, per year. </p>
<p>In response to widespread concern, organized sports organizations from <a href="https://www.scientificamerican.com/article/football-concussions-felt-long-after-retirement/">Pop Warner to the NCAA</a> to professional levels have developed and implemented concussion management protocols to help in the identification and management of concussions. </p>
<p>Yet the massive attention given to concussion management and prevention has produced a level of public pseudo-awareness about CTE that currently outstrips what is scientifically known about the disorder. </p>
<h2>Missing links and gaps in knowledge</h2>
<p>Several <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2995699/">scientific studies have linked repetitive brain trauma</a> to CTE. </p>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/25904048">CTE is a “tauopathy”</a> in which the normally occurring protein tau becomes misfolded and accumulates at the depths of the folds (sulci) of the brain, in regions that may also be susceptible to mechanical forces during head impacts. The abnormal accumulation of the <a href="https://concussionfoundation.org/CTE-resources/what-is-CTE">tau protein</a> gives rise to a cascade of brain pathology that leads to cognitive impairment, neuropsychiatric problems (depression, anxiety, aggression, reduced impulse control), functional decline and, eventually, death. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/180418/original/file-20170731-22169-1mbkj18.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/180418/original/file-20170731-22169-1mbkj18.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/180418/original/file-20170731-22169-1mbkj18.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/180418/original/file-20170731-22169-1mbkj18.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/180418/original/file-20170731-22169-1mbkj18.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/180418/original/file-20170731-22169-1mbkj18.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/180418/original/file-20170731-22169-1mbkj18.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Researchers are trying to find the best helmet to prevent concussions, just as doctors are studying the best way to treat them.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/359362067?src=7KzPErfGwx8G7f4BedC3yg-1-3&size=small_jpg">Steve Cukrov/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>The study published July 25 that showed CTE in 110 of 111 deceased, former NFL players reflected a startling 99 percent prevalence rate. </p>
<p>The results were reported by news outlets across the world, leading many people to think that CTE is an all but inevitable outcome of playing football or other sports. </p>
<p>But is it? And most importantly for parents, coaches and fans, what is the actual risk to my kids, my players and my team?</p>
<p>The answers to these questions are not yet known, though the risk to the individual player is very likely to be considerably less than would be suggested by available research findings. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/poyrAI417qg?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
</figure>
<p>Two important facts should be considered. </p>
<p>First, studies of CTE have all been conducted on <a href="http://onlinelibrary.wiley.com/doi/10.1111/bpa.12248/full">small samples of brains delivered to CTE research centers</a> by families of former players who have had concern about post-retirement cognitive, psychiatric or behavioral problems and symptoms.</p>
<p>The likelihood of finding brain pathology in these brains of symptomatic players is high, but these results cannot be generalized to all former football players, many of whom are living healthy lives in retirement. </p>
<p>Second, no study has evaluated even a single living player to determine whether he or she exhibits the cognitive, psychiatric or behavioral signs of CTE and then followed that person to autopsy to verify that CTE-associated pathology actually exists in their brains.</p>
<p>So, we do not know the actual prevalence of CTE in the general population of players, though it is assuredly much lower than those quoted by studies of symptomatic players. </p>
<h2>Why do some get CTE and others do not?</h2>
<p>We also don’t know much about who develops CTE and who doesn’t. There are over 10,000 living NFL retirees, yet the entire science of CTE is based on samples of less than a few hundred former NFL players and a handful of athletes from other sports. This means that some of those exposed to the risk of repetitive head impacts develop CTE, but most do not. </p>
<p>There are several factors that may contribute to the <a href="https://link.springer.com/article/10.1007%2Fs11065-016-9327-z">development of brain dysfunction and disease</a>, including: </p>
<ul>
<li>medical or genetic risk factors<br></li>
<li>medical and psychiatric problems such as depression, anxiety, sleep disorders and abuse of prescription medications or other drugs and substances</li>
<li>reduced educational attainment or literacy, or socioeconomic deprivation</li>
</ul>
<p>In addition, some <a href="https://www.sbnation.com/2016/3/9/11185970/retired-nfl-players-adjusting-society-regrets-free-agency">athletes have poor adjustments to retirement</a>, leading to psycho-social and psychiatric maladjustment, marital or financial difficulties, substance abuse and other behavioral problems.</p>
<p>Repetitive head impacts may heighten risk of CTE, but other factors are undoubtedly involved in determining whether risk becomes reality. Reducing risk of CTE will involve targeting and treating these other factors as well. </p>
<h2>What parents, coaches and athletes need to know</h2>
<p>We need to take seriously the possible health consequences of prolonged exposure to repetitive head impacts and concussions. </p>
<p>That said, parental decisions to remove children from contact sports should be weighed against the many proven positive aspects of participation in team sports. Decisions should not be based on inflated risk assessment. Several studies have shown that recreational or scholastic athletic participation in youth conveys <a href="http://jamanetwork.com/journals/jamaneurology/fullarticle/2635831">no significant added risk</a> to brain health later in life. </p>
<p>Still, the <a href="https://www.ncbi.nlm.nih.gov/pubmed/28566342">developing brain may be more susceptible to injury</a> and may take longer to recover. Knowledge of the individual player and his or her response to injury should guide parents, coaches and athletes in decision-making. Some youth are more injury-prone than others, and some have other conditions (e.g., ADHD, learning disability) that may affect how they react to head impact. When all factors are considered, the strongest predictor of recovery is the severity of initial symptoms.</p>
<p>All states now have legislation requiring public schools to have a <a href="http://www.momsteam.com/health-safety/every-state-has-youth-sports-concussion-safety-law">concussion program</a> in place. Parents should ask their school or athletic organization what their policies are regarding concussion management.</p>
<p>While helmet manufacturers are developing helmets that might provide greater protection, there is not enough evidence to recommend one over another. We do know, however, that <a href="http://journals.sagepub.com/doi/full/10.1177/1941738116639027">appropriate fitting of helmets </a> and protective gear is necessary to get the full protective benefit. </p>
<p>Some measures to reduce possible exposure and risk have been implemented. The <a href="https://www.cbssports.com/college-football/news/ivy-league-eliminates-full-contact-tackling-in-football-practices/">Dartmouth University</a> football program has significantly reduced contact practices for its football team. Other Ivy League teams and organizations have followed suit. The NCAA has recently recommended the elimination of two-a-day practices and restricted the <a href="http://www.ncaa.org/sport-science-institute/year-round-football-practice-contact-recommendations">number of contact practices allowed in football.</a> </p>
<p>Physicians and athletic trainers at the University of Florida are using data from helmet sensors originally designed to help detect concussions to inform coaching staff on which specific practice drills and pad configurations may incur higher risk so that such drills can be adjusted. </p>
<p>Ongoing research for this important issue is focused on developing techniques for accurate diagnosis while an individual is alive and understanding the exact pathophysiology that might inform future disease-modifying treatment, in addition to our current treatments aimed at reduction of symptoms. </p>
<p>For those athletes who choose to continue the sports they love, we hope for continued innovations and policies that make their participation as safe as possible.</p><img src="https://counter.theconversation.com/content/81794/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Russell Bauer receives funding from the Veterans' Administration and from the National Center for the Advancement of Translational Science (NIH/NCATS). </span></em></p><p class="fine-print"><em><span>Michael S. Jaffee, M.D. previously served as National Director of the Defense and Veterans Brain Injury Center</span></em></p>A recent study that showed that 110 of 111 brains of deceased NFL players had a serious brain disease raised concerns once again about concussions. But there’s a lot we still need to know.Russell M. Bauer, Professor, Clinical & Health Psychology and Neurology, University of FloridaMichael S. Jaffee, Vice chair, Department of Neurology, University of FloridaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/816562017-07-27T01:58:54Z2017-07-27T01:58:54ZConcerned about concussions and brain injuries? 4 essential reads<figure><img src="https://images.theconversation.com/files/179893/original/file-20170726-22117-8lctx9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Michelle Vansickle, center, of Flowery Branch, Ga., during a youth football safety clinic March 18, 2014, in Alpharetta, Ga. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Falcons-Youth-Football-Safety/21bee196159a497ba3caf47fbcfe7575/14/0">AP Photo/Jason Getz</a></span></figcaption></figure><p><em>Editor’s note: The following is a roundup of archival stories about concussions, including advice on how to recognize symptoms and explanations of why they can be so dangerous to children.</em></p>
