tag:theconversation.com,2011:/nz/topics/head-injury-15539/articlesHead injury – The Conversation2023-11-27T19:27:23Ztag:theconversation.com,2011:article/1941532023-11-27T19:27:23Z2023-11-27T19:27:23ZRepeated concussions can alter heart activity and impact the ‘heart-brain’ axis<figure><img src="https://images.theconversation.com/files/513107/original/file-20230302-16-tocrry.jpg?ixlib=rb-1.1.0&rect=114%2C122%2C2510%2C1803&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Exploring the interaction between the heart and the brain, known as the heart-brain axis, has shown how heart function changes due to a concussion.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/repeated-concussions-can-alter-heart-activity-and-impact-the-heart-brain-axis" width="100%" height="400"></iframe>
<p>Mild traumatic brain injury or sport-related concussions occur frequently in contact sports such as football, rugby and ice hockey. A concussion doesn’t just affect the brain; <a href="https://doi.org/10.3390/brainsci7080100">it results in stress to the entire body</a>. </p>
<p>In our laboratory comprised of exercise scientists and clinicians, we focus on studying heart function in patients with a concussion. After a concussion, there are increased demands on the body to maintain proper brain activity. To compensate for these demands, there are changes in heart function.</p>
<p>We have explored this interaction between the heart and the brain, known as the heart-brain axis, and have identified how heart function changes due to a concussion. For example, a hit to the head can send signals to the heart that <a href="https://doi.org/10.1111/cpf.12487">shifts the body to a stressful “fight-or-flight” mode</a>. This increases the stress on the body by causing a change in heart function.</p>
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<a href="https://theconversation.com/concussion-is-more-than-sports-injuries-whos-at-risk-and-how-canadian-researchers-are-seeking-better-diagnostics-and-treatments-189899">Concussion is more than sports injuries: Who's at risk and how Canadian researchers are seeking better diagnostics and treatments</a>
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<p>This mechanism is related to what we would describe as a neuro-autonomic cardiovascular dysfunction. This means that problems with the autonomic nervous system (ANS) are causing altered signals going to the heart. </p>
<p>The ANS controls things that we don’t actively think about like breathing, digestion and heart function. The ANS is also <a href="https://doi.org/10.1111/cpf.12487">responsible for controlling the rhythm of a heartbeat</a>.</p>
<h2>Changes in systole following a concussion</h2>
<p>Each heartbeat contains both a heart muscle contraction (systole) and relaxation (diastole) phase. That’s why a <a href="https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/in-depth/blood-pressure/art-20050982">blood pressure reading results in two numbers</a>: the systolic and diastolic pressures. Systolic blood pressure, which is usually listed at the top of a blood pressure reading, is generated by the heart as it contracts, pushing out blood during each heartbeat. </p>
<p>Approximately 120 mmHg is a good systolic number, and the blood pressure varies with each heartbeat. These variations between heartbeats in systolic blood pressure is known as blood pressure variability, and it is a measure that provides information about stress on the body.</p>
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<img alt="Illustration of a heart rhythm and a brain and a heart" src="https://images.theconversation.com/files/559964/original/file-20231116-15-2k6zrn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/559964/original/file-20231116-15-2k6zrn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=343&fit=crop&dpr=1 600w, https://images.theconversation.com/files/559964/original/file-20231116-15-2k6zrn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=343&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/559964/original/file-20231116-15-2k6zrn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=343&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/559964/original/file-20231116-15-2k6zrn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=431&fit=crop&dpr=1 754w, https://images.theconversation.com/files/559964/original/file-20231116-15-2k6zrn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=431&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/559964/original/file-20231116-15-2k6zrn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=431&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Within five days after sustaining a concussion, systole — the phase of the heartbeat when the heart muscle contracts to allow blood to flow into the body — is impaired, with the heart contracting for a shorter period of time during each heart beat.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p>Concussion can also alter blood pressure. Since blood pressure can also be influenced by breathing, we controlled breathing rates in concussed athletes when conducting tests within five days of injury. We showed that <a href="https://doi.org/10.3390/life12091400">blood pressure variability is suppressed during concussion</a>. </p>
<p>Within five days after sustaining a concussion, systole — the phase of the heartbeat when the heart muscle contracts to allow blood to flow into the body — is impaired, with the heart contracting for a shorter period of time during each heart beat. This has the potential to lower the efficiency with which blood is pumped from the heart. </p>
<p>Furthermore, there is <a href="https://doi.org/10.1080/15438627.2022.2102918">elevated stress on the heart</a>, causing it to squeeze harder to get blood into the body. These changes are typically transient and return to normal as concussion symptoms alleviate.</p>
<h2>Long-term concussion symptoms</h2>
<p>Concussion symptoms such as headache and pressure build-up in the head reflect the ANS not working properly. These symptoms can last if the brain is injured. Research suggests that a history of repeated concussions can have long-lasting effects. Specifically, those with a history of at least three concussions <a href="https://doi.org/10.1080/02699052.2022.2109737">show altered oxygen activity in the brain</a>.</p>
<p>Each heartbeat provides blood and oxygen to the brain. Therefore, heart complications can result in altered brain activity. This is evident during strenuous activity such as repeated squat-stand manoeuvres (10-second squat, then a 10-second stand, repeated 15 times), which <a href="https://doi.org/10.1080/02699052.2022.2109737">can result in reduced brain oxygen in those with a history of concussion</a>. This reduction in brain oxygen activity can be <a href="https://doi.org/10.3390/brainsci12111443">associated with elevated stress on the heart due to the concussion</a>.</p>
<p>Similarly, in our lab, four women suffering from post-concussion syndrome (symptoms that last for months or even years after a concussion) presented with <a href="https://doi.org/10.1139/cjpp-2021-0395">decreased systolic blood pressure variability</a>. Monitoring heart function in patients with sustained concussion complications can aid with recovery.</p>
<p>In another case study, a male patient had a history of multiple concussions that elicited heart complications. Remarkably, treatment of the heart issues alleviated all concussion symptoms in a matter of days when the patient’s cardiologist <a href="https://doi.org/10.1155/2020/7154120">treated him with the heart medication amiodarone, which is used to treat heart rhythm problems</a>.</p>
<p>Specifically, our case study presented a patient with almost 20 per cent abnormal heartbeats, which is very unusual. The stress on the heart stresses the body, which can worsen the concussion symptoms. This is the first report of a patient in whom treatment of abnormal heartbeat cleared concussion symptoms.</p>
<p>There is still limited research about the heart-brain axis. For example, it is known that <a href="https://www.heart.org/en/news/2020/02/04/chronic-stress-can-cause-heart-trouble">stress and anxiety are risk factors for heart disease</a>. For concussion, a hit to the head can send signals to the heart, resulting in higher stress levels on the heart. As shown in our research, the higher stress levels on the heart can be <a href="https://doi.org/10.3390/life12091400">measured by systolic blood pressure activity</a>. More research is being done to better understand the heart-brain axis.</p>
<h2>Future research and potential treatment options</h2>
<p>Research is beginning to investigate how compounds from the cannabis plant, such as cannabidiol (CBD), may help concussion recovery. For example, four female patients between the ages of 42 and 52 suffering from post-concussion syndrome consumed CBD oil under guidance from their physician. This was followed by improvements in their <a href="https://doi.org/10.1139/cjpp-2021-0395">systolic blood pressure variability</a>. Furthermore, their concussion symptoms improved, leading to reduced perception of anxiety. </p>
<p>This led us to complete a literature review on the implications of cannabinoids, such as CBD, on concussion. Our findings suggest that <a href="https://doi.org/10.1017/cjn.2020.23">cannabinoid therapy may have a beneficial effect on concussion recovery</a>.</p>
<p>We have recently been funded by the National Football League/National Football League Players Association to <a href="https://www.nfl.com/playerhealthandsafety/health-and-wellness/pain-management/nfl-awards-1-million-to-study-impact-of-cannabis-and-cbd-on-pain-management">study CBD’s potential influence on brain-heart function and effect on concussion symptoms</a>. This will enable us to better understand how these cannabinoids may influence the heart-brain axis relationship.</p><img src="https://counter.theconversation.com/content/194153/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>J. Patrick Neary receives funding from the National Football League/National Football League Players Association for his cannabinoid and concussion research. </span></em></p><p class="fine-print"><em><span>Jyotpal Singh and Payam Dehghani 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>Concussion doesn’t just affect the brain, but the whole body. The interaction of the ‘heart-brain axis’ means that as the brain works to heal its injury, it puts extra stress on the heart.Jyotpal Singh, Postdoctoral fellow, Kinesiology & Health Studies, University of ReginaJ. Patrick Neary, Professor, Faculty of Kinesiology & Health Studies, University of ReginaPayam Dehghani, Associate Professor, Cardiology, University of SaskatchewanLicensed 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>
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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>
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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>
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<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>
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<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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<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>
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<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>
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<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/2076862023-07-19T17:14:52Z2023-07-19T17:14:52ZBrain injuries may affect women worse than men – introduction of concussion spotters to Women’s World Cup could prove vital<figure><img src="https://images.theconversation.com/files/537815/original/file-20230717-224833-1nr3qo.jpg?ixlib=rb-1.1.0&rect=6%2C6%2C4486%2C2984&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Kelley O'Hara of the USA playing in the 2019 FIFA Women's World Cup final. O'Hara was substituted for a head injury at half time. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/kelley-o-hara-usa-lieke-martens-1445105285">Romain Biard/Shutterstock</a></span></figcaption></figure><p>The matches at the 2023 Fifa Women’s World Cup will be watched by <a href="https://www.thetimes.co.uk/article/fifa-concussion-spotters-womens-world-cup-r5cttkbcp">concussion spotters</a> for the first time. These medical staff will attempt to identify potential concussions that may have been overlooked by the officials on the pitch. </p>
<p>The role of the concussion spotter may be particularly vital in the women’s game because there is evidence that concussion has a worse impact on women.</p>
<p>Their use at the Women’s World Cup comes after a <a href="https://theconversation.com/world-cup-concussion-rules-may-be-putting-players-lives-at-risk-195150">similar trial</a> at the men’s competition in Qatar in 2022. However, while those in the men’s game were present at the stadium, in this tournament concussion spotters will work remotely, watching incidents on a screen, which may have an impact on their effectiveness.</p>
<p>A <a href="https://www.mayoclinic.org/diseases-conditions/concussion/symptoms-causes/syc-20355594">concussion</a> is a traumatic brain injury that affects your brain function. Immediately after the injury, concussion can lead to dizziness, confusion, and vomiting, but it is important to remember that sometimes there may be no initial symptoms. Losing consciousness only happens in about <a href="https://www.centracare.com/blog/2022/march/hit-your-head-look-for-these-warning-signs-of-co/#:%7E:text=Only%20about%205%2D10%25%20of,and%20forth%20within%20the%20skull.">10% of conscussions</a>. </p>
<p>Concussion can have longer-term effects, too. Research suggests that repeated concussions can lead to <a href="https://www.durham.ac.uk/research/current/research-news/rugby-concussions-and-mental-health/">poorer mental health</a> and that repeated head injuries can result in <a href="https://theconversation.com/world-cup-concussion-rules-may-be-putting-players-lives-at-risk-195150">degenerative brain diseases</a>. </p>
<p>My own research has found that people who had <a href="https://journals.sagepub.com/doi/full/10.1177/20597002221142379">experienced a concussion</a> struggled with switching between tasks more than people with no history of concussion. Task switching is important for daily life as well as in sport – it allows us to quickly adapt to different situations.</p>
<h2>Concussion in women</h2>
<p>What’s more, <a href="https://journals.sagepub.com/doi/full/10.1177/0363546509332497?casa_token=PSiaYFA0CzAAAAAA%3AqrgtYGzDAB_tuxMXRIOmuxAGngTDLWF96-aukO3-EfhvTlOxhBiLSrad4aBXEB7OBefaWhUswFq4268">research has found</a> that women reported more concussion symptoms than men. Some studies suggest that it takes women <a href="https://www.sportsmed.theclinics.com/article/S0278-5919(10)00053-0/fulltext">longer to recover</a>. </p>
<p>A <a href="https://jamanetwork.com/journals/jamanetworkopen/article-abstract/2779117">large-scale study</a> of teenage footballers found that concussion was almost twice as likely in girls than their male counterparts. The research also found that boys were over one and a half times more likely to be removed from play immediately. </p>
<p>In American football, the National Football League (NFL) introduced ATC (athletic trainer certified) spotters in 2012. Their <a href="https://operations.nfl.com/gameday/behind-the-scenes/atc-spotters/">primary job</a> is to alert the sideline medical staff of potential concussion. The NFL spotters are independent to ensure they prioritise the players’ health over the team’s fortunes. They cannot cover a game if they have worked full-time in the past for a team involved, and they must not have been employed by an NFL team in the past five years.</p>
<p>A 2019 <a href="https://meridian.allenpress.com/jat/article/54/8/852/420841/Engaging-Athletic-Trainers-in-Concussion-Detection">report</a> found that the use of ATC spotters improved the real-time detection of concussed players in the NFL.</p>
<h2>Power to the spotters</h2>
<p>Since 2015, ATC spotters have the ability to stop the game with a medical time-out. This can be enforced if there is <a href="https://operations.nfl.com/gameday/behind-the-scenes/atc-spotters/">clear visual evidence</a> that a player is obviously disorientated, or if a player is trying to stay in the game and not receive medical attention. </p>
<p>The importance of this became clear when, on just the second day of the 2022 men’s World Cup, an incident showed that, even with the concussion spotter system in place, team staff were allowing injured players to continue. </p>
<p>Iranian goalkeeper <a href="https://theconversation.com/world-cup-concussion-rules-may-be-putting-players-lives-at-risk-195150">Alireza Beiranvand</a> collided with his teammate, ultimately leading to his withdrawal from a group match against England. But first, the Iran coaching staff allowed the player the opportunity to carry on playing. Beiranvand fell over when attempting a goal kick – at which point he was finally deemed unable to continue. </p>
<p>Having independent medical staff is imperative given the pressures that club doctors are sometimes under to let a footballer play on. FIFA’s medical director <a href="https://www.theguardian.com/football/2021/may/06/fifa-to-bring-in-concussion-spotters-for-qatar-world-cup">Andrew Massey has spoken out</a> about how difficult it is for club medics to make a decision to remove a player with a possible concussion.</p>
<p>In 2019, Massey was part of Liverpool FC’s medical staff when star player Mohamed Salah sustained a heavy blow to both head and body and was substituted. Liverpool were fighting for the Premier League title and given Salah’s importance to the team, Massey has admitted to the <a href="https://www.theguardian.com/football/2021/may/06/fifa-to-bring-in-concussion-spotters-for-qatar-world-cup">possible consequences</a> of the substitution being in his mind. </p>
<p>Increased efforts to develop concussion protocols in the game is a positive step. We are increasingly learning about the significant effects of head injuries in sport, and the focus on the issue at major tournaments will help widen this understanding. The spotters will be discussed in commentary and broadcasts around the world. </p>
<p>This increased exposure should help alleviate poor attitudes towards concussion in sport. Although the current power of concussion spotters may be debatable, it is a step in the right direction. </p>
<p>As the tournament commences, the concussion spotters will have a keen eye on the players – but many people, like me, will be paying attention to the spotters, too.</p><img src="https://counter.theconversation.com/content/207686/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Daniel Walker 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>Football is starting to take concussion seriously – but there’s more to do.Daniel Walker, Lecturer in Psychology, University of BradfordLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2060842023-06-14T20:10:13Z2023-06-14T20:10:13ZFirst Nations women don’t always access health care after head injuries from family violence. Here’s why<figure><img src="https://images.theconversation.com/files/531828/original/file-20230614-21-zf11ko.jpg?ixlib=rb-1.1.0&rect=24%2C12%2C3989%2C2106&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/silhouette-woman-sitting-on-bed-beside-1439614217">Shutterstock</a></span></figcaption></figure><p><em>Please be advised this article contains details of family violence.</em></p>
<hr>
<p>Aboriginal and Torres Strait Islander women are <a href="https://www.mja.com.au/journal/2008/188/10/hospitalisation-head-injury-due-assault-among-indigenous-and-non-indigenous">69 times</a> more likely than non-Indigenous women to be hospitalised with head injuries due to assaults. </p>
<p>But some Aboriginal and Torres Strait Islander women <a href="https://www.tandfonline.com/doi/full/10.1080/14461242.2023.2173018">don’t access</a> health care and support services after head injuries from family violence. Our <a href="https://www.tandfonline.com/doi/full/10.1080/0312407X.2023.2210115?src=">research</a>, published this week, explored some of the reasons why – and how these barriers can be overcome. </p>
<p>We found fear of child removal, poverty, coercive control and low awareness of traumatic brain injury related to <a href="https://www.indigenousmhspc.gov.au/publications/dfv">family violence</a> can all impact on when and how Aboriginal and Torres Strait Islander women <a href="https://www.anrows.org.au/project/improving-family-violence-legal-and-support-services-for-indigenous-women/">access health care and support services</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/first-nations-women-are-69-times-more-likely-to-have-a-head-injury-after-being-assaulted-we-show-how-hard-it-is-to-get-help-194249">First Nations women are 69 times more likely to have a head injury after being assaulted. We show how hard it is to get help</a>
</strong>
</em>
</p>
<hr>
<h2>What is traumatic brain injury?</h2>
<p>Traumatic brain injury is <a href="https://www.archives-pmr.org/article/S0003-9993(10)00650-7/pdf">caused by</a> a blow, jolt or bump to the head. <a href="https://doi.org/10.1080/10926771.2019.1591562">Non-fatal strangulation</a> can also lead to brain injury as the brain is deprived of oxygen. </p>
<p>Traumatic brain injuries vary from mild to severe, and can cause a range of behavioural, emotional, physical and psychological symptoms, <a href="https://pubmed.ncbi.nlm.nih.gov/12924684/">including</a>:</p>
<ul>
<li>poor memory</li>
<li>dizziness</li>
<li>headaches</li>
<li>lack of concentration</li>
<li>slowness to process information or make decisions</li>
<li>emotional dysregulation, such as inability to control anger</li>
<li>anxiety and depression</li>
<li>lack of insight, where the person with the injury does not realise the effect of their injury.</li>
</ul>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1541936693799833600"}"></div></p>
<p>The <a href="https://synapse.org.au/understanding-brain-injury/effects-of-brain-injury/">experience of brain injury</a> is unique to each person.</p>
<p>The degree of recovery is largely determined by the nature and extent of the injury as well as the level of engagement in rehabilitation. For <a href="https://www.braininjuryaustralia.org.au/download-bias-report-on-australias-first-research-into-family-violence-and-brain-injury/">moderate to severe</a> traumatic brain injury, recovery is most rapid in the first six months after the injury. </p>
<p>Even mild traumatic brain injury can have <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8773525/">long-term impacts</a> on wellbeing, parenting capacity, relationships and day-to-day living. </p>
<p>Recovery can be maximised by providing education about the short- and long-term management of symptoms as well as the involvement of family in the rehabilitation and recovery phase. </p>
<h2>Listening to First Nations women</h2>
<p>To find out why Aboriginal and Torres Strait Islander women don’t always <a href="https://www.tandfonline.com/doi/full/10.1080/14461242.2023.2173018">access services</a>, we completed interviews and focus discussion groups with 28 women and 90 service provider professionals in Queensland and the Northern Territory.</p>