<p>A study published July 25 based on <a href="https://www.nytimes.com/interactive/2017/07/25/sports/football/nfl-cte.html?_r=0">examinations of brains of deceased NFL players</a> reported disturbing news about the prevalence of concussions. Of 111 brains examined, all but one were found to have chronic traumatic encephalopathy, or CTE, the degenerative brain disease caused by repeated blows to the head. </p>
<p>The concerns are many. </p>
<p>Evidence has been growing that concussions among young athletes occur far more frequently than reported. This leads to concerns among parents for the safety of their children who play football, soccer and other sports in which they could suffer head injuries. </p>
<p>The report also raises questions about the role and function of professional football in our society. On the one hand, <a href="https://theconversation.com/if-football-is-deadly-why-do-we-still-watch-54287">we love it</a>, with Super Bowl Sunday having become close to a national holiday and one of the most important advertising days of the year. </p>
<p>But on the other hand, the number of injuries to the heads of these professional athletes-entertainers is becoming as hard to ignore as a penalty flag on a game-winning touchdown. Yes, there are red flags, some argue, and then there are sirens – and in too many cases, they are coming from ambulances transporting wounded football players. </p>
<h2>What do parents need to know?</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/179901/original/file-20170726-22117-1ik7g62.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/179901/original/file-20170726-22117-1ik7g62.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/179901/original/file-20170726-22117-1ik7g62.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/179901/original/file-20170726-22117-1ik7g62.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/179901/original/file-20170726-22117-1ik7g62.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/179901/original/file-20170726-22117-1ik7g62.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/179901/original/file-20170726-22117-1ik7g62.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Young soccer players can also be at risk for brain injuries from concussions.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/youth-sports-team-young-children-players-491585068?src=3wSrfOs1UIbFG5Ay4HWXuA-1-0">Matrix/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>Youth sports are a major part of childhood and adolescence, with an <a href="https://theconversation.com/concussions-and-kids-know-the-signs-60672">estimated 44 million children playing sports</a> each year. Many parents and teachers actively encourage sports so that kids will stay physically active. In light of the growing concerns around concussions and brain injury, parents need to know that <a href="https://theconversation.com/what-every-parent-should-know-about-concussions-34964">brain injuries can occur in many ways</a>, explained Cindy Trowbridge, an associate professor of kinesiology at the University of Texas Arlington. The young brain differs from the adult brain in ways that place it in particular peril. </p>
<blockquote>
<p>“Children have smaller brains in relation to their skulls. Compared to an adult, the young child brain has less mass and more cerebrospinal fluid between the brain and the skull. By way of analogy the child’s brain is like the egg yolk in an egg – there is room for it to move. Because children’s brains have less mass in relation to the skull, their brains experience more acceleration. This means the brain can hit the skull with more force.”</p>
</blockquote>
<p>Gerald Zavorsky, an associate professor at Georgia State University, explained last year just how <a href="https://theconversation.com/concussions-and-kids-know-the-signs-60672">under-reported concussions</a> are among children. This is a big concern not only because of the health effects but also because of how children’s ability to learn can be impaired. </p>
<blockquote>
<p>“[One] study estimated that between 1.1 million and 1.9 million concussions occur in children each year. That is far greater than the number of children with concussions reported by emergency departments; their records indicates the number ranges between 115,000 to 167,000.”</p>
</blockquote>
<p>Zavorsky went on to detail how this not only affects children’s health but also their learning. </p>
<blockquote>
<p>“While rare, the effects of an untreated concussions can stay with a child for many years. The effects can cause brain malfunction, including a lack of focus and difficulty learning. Also, the risk for longer-term problems increases if a child has a second concussion… It is imperative to avoid sending a child back into a game or activity if head trauma has occurred.”</p>
</blockquote>
<h2>What do kids need to know?</h2>
<p>Young athletes need to be encouraged to <a href="https://theconversation.com/many-kids-still-dont-report-concussion-symptoms-how-can-we-change-that-72312">report a blow to the head, dizziness</a> and, indeed, any type of pain they feel, wrote J. Douglas Coatsworth of Colorado State University. But adults need to help children change a culture of “taking one for the team,” or continuing to play when injured. </p>
<blockquote>
<p>“We know characteristics of youth athletes, such as the knowledge they have about concussion, their attitudes about how serious symptoms are and their beliefs that if they report a concussion they will let the team down, all influence whether they will report concussion symptoms.”</p>
</blockquote>
<p>Coatsworth is conducting a study to see whether changes in adult attitudes could affect how children report. </p>
<blockquote>
<p>“Hiding symptoms of concussion and continuing to play in sports can result in subsequent injury, delayed recovery, delayed access to treatment and risk of catastrophic injury. An Institute of Medicine and National Research Council report on youth concussion concluded young athletes face a ‘culture of resistance’ to reporting.”</p>
</blockquote>
<h2>What our society may need to consider</h2>
<p>Even though football is one of our nation’s most beloved pastimes, some people are wondering not only whether they should forbid their children to play the game but even whether to allow them to watch it. In turn, they also wonder whether they themselves should watch the games. </p>
<p><a href="https://theconversation.com/are-parents-morally-obligated-to-forbid-their-kids-from-playing-football-39764">Kathleen Bachynski</a>, a doctoral candidate in sociomedical sciences at Columbia University Medical Center, explained how this can be a difficult decision.</p>
<blockquote>
<p>“Parents generally have final say over the activities their kids participate in. Should they…forbid their children from playing football? Unfortunately, there’s no simple answer. Instead, a host of issues – cultural, social and physical – need to be weighed.”</p>
</blockquote>
<p>And, Trowbidge reminded parents that the discussions go beyond football. Children <a href="https://theconversation.com/what-every-parent-should-know-about-concussions-34964">can be injured in many types of activities</a> and parents should know that concussions can occur from trauma other than a blow to the head.</p><img src="https://counter.theconversation.com/content/81656/count.gif" alt="The Conversation" width="1" height="1" />
A study of the brains of 111 NFL players after their deaths showed that 110 had degenerative brain disease. Here are some expert analyses of what can be done to stop brain injury from sports.Lynne Anderson, Senior Health + Medicine Editor, The Conversation, USLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/755462017-06-06T03:20:28Z2017-06-06T03:20:28ZExplainer: what is traumatic brain injury?<figure><img src="https://images.theconversation.com/files/172358/original/file-20170606-16856-gqwp6g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People with traumatic brain injuries, say after a car accident or an assault, can have behavioural problems long after their physical injuries have healed.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/success?src=syyx_gDuQnNZId7IeIgaYg-1-3">from www.shutterstock.com</a></span></figcaption></figure><p>Adam was fortunate to survive a major car accident three years ago. He was in hospital for several months but had no ongoing physical injuries. He looked like he made a full recovery. But he was argumentative, childish, vulgar and his family said he “was not the same person”. Adam had a severe traumatic brain injury. </p>
<h2>What is traumatic brain injury?</h2>
<p>A <a href="http://www.sciencedirect.com/science/article/pii/S0003999310006507">traumatic brain injury</a> is when the brain is damaged by an external mechanical force, like the type you may have in a car accident, if you fall, play sport or if you are assaulted.</p>
<p>These injuries are usually in the news when <a href="https://www.thechronicle.com.au/news/toowoomba-man-liam-cullen-is-suing-queensland-rugb/2960018/">sports players</a> have a <a href="http://www.abc.net.au/news/2017-03-20/nrl-players-brains-more-damaged-than-non-players:-study/8369226">concussion</a>; or in relation to drug and alcohol fuelled assaults where a blow to the head results in a damaging, <a href="http://www.smh.com.au/nsw/killer-punch-fall-caused-thomas-brain-damage-20120715-224q9.html">sometimes fatal</a>, <a href="http://www.dailytelegraph.com.au/news/nsw/newcastle-surfer-suffers-fractured-skull-in-coward-punch-attack/news-story/3576f0a5b3d1c8751ec78347fc210a4f">fall to the ground</a> (<a href="https://en.wikipedia.org/wiki/Sucker_punch">the coward’s punch or king hit</a>).</p>
<p>Mostly, it’s young adults, particularly men, who are affected. But many elderly people may get a traumatic brain injury when they fall.</p>
<p>Australia has a growing population of survivors of traumatic brain injury. This is due to the young age of most victims and decreased death rates <a href="https://www.psychology.org.au/publications/inpsych/2012/april/ponsford">due to better treatment</a>. Traumatic brain injury is expected to be a <a href="https://www.ncbi.nlm.nih.gov/pubmed/18162698">major cause of disability by 2020</a>.</p>
<h2>How does it affect people?</h2>
<p>Few traumatic brain injuries are the same and the outcomes of two similar injuries can be different in different people. Injuries can affect the way people think, feel, behave and relate to everyday situations.</p>
<p>People with moderate to severe injuries can have problems communicating, paying attention, processing thoughts quickly, learning, remembering, planning, problem-solving, meeting goals, and thinking abstractly or flexibly.</p>
<p>Damage to the part of the brain called the <a href="https://www.researchgate.net/profile/Catherine_Gow2/publication/232210406_Frontal_Dysfunction_After_Traumatic_Brain_Injury/links/57ea9c6908aed3a3e08aaeb6.pdf">frontal lobes</a> affects people’s ability to regulate their thoughts, emotions and behaviour. It can cause people to be impulsive, irritable, aggressive, have reduced drive, be apathetic, to have excessive emotions or a flattened mood. </p>
<p>Difficulties understanding the emotions and intentions of others (known as <a href="https://en.wikipedia.org/wiki/Social_cognition">social cognition</a>) may cause reduced empathy and socially inappropriate behaviour. Reduced self-awareness can also result in lack of insight into their abilities and the changes others perceive.</p>
<p>Traumatic brain injury can change an individual’s personality to the point where they “may no longer be the same person” that they were before. Given that many of these difficulties can occur without physical problems, they fall under the umbrella of an “<a href="http://www.changedlivesnewjourneys.com/hidden-disability-after-brain-injury/">invisible disability</a>”.</p>
<h2>How does traumatic brain injury affect the brain?</h2>
<p>Injuries can be due to the immediate effect of the impact (known as primary injuries) or ones that follow these (secondary complications).</p>
<p>Primary injuries include: <a href="https://en.wikipedia.org/wiki/Cerebral_laceration">lacerations</a>, when the brain tissue is cut or torn; <a href="https://en.wikipedia.org/wiki/Cerebral_contusion">contusions</a>, when the brain is bruised; rupturing of blood vessels; and <a href="https://en.wikipedia.org/wiki/Diffuse_axonal_injury">axonal injury</a>, where neurons are stretched and torn.</p>
<p>These can occur where the object hits the head (a <a href="https://en.wikipedia.org/wiki/Focal_and_diffuse_brain_injury">focal injury</a>) or throughout the brain (<a href="https://en.wikipedia.org/wiki/Focal_and_diffuse_brain_injury">diffuse injury</a>). Parts of the brain known as the frontal and temporal lobes are most susceptible to both of these types of injuries. This is because of their large size and as they are close to the hard and uneven surfaces of the skull that can cause damage.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/168349/original/file-20170508-20725-56q10b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/168349/original/file-20170508-20725-56q10b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=386&fit=crop&dpr=1 600w, https://images.theconversation.com/files/168349/original/file-20170508-20725-56q10b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=386&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/168349/original/file-20170508-20725-56q10b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=386&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/168349/original/file-20170508-20725-56q10b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=485&fit=crop&dpr=1 754w, https://images.theconversation.com/files/168349/original/file-20170508-20725-56q10b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=485&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/168349/original/file-20170508-20725-56q10b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=485&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The frontal and temporal lobes of the brain, shown here, are particularly susceptible to injury.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/102046603?src=Fe-S7aDefYB73SjZdXDbug-1-0&size=huge_jpg">from www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>Secondary complications include brain <a href="http://www.webmd.com/brain/brain-lesions-causes-symptomstreatments#1">lesions</a> (damaged brain tissue); <a href="https://en.wikipedia.org/wiki/Edema">brain swelling</a>, increased <a href="https://en.wikipedia.org/wiki/Intracranial_pressure">intracranial pressure</a> (pressure inside the skull), <a href="https://en.wikipedia.org/wiki/Brain_herniation">herniation</a> (movement of brain tissue), <a href="https://en.wikipedia.org/wiki/Ischemia">tissue death</a>, <a href="https://en.wikipedia.org/wiki/Hypoxia_(medical)">hypoxia</a> (oxygen deprivation) and infection. </p>
<p>How long someone loses consciousness initially and how long they’re confused for (known as post-traumatic amnesia) are used to <a href="http://emedicine.medscape.com/article/326643-overview">classify</a> traumatic brain injury as mild, moderate or severe. Most (<a href="http://online.liebertpub.com/doi/abs/10.1089/089771501750357609">about 80%</a>) hospitalisations are for mild injuries.</p>
<h2>How is it managed?</h2>
<p>People with a traumatic brain injury can be treated while staying in hospital (as an in-patient) or after they’re discharged into the community (as an out-patient).</p>
<p>In-patient rehabilitation focuses on immediate medical and functional issues, with a range of health professionals involved, like physiotherapists, speech pathologists, neuropsychologists (psychologists who specialise in assessing, diagnosing and treating disorders of the brain) and occupational therapists. Typically, a personalised rehabilitation plan is drawn up to help the patient to move back into the community. </p>
<p>Out-patient rehabilitation focuses more on the <a href="https://www.ncbi.nlm.nih.gov/pubmed/20134333">context of daily living</a>. Here, there is a shift to helping patients establish life roles and successfully complete everyday tasks, like making meals, showering and travelling. </p>
<h2>What are the challenges ahead?</h2>
<p>Recovery from a traumatic brain injury varies from person to person. Some people can easily resume their lives while others can struggle <a href="http://journals.lww.com/jnnonline/Abstract/2005/02000/The_Meaning_of_Living_with_Traumatic_Brain_Injury.7.aspx">adjusting</a> to their limitations, new lifestyle and new self. Some can have trouble living independently, fulfilling life goals and finding a meaningful place in society. </p>
<p>Behavioural and emotional difficulties are significant barriers to <a href="http://journals.sagepub.com/doi/pdf/10.1177/026921559601000215">long-term recovery</a>. These challenges may not become obvious until the person is in the community, discharged from rehabilitation services and completely dependent on their carers and/or <a href="http://www.tandfonline.com/doi/full/10.3109/02699052.2015.1005134">families</a>. </p>
<p>Behavioural and personality issues also make traumatic brain injury difficult <a href="http://online.liebertpub.com/doi/pdf/10.1089/neu.2013.2997">to manage</a>, placing burden on carers and result in difficulties finding and keeping a job.</p>
<p>Family members and friends can pull away, leading to further <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1315633/">social isolation</a> and loneliness, making survivors more susceptible to <a href="https://www.ncbi.nlm.nih.gov/pubmed/10533556">mental health problems</a> and institutionalisation. Sadly, these problems <a href="http://journal.frontiersin.org/article/10.3389/fnhum.2013.00031/full">worsen</a> as years pass, despite improvements made during early recovery.</p>
<hr>
<p><em>If you or someone you know is a survivor of traumatic brain injury, contact <a href="http://www.braininjuryaustralia.org.au/">Brain Injury Australia</a>, <a href="http://synapse.org.au/">Synapse</a> or the <a href="http://moving-ahead.com.au/">Centre for Research Excellence in Brain Recovery</a> for more information and support.</em></p><img src="https://counter.theconversation.com/content/75546/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Survivors of traumatic brain injuries might have behavioural issues or have problems holding down a job for years after a blow to the head or a bad fall.Travis Wearne, Postdoctoral Research Fellow, UNSW SydneyEmily Trimmer, Postdoctoral Research Fellow, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/766292017-05-09T01:17:54Z2017-05-09T01:17:54ZThrowing injuries in young baseball players: Is there something we are not considering?<figure><img src="https://images.theconversation.com/files/168161/original/file-20170505-19109-1xm2ef8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/506496565?src=VJJG9vO-7Tp-BWXHZKmwaQ-1-2&size=huge_jpg">From www.shutterstock.com </a></span></figcaption></figure><p>Baseball marks the end of winter and the start of spring, and we as a nation delight in watching not only the pros but also our kids play this great game.</p>
<p>Unfortunately, we sports medicine doctors are seeing an increase in injuries to the throwing arm in youngsters, and many of these require surgery. Most worrisome is that the risk for developing a throwing injury was <a href="http://journals.sagepub.com/doi/abs/10.1177/0363546505284188">shown to increase by 36 times</a> in adolescent pitchers who continued playing with a fatigued arm. </p>
<p>As a sports medicine physician and a former collegiate baseball player, I am concerned about this rise in injuries. They not only take a youngster out of commission for a game or season, but they also can have lasting effects. My team of researchers at the University of Florida is looking for ways to prevent arm injuries.</p>
<h2>Too many pitches during games a possible factor</h2>
<p>The <a href="https://www.ncbi.nlm.nih.gov/pubmed/9448950">majority of injuries</a> in overhead throwers occur in the throwing arm. When including pitcher and position players, anywhere from 51 to 69 percent of all reported injuries occurred <a href="https://www.ncbi.nlm.nih.gov/pubmed/9448950">in the throwing arm</a>.</p>