<p>Our study focused on Aboriginal and Torres Strait Islander women, as their voices are often <a href="https://theconversation.com/she-was-the-most-important-person-to-us-r-rubuntjas-story-shows-society-is-still-failing-first-nations-women-180857">silenced</a> when it comes to women’s safety.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/she-was-the-most-important-person-to-us-r-rubuntjas-story-shows-society-is-still-failing-first-nations-women-180857">'She was the most important person to us' – R. Rubuntja's story shows society is still failing First Nations women</a>
</strong>
</em>
</p>
<hr>
<h2>Fear of child removal</h2>
<p>In results similar to those from family violence studies, women told us they avoided health care or minimised the amount of information they shared with health professionals to reduce the risk of contact with child protection authorities. One woman told us:</p>
<blockquote>
<p>We won’t report when there is domestic violence. If there is any words that come from the woman that [her] children were there, children are considered at risk and so they are taken. </p>
</blockquote>
<p>Some women told us their children had been removed following reporting and seeking support following family violence.</p>
<h2>Risks of further violence</h2>
<p>Sometimes women were prevented from accessing health care by manipulation and coercive control. This included partners preventing them accessing a working phone or transport. </p>
<p>One service provider said:</p>
<blockquote>
<p>A lot of users of violence I guess employ such a level of control and coercion that sometimes women are prevented from seeking medical treatment, or attempts to seek medical treatment, or disclose violence, including assaults to the head. It might actually make the situation worse. </p>
</blockquote>
<h2>Women prioritise competing demands</h2>
<p>Community-based service providers recognised the strength and resilience of women in continuing their roles caring for children and other family members after experiencing family violence.</p>
<p>Service providers told us their clients were often also managing financial and housing worries. One service provider told us:</p>
<blockquote>
<p>When a woman arrives here, the most important thing is rest, food, and finding that space to just sit with what’s happened, and then medical attention. I don’t always hear women prioritising medical attention in the first instance. I think that rest definitely, and even hunger, on a real, basic survival level. </p>
</blockquote>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-what-is-traumatic-brain-injury-75546">Explainer: what is traumatic brain injury?</a>
</strong>
</em>
</p>
<hr>
<h2>Awareness of brain injury</h2>
<p>Community members and leaders we spoke to had low levels of awareness, knowledge and recognition of the long-term damage violence can have on the brain. One community member said:</p>
<blockquote>
<p>We didn’t know about this brain injury. </p>
</blockquote>
<p>Another participant said:</p>
<blockquote>
<p>I didn’t go to the hospital. I had a bit of [a] headache, didn’t think it was serious enough to [go] and get checked, it [headache] went away. It happened many times. One time I black out, wasn’t aware of the lasting harm that can cause.</p>
</blockquote>
<h2>So what are the solutions?</h2>
<p>There are a range of opportunities to address several of these barriers. </p>
<p>First, service providers (including <a href="https://doi.org/10.1002/ajs4.200">within child protection systems</a>) need to ensure women receive compassionate care, referrals and links to support services for traumatic brain injury in a meaningful, timely and appropriate way.</p>
<p>There are <a href="https://www.familymatters.org.au/wp-content/uploads/2022/11/20221123-Family-Matters-Report-2022-1.pdf">strong calls</a> to have community-controlled organisations deliver child protection services – with many potential benefits to families and communities. </p>
<p>We also need to resource communities to design, implement and evaluate traumatic brain injury prevention and early intervention solutions. </p>
<p>Community-wide and school-based education were among some of the recommendations from community members to help people recognise the signs of traumatic brain injury and the importance of seeking help.</p>
<p>Other strategies to improve access to services include placing supports such as social workers outside of acute, hospital settings – for example, in <a href="https://www.tandfonline.com/doi/full/10.1080/26408066.2023.2202665?src=">GP clinics</a> and Aboriginal Community Controlled Health Services. </p>
<p>Finally, front-line staff and university students need high-quality training and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6645196/">education about traumatic brain injury and family violence</a>, how it presents in parental behaviour, case management and referral pathways. </p>
<p>Any practical solutions must be implemented through local partnerships with Aboriginal and Torres Strait Islander peoples to ensure the measures are community-led, culturally safe and provide an overall benefit, without doing further harm.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/new-research-reveals-harrowing-stories-of-murdered-indigenous-women-and-the-failure-of-police-to-act-205655">New research reveals harrowing stories of murdered Indigenous women and the failure of police to act</a>
</strong>
</em>
</p>
<hr>
<p><em>If this article raises issues for you or someone you know, contact <a href="https://1800respect.org.au/">1800 RESPECT</a> (1800 737 732) or <a href="https://www.13yarn.org.au/">13YARN</a> (13 92 76). In an emergency, call 000.</em></p>
<p><em>Jody Barney is a co-author on the journal paper on which this article is based. The authors thank the project team, advisory group and participants who shared their time and knowledge.</em></p><img src="https://counter.theconversation.com/content/206084/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michelle Fitts receives funding from the Australian Research Council. </span></em></p><p class="fine-print"><em><span>Jennifer Cullen receives funding from the Department of Social Services and the NDIS. She is the CEO of Synapse Australia.</span></em></p>Some First Nations women who sustain head injuries from family violence don’t access health care and support. We studied why and found one reason is a fear their children will be taken away.Michelle Fitts, ARC DECRA Fellow, Institute for Culture and Society, Western Sydney UniversityJennifer Cullen, Adjunct Associate Professor, College of Healthcare Sciences, James Cook UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2030382023-04-26T23:44:20Z2023-04-26T23:44:20ZHit your head while playing sport? Here’s what just happened to your brain<figure><img src="https://images.theconversation.com/files/522897/original/file-20230426-28-n7he5i.jpg?ixlib=rb-1.1.0&rect=0%2C5%2C1917%2C1270&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.pexels.com/photo/boys-playing-soccer-during-day-3413645/">Patrick Case/Pexels</a></span></figcaption></figure><p>It’s Friday night, your team is playing, and scores are nail-bitingly close. A player intercepts the ball, and bam! A player tackles his opponent to the ground. Trainers and doctors gather nervously while the commentators wait for confirmation: a concussion, mild traumatic brain injury, head knock, strike, tap, bump, blow … there are many terms for it.</p>
<p>How to prevent and treat such injuries is the subject to a <a href="https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/Headtraumainsport">Senate inquiry</a>, with public hearings this week.</p>
<p>But what exactly are these injuries? What’s going on in the brain?</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>
</strong>
</em>
</p>
<hr>
<h2>What is concussion?</h2>
<p>Concussion is a form of traumatic brain injury (TBI). Concussion typically falls at the milder end of the spectrum, and so is often called mild TBI.</p>
<p>Concussions happen most often when the head directly hits against something. But it can also happen without head impact, when a blow to the body causes the head to move quickly. </p>
<p>The brain is a soft organ in a hard case, floating in a thin layer of <a href="https://medlineplus.gov/lab-tests/cerebrospinal-fluid-csf-analysis/">cerebrospinal fluid</a>. The brain can be damaged away from the site of impact for this reason, as it bounces with force within the skull.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1591444863698042883"}"></div></p>
<p>Concussions that happen during sport can be complex because the head often rotates as the person falls. This “<a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3979340/">rotational acceleration</a>” can cause more damage to the brain. This is especially the case for cells in the long tracts of white matter responsible for relaying signals around the brain.</p>
<p>As well as causing initial damage to brain cells at the time of injury, concussion sets off a cascade of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4479139/">chemical and biological changes</a>. These occur within minutes and may last for days or even weeks after concussion. </p>
<p>Cell membranes become permeable (more leaky), causing an imbalance of brain chemicals inside and outside cells. Cellular functions shift into overdrive to try to restore balance, using more fuel in the form of glucose. At the same time, blood flow to the brain is often reduced, resulting in a mismatch between energy supply and demand. </p>
<p>The structural scaffolding of cells in the white matter may begin to weaken or break, preventing or reducing the ability of cells to communicate.</p>
<p>Sensing danger, cells from the <a href="https://pubmed.ncbi.nlm.nih.gov/28910616/">immune system</a> begin to migrate to the brain in an attempt to stem the damage, spouting chemical signals to recruit other inflammatory cells to the sites of injury. </p>
<p>These initial responses to concussion typically resolve over time, but the recovery period may be different for each person, and may persist even after symptoms go away.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/repeated-head-injury-may-cause-degenerative-brain-disease-for-people-who-play-sport-juniors-and-amateurs-included-196042">Repeated head injury may cause degenerative brain disease for people who play sport – juniors and amateurs included</a>
</strong>
</em>
</p>
<hr>
<h2>What are the symptoms?</h2>
<p>Concussion <a href="https://www.mayoclinic.org/diseases-conditions/concussion/symptoms-causes/syc-20355594">symptoms</a> can differ depending on the person and the circumstances of injury. </p>
<p>Some people have more obvious symptoms like loss of consciousness, vomiting and confusion; others may have headaches, problems with their vision, or thinking and concentration. Some people may have one symptom while others have many. Some people’s symptoms may be severe, and others may have only mild symptoms.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1649993694802485250"}"></div></p>
<p>So diagnosing and managing concussion can be difficult. Most people who have a concussion will find their symptoms subside within days or weeks. But around <a href="https://pubmed.ncbi.nlm.nih.gov/26918481/">20% of people</a> will have persistent symptoms beyond three months after their concussion. </p>
<p>Ongoing symptoms can make it harder to perform at work or school, to socialise with friends and to maintain relationships. Scientists don’t know why recoveries are different for different people. We have no way to <a href="https://bmjopen.bmj.com/content/11/5/e046460.info">predict</a> who will recover from concussion and who won’t.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/having-a-brain-injury-does-not-mean-youll-get-dementia-97254">Having a brain injury does not mean you'll get dementia</a>
</strong>
</em>
</p>
<hr>
<h2>How about repeat blows to the head?</h2>
<p>People who play contact sports are more likely to have multiple concussions over a playing career. Higher numbers of concussions tend to mean <a href="https://pubmed.ncbi.nlm.nih.gov/28387556/">worse symptoms and slower recovery</a> for subsequent concussions. </p>
<p>This indicates the brain doesn’t get used to concussions, and each concussion is likely to impart additional damage. </p>
<p>Emerging evidence suggests repeated concussions may lead to <a href="https://n.neurology.org/content/88/15/1400.short">ongoing changes</a> in people’s brain cell structure and function.</p>
<p><a href="https://pubmed.ncbi.nlm.nih.gov/32326805/">Inflammation</a> may persist inside and outside the brain. Inflammation may also <a href="https://pubmed.ncbi.nlm.nih.gov/30535946/">cause or contribute</a> to someone developing symptoms, and long-term brain functional and structural changes.</p>
<p>Prolonged symptoms and long-term brain changes may be worse in the long run for people who experience their concussions as <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6595074/">young adults</a> compared to people who have concussions as older adults. </p>
<p>Scientists are also starting to find differences in <a href="https://pubmed.ncbi.nlm.nih.gov/30618335/">symptoms</a> and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8596946/">brain alterations</a> in males and females. These could be related to newfound sex differences in the <a href="https://pubmed.ncbi.nlm.nih.gov/29104114/">scaffolding proteins</a> of male and female brains, making female brains more susceptible.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/522906/original/file-20230426-16-isrm2t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Female soccer players playing match" src="https://images.theconversation.com/files/522906/original/file-20230426-16-isrm2t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/522906/original/file-20230426-16-isrm2t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/522906/original/file-20230426-16-isrm2t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/522906/original/file-20230426-16-isrm2t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/522906/original/file-20230426-16-isrm2t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/522906/original/file-20230426-16-isrm2t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/522906/original/file-20230426-16-isrm2t.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">Concussion may be different for women, but we’re still learning how.</span>
<span class="attribution"><a class="source" href="https://www.pexels.com/photo/woman-athletes-playing-soccer-906073/">Noelle Otto/Pexels</a></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/sports-concussions-affect-men-and-women-differently-female-athletes-need-more-attention-in-brain-research-160097">Sports concussions affect men and women differently. Female athletes need more attention in brain research</a>
</strong>
</em>
</p>
<hr>
<h2>We’ve known about this for a long time</h2>
<p>The long-term brain and behaviour changes resulting from repeated sports concussions have been reported since at least the <a href="https://www.bmj.com/content/1/3306/816">1920s</a>. Back then, it was seen in boxers and termed dementia pugilistica, or <a href="https://jamanetwork.com/journals/jama/article-abstract/260461">punch-drunk syndrome</a>. </p>
<p>We now call this condition <a href="https://www.sciencedirect.com/science/article/abs/pii/S1934148211005296">chronic traumatic encephalopathy</a> (CTE). People found to have CTE don’t always experience severe symptoms. Instead, symptoms tend to emerge or worsen later in life, even decades after injury or at the end of a playing career.</p>
<p>People also have <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8166432/">varied symptoms</a> that can sometimes be hard to measure, like confusion, impaired judgement and aggression. This has made diagnosis difficult while people are alive. We can only confirm CTE after someone dies, by detecting altered structural proteins of the brain in <a href="https://link.springer.com/article/10.1007/s12024-023-00624-3">specific brain areas</a>. </p>
<p>There is still a lot to learn about CTE, including the exact processes that cause it, and why some people will develop it and others won’t.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/heres-what-we-know-about-cte-the-brain-condition-that-affected-danny-frawley-145395">Here's what we know about CTE, the brain condition that affected Danny Frawley</a>
</strong>
</em>
</p>
<hr>
<h2>Concussion is common</h2>
<p>Concussion is a common injury almost <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7048626/">30%</a> of us will experience in our lifetime. </p>
<p>Although we have a lot still to learn, the current advice for people who experience concussion is to seek medical advice to help with initial management of symptoms and guide decisions on returning back to playing sports.</p>
<hr>
<p><em>For coaches, trainers, parents and others interested in learning more about how to manage concussion, resources are available from <a href="https://www.connectivity.org.au/">Connectivity Traumatic Brain Injury Australia</a>. These include its <a href="https://www.connectivity.org.au/concussion-short-course/">free concussion short courses</a> to help you understand, recognise and manage a concussion injury when it occurs.</em></p><img src="https://counter.theconversation.com/content/203038/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sarah Hellewell receives funding from the Medical Research Futures Fund and the Bryant Stokes Neurological Research Foundation.</span></em></p>Young or old, men or women. All can be at risk of concussion while playing contact sport. Here’s what we know happens in the brain.Sarah Hellewell, Research Fellow, Faculty of Health Sciences, Curtin University, and The Perron Institute for Neurological and Translational Science, Curtin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1960422022-12-22T19:08:11Z2022-12-22T19:08:11ZRepeated head injury may cause degenerative brain disease for people who play sport – juniors and amateurs included<p>Where there are players and a game to be won, you can expect some “rough and tumble” on the sporting field. But when do the bumps become a problem for players? And what can we do to protect them from traumatic brain injury? </p>
<p>Submissions are open for Australia’s senate <a href="https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/Headtraumainsport">inquiry</a> into concussions and repeated head trauma in contact sports, with findings to be reported by mid year. The inquiry was borne out of <a href="https://www.theguardian.com/sport/2022/dec/01/concussion-and-head-trauma-in-contact-sports-to-be-examined-by-parliamentary-inquiry-greens-say">growing concern</a> about the long-term impact of such injuries, whether they can cause chronic brain problems and the liability of sporting organisations. </p>
<p>Head impacts are not uncommon in some sports, particularly contact sports like football and rugby, or combat sports such as boxing and mixed martial arts. Minor head injuries are also relatively common in military settings.</p>
<p>While much of the inquiry’s focus will be on professional players and leagues, local teams and young players should also look out for its findings. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/world-cup-concussion-rules-may-be-putting-players-lives-at-risk-195150">World Cup concussion rules may be putting players' lives at risk</a>
</strong>
</em>
</p>
<hr>
<h2>How head injuries happen</h2>
<p>The severity of head injuries varies widely, depending on <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4975525/">factors</a> including the velocity and the angle of impact between the head and the ground or another player. The brain can also be injured when there is no impact, such as in a whiplash injury.</p>
<p>Appropriate assessment, diagnosis and rehabilitation is important since severe brain injury can occur with repeated impacts and have lifelong <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5384827/">consequences</a> regarding a person’s ability to learn, work, communicate and socialise.</p>
<p>Mild traumatic brain injury, also referred to as “concussion”, may not have <a href="https://www.frontiersin.org/articles/10.3389/fped.2020.00057/full">initial signs and symptoms</a> that appear as debilitating as severe brain injury. But appropriate rehabilitation can still be challenging. And researchers are exploring whether repeated concussion can lead to serious problems. </p>
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<em>
<strong>
Read more:
<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">Concussions can cause disruptions to everyday life in both the short and long term – a neurophysiologist explains what to watch for</a>
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<h2>What counts as a concussion?</h2>
<p>The senate inquiry’s <a href="https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/Headtraumainsport/Terms_of_Reference">terms of reference</a> include an examination of “the lack of a consistent definition of what constitutes ‘concussion’”.</p>
<p>While some sources define concussion as a temporary unconsciousness or confusion caused by a blow to the head, the Centres for Disease Control and Prevention <a href="https://www.cdc.gov/headsup/pdfs/providers/facts_about_concussion_tbi-a.pdf">is more specific</a>, describing it as: </p>
<blockquote>
<p>a type of traumatic brain injury caused by a bump, blow, or jolt to the head or by a hit to the body that causes the head and brain to move rapidly back and forth. This sudden movement can cause the brain to bounce around or twist in the skull, creating chemical changes in the brain and sometimes stretching and damaging brain cells.</p>
</blockquote>
<p>Adding to the challenge for clinicians dealing with assessment and rehabilitation, are the active attempts of athletes, to get an “all clear” status quickly. Some may pass tests of balance or memory even though they have not recovered fully.</p>
<p>Current “return to play” guidelines vary across sporting codes. The <a href="https://resources.afl.com.au/afl/document/2021/04/26/9a186f44-ad48-4fab-b6ab-e4be45a578d7/Management-of-Sport-Related-Concussion-in-Australian-Football-25-April-2021-FINAL.pdf?_ga=2.201676118.611541483.1670722753-2137844543.1670722753">Australian Football League guidelines</a> outline a 24–48 hour period of rest as part of a minimum 12-day break, supervised activity and medical clearance before returning to play. </p>
<p>The National Rugby League has a <a href="https://app.education.nsw.gov.au/sport/File/3397">similar guideline</a> with a minimum of seven to eight days before a player can return to play. It states they should have returned to normal daily activities, such as work or school, without symptoms and the decision to play should be made by a medical practitioner. </p>
<p>It’s unclear how well these safety protocols flow down to <a href="https://bmjopensem.bmj.com/content/3/1/e000174">semi-professional</a>, club and junior competitions.</p>
<p>Concussion in children has been treated in the same way as adults in the past, though some suggest management should be <a href="https://journals.sagepub.com/doi/10.1177/0009922814558256?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed">more conservative</a> for developing brains.</p>
<h2>Long-term effects</h2>
<p>Scientific investigation into the long-term effects of mild traumatic brain injury is <a href="https://www.sciencedirect.com/science/article/abs/pii/S0002934317304825?via%3Dihub">relatively new</a>.</p>
<p>Based on a <a href="https://pubmed.ncbi.nlm.nih.gov/20032774/">small number of autopsies</a>, researchers have suggested a link between early onset dementia among retired National Football League athletes in the United States and their history of head impacts. However, more recent research is showing the <a href="https://alz-journals.onlinelibrary.wiley.com/doi/10.1016/j.jalz.2018.12.015">link</a> between concussion and dementia remains tenuous. </p>
<p>The danger appears to be largely due to repeated impacts over long periods. Some research suggests <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4913432/">a link</a> between repeated mild traumatic brain injury and a neurodegenerative condition called <a href="https://www.mayoclinic.org/diseases-conditions/chronic-traumatic-encephalopathy/symptoms-causes/syc-20370921">chronic traumatic encephalopathy</a>, which can impair thinking, reasoning and memory. More research is needed to confirm this link.</p>
<p><div data-react-class="InstagramEmbed" data-react-props="{"url":"https://www.instagram.com/p/CmLE99vhqOA/?hl=en","accessToken":"127105130696839|b4b75090c9688d81dfd245afe6052f20"}"></div></p>
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Read more:
<a href="https://theconversation.com/families-of-athletes-with-dementia-linked-to-brain-trauma-on-watching-somebody-you-love-disappear-uncharted-brain-podcast-part-2-194210">Families of athletes with dementia linked to brain trauma on watching somebody you love disappear – Uncharted Brain podcast part 2</a>
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<h2>Protecting players</h2>
<p>The challenge with sport-related head injuries is that the athlete, their coach, manager and sponsors typically want them to remain in the contest or return to it as quickly as possible. </p>
<p>When an athlete – or amateur or junior player – returns to sport too soon, his or her skills may be compromised. Vision can be affected, balance, coordination and decision-making may be less than perfect. These deficits <a href="https://www.sciencedirect.com/science/article/abs/pii/S0028377020300333?via%3Dihub">increase the danger</a> of another similar injury. </p>
<p>So can begin a downward spiral into repeated injuries and the potential development of chronic problems later in life. </p>
<p>When an athlete does experience a concussion, a monitored rehabilitation program should include graded exercise, beginning at a very low level (such as 15 minutes walking daily) and gradually increase in intensity, with tests of balance, memory and manual dexterity every three to four days. Any symptoms such as headache, fogginess or poor sleep quality should be monitored. </p>
<p>Once the athlete has fully recovered, a maximal exercise test called the <a href="https://www.braininjuryaustralia.org.au/wp-content/uploads/Barry-Willer_2.pdf">Buffalo Concussion Treadmill Test</a> can be performed. This involves gradually increasing the intensity of treadmill running to maximal, or near maximal, effort. If this does not induce any symptoms, the athlete can be cleared to play by their medical practitioner.</p>
<h2>Slow progress</h2>
<p>There has been some progress to protect players. Some contact sports have altered their rules to reduce the chances of mild traumatic brain injury and impose heavy penalties for <a href="https://www.afl.com.au/news/802896/high-tackle-clarity">head high tackles</a>. Mandatory rest periods after injury have been <a href="https://www.afl.com.au/news/543220/concussion">outlined by the AFL</a>. Junior soccer leagues have removed “<a href="https://theathletic.com/3452665/2022/07/18/fa-to-trial-removal-of-heading-at-under-12-level-and-below/">heading</a>” (where the player strikes the ball with their head) for younger players entirely and rugby has altered tackle rules to improve player safety. </p>
<p>The challenge is to improve the understanding and safety protocols at the <a href="https://nap.nationalacademies.org/catalog/18377/sports-related-concussions-in-youth-improving-the-science-changing-the">non-professional levels of sport</a>. </p>
<p>Understanding the potential short- and long-term effects of concussion on brain health and quality of life is very important. Hearing from people who have experienced mild traumatic brain injury through sport or other incidences helps us to <a href="https://www.connectivity.org.au/living-with-tbi/">develop better protocols</a>. </p>
<p>Coaches, first aiders, players and parents of players should be aware of the dangers of mild traumatic brain injury and the importance of an appropriate return to play plan. This can reduce the likelihood of further injuries and their long-term effects, and extend players’ years on the field.</p><img src="https://counter.theconversation.com/content/196042/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew Lavender 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>While much of the inquiry into concussions and repeated head trauma in sport will focus on professional players and leagues, local teams and young players should also look out for the findings.Andrew Lavender, Senior Lecturer, Institute of Health and Wellbeing, Federation University AustraliaLicensed 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/1918302022-10-03T21:49:17Z2022-10-03T21:49:17ZNFL player Tua Tagovailoa’s concussion might have been prevented with rugby’s stricter protocols<figure><img src="https://images.theconversation.com/files/487863/original/file-20221003-20-2vmubv.jpg?ixlib=rb-1.1.0&rect=536%2C771%2C4114%2C2586&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Miami Dolphins quarterback Tua Tagovailoa runs onto the field before the team's NFL football game against the Cincinnati Bengals on Sept. 29, despite a head injury during a game a few days earlier. </span> <span class="attribution"><span class="source">(AP Photo/Joshua A. Bickel)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/nfl-player-tua-tagovailoa-s-concussion-might-have-been-prevented-with-rugby-s-stricter-protocols" width="100%" height="400"></iframe>
<p>Few moments in sport are more gut-wrenching than a player lying on the field, limp from the impact of a high-speed collision. The crowd’s visceral groans speak volumes, as they did during a game between the Miami Dolphins and the Cincinnati Bengals on Sept. 29.</p>
<p>Dolphins quarterback Tua Tagovailoa was stretchered off the field and hospitalized with a concussion.</p>
<p>In the days since his injury, questions have increasingly been raised about whether Tagovailoa should have been playing at all that night, and whether the NFL needs to revise its concussion protocols to prevent an episode like this occurring again.</p>
<h2>Concussion in sport</h2>
<p>If Tagovailoa had been playing rugby, the story of his injury would likely be very different. World Rugby, the governing body for one of the most physical contact sports, has a clear set of guidelines on concussions that map out a pathway for players’ recovery that diverge markedly from the NFL and most other professional sports. </p>
<p>There are <a href="https://passport.world.rugby/player-welfare-medical/concussion-management-for-match-day-medical-staff-using-the-hia-protocol/hia-protocol/hia-procedures/">12 symptoms</a> of possible concussion that require immediate removal from a rugby game with no return to the field of play. A further series of assessments, which take at least a week, and a gradual scaling up of activity ensue in order for players to safely resume participation in contact sport.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/487879/original/file-20221003-14-m6zuct.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Officials with a stretcher are seen emerging from a cluster of men in teal football uniforms" src="https://images.theconversation.com/files/487879/original/file-20221003-14-m6zuct.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/487879/original/file-20221003-14-m6zuct.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/487879/original/file-20221003-14-m6zuct.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/487879/original/file-20221003-14-m6zuct.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/487879/original/file-20221003-14-m6zuct.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/487879/original/file-20221003-14-m6zuct.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/487879/original/file-20221003-14-m6zuct.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">Miami Dolphins quarterback Tua Tagovailoa is taken off the field on a stretcher during the first half of an NFL football game against the Cincinnati Bengals on Sept. 29, in Cincinnati.</span>
<span class="attribution"><span class="source">(AP Photo/Jeff Dean)</span></span>
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<p>These measures are due in no small part to rugby’s high incidence of concussion (<a href="https://doi.org/10.1177/0363546515622389">conservatively more than two and a half times the rate of football</a> and <a href="https://doi.org/10.1177/2059700219860641">growing</a>) and the large number of players embroiled in <a href="https://www.theguardian.com/sport/2022/jul/25/case-against-rugby-union-governing-bodies-on-dementia-destined-for-courts">lawsuits related to after-effects of concussion</a>, such as early-onset dementia.</p>
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Read more:
<a href="https://theconversation.com/concussion-is-more-than-sports-injuries-whos-at-risk-and-how-canadian-researchers-are-seeking-better-diagnostics-and-treatments-189899">Concussion is more than sports injuries: Who's at risk and how Canadian researchers are seeking better diagnostics and treatments</a>
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</em>
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<p>The size of rugby players <a href="https://doi.org/10.1080/026404101750158312">has ballooned</a> over the past few decades. Since 1975, the average player’s body mass has increased by nearly four times the amount observed in the previous 70 years. That, together with rugby players’ sparse protective gear and the avalanche of lawsuits, has encouraged the game’s regulatory bodies to take a far more cautious view of head injuries than almost any other sport.</p>
<h2>An injury in an earlier game</h2>
<p>World Rugby’s criteria for concussion would undoubtedly have applied to Tagovailoa in a game on Sept. 25 — in other words, four days before he played against the Bengals. <a href="https://www.espn.com/nfl/story/_/id/34670980/miami-dolphins-qb-tua-tagovailoa-not-concussion-protocol-coach-mike-mcdaniel-says">He was tackled and his head struck the ground in the second quarter</a> of a Dolphins’ game against the Buffalo Bills. </p>
<p>After that play, he reached for his head with his hands, struggled to get to his feet and fell after a couple of steps, clear signs of concussion. He seemed to be propped up by his team mates. Yet, less than an hour later, he was cleared to play and returned in the game.</p>
<figure class="align-center ">
<img alt="Two men in peaked caps assist a man in a white football uniform and helmet, seen from behind" src="https://images.theconversation.com/files/487874/original/file-20221003-26-38yca.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/487874/original/file-20221003-26-38yca.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/487874/original/file-20221003-26-38yca.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/487874/original/file-20221003-26-38yca.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/487874/original/file-20221003-26-38yca.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/487874/original/file-20221003-26-38yca.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/487874/original/file-20221003-26-38yca.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">Miami Dolphins quarterback Tua Tagovailoa (1) is assisted off the field during the first half of an NFL football game against the Buffalo Bills on Sept. 25 in Miami Gardens. He was later cleared to return to the game, despite indication of concussion.</span>
<span class="attribution"><span class="source">(AP Photo/Rebecca Blackwell)</span></span>
</figcaption>
</figure>
<p>If Tagovailoa had been playing rugby, he would almost certainly have been barred from returning to that game and been kept on the sidelines on Sept. 29.</p>
<p>In the days following the Bills incident, Dolphins officials, including coach Mike McDaniel insisted that Tagovailoa was being evaluated daily and that his <a href="https://www.espn.com/nfl/story/_/id/34670980/miami-dolphins-qb-tua-tagovailoa-not-concussion-protocol-coach-mike-mcdaniel-says">instability after the hit was related to back and ankle injuries</a>.</p>
<p>He was cleared to start against the Bengals on Sept. 29, but hit his head on the ground again following a tackle in the second quarter. His symptoms pointed to indisputable neurological damage, including a potential brainstem injury. He was carried from the field on a stretcher and taken to hospital for evaluation.</p>
<p><a href="https://www.nfl.com/playerhealthandsafety/health-and-wellness/player-care/concussion-protocol-return-to-participation-protocol">NFL concussion guidelines</a> mandate that players suspected of concussion undergo an independent review by an unaffiliated neurotrauma consultant. </p>
<p>According to the NFL, the unidentified specialist who assessed Tagovailoa after the first impact <a href="https://www.sportsnet.ca/nfl/article/report-nflpa-fires-unaffiliated-neurotrauma-consultant-involved-in-tagovailoas-concussion-check/">has since been terminated as a result of investigations</a> into the decision to clear him for further play. The review is being conducted jointly by the NFL and the players’ association, with full results expected within a week or two.</p>
<p>Neuroscientist Chris Nowinski of the <a href="https://concussionfoundation.org/">Concussion Legacy Foundation</a>, a not-for-profit concussion advocacy organization based in Boston, tweeted after the second head injury: “Two concussions in five days can kill someone. This can end careers.”</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1575659558613172224"}"></div></p>
<p>Tagovailoa was the fifth overall draft pick in 2020, touted as a possible successor to legendary Dolphins quarterback <a href="https://www.profootballhof.com/players/dan-marino/">Dan Marino</a>. While he may have an exciting future, it is hard to argue that a third-round game, even with the Dolphins’ unbeaten record on the line, was a strong enough reason to put his health at risk. So why was he cleared to play?</p>
<h2>Conflicting pressures and interests</h2>
<p>Coaches, players and medical providers are constantly under intense pressure to allow an injured teammate back on the field, given the millions of dollars on the line in salaries, TV rights, endorsements and advertising.</p>
<p>A central issue is that most concussion protocols in professional sports, including the NFL, are subject to an element of human interpretation and judgement. Precise <a href="https://theconversation.com/concussion-is-more-than-sports-injuries-whos-at-risk-and-how-canadian-researchers-are-seeking-better-diagnostics-and-treatments-189899">diagnostic tools do not exist and players often under-report symptoms</a>. This leaves doctors leaning heavily on their judgement to make quick assessments in the heat of the moment. </p>
<p>In the case of the NFL, the final decision of whether a player should return to the field lies not with the independent specialist, but with the team physician, adding pressure on the doctor to put the team’s interests above those of the injured player.</p>
<p>The more conservative approach favoured by professional rugby has strategic and financial consequences that may discourage its adoption by football and other sport authorities. For example, football’s <a href="https://www.nfl.com/news/ranking-each-position-s-importance-from-quarterback-to-returner-0ap3000000503855">highly specialized positional game</a> means that the removal of important players for concussion assessments at key times in play can have an immediate and dramatic effect on the outcome of the game. </p>
<p>Furthermore, far more money is involved in football than rugby.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/487877/original/file-20221003-24-gak47e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A football player in a teal uniform about to fall to the ground as a player in a white uniform tackles him, while another player in a white uniform runs towards them" src="https://images.theconversation.com/files/487877/original/file-20221003-24-gak47e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/487877/original/file-20221003-24-gak47e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/487877/original/file-20221003-24-gak47e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/487877/original/file-20221003-24-gak47e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/487877/original/file-20221003-24-gak47e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/487877/original/file-20221003-24-gak47e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/487877/original/file-20221003-24-gak47e.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">Miami Dolphins quarterback Tua Tagovailoa (1) is sacked by Cincinnati Bengals’ Josh Tupou (68) during the first half of an NFL football game on Sept. 29, in Cincinnati.</span>
<span class="attribution"><span class="source">(AP Photo/Joshua A. Bickel)</span></span>
</figcaption>
</figure>
<p>The advantage of rugby’s approach, however, is that it greatly improves the <a href="https://blogs.bmj.com/bjsm/2021/11/17/concussion-in-professional-mens-rugby-union-improvement-in-detection-or-increased-risk/">recognition and diagnosis of concussion among players</a>. Since 2011 the number of concussions reported in professional rugby games has quadrupled, an increase largely attributed to heightened awareness and changes to protocols.</p>
<p>There is little evidence that the incidence of long-term brain damage is different in the two sports, since the medical consequences of concussion take decades to become evident. However, recognition and removal from play are key to preventing further harm. According to an <a href="http://dx.doi.org/10.1136/bjsports-2017-097699">international consensus statement on sport-related concussion</a> issued by the Concussion in Sport Group in 2017: </p>
<blockquote>
<p><em>“Having a past sport-related concussion is a risk factor for having a future sport-related concussion, and having multiple past sport-related concussions is associated with having more physical, cognitive and emotional symptoms.”</em></p>
</blockquote>
<p>The NFL has signalled that Tua Tagovailoa’s case <a href="https://www.nfl.com/news/changes-coming-to-nfl-concussion-protocol-a-needed-step-for-player-safety">may lead to some far-reaching changes</a> to its rules for the evaluation and identification of concussion. Here’s hoping the changes come soon enough to help the next player who suffers a serious head injury on the field.</p><img src="https://counter.theconversation.com/content/191830/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Adam Pyle has worked for Rugby Canada. </span></em></p>Miami Dolphins quarterback Tua Tagovailoa was carried off the field during a game on Sept. 29 after his second injury in only a few days, raising questions about NFL concussion protocols.Adam Pyle, Emergency Medicine Physician and Lecturer, University of TorontoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1898992022-09-25T10:00:46Z2022-09-25T10:00:46ZConcussion is more than sports injuries: Who’s at risk and how Canadian researchers are seeking better diagnostics and treatments<figure><img src="https://images.theconversation.com/files/486306/original/file-20220923-16-bx9qew.jpg?ixlib=rb-1.1.0&rect=11%2C170%2C7171%2C4867&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Concussion doesn’t just happen in sports or only in teens and young adults; it affects people of all ages and backgrounds.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Concussions are becoming more common again as people return to regular activities following COVID-19 lockdowns and restrictions, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8873554/">when concussion rates declined</a>. Each year, <a href="https://doi.org/10.1097/htr.0000000000000503">about one per cent of Canadians sustain concussions</a>, amounting to some 400,000 concussions in Canada alone. Worldwide, that number grows to over 40 million annually.</p>
<p>Concussion is a critical public health concern. Up to 30 per cent of <a href="https://doi.org/10.1016/j.jpeds.2022.03.039">children</a> and <a href="https://doi.org/10.1089/neu.2016.4677">adults</a> will have persistent problems after concussion that lower their quality of life and hinder their return to work, sport, school and other activities. </p>
<h2>Prevention, diagnosis and treatment</h2>
<p>Important questions remain about concussion prevention, diagnosis and treatment. In 2019, <a href="https://www.ourcommons.ca/DocumentViewer/en/42-1/HESA/report-24/">the Parliamentary Subcommittee on Sports-Related Concussions in Canada</a> called for the creation of a national expert group and a coordinated national research program. </p>
<p>In response, the <a href="https://ccn-rcc.ca/en/">Canadian Concussion Network/Réseau Canadien des Commotions</a> (CCN-RCC) was launched in 2020 to establish a Canadian research agenda spanning all causes of concussions, as well as to support knowledge translation to bring research evidence into clinical practice where it can improve patient care.</p>
<p>We are all members of the CCN-RCC Executive Committee or Advisory Council. We include a neuropsychologist, neurosurgeon and neuroscientist. We are all active researchers whose interests reflect the broader concussion research community in Canada, and two of us are also clinicians. Some recent advances in Canadian concussion research — including who is affected by concussions — may come as a surprise to readers.</p>
<h2>Who gets concussions?</h2>
<figure class="align-center ">
<img alt="Person sitting on the ground" src="https://images.theconversation.com/files/484996/original/file-20220916-18-i7e2p1.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/484996/original/file-20220916-18-i7e2p1.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/484996/original/file-20220916-18-i7e2p1.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/484996/original/file-20220916-18-i7e2p1.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/484996/original/file-20220916-18-i7e2p1.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/484996/original/file-20220916-18-i7e2p1.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/484996/original/file-20220916-18-i7e2p1.jpeg?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">Homelessness is linked to increased risk of concussion.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Concussion doesn’t just happen in sport or only in teens and young adults; it affects people of all ages and backgrounds. Young children and older adults often sustain concussions in falls. Recently, <a href="https://doi.org/10.1080/02699052.2019.1658129">intimate partner violence</a> has been identified as a common cause of concussion, with traumatic brain injury (TBI) occurring in up to 80 per cent of survivors, mostly women. </p>