<p>Increased awareness about the injuries could be a factor in the projected slowdown of surgeries. Greater awareness could lead to increased reporting of the injuries from the pre-internet era until now.</p>
<p>In addition, attention to the reporting of Major League Baseball injuries creates consciousness by young players, coaches and parents of the growing concern of these overuse throwing injuries. </p>
<p>There is more to the increase than just more reporting, however. A more serious reason in higher usage of the throwing arm.</p>
<p>For example, during the Koshien Baseball Tournament in Japan, a study of <a href="http://www.beyondtheboxscore.com/2016/8/29/12571952/2016-summer-koshien-japanese-high-school-baseball-pitch-count-report-nagekomi">Japanese high school-aged pitchers</a> showed pitch counts greater than 150 pitches in multiple pitchers, with a high of 187 pitches – for one pitcher – in 2016. </p>
<p>And in Kansas a high school pitcher attracted national media attention in 2016 by <a href="https://sports.yahoo.com/news/how-a-157-pitch-game-in-kansas-explains-everything-wrong-with-youth-baseball-212918744.html">pitching 157 pitches</a> in one game.</p>
<p>Surgeries to reconstruct a frequent injury to a ligament in the elbow of the throwing arm – also known as Tommy John surgery – <a href="http://www.asmi.org/research.php?page=research&section=UCL">have been increasing</a> in baseball players at all levels of play for the past 20 years. One study showed about a <a href="http://www.asmi.org/research.php?page=research&section=UCL">9.5 percent increase</a> per year from 2007 to 2011.</p>
<p>Unfortunately, <a href="https://www.ncbi.nlm.nih.gov/pubmed/27197888">data suggest</a> that this trend toward more Tommy John surgeries, which reconstruct the ulnar collateral ligament(UCL) in the elbow, is not likely to decrease until at least 2025.</p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/168165/original/file-20170505-19124-1yez99n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/168165/original/file-20170505-19124-1yez99n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/168165/original/file-20170505-19124-1yez99n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/168165/original/file-20170505-19124-1yez99n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/168165/original/file-20170505-19124-1yez99n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1131&fit=crop&dpr=1 754w, https://images.theconversation.com/files/168165/original/file-20170505-19124-1yez99n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1131&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/168165/original/file-20170505-19124-1yez99n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1131&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Baseball Hall of Famer Greg Maddux, who was known to keep his pitch count low, is shown in this August 2015 file photo.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/baseball-pitcher-throwing-ball-selective-focus-147286310?src=FGQ37ljWdupKEp_Uv6IGRQ-1-49">Brett Jones/AP</a></span>
</figcaption>
</figure>
<h2>And maybe too many pitches before games?</h2>
<p>It is important for parents, players and coaches to be aware of <a href="https://www.ncbi.nlm.nih.gov/pubmed/11689728">simple methods</a> to prevent these overuse injuries. Some approaches include not playing on multiple teams at the same time and throwing restrictions, such as taking a day of rest based on the number of pitches thrown. Also, players should keep their rotator cuff strong and never pitch if an arm is in pain. </p>
<p>However, these actions have not reduced the number of overuse throwing injuries given the growing number of injuries.</p>
<p>Thus, there has been an increased emphasis on pitch restrictions, particularly at the youth and high school levels. Originally, Little League Baseball and the USA Baseball Medical Advisory Committee (USAB-MAC) developed <a href="http://www.asmi.org/research.php?page=research&section=positionStatement">pitch count restriction</a> recommendations based upon age.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/168164/original/file-20170505-19129-10ssfns.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/168164/original/file-20170505-19129-10ssfns.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/168164/original/file-20170505-19129-10ssfns.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/168164/original/file-20170505-19129-10ssfns.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/168164/original/file-20170505-19129-10ssfns.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/168164/original/file-20170505-19129-10ssfns.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/168164/original/file-20170505-19129-10ssfns.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A baseball en route from a pitcher’s hand.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/baseball-pitcher-throwing-ball-selective-focus-147286310?src=FGQ37ljWdupKEp_Uv6IGRQ-1-49">From www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>More recently, Major League Baseball developed <a href="http://m.mlb.com/pitchsmart/pitching-guidelines/">PitchSmart</a>, a website that provides information to players, coaches and parents to prevent overuse injuries in youth and adolescent pitchers. As of 2016, the National Federation of State High School Associations began requiring a <a href="https://www.nfhs.org/articles/pitching-restriction-policies-in-baseball-to-be-based-on-pitches/">pitching restriction policy</a> in each state based on the number of pitches thrown in a game, not based upon innings (which was previously used).</p>
<p>One interesting aspect of the pitch restriction recommendations is that there is no consideration for number of pitches thrown in the bullpen or during before-inning warm-ups. Players may therefore be considered in the “safe” zone of pitches thrown when compared to state guidelines – when in reality, the pitching volume and unaccounted workload including the bullpen and before-inning warm-up pitches would be significantly higher than recommended. </p>
<p>With that in mind, our team at the University of Florida began considering the actual number of pitches a pitcher throws in each high school game. Our theory is that there is an unaccounted workload factor right in front of us. </p>
<p>While our study’s data are ongoing, initially we have found it is very typical to have a pitcher throw 70-80 pitches in a game but actually “pitch” more than 120-130 pitches if we include the bullpen and between-inning warm-ups. We should note we are not looking at injuries at this time, as this is an observational study only.</p>
<p>It should also be stated that while there is significant variation in bullpen warm-up volume, it is our opinion that it would not be appropriate to “regulate” how a pitcher warms up as every pitcher has his or her own style to feel comfortable prior to entering live game competition. </p>
<p>However, our study thus far shows that there is significant variability in the number of bullpen pitches thrown, varying from less than 20 pitches to more than 50 pitches.</p>
<p>One unanswered question is that if there are now pitch limitations but there is a certain percentage of pitches unaccounted for, do we need to train our pitchers differently? Given that an increase of early season throwing injuries is potentially <a href="https://www.ncbi.nlm.nih.gov/pubmed/21709023">due to not training appropriately</a> in the off-season, our study reinforces the importance of a preseason pitching program to ready the arm and body for the coming season. </p>
<p>The ultimate goal of our study is to is prevent throwing injuries before they happen in our adolescent pitchers. Our hope is that years from now, the number of overuse throwing injuries will decrease, allowing our youth and adolescent overhead throwing athletes every opportunity to enjoy America’s pastime on the field of play, not in the doctor’s office.</p><img src="https://counter.theconversation.com/content/76629/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jason Zaremski does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Injuries to the throwing arm of young baseball players have been increasing for years. Studies that assess pitch count are helping, but there are also actions that parents and coaches can take.Jason Zaremski, Assistant Professor of Medicine, University of FloridaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/720442017-03-06T02:18:02Z2017-03-06T02:18:02ZWhy artificial turf may truly be bad for kids<figure><img src="https://images.theconversation.com/files/156241/original/image-20170209-8646-8j5v4k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Soccer player on artificial turf. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/synthetic-soccer-field-467227091?src=9j3C6qf-X6FT0S9dElf_bw-1-40">From www.shutterstock.com</a></span></figcaption></figure><p>If you want to get a soccer mom’s attention, bring up the subject of artificial turf, the preferred playing surface for children from pre-K to college – or at least preferred by school boards and parks and recreation departments.</p>
<p>From concerns about <a href="https://www.ncbi.nlm.nih.gov/pubmed/12394868">concussions</a> to <a href="http://www.cnn.com/2017/01/27/health/artificial-turf-cancer-study-profile/">cancer</a>, parents have become alarmed by reports in the media of increased injuries and illnesses. </p>
<p>And there is the further question of who is responsible for assuring the safety of these fields: the <a href="https://www.epa.gov">Environmental Protection Agency</a>? The <a href="https://www.cpsc.gov">Centers for Disease Control</a>? The<a href="https://www.cpsc.gov"> Consumer Product Safety Commission</a>? </p>
<p>As an environmental health professor who has examined a variety of environmental problems and as a soccer dad who watched my son play on these fields for years, I think it’s worth examining the facts and myths about artificial turf fields and what hazards may or may not be associated with playing on them. Based on studies I have reviewed and conducted, I believe there is a potential health risk, because of the chemicals in tires, which are recycled into crumbs to support the plastic blades of synthetic grass.</p>