<p>Concussion and TBI are also extremely common among individuals experiencing <a href="https://doi.org/10.1089/neu.2017.5076">homelessness</a>. About 35 per cent of study subjects experiencing homelessness reported a head injury with TBI symptoms. </p>
<p>More research on concussion is needed among systemically disadvantaged groups, especially Indigenous people, who <a href="https://theconversation.com/indigenous-women-suffer-greatest-risk-of-injury-87164">experience higher rates of injury</a>. Building on Canada’s many advances in sport-related concussion research, we now need to ask how we can better prevent, diagnose and treat <em>all</em> concussions.</p>
<h2>Preventing sport-related concussion</h2>
<p>The best concussion is one that never happens. Prevention of sport-related concussion is a key focus of Canadian concussion research. When body checking was shown to increase the risk of concussion in <a href="http://doi.org/10.1001/jama.2010.755">youth hockey</a>, policy changes disallowing body checking for players under 13 resulted in a <a href="http://dx.doi.org/10.1136/bjsports-2019-101092">reduction of over 4,500 concussions annually</a>. </p>
<p>Recently, one of the largest <a href="http://dx.doi.org/10.1136/bjsports-2019-101011">studies of mouthguards</a> to date found they likely prevent concussions in youth ice hockey. This evidence will interest parents concerned about their children playing contact sports and may encourage sporting organizations to institute policies requiring mouthguards. </p>
<figure class="align-center ">
<img alt="Field hockey team in a huddle" src="https://images.theconversation.com/files/484994/original/file-20220916-16-p2bwez.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/484994/original/file-20220916-16-p2bwez.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=428&fit=crop&dpr=1 600w, https://images.theconversation.com/files/484994/original/file-20220916-16-p2bwez.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=428&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/484994/original/file-20220916-16-p2bwez.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=428&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/484994/original/file-20220916-16-p2bwez.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=538&fit=crop&dpr=1 754w, https://images.theconversation.com/files/484994/original/file-20220916-16-p2bwez.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=538&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/484994/original/file-20220916-16-p2bwez.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=538&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Contact sports are a common cause of concussions among adolescents.</span>
<span class="attribution"><span class="source">(Pixabay)</span></span>
</figcaption>
</figure>
<p>More broadly, <a href="https://www.parachute.ca/en/">Parachute</a>, the largest charitable organization in Canada devoted to injury prevention, is leading the <a href="https://www.parachutecanada.org/en/professional-resource/concussion-collection/concussion-harmonization-project/">Concussion Harmonization Project</a>, supported by the Public Health Agency of Canada and in collaboration with Sport Canada. The project’s goal is to establish consistent concussion guidelines and protocols in more than 50 sports in Canada based on the <a href="https://parachute.ca/en/professional-resource/concussion-collection/canadian-guideline-on-concussion-in-sport/">Canadian Guideline on Concussion in Sport</a>, which is grounded in scientific evidence.</p>
<h2>Diagnosing concussion with biomarkers</h2>
<p>Concussions are not usually visible using standard neuroimaging diagnostic tools, such as CT scans. The diagnosis of concussion relies largely on the observation of signs such as unconsciousness or vomiting and the reporting of symptoms such as headache, dizziness or “brain fog.”</p>
<p>However, injuries are not always directly observed, and people cannot or do not always report their symptoms accurately. Canadian researchers are studying <a href="https://doi.org/10.3389/fneur.2021.787480">biomarkers of concussion</a> — using biofluids like saliva or blood, or advanced neuroimaging — that may eventually be used on the sideline or in the emergency room to identify concussion more accurately. </p>
<figure class="align-center ">
<img alt="Medical imaging of human brain" src="https://images.theconversation.com/files/484997/original/file-20220916-14-45ags5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/484997/original/file-20220916-14-45ags5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/484997/original/file-20220916-14-45ags5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/484997/original/file-20220916-14-45ags5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/484997/original/file-20220916-14-45ags5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/484997/original/file-20220916-14-45ags5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/484997/original/file-20220916-14-45ags5.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">Advanced neuroimaging may identify biomarkers of concussion.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>In collaboration with Statistics Canada, <a href="https://alz.confex.com/alz/2022/meetingapp.cgi/Paper/64762">age-based reference intervals</a> for blood-based biomarkers are being developed that could be applied in concussion diagnosis across the lifespan.</p>
<h2>Predicting concussion outcomes</h2>
<p>When a child sustains a concussion, parents want to know their prognosis and how long their recovery will take. Although most children recover in two to four weeks, some show more prolonged symptoms. </p>
<p>Researchers have developed a <a href="http://doi.org/10.1001/jama.2016.1203">clinical prediction rule</a> for children and adolescents that can be used to tell families the likelihood of persistent symptoms. Physicians can reassure parents of children who are at low risk and target help for those with higher risk, based on easily accessible information.</p>
<h2>Promoting recovery from concussion</h2>
<figure class="align-center ">
<img alt="Woman with gray hair on the floor, holding her head after a fall" src="https://images.theconversation.com/files/484993/original/file-20220916-22-p2bwez.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/484993/original/file-20220916-22-p2bwez.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/484993/original/file-20220916-22-p2bwez.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/484993/original/file-20220916-22-p2bwez.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/484993/original/file-20220916-22-p2bwez.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/484993/original/file-20220916-22-p2bwez.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/484993/original/file-20220916-22-p2bwez.jpeg?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">Falls are a leading cause of concussion in older adults.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>People with concussion used to be told to rest in a dark room until their symptoms stopped. However, we now know resting more than one or two days can slow recovery. </p>
<p>Instead, <a href="http://dx.doi.org/10.1136/bjsports-2021-105030">early reintroduction of activity</a>, and even low-intensity exercise, can promote recovery and reduce persistent symptoms. </p>
<p>Researchers are also developing effective, targeted treatments for persistent symptoms. For instance, <a href="http://doi.org/10.1097/HTR.0000000000000504">cognitive behavioral therapy for insomnia</a> is very effective at reducing the sleep problems that often happen after concussion.</p>
<h2>Concussion Awareness Week</h2>
<p>In 2013, high school rugby player <a href="http://doi.org/10.1017/cjn.2019.14">Rowan Stringer tragically died</a> after incurring multiple concussions in rugby over six days. Rowan’s death prompted the passage of <a href="https://www.ontario.ca/page/rowans-law-concussion-safety">Rowan’s Law in Ontario</a>, the only concussion legislation to date in Canada (by comparison, all 50 U.S. states have passed concussion legislation). </p>
<p>Rowan’s death was an impetus for the creation of the <a href="https://www.ourcommons.ca/DocumentViewer/en/42-1/HESA/report-24/">Parliamentary Subcommittee on Sports-Related Concussions in Canada</a>. One of the Subcommittee’s recommendations was to establish a pan-Canadian Concussion Awareness Week, which began in 2021 and takes place this year from Sept. 25 to Oct. 1.</p>
<p>We wanted to make Canadians aware that Canadian researchers are conducting innovative research to reduce concussion, improve its identification and diagnosis, and find better treatments. Promoting the translation of that research into more evidence-informed practices and policies, nationally and internationally, is a crucial next step.</p><img src="https://counter.theconversation.com/content/189899/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Keith Yeates receives funding from Canadian Institutes of Health Research, and has had recent funding from Brain Canada and Alberta Health Services. He also receives an editorial stipend from the American Psychological Association.</span></em></p><p class="fine-print"><em><span>Cheryl Wellington receives funding from Canadian Institutes of Health Research, Weston Brain Institute, Department of Defence, National Institutes of Health. </span></em></p><p class="fine-print"><em><span>Charles H. Tator 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>Canadian researchers are exploring unanswered questions about concussion: How to diagnose it accurately and quickly, how to predict outcomes and promote recovery, and how to prevent it altogether.Keith Yeates, Professor and Head, Psychology, and Ronald and Irene Ward Chair in Pediatric Brain Injury, University of CalgaryCharles H. Tator, Program Director, Canadian Concussion Centre, and Professor of Neurosurgery, University of TorontoCheryl Wellington, Professor and Vice Chair Research, Department of Pathology and Laboratory Medicine, University of British ColumbiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1578422021-03-29T12:27:33Z2021-03-29T12:27:33ZConcussions in sport can now be rapidly diagnosed using spit – new research<figure><img src="https://images.theconversation.com/files/392223/original/file-20210329-17-t0e858.jpg?ixlib=rb-1.1.0&rect=4%2C0%2C3190%2C2131&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many rugby players suffer concussions.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/singaporeapril-16-action-during-hsbc-world-638089558">mfauzisaim/ Shutterstock</a></span></figcaption></figure><p>Concussion is now recognised as the <a href="https://pubmed.ncbi.nlm.nih.gov/33187601/">most common injury</a> in many contact sports, such as rugby and American football. But while it’s possible to recover from a concussion, multiple head injuries or improperly treated ones can lead to long-term problems, including <a href="https://pubmed.ncbi.nlm.nih.gov/32712946/">chronic traumatic encephalopathy</a> (CTE), a condition which can cause behavioural problems, mood problems, and difficulty thinking. </p>
<p>Over time, is can also cause dementia. Multiple <a href="https://www.theguardian.com/sport/2020/dec/08/steve-thompson-former-rugby-union-players-dementia-landmark-legal-case">ex-rugby players</a> in the UK have been diagnosed with early-onset dementia, believed to be the result of suffering multiple concussions during their years of play. This has also been the case for many <a href="https://www.washingtonpost.com/sports/2021/03/12/willie-wood-packers-cte/">ex-NFL players</a>, who have been <a href="https://www.nytimes.com/interactive/2017/07/25/sports/football/nfl-cte.html?mtrref=www.google.com&assetType=REGIWALL&mtrref=www.nytimes.com&assetType=REGIWALL">diagnosed with CTE</a>, thought to be the result of the traumatic brain injuries they sustained during their career.</p>
<p>Although awareness of the damaging long-term consequences of concussions has led to <a href="https://pubmed.ncbi.nlm.nih.gov/27587799/">some changes</a> in the way concussions are managed in players, it’s still a problem many players face. And given there’s currently no way to diagnose CTE while a person is alive, being able to better diagnose concussions as soon as they happen may be important for preventing this condition from developing in the first place.</p>
<p>At the University of Birmingham, we led a study which looked to uncover whether we could <a href="http://dx.doi.org/10.1136/bjsports-2020-103274">spot signs of concussion</a> in a person’s spit. Our study – which is the largest to date of its kind – identified unique signatures of concussion in the saliva of male rugby players. By comparing our results against head injury assessments carried out on the professional players, we found our technique was accurate at detecting concussion from saliva 96% of the time.</p>
<p>We obtained saliva samples from male professional rugby players in the top two tiers of England’s elite rugby union competitions (Premiership and Championship) during the 2017-18 and 2018-19 rugby seasons. Samples were collected pre-season from 1,028 players. </p>
<p>Of the total cohort, 156 of these players received a head injury assessment after suffering a suspected concussion. In these players, saliva samples were taken at three points: in-game, post-game, and 36-48 hours post-game. Control samples were also collected from 102 uninjured players and 66 players who were removed from the game due to other injuries (such as a sprained ankle). </p>
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<img alt="A rugby player is in the middle of tackling another player from the opposing team." src="https://images.theconversation.com/files/392224/original/file-20210329-21-1w5pp8f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/392224/original/file-20210329-21-1w5pp8f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=403&fit=crop&dpr=1 600w, https://images.theconversation.com/files/392224/original/file-20210329-21-1w5pp8f.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=403&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/392224/original/file-20210329-21-1w5pp8f.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=403&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/392224/original/file-20210329-21-1w5pp8f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=507&fit=crop&dpr=1 754w, https://images.theconversation.com/files/392224/original/file-20210329-21-1w5pp8f.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=507&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/392224/original/file-20210329-21-1w5pp8f.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=507&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">We collected samples from 156 players who’d suffered a head injury.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/northampton-uk-28th-september-2019-marcus-1517206472">atsportphoto/ Shutterstock</a></span>
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<p><a href="https://www.frontiersin.org/articles/10.3389/fnmol.2018.00290/full">Previous research</a> we conducted had identified specific molecules in saliva which change after a concussion. The molecules we identified are called <a href="https://www.frontiersin.org/articles/10.3389/fgene.2019.00364/full#:%7E:text=Small%20non%2Dcoding%20RNAs%20(MicroRNA,of%20biomarkers%20to%20be%20explored.)%20(sncRNAs).%20For%20years,%20these%20molecules%20were%20considered%20%22junk%20molecules%22%20--%20waste%20products%20shed%20by%20other%20cells.%20Only%20in%20the%20last%20two%20decades%20has%20it%20become%20evident%20that%20these%20non-coding%20species,%20which%20represent%2098%%20of%20our%20entire%20genome,%20are%20molecular%20regulators.%20They%20freely%20circulate%20in%20biofluids%20(such%20as%20blood,%20saliva,%20urine,%20or%20tears">small non-coding RNAs</a> and bring messages to other cells telling them how they should behave. These molecules can be easily detected in a lab.</p>
<p>But we needed to see whether these molecules could be used to diagnose concussion. Using standard molecular technology to test the saliva samples we noticed that these molecules were abundantly present immediately after a heady injury. We were able to successfully identify the presence of these molecules in minutes – moments after a concussion happened. This means it’s now possible to accurately identify concussions simply by analysing a player’s saliva. </p>
<h2>Rapid diagnosis</h2>
<p>Quickly and accurately diagnosing a concussion when it happens means players can be treated more effectively. This may also one day help prevent neurodegenerative problems from developing.</p>
<p>A commercial version of the salivary test which uses the biomarkers we discovered is currently under development. This would allow the test to be used alongside other injury assessment protocols (such as cognitive tests and gait analysis) to improve the accuracy of concussion diagnoses. Physicians would collect a sample after an injury takes place, and mail it to a lab for analysis. The sample would be processed, and the biomarker evaluation algorithm we developed would determine the probability of concussion. This analysis takes a working day. Once portable equipment becomes available, even saliva samples collected at pitch-side could be used to identify concussion in minutes, as our study showed.</p>
<p>Concussion can be hard to diagnose and is often missed, especially where a structured evaluation by an expert clinician is not possible or available. Small non-coding RNAs can provide a simpler diagnostic tool that could be used by pitch-side medical staff in future. may reduce the risk of missing this type of injury at all levels of participation. It can also be used to diagnose concussion in a variety of settings, not just in sports.</p>
<p>In the meantime, further research is being conducted to better understand when it may be safe for a player to return to contact training or competition following a concussion. Other studies will also need to investigate whether these biomarkers are the same in other groups – including females and children.</p><img src="https://counter.theconversation.com/content/157842/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Valentina Di Pietro works for/consults to/owns shares in Marker Diagnostics and MiRNA Diagnostics. She receives funding from National Institute for Health Research, Medical Research Council. She is affiliated with Marker Diagnostics and MiRNA diagnostics. </span></em></p><p class="fine-print"><em><span>Antonio Belli consults to and owns shares in Markers Diagnostics. He receives funding from NIHR.</span></em></p>Our research, conducted on elite rugby players, may someday mean concussions can be diagnosed right on the pitch.Valentina Di Pietro, Lecturer in Neurotrauma, University of BirminghamAntonio Belli, Professor of Trauma Neurosurgery, University of BirminghamLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1464952020-10-15T13:44:03Z2020-10-15T13:44:03ZConcussion can accelerate ageing of the brain – research from the rugby pitch<figure><img src="https://images.theconversation.com/files/362455/original/file-20201008-18-1a5c086.jpg?ixlib=rb-1.1.0&rect=287%2C197%2C11658%2C5730&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/rugby-players-fight-ball-on-professional-1150451498">Shutterstock/Alex Kravtsov</a></span></figcaption></figure><p>The serious harm caused by concussion in sport first became apparent among the “<a href="https://link.springer.com/article/10.2165/00007256-200737060-00001#ref-CR1">punch-drunk</a>” boxers who suffered repetitive blows to the head over the course of their fighting careers. A related form of brain damage is known to affect a <a href="http://sites.bu.edu/mckeelab/files/2014/06/Chronic-traumatic-encephalopathy-neurodegeneration-following-repetitive-concussive-and-subconcussive-brain-trauma1.pdf">range of other sports and professions</a>, where repeated head injuries kill brain cells and gradually cause the brain to shrink.</p>
<p>By working closely with elite rugby union players, <a href="https://www.physoc.org/abstracts/elevated-systemic-oxidative-nitrosative-stress-and-cerebrovascular-function-in-professional-rugby-union-players-the-link-to-impaired-cognition/">our research</a> has now helped us to understand the impact of concussion on the brain as we get older. We have shown that brain function in a young player with a history of concussion is on a par with someone in their 60s. In simple terms, concussion seems to accelerate biological brain ageing by as much as three decades. </p>
<p>One important discovery was that concussed rugby union players have more “free radicals” – unstable, cell-damaging molecules – in their blood. They also have less nitric oxide, a beneficial molecule which allows more oxygen and glucose to get to the brain. As a result, blood vessels in the concussed brain react sluggishly to changes in blood flow, a condition known as “cerebrovascular impairment”.</p>
<p>Cerebrovascular impairment has been <a href="https://physoc.onlinelibrary.wiley.com/doi/full/10.1113/JP276898">linked to cognitive dysfunction</a>, and can have a negative effect on the way a person thinks, concentrates, formulates ideas and remembers. It can also make them more vulnerable to <a href="https://www.ahajournals.org/doi/full/10.1161/CIRCULATIONAHA.117.027448">dementia</a> in later life. In our analysis, these impairments were mostly seen in the regions of the brain where head contact is most frequently made during play. </p>
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<p>Both active and retired elite rugby union players were found to be cognitively impaired compared with people of a similar age and fitness, who had not been concussed or participated in contact sports. The effects also appeared to be related to a player’s position in the rugby team. They were particularly prevalent among forwards, who usually experience more tackles and collisions in a game compared to the backs.</p>
<h2>Game changer?</h2>
<p>Positive steps have been taken in the world of rugby as awareness has grown from the negative effects that concussion has on the brain. Indeed, we have come a long way since 2005, when a neuropathologist working in a Pittsburgh coroner’s office became the <a href="https://pubmed.ncbi.nlm.nih.gov/20201914/">first to identify</a> a form of neurodegeneration called “chronic traumatic encephalopathy” (CTE) in an American Footballer who had suffered repetitive brain injuries. </p>
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Read more:
<a href="https://theconversation.com/will-the-law-strike-a-knockout-blow-on-concussion-in-rugby-37863">Will the law strike a knockout blow on concussion in rugby?</a>
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<p>But the problem has not been solved. And the increasingly gladiatorial nature of the modern game, with <a href="https://bjsm.bmj.com/content/46/8/580">players whose physiques resemble</a> those of a bodybuilder, mean the risks could be worsening. So what can be done to reduce the potentially life-altering effects of concussion in rugby players? </p>
<p>One approach involves changing the rules of the game. While some adjustments have been proposed, such as <a href="https://www.rugbypass.com/news/super-controversial-waist-height-tackling-among-6-law-changes-endorsed/">waist height tackling</a> to reduce the number of head-to-head collisions, <a href="https://www.bbc.co.uk/sport/rugby-union/41398969">some argue</a> that the tackle should be banned altogether. Others, including ourselves, have focused on establishing effective molecular (blood, saliva, urine) and cerebrovascular (brain blood flow) assessments for pitchside detection of concussion to enable swifter treatment and recovery. </p>
<p>While these remain in development, there are methods that rugby players – and anyone else – can use to help our brains fight off the risk of dementia. These include high-intensity interval training (HIIT) and regular aerobic exercise. </p>
<p>This is because exercise helps maintain a healthy body weight and promotes the release of nitric oxide, which improves the way our blood vessels function and <a href="https://physoc.onlinelibrary.wiley.com/doi/pdf/10.1113/JP275021?casa_token=dGGWYrRmI3YAAAAA:edWmY49H0sNQ78ts1QZJvOsN-TkkkqgM4hvGVpw7iKYynxrpW2g-_KerXIoQ9JonSBzJNPgKBwLKrg">contributes to better brain health</a>. </p>
<p>For now, though, concussion across all sports remains a prominent and potentially life-altering injury, with the true consequences often only noticed when it is too late. There are almost <a href="https://resources.world.rugby/worldrugby/document/2020/07/28/212ed9cf-cd61-4fa3-b9d4-9f0d5fb61116/P56-57-Participation-Map_v3.pdf">10 million rugby players</a> around the world, and professional players are more likely than not to <a href="https://bjsm.bmj.com/content/bjsports/early/2018/03/12/bjsports-2017-098417.full.pdf">sustain a concussion within 25 games</a>. </p>
<p>And while modern treatments and management protocols for concussion have improved with increased monitoring and neurological testing, the mechanisms which increase an athlete’s susceptibility to CTE and other neurological complications remain poorly understood. </p>
<p>Meanwhile, rugby union’s governing bodies have faced <a href="https://www.espn.co.uk/espn/story/_/id/16029747/rugby-nfl-concussion-issue-figured-out">criticism</a> for the lack of concussion management. But perhaps this should come as little surprise given that not very long ago, in the amateur era of the game, the traditional treatment for a knock to the head was a “magic sponge” doused in cold water.</p><img src="https://counter.theconversation.com/content/146495/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Damian Bailey receives funding from the Royal Society, Japan Society for the Promotion of Science and the JPR Williams Foundation Trust</span></em></p><p class="fine-print"><em><span>Chris Marley and Tom Owens 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>Thankfully treatment has moved on from the cold sponge of the amateur era. But brain damage continues to be a serious risk in many sports.Tom Owens, PhD Candidate, University of South WalesChris Marley, Senior Lecturer in Exercise Physiology, University of South WalesDamian Bailey, Professor of Physiology and Biochemistry, University of South WalesLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1463742020-09-22T15:29:52Z2020-09-22T15:29:52ZCycling: head injuries ignored because of entrenched macho culture<p>Competitive road cycling is a demanding and unique sport. One where <a href="https://theconversation.com/tour-de-france-does-pro-cycling-have-a-concussion-problem-100419">crashing is inevitable</a> – especially at the professional level. </p>
<p>While the risk of head injury is relatively low in cycling – <a href="https://bjsm.bmj.com/content/50/11/669.short">approximately 5-13%</a> – compared to contact sports such as rugby, the consequences of a head impact when riding at speeds of over 40 kilometre per hour can be life changing or worse. </p>
<p>Yet too often, riders are helped back onto their bikes following a crash, without a clear examination for head injuries. And little seems to have changed in the past three years since the high-profile case of Latvian cyclist <a href="https://www.washingtonpost.com/news/early-lead/wp/2017/05/16/concussed-cyclist-crashes-in-tour-of-california-tries-to-rejoin-race-and-is-pulled/">Tom Skujins</a> – who was allowed to continue racing at the 2017 Tour of California while showing clear signs of head trauma. </p>
<p>Even in the recent 2020 Tour de France, French rider <a href="https://www.cyclingweekly.com/news/racing/tour-de-france/scan-reveals-romain-bardet-suffered-small-brain-haemorrhage-in-tour-de-france-crash-467917">Romain Bardet crashed</a> on stage 13 and was cleared to ride the remaining 90 km by race medics. This was despite showing clear signs of concussion. He was later diagnosed with a brain haemorrhage. </p>
<p>Cycling’s world governing body, Union Cycliste Internationale, UCI, <a href="https://www.uci.org/docs/default-source/rules-and-regulations/part-xiii--medical-rules.pdf">regulations state</a> that: “any rider with a suspected concussion should be immediately removed from the competition or training and urgently assessed medically”. Yet this is rarely enforced in road cycling, at any level. </p>
<h2>Head injury in other sports</h2>
<p>In other sports, visible efforts and new policies are being developed to help tackle this issue. In the 2019 Rugby World Cup, for example, the implementation of the <a href="https://playerwelfare.worldrugby.org/concussion">head injury assessment</a> protocol was more prominent than ever, with fans witnessing the use of this in the competition. </p>
<p><a href="https://www.independent.co.uk/sport/cricket/ashes-2019-icc-england-australia-concussion-rules-news-latest-a9012471.html">Cricket has also introduced</a> concussion substitutions to minimise risk to players. And some football teams have now imposed <a href="https://www.skysports.com/football/news/11743/11845087/eddie-howe-bournemouth-have-heading-ban-for-youth-players">heading bans</a> at youth level.</p>
<p>Seeing these measures in place at professional and grassroots levels helps to normalise safer injury management and raises awareness of traumatic brain injuries. It also empowers athletes to more readily disclose any concerns about potential head injuries. </p>
<p>Yet cycling remains a leading example of athletes sacrificing their bodies for sporting glory. Indeed, <a href="https://jsc-journal.com/index.php/JSC/article/view/499/534">new research</a> reveals a significant numbers of competitive cyclists would compete following a concussion – or mask it to continue in a competition. </p>
<p>These athletes are often then celebrated for <a href="https://www.mirror.co.uk/sport/other-sports/cycling/tour-de-france-fractured-pelvis-2947799">competing through injury</a> and are usually met with cheering fans – all of which only serves to reinforce a vicious cycle. </p>
<h2>Cycling problems</h2>
<p>Of course, traumatic brain injuries and concussions, can and do have life changing impacts. And many <a href="https://cyclingtips.com/2020/01/the-crash-that-ended-one-career-and-started-another/">high profile athletes</a> have been forced to retire as a result – often living with the aftereffects of brain injury for a long time to come.</p>
<p>But part of the problem within cycling is that there are no internationally agreed concussion management <a href="https://www.headcheckhealth.com/concussion-cycling-call-to-action/">protocols in place</a>. This risks the health of the athletes at all levels of the sport and fails to protect young aspiring riders as they work their way up the ranks.</p>
<p>The management of injuries in cycling is also frequently sacrificed to the entrenched “hardman” culture of the sport and the <a href="https://www.theguardian.com/sport/2018/apr/30/philippa-york-macho-culture-cyclists-coming-out">macho environment</a> of professional road cycling. </p>
<p>The structural makeup of cycling also jeopardises safe injury management. Races are rarely stopped for medical assessments after crashes and during high-profile multi-day races athletes must complete all stages to continue in competition – withdrawal is seen as an absolute last resort. </p>
<h2>Challenging attitudes</h2>
<p>A shift in the way the media reports crashes and injuries would help. Framing riders as heroes for removing themselves from competition, rather than praising athletes for putting sporting glory before their health, would be a first step. This would help to increase awareness and protect the long-term health of the athletes – and would also hopefully lead to action by the sport’s governing bodies.</p>
<p>This is important because the current situation not only puts pro cyclists at high risk of injury, but many amateur athletes also model their behaviours, training and style on their professional idols. And with limited protocols in place around head injuries, it’s likely they’ll turn to the culture of the sport – and what their idols do – for guidance.</p><img src="https://counter.theconversation.com/content/146374/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>Cycling remains a leading example of athletes sacrificing their bodies for sporting glory.Howard Hurst, Senior lecturer in Sport, Exercise and Nutrition Sciences, University of Central LancashireJack Hardwicke, PhD candidate in Sport, Health and Social Policy, University of WinchesterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1453952020-09-04T06:02:42Z2020-09-04T06:02:42ZHere’s what we know about CTE, the brain condition that affected Danny Frawley<p>News emerged this week former AFL footballer Danny Frawley was <a href="https://www.theage.com.au/sport/afl/danny-frawley-was-suffering-from-chronic-brain-disease-when-he-died-20200831-p55r3k.html">suffering from a brain disease</a> called CTE when he died last year, according to reports received by the Victorian Coroner.</p>
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<p>Chronic traumatic encephalopathy, or CTE, refers to changes in the brain that have been linked to repeated blows to the head, <a href="https://www.heraldsun.com.au/sport/afl/danny-frawleys-subtle-changes-can-now-be-understood-of-his-cte-diagnosis/news-story/4abf6e3be1448dbae8912878bd93ee31">sometimes seen in former players</a> of sports such as rugby and Australian and American football codes. It’s believed these changes relate to an abnormal buildup of a protein called “tau” in the brain, which can <a href="https://molecularneurodegeneration.biomedcentral.com/articles/10.1186/1750-1326-4-13">damage brain cells</a>. </p>
<p>Frawley’s is the second confirmed case of CTE in a former AFL player, while two former NRL players are also thought to have had the condition.</p>
<p>CTE has prompted concern among the media and public, and researchers still don’t fully understand the condition. It is not yet clear whether CTE is directly caused by repeated hits to the head, as the condition has also been found in people with no known history of repetitive brain trauma.</p>
<p>There’s been a big increase in research on the topic over the past decade, which will hopefully teach us more about the condition and its possible treatments. But this will only happen if more funding is given to scientists to study it.</p>
<h2>What are the symptoms?</h2>
<p>The prevalence of CTE is unknown. Although it’s believed to be more common in athletes who suffer repeated head injuries, there has been <a href="https://www.thelancet.com/journals/laneur/article/PIIS1474-4422(19)30020-1/fulltext">no rigorous epidemiological study</a> to confirm this claim. This may be because there’s no consensus on how to diagnose it while someone is alive – CTE can currently only be diagnosed retrospectively via an autopsy of brain tissue.</p>
<p>What’s more, the symptoms attributed to CTE are common in the general population, and are <a href="https://pubmed.ncbi.nlm.nih.gov/31670780/">not specific to the condition</a>. They range from mental health issues such as depression and anxiety, to substance abuse, suicidal behaviour, and even marital problems. </p>
<p>Proponents of CTE argue it’s a <a href="https://pubmed.ncbi.nlm.nih.gov/25904048/">distinct neurodegenerative disease</a>, separate from conditions such as Alzheimer’s. But <a href="https://pubmed.ncbi.nlm.nih.gov/31670780/">other researchers say</a> the brain changes in CTE are not unique, not necessarily progressive, and not specific to people exposed to repeated brain injury.</p>
<h2>Where is the research up to?</h2>
<p>Significant strides have been made in developing tools that may help <a href="https://pubmed.ncbi.nlm.nih.gov/31287716/">diagnose or predict CTE</a> in living people. These include <a href="https://pubmed.ncbi.nlm.nih.gov/31904765/">brain imaging methods</a> that might allow for the early detection of the <a href="https://pubmed.ncbi.nlm.nih.gov/30969506/">specific tau changes</a> believed to occur in the condition. Other research has focused on <a href="https://pubmed.ncbi.nlm.nih.gov/32712945/">identifying genetic factors</a> that may make some individuals more susceptible to CTE.</p>
<p>Scientists have also been investigating potential treatments, both for the symptoms and the underlying biological causes of CTE. For example, our laboratory at Monash University’s Department of Neuroscience has found a drug called sodium selenate can <a href="https://pubmed.ncbi.nlm.nih.gov/25771151/">reduce the amount of abnormal forms of tau</a>. This drug is currently in clinical trials for Alzheimer’s and another condition called frontotemporal dementia. It has also been <a href="https://pubmed.ncbi.nlm.nih.gov/27163189/">shown</a> to reduce the extent of cognitive deficits in rodents with repeated mild brain trauma.</p>
<h2>Concussions can be devastating, even without CTE</h2>
<p>While Frawley’s tragic death has renewed the focus on CTE, it’s important to recognise there are other devastating neurological complications that may be more likely to result from repetitive head injury. In particular, the risk of suffering from persistent post-concussion symptoms such headache, dizziness, and fatigue appears to be <a href="https://pubmed.ncbi.nlm.nih.gov/25763565/">significantly greater</a> in people with a history of multiple concussions. </p>
<p>Risk of these symptoms persisting after a concussion appears to be particularly high if repeat concussions <a href="https://pubmed.ncbi.nlm.nih.gov/23753087/">happen in short succession</a>. Some researchers <a href="https://pubmed.ncbi.nlm.nih.gov/28641105/">think</a> the recently concussed brain may have a “window of increased vulnerability” to repeated concussion. However, the length of time, and the underlying biological causes, of this vulnerable period are not yet well understood.</p>
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<strong>
Read more:
<a href="https://theconversation.com/for-an-unlucky-10-of-people-with-concussion-the-symptoms-may-be-long-lasting-116825">For an unlucky 10% of people with concussion, the symptoms may be long-lasting</a>
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<p>In sport, this creates a lot of uncertainty around when it’s OK for a previously concussed athlete to resume playing. Caution around allowing players to get back on the field is increasingly appreciated in some sporting codes, conveyed in the widely touted “<a href="https://www.afl.com.au/afl-education/concussion">when in doubt, sit them out</a>” message.</p>
<figure class="align-center ">
<img alt="A young person complaining of a headache" src="https://images.theconversation.com/files/356235/original/file-20200903-20-1dot5vo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/356235/original/file-20200903-20-1dot5vo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=316&fit=crop&dpr=1 600w, https://images.theconversation.com/files/356235/original/file-20200903-20-1dot5vo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=316&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/356235/original/file-20200903-20-1dot5vo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=316&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/356235/original/file-20200903-20-1dot5vo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=398&fit=crop&dpr=1 754w, https://images.theconversation.com/files/356235/original/file-20200903-20-1dot5vo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=398&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/356235/original/file-20200903-20-1dot5vo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=398&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">How long is long enough? Researchers are working on ways to identify when it’s safe for players to return to sport after a concussion.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>But what we don’t know yet is, for how long? In attempt to shed some light on this, our laboratory is investigating how new blood and MRI tests may be able to objectively indicate when the brain has recovered from concussion and is no longer in a vulnerable state, thereby allowing previously concussed athletes to resume playing. </p>
<p>In the meantime, we must use the current knowledge available to manage the risks from blows to the head. Many sports have implemented rule changes in an attempt to decrease the risk of brain injury, which is welcome. Some people have gone further, advocating for participation in collision or contact sports to be banned to prevent CTE.</p>
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Read more:
<a href="https://theconversation.com/sports-coaches-need-to-be-educated-about-concussion-to-keep-players-safe-on-the-field-61975">Sports coaches need to be educated about concussion to keep players safe on the field</a>
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<p>But when considering this option, it’s important to emphasise evidence of CTE in people with no known history of repetitive brain trauma or collision sport participation. Further, there are many health benefits to participating in sport. In fact, exercise is considered a promising treatment strategy for both <a href="https://pubmed.ncbi.nlm.nih.gov/30239422/">concussion</a> and <a href="https://pubmed.ncbi.nlm.nih.gov/27521273/">neurodegenerative</a> disorders.</p>
<p>While we wait for further discoveries about CTE, it’s important to carefully weigh the known negatives and positives of sport participation. The interaction between physical activity and brain health is complex; we cannot ignore the problem of repeated brain trauma in sports, but stopping participation in all contact sports will also not lead to optimal brain health. </p>
<p>Making informed, evidence-based decisions about risk and benefit needs to rely on objective data (of which we need much more) rather than media hype.</p><img src="https://counter.theconversation.com/content/145395/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Richelle Mychasiuk receives funding from the Australian National Health and Medical Research Council and the Canadian Institutes for Health Research. </span></em></p><p class="fine-print"><em><span>Sandy Shultz receives funding from NHMRC. </span></em></p><p class="fine-print"><em><span>Stuart McDonald 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>Although a great deal of research is still required, it may one day be possible to identify and treat people either with CTE, or at risk of it.Richelle Mychasiuk, Associate Professor (Research), Department of Neuroscience, Monash UniversitySandy Shultz, Associate Professor (Research), Department of Neuroscience, Monash UniversityStuart McDonald, Research Fellow, Department of Neuroscience, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1415572020-07-22T13:02:12Z2020-07-22T13:02:12ZFalls and injuries are a persistent public health problem in long-term care<figure><img src="https://images.theconversation.com/files/348179/original/file-20200717-19-176uzdv.jpg?ixlib=rb-1.1.0&rect=10%2C14%2C936%2C659&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Hip fractures are a common injury sustained in falls in long-term care.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Long-term care homes in Canada provide essential round-the-clock care for approximately <a href="https://www150.statcan.gc.ca/n1/daily-quotidien/170503/dq170503a-eng.htm">425,000 of Canada’s most vulnerable</a> people. Among Canadians aged 85 and older — the fastest growing segment of our population — <a href="https://www12.statcan.gc.ca/census-recensement/2016/as-sa/98-200-x/2016004/98-200-x2016004-eng.cfm">32 per cent live in long-term care</a>.</p>
<p>Residents often have multiple complex <a href="https://doi.org/10.1371/journal.pmed.1002843">medical conditions and take numerous medications</a>. Physically frail and cognitively impaired, many residents rely on care staff to get in and out of bed, use the toilet, bathe and eat. Most are very likely to fall.</p>
<p>I work with a team of biomedical scientists at Simon Fraser University and the Fraser Health Authority studying falls in long-term care. Over our <a href="https://doi.org/10.1371/journal.pmed.1002843">four-year study</a>, we learned that approximately 70 per cent of residents fall at least once in any given year, and many do so multiple times. Injuries occur in about 50 per cent of these cases, the most serious of which are hip fracture and traumatic brain injury. These rates are cause for concern — they are <a href="https://doi.org/10.1093/oxfordjournals.aje.a116681">two to three times higher</a> than we typically observe among older adults who live independently.</p>
<h2>High incidence of falls and injuries</h2>
<p>A separate study <a href="https://doi.org/10.1016/S0140-6736(12)61263-X">recorded videos</a> of hundreds of real-life falls in dining rooms, hallways and lounges in long-term care homes. In these public settings, falls happen during common, everyday activities such as forward walking, standing and sitting down. </p>
<p>The underlying cause is most often incorrect weight shifting, followed by tripping. What’s particularly shocking is that in close to 40 per cent of events, residents sustain impact to their heads. </p>
<figure class="align-center ">
<img alt="A woman in a large room reaches for a counter to try to steady herself as she falls to the floor" src="https://images.theconversation.com/files/348174/original/file-20200717-35-1er757w.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/348174/original/file-20200717-35-1er757w.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=449&fit=crop&dpr=1 600w, https://images.theconversation.com/files/348174/original/file-20200717-35-1er757w.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=449&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/348174/original/file-20200717-35-1er757w.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=449&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/348174/original/file-20200717-35-1er757w.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=564&fit=crop&dpr=1 754w, https://images.theconversation.com/files/348174/original/file-20200717-35-1er757w.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=564&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/348174/original/file-20200717-35-1er757w.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=564&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">A screen shot from video footage of a fall that led to a broken hip.</span>