<h2>Just what is it, anyway?</h2>
<p>Artificial turf is made up of three major parts: </p>
<ol>
<li>Backing material that will serve to hold the individual blades of artificial grass.</li>
<li>The plastic blades themselves.</li>
<li>The infill, those tiny black crumbs, that helps support the blades.</li>
</ol>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/155703/original/image-20170206-18529-18ehj5y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/155703/original/image-20170206-18529-18ehj5y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=403&fit=crop&dpr=1 600w, https://images.theconversation.com/files/155703/original/image-20170206-18529-18ehj5y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=403&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/155703/original/image-20170206-18529-18ehj5y.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=403&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/155703/original/image-20170206-18529-18ehj5y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=506&fit=crop&dpr=1 754w, https://images.theconversation.com/files/155703/original/image-20170206-18529-18ehj5y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=506&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/155703/original/image-20170206-18529-18ehj5y.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=506&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The crumbs of artificial turf.</span>
</figcaption>
</figure>
<p>Various pigments are used to provide the green color of the blades. These can include lead or titanium for the white lines and still other metals for school logos on the field.</p>
<p>Those little black crumbs are the problems. Tires can be toxic.</p>
<p>Modern tires <a href="https://www.scientificamerican.com/article/greener-tires/">are a mixture</a> of natural and synthetic rubber, carbon black – a material made from petroleum – and somewhere between four and 10 gallons of petroleum products. They also contain metals, including cadmium, lead, which is neurotoxic, and zinc. </p>
<p>Some of the chemicals in tires, such as dibenzopyrenes, are known <a href="https://www.ncbi.nlm.nih.gov/pubmed/22352997">carcinogens</a>. </p>
<p>Also, in addition to chemicals used in the manufacture of the tire, any chemical the tires were exposed to in their use can become absorbed on the carbon black in the tires. </p>
<h2>More to the problem than crumbs</h2>
<p>Even though artificial turf does not have to be mowed,<br>
it turns out that <a href="http://www.simpleturf.com/artificial-lawn-turf-maintenance-warranty/">crabgrass and other weeds</a> can start growing in it. To keep its finely manicured appearance, <a href="https://www.washingtonpost.com/national/health-science/what-to-know-before-you-spray-your-lawn-with-pesticides/2014/07/07/77d719a2-f63c-11e3-a606-946fd632f9f1_story.html?utm_term=.763d7c159726">weedkillers</a> need to be applied, a relatively common practice. </p>
<p>Unfortunately, a variety of <a href="https://www.scientificamerican.com/article/weed-whacking-herbicide-p/">health concerns</a> have been linked to these products.</p>
<p>Also, artificial turf is often treated with biocides, as turf has been associated with increased risk of infections from Methicillin Resistant Staphylococcus aureus (MRSA). <a href="https://www.cdc.gov/mrsa/">MRSA</a> is a dangerous infection because it is resistant to many antibiotics. It can lead to pneumonia, sepsis and bloodstream infections that can prove fatal. An MRSA infection can happen after skin is scraped or cut, which can occur from sliding on artificial turf.</p>
<p>Biocides, however,<a href="https://ehjournal.biomedcentral.com/articles/10.1186/1476-069X-9-7"> may have toxic effects of their own</a>. And, they may also contribute to increased resistance of bacteria to the efficacy of these agents. </p>
<h2>The list of drawbacks goes on…and on…</h2>
<p>Fields with artificial turf tend to get far hotter than grass fields. <a href="http://plantscience.psu.edu/research/centers/ssrc/documents/temperature.pdf">Field surface temperatures</a> can reach as high as 200 degrees Fahrenheit. At these temperatures, even with athletic shoes on, children can get burned feet. It is rare, even on a very hot day, that natural grass exceeds half that (100°F).</p>
<p>While manufacturers recommend spraying fields with water to keep the temperature down, this improvement can vanish in as little as 20 minutes.</p>
<p>Because it is laid over either concrete or compacted earth, artificial turf is a harder surface than grass. This can increase the risk of injuries, particularly concussions.</p>
<p>The unit used to describe hardness is <a href="http://plantscience.psu.edu/research/centers/turf/extension/factsheets/playing-surfaces/gmax">Gmax</a>. While different numbers have been reported for the Gmax for artificial turf, ranging from the high 60’s to over 125, it is important to keep in mind that these numbers are highly dependent on the substrate, temperature, age and maintenance of the field. The key is that the higher the number, the higher the likelihood of concussion. </p>
<h2>Can the tire chemicals get into kids?</h2>
<p>The key question on exposure is: Do these chemicals get into children playing on these fields? </p>
<p>While it is true that the tire crumbs are large, it is easy to show that they don’t necessarily remain large over the life of the field. <a href="http://www.nj.gov/dep/dsr/publications/artificial-turf-report.pdf">In a New Jersey study</a> we employed a robot we call <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4311520/">PIPER</a> (Pretoddler Inhalable Particulate Environmental Robotic) to study if there were inhalable exposures from the artificial turf. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/155035/original/image-20170131-3285-t8fxn3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/155035/original/image-20170131-3285-t8fxn3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/155035/original/image-20170131-3285-t8fxn3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/155035/original/image-20170131-3285-t8fxn3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/155035/original/image-20170131-3285-t8fxn3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/155035/original/image-20170131-3285-t8fxn3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/155035/original/image-20170131-3285-t8fxn3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/155035/original/image-20170131-3285-t8fxn3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">PIPER collecting air sample on artificial turf field.</span>
<span class="attribution"><span class="source">Personal photo</span></span>
</figcaption>
</figure>
<p>We showed the tiny particles from the turf can become suspended in air above the field and inhaled by children playing on the field. What has become apparent is that <a href="http://www2.mst.dk/udgiv/publications/2008/978-87-7052-866-5/html/images/fig6_1.jpg">microscopic carbon black particles</a> break off from the crumb rubber and are small enough to be inhalable. Additionally, the blades of grass can also break down into microscopic particles over years of exposure to sunlight and weather, forming a respirable dust. </p>
<p>How do these particles get into a child? </p>
<p>Think of the “Peanuts” comic strip character Pig Pen, the child always followed around by a visible cloud. The truth is that all children – indeed, all people – have a cloud around them of microscopic particles. This personal micro-environment of dust particles, invisible to the naked eye, is just as real as Pig Pen’s. </p>
<p>These small particles and their chemicals can be inhaled or swallowed by a child.</p>
<h2>And if so, do they cause illness?</h2>
<p>A clear answer on whether artificial turf increases the risk of injury or illness is far more challenging. </p>
<p>Let’s consider the two major concerns with regard to artificial turf: cancer and neurologic effects. </p>
<p>The question of cancer and artificial turf gained significant national attention in the U.S. with a series of news stories on NBC Nightly News regarding a cluster of cancers in <a href="http://www.nbcnews.com/storyline/artificial-turf-debate/how-safe-artificial-turf-your-child-plays-n220166">young women soccer players</a>. </p>
<p>A cancer cluster is the appearance of an unusually high rate of cancer in one location in a particular time frame. The story, while dismissed by the turf industry, again resurfaced in the <a href="http://www.nbcnews.com/storyline/artificial-turf-debate/mom-cancer-stricken-soccer-player-wants-answers-artificial-turf-n435146">fall of 2015</a>. </p>
<p>Information has continued to accrue on this cancer <a href="https://www.cancer.gov/about-cancer/causes-prevention/risk/substances/cancer-clusters-fact-sheet#q1">cluster</a>. While as many as <a href="https://www.cancer.org/cancer/cancer-causes/general-info/cancer-clusters.html">80 percent of suspected cancer clusters are determined not to be true increases in cancer cases</a> and due only to random chance, the problem is that, without detailed and often expensive scientific investigation, whether it is real or not cannot be determined. </p>
<p>Just recently the <a href="http://www.doh.wa.gov/Portals/1/Documents/Pubs/210-091.pdf">Washington State Department of Health issued a report</a> on its study of the reported cancer cluster in these soccer players. Their report found no evidence of a causal effect of playing on artificial turf and cancer. As they acknowledge, that does not mean there is no risk, only that this study did not find one. They also suggested there is still room for broader investigation on this question.</p>
<p>What about the potential risk of neurologic impairment from ingestion or inhalation of any lead present in the turf? The lead can be present in both the blades, as a color pigment for logos and white lines, as well as in the infill crumb rubber. For more information on lead, see <a href="https://theconversation.com/toxic-lead-can-stay-in-the-body-for-years-after-exposure-53607">my earlier article for The Conversation</a>.</p>
<h2>What’s the bottom line on safety?</h2>