<span class="attribution"><span class="source">(Stephen Robinovitch/Injury Prevention and Mobility Laboratory, Simon Fraser University)</span>, <span class="license">Author provided</span></span>
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</figure>
<p>Despite decades of effort to design, evaluate and implement interventions to prevent falls in long-term care, we still do not have effective methods for doing so. Strategies that are effective for older adults living independently in the community, namely <a href="https://doi.org/10.1002/14651858.CD012424.pub2">balance and functional exercises</a>, simply <a href="https://doi.org/10.1002/14651858.CD005465.pub4">don’t work in long-term care</a> because residents have complex medical histories and multiple risk factors.</p>
<p>In the past, residents were sometimes physically or chemically restrained so they were less likely to fall. But that seriously restricted quality of life. Thankfully long-term care homes today favour progressive policies that honour and respect the dignity and individuality of residents. This includes giving residents the right to choose to move freely, which may mean <a href="https://doi.org/10.1111/j.1532-5415.2010.03278.x">falling down more often</a>.</p>
<p>Given the persistent challenge of preventing falls in long-term care homes, researchers and health-care organizations are shifting their focus toward the management of falls. A pressing question now is how can we prevent and reduce the severity of injuries when falls do happen?</p>
<p>We’re working on this, but it’s not an easy task. Two main strategies to prevent fall-related injuries are emerging.</p>
<h2>Wearable protective gear</h2>
<p>Wearable protective gear is designed to reduce impact forces sustained by the body during falls. One example is hip protectors. These are undergarments, shorts or pants with soft pads or hard shields on the sides that absorb some of the impact of a fall to protect the bone. </p>
<p>When worn during a fall, hip protectors substantially reduce the <a href="https://doi.org/10.1016/j.jamda.2019.07.010">chance of a hip fracture</a> among long-term care residents. Low compliance in wearing hip protectors is an issue, however, and has limited their effectiveness on the population level. Increasing the use of hip protectors in long-term care homes across the country is a major focus of new research.</p>
<figure class="align-center ">
<img alt="A woman sits on the corner of a table demonstrating the fit of a hip protector pad. Several types of hip pads are arranged on the table" src="https://images.theconversation.com/files/345607/original/file-20200704-33943-1703gu1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/345607/original/file-20200704-33943-1703gu1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=424&fit=crop&dpr=1 600w, https://images.theconversation.com/files/345607/original/file-20200704-33943-1703gu1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=424&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/345607/original/file-20200704-33943-1703gu1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=424&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/345607/original/file-20200704-33943-1703gu1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=532&fit=crop&dpr=1 754w, https://images.theconversation.com/files/345607/original/file-20200704-33943-1703gu1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=532&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/345607/original/file-20200704-33943-1703gu1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=532&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">A selection of hip protector pads.</span>
<span class="attribution"><span class="source">(Stephen Robinovitch/Injury Prevention and Mobility Laboratory, Simon Fraser University)</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>Given the prominence of serious head injuries during falls, researchers are also exploring the development and effectiveness of protective head gear, like helmets, that are designed to protect against fall-related traumatic brain injury. This is a very <a href="https://forum.agewell-nce.ca/index.php/AWCRP-2020-04:Main">new area of research</a> and one where having patients as partners in the creation of these technologies will be key to their acceptance.</p>
<h2>Environmental interventions</h2>
<p>Modifications to the physical environment at long-term care homes aim to promote safer mobility. Their promise lies, in part, in the ubiquitous nature of protection they could provide — unlike wearable protective gear, the effectiveness of environmental interventions does not rely on active user compliance. </p>
<p>One example is compliant flooring, which provides a softer landing surface than standard flooring to protect against injury. Our four-year randomized <a href="https://doi.org/10.1371/journal.pmed.1002843">study of one type of compliant flooring</a> at a long-term care home did not find any reduction in fall-related injuries, so the search for alternate strategies continues. Newer brands and models of flooring systems may prove more effective.</p>
<figure class="align-center ">
<img alt="Cross-section of flooring showing rubber cylinders on the underside." src="https://images.theconversation.com/files/345605/original/file-20200704-33935-5jbjfe.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/345605/original/file-20200704-33935-5jbjfe.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=192&fit=crop&dpr=1 600w, https://images.theconversation.com/files/345605/original/file-20200704-33935-5jbjfe.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=192&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/345605/original/file-20200704-33935-5jbjfe.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=192&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/345605/original/file-20200704-33935-5jbjfe.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=241&fit=crop&dpr=1 754w, https://images.theconversation.com/files/345605/original/file-20200704-33935-5jbjfe.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=241&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/345605/original/file-20200704-33935-5jbjfe.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=241&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A rubber compliant floor with vinyl overlay.</span>
<span class="attribution"><span class="source">(Dawn Mackey)</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>Canada’s population will age considerably in the coming decades. By 2031, approximately <a href="https://www150.statcan.gc.ca/n1/daily-quotidien/170503/dq170503a-eng.htm">one in four Canadians</a> will be 65 years or older. As such, the number of long-term care residents will likely grow rapidly. The health and well-being of residents demands increased attention, action and innovation from government, policy-makers, health-care organizations, clinicians, industry, researchers and the public. The people who spend their final years in long-term care — our parents and grandparents — deserve it.</p><img src="https://counter.theconversation.com/content/141557/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dawn Mackey receives funding from the Canadian Institutes of Health Research; the Natural Sciences and Engineering Research Council of Canada; AGE-WELL National Centres for Excellence; and the Drummond Foundation.</span></em></p>Every year, about 70 per cent of long-term care residents have at least one fall, and half of those result in injury. Wearable gear and changes to living spaces aim to prevent falls and limit injury.Dawn Mackey, Associate Professor in Biomedical Physiology and Kinesiology, Simon Fraser UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1300612020-05-26T19:43:26Z2020-05-26T19:43:26ZConcussion affects 1 in 10 youth athletes every year. Here’s what needs to change.<figure><img src="https://images.theconversation.com/files/336927/original/file-20200522-57725-azc8dm.jpg?ixlib=rb-1.1.0&rect=10%2C339%2C3641%2C2124&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Rule changes, training strategies and equipment recommendations can help protect youth athletes from concussion.</span> <span class="attribution"><span class="source">(Unsplash)</span></span></figcaption></figure><p>While sports facilities and leagues are still gauging how and when to reopen in the wake of the coronavirus, now is the best time to think about concussion prevention: before young people get back on the playing field. </p>
<p>The benefits of <a href="https://www150.statcan.gc.ca/n1/pub/82-625-x/2019001/article/00003-eng.htm">sport and physical activity are significant</a>, and yet, every day young people put themselves at risk of concussion through participation in sports. The highest concussion incidence rates among youth in Canada are seen in <a href="http://dx.doi.org/10.1136/bjsports-2015-094978">rugby, ice hockey and football</a>.</p>
<p>We expect <a href="https://doi.org/10.1097/01.jsm.0000184638.72075.b7">one in 10 Canadians ages 13 to 18 to seek medical attention</a> every year for a sport-related concussion. Forty per cent of these <a href="https://doi.org/10.1097/jsm.0000000000000673">youth have experienced a previous concussion, and 20 per cent will have a variety of persistent symptoms for longer than one month</a>. </p>
<p>These symptoms may include <a href="http://dx.doi.org/10.1136/bjsports-2017-097699">headache, dizziness, sleep disturbance, cognitive difficulties or depression</a>. Long-term consequences of concussion in youth may also include reduced levels of physical activity, overweight or obesity, psychosocial consequences and significant health-care costs. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/333921/original/file-20200511-49556-1jhho18.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/333921/original/file-20200511-49556-1jhho18.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/333921/original/file-20200511-49556-1jhho18.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/333921/original/file-20200511-49556-1jhho18.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/333921/original/file-20200511-49556-1jhho18.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/333921/original/file-20200511-49556-1jhho18.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/333921/original/file-20200511-49556-1jhho18.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">Rugby, hockey and football have the highest concussion incidence in Canadian youth.</span>
<span class="attribution"><span class="source">(Unsplash/BJ Pearce)</span></span>
</figcaption>
</figure>
<p>As chair of the <a href="https://ucalgary.ca/siprc/">Sport Injury Prevention Research Centre (faculty of kinesiology, University of Calgary)</a>, I lead a research program that aims to reduce the burden of youth concussion in Canada. The best way to do that, and to keep kids active in the sports they love, is by moving towards prevention. Providing a safe environment for youth to participate in sport is critical to ensure lifelong participation in sport and recreation. As such, a key public health priority should be concussion prevention in youth sport to promote an active lifestyle in all Canadian youth.</p>
<h2>How can we prevent concussion in youth sport?</h2>
<p><a href="http://dx.doi.org/10.1136/bjsports-2016-097452">Research has shown</a> that rule changes, training strategies, equipment recommendations and legislation of evidence-informed management protocols can all help to prevent concussion and the recurrence of concussion in youth sport.</p>
<p><a href="https://doi.org/10.1001/jamapediatrics.2018.5498">Rule changes may be the low-hanging fruit</a> in reducing the risk of concussion in youth sport. In 2010, we demonstrated a <a href="http://doi.org/10.1001/jama.2010.755">four-fold greater risk of concussion</a> in 11- and 12-year-old ice hockey players when body checking was allowed in games at all levels of play, compared to Québec where body checking was not allowed. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/336923/original/file-20200522-57670-1l0ru0o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/336923/original/file-20200522-57670-1l0ru0o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=391&fit=crop&dpr=1 600w, https://images.theconversation.com/files/336923/original/file-20200522-57670-1l0ru0o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=391&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/336923/original/file-20200522-57670-1l0ru0o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=391&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/336923/original/file-20200522-57670-1l0ru0o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=491&fit=crop&dpr=1 754w, https://images.theconversation.com/files/336923/original/file-20200522-57670-1l0ru0o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=491&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/336923/original/file-20200522-57670-1l0ru0o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=491&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Every year, one in 10 youth athletes seeks medical attention for concussion.</span>
<span class="attribution"><span class="source">(Unsplash)</span></span>
</figcaption>
</figure>
<p>This study, among others, informed a 2013 Hockey Canada national policy change delaying body checking until age 13. This led to a <a href="http://dx.doi.org/10.1136/bjsports-2016-097392">64 per cent reduction in concussion rates, preventing over 4,800 concussions nationally each year</a> in young players, and keeping more players in the game.</p>
<p>This research further informed local and provincial policy change in non-elite levels of play (70 per cent of players by division of play) in older age groups (ages 13-17). <a href="http://dx.doi.org/10.1136/bjsports-2019-101092">Evidence in 13- and 14-year-old non-elite ice hockey leagues supports a policy disallowing body checking in games</a>, with a 54 per cent reduction in all injuries and estimated prevention of 4,000 injuries in 13- and 14-year-old players annually in Canada.</p>
<p>If body checking continues to be disallowed in games in 11- and 12-year-old leagues and non-elite levels in 13- to 17-year-old leagues, the public health impact would be the prevention of 10,000 concussions annually. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/333692/original/file-20200508-49565-ltbc6a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/333692/original/file-20200508-49565-ltbc6a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=744&fit=crop&dpr=1 600w, https://images.theconversation.com/files/333692/original/file-20200508-49565-ltbc6a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=744&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/333692/original/file-20200508-49565-ltbc6a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=744&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/333692/original/file-20200508-49565-ltbc6a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=934&fit=crop&dpr=1 754w, https://images.theconversation.com/files/333692/original/file-20200508-49565-ltbc6a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=934&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/333692/original/file-20200508-49565-ltbc6a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=934&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">One of Canada’s largest hockey associations will ban bodychecking for peewee players.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Andrew Vaughan</span></span>
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</figure>
<p>Prevention should be our priority, but not everyone involved in the game sees it this way. Some parents believe that delaying body checking to age 13 may reduce concussion risk but that this policy will also reduce their child’s opportunities to play at elite and professional levels. </p>
<p><a href="https://cdn.agilitycms.com/hockey-canada/Corporate/About/Downloads/2018-19-hockey-canada-annual-report-e.pdf">In Canada, 70,000 11- and 12-year-old ice hockey players are registered annually</a>. Possibly 70 of these kids may have an opportunity to compete in the National Hockey League (<a href="https://bleacherreport.com/articles/1533035-nhl-hockey-how-much-are-a-childs-hockey-dreams-worth">one in 1,000</a>) and perhaps 7,000 may continue to play in an adult recreational league. </p>
<p>One might argue that the other 62,930 young players should be our public health priority. Our goal should be to keep these kids in the game for lifelong participation in sport and recreation. </p>
<p>Another rule change targeting concussion prevention in youth sport includes <a href="https://doi.org/10.1177%2F0363546519860120">limiting full-contact play during football practice</a>. </p>
<p>Other evidence-informed prevention strategies include sport-specific <a href="http://dx.doi.org/10.1136/bjsports-2015-094639">neuromuscular training (NMT) warm-up programs</a> (including aerobic, balance, strength, agility) that have been shown to reduce the risk of all injury, including concussion, by more than 35 per cent across multiple team sports including <a href="https://www.ncbi.nlm.nih.gov/pubmed/20547668">soccer</a>, <a href="http://dx.doi.org/10.1136/bjsports-2016-097434">rugby</a>, <a href="https://www.ncbi.nlm.nih.gov/pubmed/29864071">basketball</a> and in <a href="http://dx.doi.org/10.1136/bjsports-2019-101117">physical education</a>.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/333700/original/file-20200508-49573-ez8s8o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/333700/original/file-20200508-49573-ez8s8o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/333700/original/file-20200508-49573-ez8s8o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/333700/original/file-20200508-49573-ez8s8o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/333700/original/file-20200508-49573-ez8s8o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/333700/original/file-20200508-49573-ez8s8o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/333700/original/file-20200508-49573-ez8s8o.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">Limiting full-contact play during practices may help prevent concussion in youth football.</span>
<span class="attribution"><span class="source">(Unsplash/Ben Hershey)</span></span>
</figcaption>
</figure>
<p>We should not underestimate the potential of preventive equipment including <a href="https://bjsm.bmj.com/content/early/2020/01/14/bjsports-2019-101011">mouth guards</a> with recent evidence demonstrating that wearing a mouth guard (off the shelf or custom fit) reduced odds of concussion in youth ice hockey players by more than 60 per cent. <a href="https://doi.org/10.1177/1941738116639027">Helmet fit</a> criteria have also been developed and evaluated in youth ice hockey and tackle football, suggesting the potential for a protective effect and reduced concussion severity with optimal helmet fit.</p>
<h2>Can concussions lead to catastrophic outcomes?</h2>
<p>Catastrophic outcomes following concussion in youth sport are rare, however we should work to ensure that not one more child dies following concussion. Rowan Stringer was a 17-year-old high school rugby player who suffered multiple concussions in one week in 2013 and died as a result of her injuries. Stringer’s lasting legacy is <a href="https://www.ola.org/en/legislative-business/bills/parliament-41/session-2/bill-193">Rowan’s Law</a> that was subsequently introduced into Ontario legislation following her death.</p>
<p>Rowan’s Law is a wake-up call to sport associations, sport facilities and schools to implement concussion protocols mandating the removal from play of any youth athlete with a suspected concussion. Rowan’s Law also makes concussion education mandatory for certain individuals involved with youth sport. Additionally, it informs appropriate protocols for concussion follow-up including assessment by a physician and adherence to evidence-informed return-to-sport and return-to-school guidelines. </p>
<p>The <a href="https://parachute.ca/wp-content/uploads/2019/06/Canadian-Guideline-on-Concussion-in-Sport.pdf">Canadian Guidelines on Concussion in Sport</a> were informed by the <a href="http://dx.doi.org/10.1136/bjsports-2017-097699">International Consensus on Concussion in Sport</a>, available online at <a href="https://parachute.ca/en/injury-topic/concussion/">Parachute</a> along with other evidence-informed concussion resources.</p>
<h2>Canadian researchers raising the bar</h2>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/333919/original/file-20200511-49542-7pd2ho.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/333919/original/file-20200511-49542-7pd2ho.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/333919/original/file-20200511-49542-7pd2ho.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/333919/original/file-20200511-49542-7pd2ho.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/333919/original/file-20200511-49542-7pd2ho.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1131&fit=crop&dpr=1 754w, https://images.theconversation.com/files/333919/original/file-20200511-49542-7pd2ho.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1131&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/333919/original/file-20200511-49542-7pd2ho.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">Sports with high concussion risk include hockey, football, rugby, lacrosse, wrestling, ringette, soccer, basketball, volleyball and cheerleading.</span>
<span class="attribution"><span class="source">(Pixabay)</span></span>
</figcaption>
</figure>
<p>Through a research program funded by the NFL’s Scientific Advisory Board, our team at the Sport Injury Prevention Research Centre is leading a pan-Canadian multidisciplinary research group focused on the prevention, detection, diagnosis, prognosis and management of sport-related concussion in youth. <a href="https://www.ucalgary.ca/news/nfl-gives-significant-funding-help-youth-shred-burden-concussion">SHRed Concussions</a> (Surveillance in High School to Reduce Concussions and their Consequences in Youth Sport) is the first study of its kind in Canada. It aims to recruit 6,000 high school athletes (ages 13-18) in 60 schools (in British Columbia, Alberta, Manitoba, Ontario and Québec), with followup over three years. </p>
<p>The goal of SHRed Concussions is to raise the bar in youth sport-related concussion research and to inform a significant public health impact in the reduction of sport-related concussions and their consequences in youth across multiple sports including tackle football, rugby, ice hockey, lacrosse, wrestling, ringette, soccer, basketball, volleyball and cheerleading.</p>
<h2>Why are we so afraid of change?</h2>
<p>Canada’s youth are our biggest and most important natural resource. <a href="https://www.cbc.ca/news/canada/ottawa/rowan-stringer-hit-stop-sit-ontario-concussion-ad-1.5169263">Rowan Stringer</a> reminds us every day that there is a lot to do to keep sports safe and prevent sport-related concussions in youth. We must ensure legislation is in place for concussion prevention and management protocols to minimize the risk of catastrophic outcomes and reduce the burden of concussions in youth sport. </p>
<p>The benefits of changing the rules of the game, safety equipment legislation and evidence-informed training strategies have been significant in reducing the burden of concussion in youth sport. <a href="https://www.ucalgary.ca/news/nfl-gives-significant-funding-help-youth-shred-burden-concussion">Evaluation of concussion prevention strategies is ongoing across multiple youth sports</a>. Our priority must be to keep all youth participating in sports and also physically active for life.</p><img src="https://counter.theconversation.com/content/130061/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Carolyn Emery receives funding from Canadian Institutes of Health Research, Canadian Foundation for Innovation, Canada Research Chairs Government of Canada, National Basketball Association/General Electric, National Football League Scientific Advisory Board, Alberta Innovates, Alberta Children's Hospital Foundation, Hotchkiss Brain Institute, O'Brien Institute of Public Health and the University of Calgary.</span></em></p>Every year, about 10 per cent of youth athletes experience a concussion. Research shows there are steps we can take to help prevent these injuries, but we can’t be afraid to make changes.Carolyn Emery, Professor, Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of CalgaryLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1168252019-05-20T19:47:57Z2019-05-20T19:47:57ZFor an unlucky 10% of people with concussion, the symptoms may be long-lasting<figure><img src="https://images.theconversation.com/files/275095/original/file-20190517-69204-983k6e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">When symptoms of a concussion persist beyond three months, this is called persistent post-concussion symptoms. </span> <span class="attribution"><span class="source">From shutterstock.com</span></span></figcaption></figure><p>Concussion is a temporary disturbance in brain function following an impact to the head. It can also occur after a blow to the body, if the force is transmitted to the head.</p>
<p>Most people associate concussion with sports but they can occur anywhere, even at work or school. </p>
<p>There are many signs and symptoms of concussion, which may present differently between individuals. These include headaches, nausea, vomiting, slurred speech, dizziness, temporary loss of memory, and inability to focus. Loss of consciousness only occurs in around 10% of concussions.</p>
<p>Most people with concussions recover relatively quickly. Around 90% will recover within several days to a <a href="https://bjsm.bmj.com/content/51/11/838">couple of weeks</a>. </p>
<p>But sometimes symptoms continue beyond a couple of weeks. When symptoms persist beyond three months, the person may be diagnosed as having persistent post-concussion symptoms.</p>
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Read more:
<a href="https://theconversation.com/how-injuries-change-our-brain-and-how-we-can-help-it-recover-91952">How injuries change our brain and how we can help it recover</a>
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<h2>Rest is not always best</h2>
<p>We don’t know exactly how common concussions are, because they’re <a href="https://www.mja.com.au/journal/2013/198/8/increasing-incidence-hospitalisation-sport-related-concussion-victoria-australia">under-reported</a>. Some people don’t think they are a serious injury, so don’t seek treatment, while others mask their injury because they don’t want to be seen as weak. </p>
<p>The World Health Organisation classifies concussion, which is a type of traumatic brain injury, as a <a href="https://www.who.int/mental_health/neurology/neurodiso/en/">critical public health issue</a>.</p>
<p>Complete physical and mental rest used to be recommended after a concussion. Since 2017, however, the <a href="https://bjsm.bmj.com/content/51/11/838">concussion treatment guidelines have evolved to reflect the science</a>. </p>
<p>While rest in the immediate 24-48 hours after a concussion is still advised, patients are now encouraged to undertake low-intensity exercise (such as walking, light jogging, or stationary cycling) and light mental stimulation (such as work or study) over the following days.</p>
<p>Recovery is individual, but the intensity of physical and mental activity should <a href="https://www.cdc.gov/headsup/providers/return_to_activities.html">gradually increase over time</a> and should not exacerbate or worsen the symptoms.</p>
<h2>Persistent symptoms</h2>
<p>Formerly known as post-concussion syndrome, persistent post-concussion symptoms occur in <a href="https://www.tandfonline.com/doi/abs/10.3109/02699052.2014.974674?casa_token=gdHlaoPPiUwAAAAA:W4y4x1Jcb-7Gz8KGKg49ZAQlTLvUxVD9JKreFEgKQAyRmx9Ygb_r58GUWv9IlCg1b5CT3jjneZ3JLvc">around 1-10% those who have suffered a concussion</a>. The exact prevalence is unknown due to <a href="https://www.intechopen.com/download/pdf/30498">methodological differences</a> between studies and how persistent post-concussion symptoms are defined within these studies. </p>
<p>As with concussion, persistent post-concussion symptoms vary among individuals but <a href="https://www.tandfonline.com/doi/abs/10.1080/09540260310001606692?casa_token=cEnaY_-rdjsAAAAA:C1TrnYGfR0DcTKy0fE17yOw2zdfbi8joRbqtFUc1xe9qb8pn65-KKhuRT46scjCSvdbxumr3WwnnlTc">may include</a> headaches, balance problems, light or noise sensitivity, anxiety and depression.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/sports-coaches-need-to-be-educated-about-concussion-to-keep-players-safe-on-the-field-61975">Sports coaches need to be educated about concussion to keep players safe on the field</a>
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<p>We still don’t know why some people’s symptoms persist for many months, sometimes even years. </p>
<p>But we suspect psychology may play a role. While the evidence is limited, <a href="https://www.tandfonline.com/doi/abs/10.1080/09638288.2018.1558292?casa_token=P7ipWEot57cAAAAA:RGc3Z9t9C2KfE3-e2-xpu0fN2luMjrV12FevpCmYZv_LWpGolhhAs81lpWB5qZXX9ECQxylnaRN4oxU">early psychological intervention for those with ongoing symptoms</a>, which involves educating the person on why they are feeling this way, has been shown to be effective at reducing the anxiety and depression that accompany persistent post-concussion symptoms.</p>
<p>Despite psychological support, some express continued physical symptoms, such as headaches, balance problems, and light/noise sensitivity; reflecting possible changes or abnormalities in the brain. </p>
<p>Fatigue, both mental and physical, is common in people with persistent post-concussion symptoms, but is often overlooked, despite it significantly impacting on quality of life.</p>
<h2>What can measures of fatigue tell us?</h2>
<p>Our <a href="https://www.sciencedirect.com/science/article/abs/pii/S0306452219302593">new research</a> suggests people with persistent post-concussion symptoms may have ongoing problems with fatigue and cognitive function because of changes to the way information is transmitted to and from their brain. </p>
<p>We used <a href="https://en.wikipedia.org/wiki/Transcranial_magnetic_stimulation">transcranial magnetic stimulation</a>, a non-invasive brain stimulation technique, to measure participants’ brain function and neural processing. </p>
<p>When compared to both age-matched controls, as well as a group of people who have recovered from a previous concussion, we found people with persistent post-concussion symptoms were slower to complete the set activities – and their outcomes were more varied. </p>
<p>We have previously compared brain responses via this method in <a href="https://www.liebertpub.com/doi/abs/10.1089/neu.2013.3219">retired Australian Rules</a> and <a href="https://www.tandfonline.com/doi/abs/10.1080/02699052.2018.1430376">Rugby league players</a> and found abnormal responses compared to other people of the same age with no history of head trauma. </p>
<p>The next stage of our research is to better understand who is vulnerable to persistent post-concussion symptoms and how the condition can be treated. </p>
<p>We understand how to diagnose and treat concussion in the short term, but we’re yet to uncover how to best assist people with persistent post-concussion symptoms to return to leading productive lives.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/preventing-kids-concussion-is-about-duty-of-care-not-cotton-wool-24783">Preventing kids' concussion is about duty of care, not cotton wool</a>
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<img src="https://counter.theconversation.com/content/116825/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alan Pearce receives part funding from Sports Health Check charity. Alan has previously received partial research funding from the Australian Football League, Impact Technologies Inc., and Samsung Corporation. </span></em></p>Usually people recover from concussions in a few days, or weeks at most. But 1-10% will still have symptoms three months later.Alan Pearce, Associate Professor, School of Allied Health, La Trobe UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1004192018-07-27T08:59:06Z2018-07-27T08:59:06ZTour de France: does pro-cycling have a concussion problem?<figure><img src="https://images.theconversation.com/files/229069/original/file-20180724-194146-r625v7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">How to change cycling's concussion culture.</span> <span class="attribution"><span class="source">shutterstock</span></span></figcaption></figure><p><a href="https://theconversation.com/lets-hear-it-for-carbs-tour-de-france-cyclists-couldnt-do-it-without-them-44923">The Tour de France</a> is unquestionably one of the most famous events in the professional sporting calendar. Some of the finest athletes on the planet, along with their expert, multimillion dollar support teams, display exceptional physical, mechanical, tactical and psychological attributes. </p>
<p>The demands are vast, and many riders suffer a number of illnesses and injuries during the three weeks of the race. While the majority of injuries will tend to be related to soft tissue damage, abrasions, lacerations or bone fractures, there are increasing numbers of head injuries – notably concussions – now <a href="https://www.procyclingstats.com/statistics/rider-injuries">being reported</a> in professional road cyclists.</p>
<p>The death of Italian cyclist and Olympic gold medalist, <a href="https://en.wikipedia.org/wiki/Fabio_Casartelli">Fabio Casartelli</a>, in 1995, was attributed to a major head injury. His death stimulated discussions that led to the enforcement of helmet wearing during events. </p>
<p>Another notorious crash was that of <a href="https://en.wikipedia.org/wiki/Toms_Skuji%C5%86%C5%A1">Tom Skujiņš</a>, the Latvian professional road racing cyclist, who came off his bike at the 2017 Tour of California. This crash was <a href="https://www.youtube.com/watch?v=lTn8IPhcDyo">caught on camera</a> and highlights one of the major issues in professional cycling, a lack of an established protocol when a suspected concussion happens. In our view, Skujņš – seen wobbling all over the road after his crash – should never have been allowed to remount his bike</p>
<h2>Spotting a head injury</h2>
<p>A key problem is that there is an incredibly disjointed approach to reporting concussions in cycling events, a problem caused by the complexities of the sport itself. In soccer, football or rugby, if a player is suspected of having a head injury, it is more than likely going to be spotted on one or more of the media platforms recording the event. </p>
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<figcaption><span class="caption">Tom Skujiņš in the tour of California 2017.</span></figcaption>
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<p>These sports occur in closed locations, where multiple viewpoints inform decision making by medical staff stationed in close proximity to the action. In all outdoor cycling events, apart from BMX, this is simply not possible, and such incidents are more challenging to spot. </p>
<p>This is because TV cameras usually focus on the lead group. So if an accident happens further back, it is often not seen by the cameras, race director or team cars. It also means that any head injury assessment can only be applied on an “opportunistic basis” rather than by the structured removal of the player – as seen in many team sports.</p>
<h2>Controlling concussions</h2>
<p>To identify head injuries in cycling, and for medics to be able to undertake roadside assessments, a “<a href="https://www.theguardian.com/sport/2018/mar/20/link-between-concussion-and-brain-damage-to-ensure-afl-debate-rages">multiview approach</a>” needs to be used. This has been used successfully in <a href="https://www.theage.com.au/sport/afl/afl-eyes-berlin-concussion-conference-to-guide-head-knocks-policy-20161026-gsb7q8.htmlhttps:/www.theage.com.au/sport/afl/afl-eyes-berlin-concussion-conference-to-guide-head-knocks-policy-20161026-gsb7q8.html">Australian Rules Football</a>, where video footage along with eyewitness observations relays information to clinicians. But in terms of cycling, this would only really work during televised events meaning that addressing the issue at sub-elite levels still remains a challenge. </p>
<p>Contact and collision sports have been extremely proactive in engaging with research on concussion and implementing pitch side “head injury assessments”. This along with “return to play” protocols – which see players only allowed to return when medically approved – and <a href="https://sportscotland.org.uk/media-imported/1534421/scottish-sports-concussion-guidance.pdf">excellent education campaigns</a> has helped to raise awareness of the signs and symptoms of concussions. And there is <a href="http://natajournals.org/doi/full/10.4085/1052-6050-51.6.06?code=nata-site">emerging evidence</a> that such approaches have improved reporting of concussions and have helped to ensure athletes do not “return to play” unless approved.</p>
<p>In cycling, however, there is very limited research available. To date, only a single, unpublished, <a href="http://science-cycling.org/?page_id=524">systematic review</a> investigating concussion in cycling has been undertaken, by Richard Anderson at the University of Cambridge. This valuable review identified that very little published research exists relating to concussions in cycling, which is surprising given the high profile incidents that occur during internationally televised events. </p>
<h2>Cycling forward</h2>
<p><a href="http://www.cyclingcanada.ca/disciplines/sites/default/files/CCA_ConcussionCard_EN.pdf">Cycling Canada</a> is one of the first national governing bodies to formalise an educational package on this topic. It informs riders of concussion signs and symptoms and provides management and rehabilitation advice. Whether this approach is effective remains to be seen, though it is a very positive move forwards in concussion education, management and return to riding. </p>
<p>Another issue that cycling must address is the imperative for riders to “get back on the bike”. Team principals, medics and coaches must engage in concussion education, along with an agreement to utilise recognised concussion based management protocols. <a href="https://sportscotland.org.uk/media-imported/1534421/scottish-sports-concussion-guidance.pdf">Sport Scotland</a>, for example, use a simple message to recognise and manage concussion during events: “If in doubt, sit them out.” This is an excellent mantra for cyclists, and their support teams, to engage with.</p>
<p>Clearly, more must also be done to get an idea of the frequency of concussions during cycling events. This, along with a better understanding of the outcomes associated with concussion, is essential if cycling is going to get to grips with this issue.</p><img src="https://counter.theconversation.com/content/100419/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Howard Hurst works for Proform Sport Science coaching consultancy. </span></em></p><p class="fine-print"><em><span>Stephen Atkins 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>More needs to be done to manage concussions in road cycling.Stephen Atkins, Director of Sport, Exercise and Physiotherapy, University of SalfordHoward Hurst, Senior lecturer in Sport, Exercise and Nutrition Sciences, University of Central LancashireLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/978822018-06-13T14:27:15Z2018-06-13T14:27:15ZA head injury could cost a footballer more than the World Cup<p>Liverpool goalkeeper, Loris Karius, made crucial errors during the recent Champions League final, including throwing the ball to Real Madrid striker, Karim Benzema. Five days after the match, Karius was <a href="https://www.bbc.co.uk/sport/football/44367148">diagnosed with concussion</a>. </p>
<p>Head injuries can have more serious consequences than losing an important match or <a href="https://www.bbc.co.uk/sport/football/43057859">ending a career</a>, however. In Europe, it is the <a href="https://www.center-tbi.eu/">leading cause of death in young adults</a>, and football players could be a particularly vulnerable group.</p>
<p>About 1% of people who suffer a blow to the head have life-threatening injuries (mainly bleeding in the brain) and need <a href="https://www.nice.org.uk/guidance/cg176/ifp/chapter/Head-injuries">advanced medical treatment</a>, sometimes including brain surgery. About 30% of people develop concussion – a catch-all term that describes impaired brain function due to head injury – with a range of symptoms, such as nausea, vomiting and dizziness, as well as impaired thinking that <a href="https://patient.info/health/post-concussion-syndrome">can last months</a>. But most people who suffer a blow to the head have no lasting ill effects. The problem is that all three groups can initially appear the same. </p>
<p>When a patient is admitted to an emergency department (A&E) with a head injury, a structured assessment and brain scans are used to identify patients who may have life-threatening injuries. However, despite a ton of research in this area, we still can’t reliably predict who will develop concussion. </p>
<p>If a patient injures their head again, while concussed, it can lead to a catastrophic worsening of their symptoms. So the standard advice in the UK is that all patients with head injuries should avoid contact sports for two to four weeks following injury, and they should seek further medical attention if their symptoms persist.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/222979/original/file-20180613-32339-f1qws1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/222979/original/file-20180613-32339-f1qws1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/222979/original/file-20180613-32339-f1qws1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/222979/original/file-20180613-32339-f1qws1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/222979/original/file-20180613-32339-f1qws1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1131&fit=crop&dpr=1 754w, https://images.theconversation.com/files/222979/original/file-20180613-32339-f1qws1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1131&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/222979/original/file-20180613-32339-f1qws1.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">Jamie Roberts played for 15 minutes with a fractured skull.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/w/index.php?curid=27655256">Blackcat/Wikimedia Commons</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Assessing a player, pitch side, in the middle of a competitive football match, is a very different challenge, though. Without the benefit of CT scans, the medic must first determine whether the player has a potentially life-threatening injury that needs hospital treatment. Then they must determine whether the player has a concussion and cannot play on. </p>
<p>The symptoms of concussion may not be immediately apparent, making it difficult to diagnose. This difficulty was demonstrated in the case of Jamie Roberts, the Welsh international rugby player, who played on for 15 minutes in 2008 with a fractured skull, after passing a pitch-side medical assessment.</p>
<p>Most footballers who suffer a blow to the head will have no underlying brain injury. A balance must be found that protects player welfare and allows players to safely play on when possible. </p>
<h2>Lessons from rugby union</h2>
<p>This is an area where football could learn from rugby. In August 2015, rugby union introduced a head injury assessment that outlines criteria for the immediate assessment and removal of players with a head injury, pitch side, and for the identification of delayed concussion symptoms. </p>
<p>Identifying head injury in rugby union is perhaps easier, as it’s a full contact sport and <a href="http://www.espn.co.uk/football/blog/fifa/243/post/3091640/video-assistant-referees-football-can-learn-from-rugby-cricket-tennis-nfl">recently introduced pitch-side video assisted referees</a>. The UK Football Association, to its credit, has released recent guidance recommending that head-injured players who have periods of loss of consciousness should be removed from play. FIFA might also want to consider strengthening its position on head injuries in football. Extending existing guidelines to include the assessment of delayed concussion symptoms would be helpful. </p>
<p>Hopefully, greater awareness in football will equip coaches and the medical support team to recognise when a player has been affected by a head injury and empower them to remove the athlete from play.</p><img src="https://counter.theconversation.com/content/97882/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Carl Marincowitz is funded by a National Institute for Health Research Doctoral Fellowship.
This article presents independent research funded by the National Institute for Health Research (NIHR). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.
</span></em></p><p class="fine-print"><em><span>Andrew Garrett received funding from the João Havelange Research Scholarship (FIFA) in 2015. Investigating the health and safety of female footballers, as they adapt to playing in hot conditions. </span></em></p>Football could take a leaf from rugby union’s book on how to treat head-injured players, pitch side.Carl Marincowitz, NIHR Doctoral Research Fellow, University of HullAndrew Garrett, Lecturer in Exercise and Environmental Physiology, University of HullLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/961012018-05-09T23:00:44Z2018-05-09T23:00:44ZThis Mother’s Day, know the symptoms of concussion<figure><img src="https://images.theconversation.com/files/218324/original/file-20180509-34024-5j650x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The changes in the brain from a concussion do not appear on conventional imaging tests such as CT scans or MRIs; nor are there any other tests to diagnose a concussion.