<p>While the turf <a href="http://www.fieldturf.com/en/innovation/research-and-studies">industry says it’s safe</a>, we know that <a href="http://www.calrecycle.ca.gov/publications/Documents/Tires%5C43296029.pdf">tires</a> contain established carcinogens. If we considered only what tires are made of, we would think they should be classified as hazardous waste, though currently EPA classifies tires as municipal waste. </p>
<p>The EPA has been conducting research into the question of <a href="https://www.epa.gov/chemical-research/tire-crumb-questions-and-answers">toxicity of crumb rubber</a>, but the jury is still out.</p>
<p>There is little question in the mind of many scientists that crumb rubber should not be a first choice material for children to play on. Parents should be able to just enjoy watching their children playing sports and not worry that they are being put unnecessarily at risk.</p>
<p><em>A correction was made to this article March 23, 2017 to accurately describe MRSA, which is Methicillin Resistant Staphylococcus aureus, not Multi-drug Resistant Staphylococcus aureus, as was originally stated. In addition, MRSA is not flesh-eating bacteria. It can cause serious consequences, including sepsis and bloodstream infections.</em></p><img src="https://counter.theconversation.com/content/72044/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stuart Shalat received funding from New Jersey Department of Environmental Protection.</span></em></p>Artificial turf has become popular for kids’ sports as well as for professional players. The little black crumbs that help support the blades of fake grass may not be so harmless.Stuart Shalat, Professor and Director of the Division of Environmental Health, School of Public Health, Georgia State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/711632017-02-14T14:19:20Z2017-02-14T14:19:20ZConcussions from schoolboy rugby: why parents need coaching<figure><img src="https://images.theconversation.com/files/154349/original/image-20170126-23875-65htl1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Young rugby players have a higher risk of sustaining a concussion and take longer to recover from the injury.</span> <span class="attribution"><span class="source">Yuya Shino/Reuters</span></span></figcaption></figure><p>Concussions are one of the most commonly reported <a href="https://theconversation.com/concussions-arent-only-a-medical-issue-35304">rugby-related injuries</a>. </p>
<p>Young rugby players have a <a href="http://bjsm.bmj.com/content/47/5/250.full.pdf+html">higher risk</a> of prolonged recovery following a concussion. Preventing concussions in schoolboy rugby is therefore very important. </p>
<p>As part of a global concussion prevention strategy, World Rugby, the body that manages rugby internationally, has introduced guidelines on how to manage concussions. These include regulations and return-to-play <a href="http://playerwelfare.worldrugby.org/?documentid=module&module=21">protocols</a>. One of these guidelines require that concussed players are assessed by a medical doctor before <a href="http://playerwelfare.worldrugby.org/content/getfile.php?h=d66f98b9815023fbf00e8ef28b20cdb6&p=pdfs/World_Rugby_Concussion_Guidance_EN.pdf">returning to play</a>. </p>
<p>Despite these international guidelines, many players ignore this warning and return to play prematurely. We looked at this defiance in South Africa and tried to understand why young South African rugby players failed to comply with the requirement of medical clearance. </p>
<p>We found that many did not seek medical clearance because their parents or legal guardians <a href="https://journals.assaf.org.za/sajsm/article/view/1575/1318">deemed it unnecessary</a>. This is concerning because returning to play before complete healing could have long-lasting effects, particularly in younger boy’s brains. In rare cases, it could even be <a href="http://www.mayoclinic.org/diseases-conditions/concussion/expert-answers/concussion-in-children/faq-20058282">fatal</a>.</p>
<p>There are several <a href="http://www.boksmart.com">rugby injury-prevention programmes</a> in the world. These mainly target coaches and referees with their injury prevention education. But our study shows that there is a gap – and unless parents of young rugby players are given concussion education, they won’t manage the injury properly.</p>
<h2>What happens during a concussion</h2>
<p>A concussion is a brain injury induced by a heavy blow on the head that results in a temporary loss of consciousness. Previously loss of consciousness or being “knocked out” were considered the only signs of a concussion. But there are many other signs. This includes being confused or dazed days later.</p>
<p>More recently, concussions have been recognised as more of a chemical than a structural disruption. For example, in contrast to an injury such as a hamstring muscle tear, most concussions are not visible – even with highly sophisticated scans.</p>
<p>This chemical underpinning also might explain why this injury can evolve over time. For example, a concussed child might have no signs of their injury during their match, but develop some confusion after they return home. </p>
<p>These signs of concussion should all need to be considered with the same level of seriousness. A “knock-out” is not necessarily more severe than a player presenting with confusion six hours after their match.</p>
<p>The delayed effect is critical in schoolboy rugby – and needs parents to be aware of the symptoms and how to treat it. </p>
<h2>Unnecessary treatment</h2>
<p>Our study showed that parents were not particularly involved in the management of concussions. To gather evidence, we interviewed teenagers who participated in schoolboy rugby in South Africa. </p>
<p>There were three reasons they didn’t get medical clearance from a doctor before returning to play. </p>
<p>First, there was the perception that it “was not necessary”. In most of the cases it was the parent or player that decided it was unnecessary. This was the most commonly mentioned barrier. </p>
<p>Second, some players were unaware of the requirement to seek medical clearance before returning to play. </p>
<p>Third, others said it took too much time to see a medical doctor. </p>
<p>In contrast, most sought medical clearance because they had been instructed to do so –- either by the tournament doctor or their school coach. Another reason for seeking medical clearance was because there was a concern for their wellbeing as they were still symptomatic.</p>
<p>The challenge arises when a concussed player who has still not recovered properly chooses not to seek medical clearance because they are mainly asymptomatic. They may not have completely recovered and may still be at risk if returned to full contact rugby too early. For example, when players are subjected to physical exertion, symptoms might re-emerge that were not there at rest.</p>
<h2>Involved parents</h2>
<p>Schoolboy rugby is governed by South African Rugby, the sport’s official regulator. The regulator has a national rugby safety program: BokSmart. </p>
<p>Despite numerous efforts in the past, BokSmart have had difficulty in filling a classroom with parents to discuss concussion management. This is in stark contrast to talks on nutritional supplements or player selection, where often the entire school hall has been filled. </p>
<p>If parents were more educated on the importance of managing a concussion, players would seek treatment more regularly. Therefore, they should be involved from the time of initial injury through to the safe return of their child to playing rugby. </p>
<p>Parents should educate themselves on concussion management, both at home, in the child’s classroom environment and on the field. They can also access a freely available <a href="http://www.irbplayerwelfare.com/?documentid=126">pocket concussion recognition tool</a> that World Rugby endorses. </p>
<p>If a parent even suspects that their child has sustained a concussion, they should be removed from play immediately and be assessed by a medical doctor as soon as possible. </p>
<p>If concussed, the player will need to be guided through a clearly defined return-to-play protocol by a medical doctor with experience in sport-related concussion management.</p><img src="https://counter.theconversation.com/content/71163/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>James Craig Brown's research position is contributed to by the BokSmart programme and Chris Burger/Petro Jackson Players' Fund.</span></em></p>Parents play a vital role in managing concussions when their children play rugby.James Craig Brown, Post-Doctoral Researcher in rugby injury prevention, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/723122017-02-02T21:20:22Z2017-02-02T21:20:22ZMany kids still don’t report concussion symptoms. How can we change that?<figure><img src="https://images.theconversation.com/files/155288/original/image-20170202-22563-yu6zfu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A mother from suburban Atlanta attending an educational session about concussions with Falcons fullback Patrick DiMarco in 2014. </span> <span class="attribution"><span class="source">Jason Getz/AP</span></span></figcaption></figure><p><a href="https://www.nfl.com/super-bowl">As Superbowl LI</a> between the Atlanta Falcons and the New England Patriots approaches, football fans reflect on a season of intense competition, hard-fought battles and the tenacity of elite professional athletes. Among the over 100 million fans watching the game this Sunday will be approximately <a href="http://www.espn.com/espn/otl/story/_/id/15210245/slight-one-year-increase-number-youth-playing-football-data-shows">three million youth</a> athletes who play the game themselves.</p>
<p>Entangled in the enthusiasm and attention to professional football is the <a href="http://www.cnn.com/2013/08/30/us/nfl-concussions-fast-facts/">conversation of concussive injury</a> and how playing professional football is related to brain injuries, neurocognitive problems and neurodegenerative diseases such as Parkinson’s, Alzheimer’s and Chronic Traumatic Encephalopathy (CTE). </p>
<p>The National Football League has taken steps to protect their players from head injuries, such as changing rules and improving equipment, yet as the <a href="https://www.wsj.com/articles/despite-modest-decline-nfl-concussion-rate-remains-work-in-progress-1485459791">Wall Street Journal</a> reports, rates in 2015 declined only slightly. </p>
<p>And while most of the media attention is directed at professional athletes, concussion and brain injuries are also a concern for soldiers in the military and for millions of youth athletes. Rates of concussion in these groups have led researchers and medical professionals to identify concussion as a <a href="http://www.mdedge.com/neurologyreviews/article/81884/alzheimers-cognition/concussion-public-health-crisis">public health crisis</a>.</p>
<p>As a prevention scientist, I’ve worked extensively with schools and community groups to change personal, social and environmental factors that contribute to unhealthy behaviors such as adolescent substance use, risky sexual behavior or violence. Many of the methods used to address those public health issues can be applied to youth concussions as well. </p>
<h2>A widespread problem</h2>
<p>About <a href="http://www.aspenprojectplay.org/the-facts">56 percent of youth</a> ages 6-17 play an organized sport, and the Centers for Disease Control estimates that each year in the United States, between 1.6 and 3.8 million youth suffer a concussion. </p>
<p>Growing media attention and new educational opportunities, such as the CDC’s <a href="https://www.cdc.gov/headsup/youthsports/">Heads Up program</a>, seek to inform and encourage reporting of concussion and include specific programs to help coaches, parents, health care providers and athletes learn about the signs of concussion and the need to report them. <a href="http://www.jsams.org/article/S1440-2440(14)00134-0/abstract">Research indicates</a>, however, that youth athletes may still underreport concussion. </p>
<p>A survey of Massachusetts youth indicated that almost half of athletes who experienced concussion symptoms continued to play that day, and <a href="http://www.mass.gov/eohhs/docs/dph/behavioral-risk/sports-related-concussions-among-youth-2015.pdf">only one-third stopped playing</a> and were checked by a doctor <a href="http://www.mass.gov/eohhs/docs/dph/behavioral-risk/sports-related-concussions-among-youth-2015.pdf">that day</a>. </p>
<p>Hiding symptoms of concussion and continuing to play in sports can result in subsequent injury, delayed recovery, delayed access to treatment and risk of catastrophic injury. An Institute of Medicine and National Research Council report on youth concussion concluded young athletes face a <a href="https://www.nap.edu/catalog/18377/sports-related-concussions-in-youth-improving-the-science-changing-the">“culture of resistance”</a> to reporting. It found research is needed to understand individual and social factors that create this culture and how it can be changed.</p>
<p>My colleague, <a href="https://www.orthohealth.com/staff/alissa-wicklund-phd-abpp-cn/">Alissa Wicklund</a>, who leads the Regional Concussion Center at the Orthopaedic and Spine Center of the Rockies, and I have a research project to address these issues. The project is part of the <a href="http://www.ncaa.org/about/resources/media-center/news/mind-matters-challenge-research-winners-announced">MindMatters Challenge</a>, funded by the National Collegiate Athletic Association (NCAA) and the Department of Defense (DOD), and focuses on three questions: </p>
<ol>
<li><p>What factors influence whether youth report concussion symptoms? </p></li>
<li><p>How to characterize and measure the culture of resistance? </p></li>
<li><p>How to change the culture of resistance? </p></li>
</ol>
<p>Although much of the research in this NCAA-DOD initiative focuses on collegiate athletics or the military, or both, our team of developmental clinical psychologists and athletic trainers will work with middle and high school youth. The students will be from nine schools in northern Colorado. The research team will try to shape the early knowledge, attitudes, beliefs and behaviors around concussion reporting. </p>
<p>We know characteristics of youth athletes, such as the knowledge they have about concussion, their attitudes about how serious symptoms are and their beliefs that if they report a concussion they will let the team down, all influence <a href="http://www.tandfonline.com/doi/abs/10.3109/02699052.2014.904049?journalCode=ibij20">whether they will report</a> concussion symptoms. </p>
<p>But to understand the culture of resistance, our study is gathering data about the knowledge, beliefs and attitudes of coaches, parents and peers – the key people in the athletes’ social networks that influence athletes’ decisions whether or not to report concussion symptoms. </p>
<p>We will study the environmental factors such as access to concussion materials and whether schools, districts or states have concussion reporting policies. While some studies have examined different factors independently, our study looks at them together to gain a fuller picture of the “culture” that middle school and high school athletes exist in. </p>
<p>Because we believe the culture may differ for girls and boys, in different schools or by sports and teams (girls’ volleyball vs. boys’ football), we will examine these subcultures and their influences on youth concussion reporting.</p>
<h2>Involving stakeholders to change the culture</h2>
<p>To change the culture, we are testing a process in which key members of the schools (students, teacher, coaches, trainers, parents) will learn about concussion, examining the data from their school. From there, the intent is to discuss what the data suggest is needed to change the culture, create an action plan for using evidence-based programs, practices or policies, and then implement those programs and policies in their schools. Rather than implementing identical programs at each school, the process emphasizes school-specific practices so schools will choose the interventions that are likely to work most efficiently and best for them. </p>
<p>Our intervention is based on empirically validated processes that have been used to change school and community “cultures” of substance use and violence. </p>
<p>Programs that teach about concussion are not likely to be sufficient, some studies have shown, and may in some cases <a href="http://journals.sagepub.com/doi/abs/10.1177/1090198114543011">have a negative effect</a> on reporting behavior. We believe it will be important to take a broader approach that also addresses the emotional aspects of sport participation and nonreporting, the social pressures such as feeling embarrassed, letting the team down or being perceived as weak. We also need to look at the relationships athletes have with coaches and parents.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/155289/original/image-20170202-22575-uqhwlv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/155289/original/image-20170202-22575-uqhwlv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=396&fit=crop&dpr=1 600w, https://images.theconversation.com/files/155289/original/image-20170202-22575-uqhwlv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=396&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/155289/original/image-20170202-22575-uqhwlv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=396&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/155289/original/image-20170202-22575-uqhwlv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=497&fit=crop&dpr=1 754w, https://images.theconversation.com/files/155289/original/image-20170202-22575-uqhwlv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=497&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/155289/original/image-20170202-22575-uqhwlv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=497&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Memphis teen Gracie Hussey, who suffered headaches and nausea after concussions from heading soccer balls.</span>
<span class="attribution"><span class="source">Karen Pulfer Focht/AP</span></span>
</figcaption>
</figure>
<p>Youth sports have many <a href="https://www.aspenprojectplay.org/the-facts">positive benefits</a> that can last a lifetime. Keeping youths safe in sport should be a primary objective of all individuals involved in youth athletics. While changes in equipment, coaching, rules and style of play can all contribute to reducing the likelihood of sport-related concussions, trainers must also be aware of the social, emotional and behavioral factors that contribute to whether an athlete will disclose symptoms. The diagnosis and treatment of concussions is almost entirely dependent on athletes’ accurate reporting of symptoms to parents, trainers and coaches. Effectively addressing the public health concern of concussion non-reporting in youth sports will require the active involvement and dedicated efforts of parents, coaches, peers, teammates, administrators, athletic trainers and medical personnel.</p><img src="https://counter.theconversation.com/content/72312/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Doug Coatsworth receives funding from NIDA, SAMHSA, NCA/DOD</span></em></p>The Super Bowl is a good time to party and celebrate, but it’s also a good time to reflect on where we stand culturally with concussions.J. Douglas Coatsworth, Professor of Human Development and Family Studies, Colorado State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/626762016-09-15T01:57:55Z2016-09-15T01:57:55ZCan headband sensors reduce underreported concussions in kids?<p>In one of the most exciting soccer games of the season, Kelly jumped to head the ball and score, imagining this would be the game-winning goal. Out of nowhere, the goalie jumped and met Kelly’s head with both fists. Kelly felt the jolt and landed harshly on the grass. Most of all, she was furious she had been robbed of the opportunity to score. </p>
<p>Next to Kelly, the goalie screamed and got most of the attention from players and coaches because of a broken finger. Kelly wanted to get back on the field. Her teammates and coach asked if she was fine. She said yes and was helped up by her teammates. When she heard the applause from the sidelines she was convinced she was doing right by her team. </p>
<p>Fortunately for her, her coach noticed Kelly was unable to track balls in the air when she was back on the field; she seemed to be squinting and was not smiling as usual. She asked Kelly to sit for the rest of the game. Kelly developed a headache and her coach recommended that her parents take her to the ER to be examined for a possible concussion.</p>
<p>Scenes like this true story, even though Kelly’s name has been changed, occur thousands of times every day around the country. With football and soccer in full swing in schools and recreation leagues around the country, it is important to continue to draw attention to the real risk for concussions that youngsters face – and to try to find solutions. </p>
<p>Concussions in football have drawn a lot of attention, but men’s and women’s soccer account for at least <a href="https://www.ncaa.org/sites/default/files/SMH_Guideline_21_20160217.pdf">19 percent</a> of concussive sports injuries. While those of us who study concussions know they are common, we also know they are difficult to assess.</p>
<p>When an athlete has difficulty standing up, walking or talking after a “hit,” or collision with another athlete, it is easier to suspect a concussion. Often, however, such an immediate symptom does not occur. A recent study suggested that <a href="https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0ahUKEwiG56WH-ozPAhUFRyYKHXocC0MQFggcMAA&url=http%3A%2F%2Fpediatrics.aappublications.org%2Fcontent%2Fpediatrics%2F138%2F1%2Fe20154635.full.pdf%3Fdownload%3Dtrue&usg=AFQjCNH-ChBv7eTnzr9uiYiZoWlBzDvayA&sig2=bQoZe5IprhHyAGzV0QrIng&cad=rja">more than half a million</a> concussions in youth go unreported. Too often, the athlete is asked to provide a self-evaluation seconds after a traumatic brain injury. </p>
<p>Unfortunately, in most cases the outward signs of concussion are <a href="http://www.cdc.gov/traumaticbraininjury/symptoms.html">subtle and easy to miss</a>. When it occurs a few feet from the ball, it can go unnoticed. The NFL and now the larger collegiate football conferences <a href="http://operations.nfl.com/the-game/gameday-behind-the-scenes/atc-spotters/">include spotters</a> and a physician whose primary role is to look out for the player’s safety.</p>
<p>This, however, leaves about <a href="http://pediatrics.aappublications.org/content/early/2016/06/16/peds.2015-4635">98 percent of players</a> in high school, middle school and all youth leagues without the benefit of these safety measures. Between <a href="http://pediatrics.aappublications.org/content/early/2016/06/16/peds.2015-4635">1.1 million and 1.9 million concussions occur</a> in children each year. That is far greater than the number of children with concussions reported by emergency departments; their records indicate the number <a href="http://pediatrics.aappublications.org/content/early/2016/06/16/peds.2015-4635">ranges between 115,000 and 167,000</a>.</p>
<p>Given the <a href="https://theconversation.com/concussions-and-kids-know-the-signs-60672">desire of the players</a> to compete and not to disappoint their teammates as well as <a href="https://theconversation.com/concussions-and-kids-know-the-signs-60672">lack of awareness of the early symptoms</a> of concussion and the importance of avoiding a second concussive injury, many athletes return to playing after having experienced a concussion. </p>
<p>Swelling following a concussion reduces the brain’s ability to absorb a <a href="http://www.mayoclinic.org/diseases-conditions/concussion/basics/complications/con-20019272">second impact</a>. In addition, concussion often results in impaired peripheral vision and coordination, increasing the likelihood of a second impact.</p>
<p>Asking the person who has been concussed to self-diagnose makes little sense. As measurement experts, we sought to come up with a solution to unreported concussions. </p>
<h2>Heading off an often debilitating diagnosis</h2>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/137770/original/image-20160914-4980-ncx53w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/137770/original/image-20160914-4980-ncx53w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/137770/original/image-20160914-4980-ncx53w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/137770/original/image-20160914-4980-ncx53w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/137770/original/image-20160914-4980-ncx53w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/137770/original/image-20160914-4980-ncx53w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/137770/original/image-20160914-4980-ncx53w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Asking a child to self-report a head injury is unreliable.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-294435863/stock-photo-sports-injury-youth-asian-thai-soccer-player-in-blue-uniform-painful-child-closed-eyes-and-touching-his-forehead-on-white-background-studio-shot-boy-lie-down-top-view.html?src=JYz0xN1VyURQ7b1TTQkdKg-1-32">From www.shutterstock.com</a></span>
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<p>Having kids who participated in youth, high school and college sports, we recognized the need for a simple device that could detect if a player had experienced a blow to the head. Unlike most parents, we collectively have over 50 years of experience in experimental measurement science. </p>
<p>We sought to detect the magnitude and location of the head impact in order to provide information for parents, coaches and health care providers as an aid in determining if a concussion has taken place. </p>
<p>We set out to design a device that could be used as an extension of the clinical evaluation by showing the location and magnitude of a head impact. Given that impact sensing is outside our immediate field of expertise, which involves ultrafast lasers and single layers of molecules, we partnered with Michigan State University’s football and soccer athletic trainers and players to evaluate our initial prototypes. From each meeting and trial, we learned what works best, and what simply does not work. </p>
<p>We initially thought of using accelerometers similar to those on smart phones that can sense abrupt changes in direction; however, our experience with sometimes finicky high-tech gadgets and continuously updating operating systems forced us to seek a more reliable platform.</p>
<p>We focused on the use of a recording media that would respond to localized pressure. We then developed a sensor design that could be calibrated so that the measurements would accurately reflect how severe a head impact is. Finally, we tested multiple headbands and skullcaps to come up with a design that would be comfortable to wear. </p>
<p>The help from Michigan State Head Athletic Trainer Dr. Sally Nogle and neurologist Dr. David Kaufman was critically important to capture the essence of the problems encountered in the field. </p>
<p>One of the biggest problems in keeping players safe is that it is hard to keep track of all the players. Therefore, it is important to have a rapid on-site sensor that records the magnitude and location of a head impact. Nogle and Kaufman stressed that only a trained professional can diagnose a concussion. But knowing the location and severity of the impact can help them determine if a player should be kept from returning to the field before a concussion protocol. </p>
<p>The process took 18 months, 200 failed prototypes and several broken accelerometers, which are used for calibrating the magnitude of impact. Ultimately we arrived at a headband or cap design that contains four sensor strips that were used by several football and men’s and women’s soccer players during the spring 2016 season. The sensor strips have four to six sensors each that are easy to read.</p>
<p>Our sensors measure force, which, according to <a href="http://teachertech.rice.edu/Participants/louviere/Newton/law2.html">Newton’s second law</a>, equals mass times acceleration. Therefore, unlike accelerometers that are sensitive to motion, our sensors take into account mass and are sensitive to force. In practical terms, this means our sensors are much less likely to indicate false impacts.</p>
<p>When impacted, the sensors show an image that can be understood intuitively: no image for a weak impact, a circle for moderate impact or a circle with a star inside for a severe impact. These sensors have no electronic components, so there is no need to interface them with a phone or computer. </p>
<p>We can’t yet disclose all the technology <strong>that</strong> in the patent-pending sensor strips, which we intend to further develop and sell through a <a href="http://roshsensors.com/">company we formed</a>. The sensor strips are calibrated using a testing system developed to simulate the actual size, shape and weight of a human head attached to a flexible neck. </p>
<p>In addition, industrial electronic accelerometers capable of taking impacts are five to 10 times greater than those associated with concussion are used to calibrate the design parameters of the sensor strips. </p>
<p>We would like to see that their affordable sensors make youth sports safer and minimize the risk of repeated concussive injuries. They would like to know that the next time a soccer player wants to get up and return to the playing field, there will be a way to let coaches, trainers and/or parents know the location and severity of a head impact. This information can help in making a better-informed decision regarding the possibility of concussion. The hope is to put information in the hands of professionals, so that more severe traumatic brain injuries can be avoided.</p><img src="https://counter.theconversation.com/content/62676/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gary Blanchard is founder and member of MTBIsense LLC. </span></em></p><p class="fine-print"><em><span>Marcos Dantus is founder and member of MTBIsense LLC. </span></em></p>As many as half a million concussions in youth go unreported each year. Finding a way to measure whether a hit has occurred on the field is an important way to address these injuries.Gary Blanchard, Professor of Chemistry, Michigan State UniversityMarcos Dantus, Professor of Chemistry, Michigan State UniversityLicensed as Creative Commons – attribution, no derivatives.