</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>A bump on the head. And then another. That’s all there was to it. Yet, Mother’s Day 2013 would change one mother’s life. Her daughter <a href="http://www.cbc.ca/news/canada/ottawa/rowan-stringer-ignored-concussion-symptoms-days-before-death-1.3077245">Rowan Stringer, a high school rugby player with her whole life ahead of her, died</a> after sustaining multiple concussions in the span of a few days. </p>
<p>Second-impact syndrome, the cause of Rowan’s death, is rare. However, persisting symptoms after concussion — also known as <a href="https://www.mayoclinic.org/diseases-conditions/post-concussion-syndrome/symptoms-causes/syc-20353352">post-concussion syndrome</a> — are more common and can have devastating effects on people’s lives. </p>
<p>Rowan’s parents envisioned a world where this happens to no other family. They petitioned for more education on concussions, for better surveillance and for improved return-to-learn and return-to-play practices.</p>
<p>On March 7, 2018, concussion safety legislation known as <a href="http://www.ontla.on.ca/web/bills/bills_detail.do?locale=en&BillID=5575&isCurrent=false&ParlSessionID=412&detailPage=bills_detail_the_bill">Rowan’s Law</a> was passed by the Ontario legislature, compelling sport organizations across the province to take concussions seriously.</p>
<p>As a cognitive neurologist and concussion researcher with the <a href="http://www.uhn.ca/KNC/Research/Projects/Canadian_Concussion_Centre">Canadian Concussion Centre at Toronto Western Hospital</a> who sees people with brain diseases, I believe Rowan’s Law is a necessary, important step that will help protect the young athletes of Ontario. </p>
<p>However, all its recommendations highlight the need for better understanding, detection and management of concussions. We must admit there is a lot we do not know.</p>
<p>This law should also have more widespread ramifications. People of all ages can suffer concussions. <a href="https://theconversation.com/how-to-avoid-recognize-and-treat-concussion-in-sports-83204">Many do happen in the context of sport</a>. But many are the consequence of motor vehicle accidents, trauma, <a href="https://theconversation.com/traumatic-brain-injury-the-unseen-impact-of-domestic-violence-92730">domestic violence</a> and falls. </p>
<h2>Symptoms of a brain injury</h2>
<p>Until recently, concussions were considered trivial incidents, not worthy of medical attention. We now know that the symptoms that accompany concussions are the result of a brain injury. </p>
<p>The changes in the brain from a concussion do not appear on conventional imaging tests such as CT scans or MRIs; nor are there any other tests to diagnose a concussion. </p>
<p>But we know that these changes can cause symptoms such as headache, dizziness and unsteadiness, as well as changes in mood, concentration and memory. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/pGFq0jDr3Tw?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Concussions: 10 things you may not know.</span></figcaption>
</figure>
<p>Although most people recover from a concussion, <a href="http://dx.doi.org/10.1017/S1355617712000872">10 to 15 per cent can develop persistent symptoms</a> lasting months or years. </p>
<p>This can have profound effects on school, work and relationships. These consequences from head injury can make return to one’s life difficult, and in some cases impossible, as <a href="http://dx.doi.org/10.1089/neu.2016.4677">not everyone recovers</a>. </p>
<p>I am always amazed that most people realize that memory, attention, language, movement and such activities are functions of the brain but don’t understand it is also responsible for mood, love, judgment and the like. </p>
<p>The idea that someone who has been concussed is in the best position to know whether they should continue to play or not reflects our poor understanding of brain function. A concussion that causes headache or poor memory is also likely to impair other aspects of behaviour.</p>
<p>The long-term effects of multiple concussions and the <a href="http://dx.doi.org/10.1136/bjsports-2017-097791">long-term risk of developing a neurodegenerative disease in the form of chronic traumatic encephalopathy (CTE)</a>, is now being recognized by the medical community. </p>
<h2>Mandatory concussion education</h2>
<p>Rowan’s Law imposes requirements on sports organizations. These are all geared towards recognizing a concussion and avoiding repeat concussion while an individual is still recovering. </p>
<p>Rowan’s Law, Concussion Legislation requires: </p>
<ol>
<li> Medical clearance of a concussed athlete before they return to play.</li>
<li> Mandatory concussion education for young athletes, parents and coaches.</li>
<li> The immediate removal of a young athlete from play if a concussion is suspected.</li>
<li> Strict adherence to return-to-learn and return-to-play protocols for youth athletes with concussions.</li>
</ol>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"971018425043533830"}"></div></p>
<p>Thanks to the Stringers’ tireless advocacy, it will not be up to the athletes to decide whether to pull themselves out, or put themselves back, into a game after a concussion. </p>
<p>The law mandates that coaches and others responsible for young athletes are educated about concussion and take action when they suspect one has occurred. </p>
<h2>You have one brain</h2>
<p>Currently, we have no methods to detect concussions. There is no marker of persistent concussion symptoms and so we have no way to predict the length of recovery. And we do not know what predisposes someone to persistent concussion symptoms. </p>
<p>We also have no treatments that are specific for concussion and so we borrow ideas from other areas without much evidence. </p>
<p>We still do not even know what happens to the brain to cause a concussion and all its symptoms. Answering this last question is essential to move us toward treatments. </p>
<p>Although Rowan’s Law focuses on young athletes, people of all ages can suffer concussions. These can occur as a result of motor vehicle accidents, trauma, falls, domestic abuse and many other types of incident. Many concussions happen outside the context of sport. </p>
<p>Protecting one’s brain from concussion, appropriate treatment of concussion and importantly, prevention of further concussions, should be on everyone’s agenda. </p>
<p>You only have one brain, it defines who you are — when it changes you change. Multiple concussions can permanently change the brain and result in grave consequences for you, those around you and, most of all, your loved ones.</p><img src="https://counter.theconversation.com/content/96101/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Carmela Tartaglia 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>All parents should understand the symptoms of concussion, whether their child plays sports or not.Carmela Tartaglia, Clinician-Scientist, University Health Network and Associate Professor, University of TorontoLicensed 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/639032016-09-30T01:18:03Z2016-09-30T01:18:03ZThe curious origin of the double-conk theory for curing amnesia<figure><img src="https://images.theconversation.com/files/139498/original/image-20160927-30419-n6mxpg.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="http://www.shutterstock.com/pic-93019000/stock-vector-head-bandage-vintage-engraved-illustration-manuel-des-hospitalire-et-des-garde-malaldes-edited-by-librairie-poussielgue-paris-1907.html?src=VVEj3_tBFYLcKRLVIV6m_w-3-62">Image of head bandage engraving via www.shutterstock.com.</a></span></figcaption></figure><p>You’re probably familiar with the TV or movie plot device where a character is conked on the head, loses memory or identity and then gets conked again and memory is restored. Classic examples are in the 1951 Tom and Jerry Cartoon <a href="http://www.dailymotion.com/video/x2i35s0">Nit-Witty Kitty</a> and the movie “Clean Slate.”</p>
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<figcaption><span class="caption">Trailer for ‘Clean Slate,’ 1994.</span></figcaption>
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<p>This “double-conk” myth is so far off from neurological fact that it is laughable to scientists and physicians. It’s never a good idea to hit someone on the head as a cure for any type of concussion or brain injury. Yet surveys of the public find that around 40 percent believe that <a href="http://dx.doi.org/10.1016/S0887-6177(03)00025-8">a second blow to the head</a> can help someone recover forgotten memories.</p>
<p>I’m a clinical neuropsychologist and I study memory and memory disorders. In the classroom, I use movies to demonstrate how brain science and neuro-myths are depicted in popular film. Amnesia is a popular theme. In fact, there have been <a href="http://www.neuropsyfi.com/movies.html">more amnesia movies made</a> than for any other type of neurological disorder and many of them depict the myth of the “double-conk.” </p>
<p>So I wanted to find where this idea first came from. Did it just emerge from the mind of a creative Hollywood writer or filmmaker? I was surprised to find the origins of this particular myth <a href="http://www.neurology.org/content/86/24/2291.abstract">go back to the early 19th century</a>. </p>
<h2>Back to the early 19th century</h2>
<p>I went through troves of old movies and books, tracing the myth back to the silent movies of the early 20th century and late 19th-century fiction, including novels published in serialized form in newspapers.</p>
<p>In my research I also uncovered what I would call “pop psychology” newspaper stories about memory, many of which are wildly inaccurate, but reflected what was being written for the public. Then I tried to align the emergence of the double-conk story theme with both scientific and popular writings about brain and memory functioning from the 19th century. </p>
<p>To my surprise, I found what I believe may be the first “scientific” endorsement of a “double-conk” cure in the writings of French physician Francois Xavier Bichat, published after his death in 1802. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/138887/original/image-20160922-25473-2qmr2q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/138887/original/image-20160922-25473-2qmr2q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=795&fit=crop&dpr=1 600w, https://images.theconversation.com/files/138887/original/image-20160922-25473-2qmr2q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=795&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/138887/original/image-20160922-25473-2qmr2q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=795&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/138887/original/image-20160922-25473-2qmr2q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=998&fit=crop&dpr=1 754w, https://images.theconversation.com/files/138887/original/image-20160922-25473-2qmr2q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=998&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/138887/original/image-20160922-25473-2qmr2q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=998&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Portrait of Francois Xavier Bichat.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File%3APortrait_of_Marie_Francois_Xavier_Bichat_(1771-1802)_Wellcome_L0011401.jpg">Wellcome Images, via Wikimedia Commons</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Bichat was a young up-and-coming anatomist who believed that the two brain hemispheres were identical in structure and function. In a healthy brain, he reasoned, the hemispheres are in balance with each other and therefore in symmetry. Therefore, if a person is hit on one side of the head, the brain can lose balance, causing confusion or mental derangement. </p>
<p>The cure, in Bichat’s opinion, was a blow to other side. He wrote that “observations so frequently repeated of an accidental blow upon one side of the head having restored the intellectual functions, which had long remained dormant in consequence of a blow received upon the other side.” </p>
<p>My suspicion is that Bichat’s endorsement of a double-conk cure is based on folklore idea because he doesn’t cite or explain any individual cases to support his claim, while implying that a second blow restoring function is a common occurrence. He then uses this example, without question, to support his ideas of brain symmetry and balance. </p>
<h2>Bichat’s idea fit prevailing views of brain injury</h2>
<p>To a modern scientist, it’s easy to wonder why anyone would think a double-conk cure is reasonable. We now know that hitting the brain, or even shaking it, can cause temporary or permanent structural damage to neurons. </p>
<p>But, in the early 19th century the thinking was that concussion, or any brain injury, did not cause permanent structural or neuronal damage but a general “commotion” or “derangement” of the brain. It was generally thought that concussions, or any imbalance in the brain, could cause problems in thinking and memory, and could also lead to insanity. So Bichat’s proposal of brain symmetry and a second blow helping to “rearrange” the problems caused by a first blow fit into the prevailing view about concussions.</p>
<p>Later on Victorians also thought that any type of “nervous shock” caused a physical effect on the nervous system. Electricity could provide a nervous shock, as could terror, grief or a blow to the head. All physical or emotional shock was considered to have the same effect on the brain and nervous system.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/138884/original/image-20160922-25457-5v4bq9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/138884/original/image-20160922-25457-5v4bq9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=512&fit=crop&dpr=1 600w, https://images.theconversation.com/files/138884/original/image-20160922-25457-5v4bq9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=512&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/138884/original/image-20160922-25457-5v4bq9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=512&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/138884/original/image-20160922-25457-5v4bq9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=643&fit=crop&dpr=1 754w, https://images.theconversation.com/files/138884/original/image-20160922-25457-5v4bq9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=643&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/138884/original/image-20160922-25457-5v4bq9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=643&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The Victorians thought of the brain as a machine.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-147446807.html?src=download_history">Brain mechanism image via www.shutterstock.com.</a></span>
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<p>Many problems were thought to be the result of an unbalanced brain. Indeed, several early and mid-19th-century practitioners believed shocks, whether physical or emotional, could be useful to bring someone out of coma, or a stupor. Hysteria, a catch-all diagnosis often given to women for a wide variety of “nervous” symptoms, was sometimes treated by slapping the patient. </p>
<p>Considering that many Victorians saw the brain as a machine it may have appeared reasonable to them to “knock some sense” back into someone. A shock to the system would get the cogs moving again and bring the brain back in balance, like someone hitting a machine on the side to get it working again. </p>
<h2>What about amnesia?</h2>
<p>So how did all of this become connected to amnesia? While Bichat wrote only generally about “intellectual” problems, it had been known since ancient times that traumatic brain injury could cause memory problems. However, there was another prevailing myth circulating at the time that memories could never be lost. This was also was reinforced by “pop psychology” writers of the 19th century.</p>
<p>Many of us have had the experience of a “memory jog,” or a cue that brings up a long forgotten memory. Perhaps because our own experiences serve as powerful evidence to us, this also reinforces the myth that all memories are forever stored in the brain and only need some sort of jolt to come back.</p>
<p>It’s hard to know exactly how the double-conk myth became intertwined with the myth of memory restoration, but forgetting and amnesia were also popular themes in Victorian novels. If memory could be restored with a shock, a second conk could provide that jolt. </p>
<p>It wasn’t until the middle of the 19th century that a few scientists studying memory began to fully realize that a blow to the head might destroy some memory abilities completely. A second blow wasn’t likely to jump start the brain, they realized, but create further damage. </p>
<p>But the double-conk myth was already in circulation by then. The fact that the myth was originally supported by some scientists and physicians probably lent it some credence even as evidence that it wasn’t true mounted. It’s hard to change a myth with a 50-year head start.</p><img src="https://counter.theconversation.com/content/63903/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mary Spiers 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 myth that a blow to the head can both cause and cure amnesia – a common one on TV and in the movies – may have begun during the 19th century.Mary Spiers, Associate Professor of Psychology, Drexel UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/541392016-02-05T11:31:22Z2016-02-05T11:31:22ZConcussion: horror of sports-related brain damage is only now emerging<p>Not so long ago, it was a diagnosis that was barely mentioned. Now it feels like <a href="http://fansided.com/2016/02/03/dennis-wideman-diagnosed-concussion-hitting-ref/">there’s</a> a <a href="https://www.thewrap.com/concussion-doctor-believes-o-j-simpson-suffers-from-cte/">plague</a> of concussion in <a href="http://www.dailymail.co.uk/wires/afp/article-3424927/Tech-sector-tackles-Americas-concussion-epidemic.html">modern sport</a>, with endless news articles and commentaries on the injury and its consequences. There are <a href="http://www.bbc.co.uk/sport/football/34780549">calls for</a> heading to be banned in children’s football and for <a href="https://theconversation.com/rugby-is-dangerous-and-were-not-doing-enough-to-protect-children-who-play-it-47974">parents to</a> think again about letting their sons and daughters play rugby. Most recent is an award-winning <a href="http://www.imdb.com/title/tt3322364/">Hollywood movie</a> on the subject starring Will Smith, imaginatively titled Concussion, which launches in the UK on February 12. So why all the fuss? Should we all be wearing helmets?</p>
<p>Concussions were traditionally seen as causing short-term functional problems like memory loss and impaired concentration. Now people are becoming increasingly aware that they result in structural damage, <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3979341/">in particular to</a> fine nerve-cell fibres called axons deep inside the brain. </p>
<p>A further common misperception is that you need to be knocked out to be concussed. In truth, <a href="http://www.momsteam.com/health+and+safety/loss-of-consciousness-not-required-for-concussion-finding">as little</a> as 10% of concussion is associated with loss of consciousness. Concussion is any disturbance in brain function caused by injury, either through direct contact with the head or through whiplash as a result of a blow somewhere else on the body. </p>
<p>The long list of signs and symptoms includes headaches, seizures, memory loss and visual disturbance, of which the commonest is headaches. Symptoms can be delayed, presenting hours or even a day after the event. Yet recent data <a href="http://www.ncbi.nlm.nih.gov/books/NBK185336/">shows that</a> concussed athletes remaining in play are at increased risk of further injury. This can include non-brain injuries, although they particularly run the risk of worsening their brain injury if they sustain another blow – <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2672291/">including the</a> rare complication “second impact syndrome”, which can lead to severe complications and even death. “If in doubt, sit it out,” is the advice in all sports at all levels. </p>
<h2>Increased dementia risk</h2>
<p>Specialists are becoming more aware of the fact that brain injury, including even concussion, <a href="http://www.annualreviews.org/doi/abs/10.1146/annurev-pathol-012615-044116">increases the</a> risk of degenerative brain disease leading to dementia. Originally thought to be exclusive to retired boxers, this dementia was for many decades recognised as punch-drunk syndrome or <a href="https://www.dementia.org/dementia-pugilistica">dementia pugilistica</a>. </p>
<p>But as the new Will Smith film makes clear, just over a decade ago we began to see cases of the same pathology in other athletes exposed to repetitive concussions, including rugby and soccer. The film tells the story of the first case described in American footballers, and the <a href="http://www.theguardian.com/us-news/2015/dec/28/concussion-prevention-football-safety-brain-injury-bennet-omalu-nfl-will-smith">struggle of</a> pathologist Dr Bennet Omalu (Will Smith) to raise awareness of the condition with the National Football League (NFL). </p>
<p>Following the recognition that it is brain injury rather than a single sport that carries the risk of this degenerative brain disease, the condition is now referred to as chronic traumatic encephalopathy (CTE). But despite increasing reports of CTE in a growing list of sports, as yet there is no diagnostic test. So far, all cases diagnosed have been at post-mortem examination. This has included over 100 former NFL players, <a href="http://www.nytimes.com/2016/02/04/sports/football/ken-stabler-nfl-cte-brain-disease.html?_r=0">for instance</a>. </p>
<p>Undoubtedly there have been many more cases of CTE diagnosed as an alternate dementia. With current best estimates <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3716376/">suggesting</a> between 5% and 15% of dementia may be brain-injury related, there are probably many people living now with CTE without knowing it. Do you know a former rugby or soccer player with dementia? With the Six Nations annual rugby tournament <a href="http://www.independent.co.uk/sport/rugby/rugby-union/international/six-nations-2016-england-pack-goes-back-to-basics-as-eddie-jones-calls-for-forwards-to-stand-up-a6851911.html">getting underway again</a>, it is a sobering thought. </p>
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<h2>What’s the cure?</h2>
<p>We are inevitably only at the beginning of understanding CTE. This will gradually change through programmes of research in sports concussion and the pathology of CTE like my one in Glasgow. As this knowledge grows, targets for treatments might emerge, which may also help us treat other similar degenerative brain diseases such as Alzheimer’s.</p>
<p>In the absence of a full understanding of the risk factors and with no diagnostic tests or treatments, CTE is one condition that seems best managed by the mantra “prevention is better than cure”. The simplest and most effective way of reducing the incidence of this form of dementia might just be to lower the risk of concussion and become better at recognising and managing the injury. </p>
<p>In the meantime, while there may be anxieties about the risks of concussion, there remains no doubt about the lifelong health benefits of sport. As such, my view is that we should continue to encourage wider participation in sport, while promoting better recognition and management of the inevitable concussions. This includes being aware that despite all the technology and research invested in headgear, it <a href="http://bjsm.bmj.com/content/47/5/250.long">still provides</a> no meaningful protection against concussion. But if we approach the problem with the best available knowledge, we can get the benefits of sport while reducing the risks from concussion.</p><img src="https://counter.theconversation.com/content/54139/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>William Stewart is Consultant and Lead Neuropathologist at the Queen Elizabeth University Hospital, Glasgow. He receives research funding from the National Institutes of Health, Department of Defense (US) and NHS Research Scotland. He acts as an unpaid expert advisor on concussion to World Rugby and the Football Association, and is also patron of the Jeff Astle Foundation. </span></em></p>Once the stuff of tweeting birds and rolling cartoon eyes, bumps on the head are now linked to dementia. Will Smith’s latest movie tells how sports authorities tried to cover it up.William Stewart, Honorary Clinical Associate Professor, University of GlasgowLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/389072015-03-19T19:28:53Z2015-03-19T19:28:53ZShould boxing be banned?<figure><img src="https://images.theconversation.com/files/75314/original/image-20150319-1562-13adqmd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">It may be that the seemingly inhumane aim of causing your opponent to lose consciousness by punching them separates boxing from other sports.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/ennuiislife/3415283249">Kate Gardiner/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span></figcaption></figure><p>The <a href="http://www.theguardian.com/australiac-news/2015/mar/17/queensland-boxers-death-prompts-doctors-to-call-for-sport-to-be-banned">death of a 23-year-old boxer</a> has prompted a call by the Queensland branch of the Australian Medical Association for the sport to be banned in Australia. But before we decide whether this is the right response, we should consider what attracts people to participate in and watch high-risks spectacles such as boxing. </p>
<p>Braydon Smith died when <a href="http://www.theguardian.com/sport/2015/mar/16/boxer-dies-less-than-two-days-after-losing-10-round-featherweight-bout">his life support was turned off</a> around two days after he collapsed. He had lost a ten-round fight 90 minutes earlier but had not been knocked out and appeared all right after the fight.</p>
<h1>Not uniquely deadly</h1>
<p>Boxing is not the only sport associated with fatal injuries. But we seem more tolerant of fatalities in other sports; you don’t see calls for their abolition when someone dies. The recent <a href="https://theconversation.com/explainer-what-is-traumatic-brain-injury-and-how-is-it-treated-34697">death of cricketer Phillip Hughes</a> due to a traumatic brain injury led to calls for better helmets, for instance, but no one suggested banning the sport. </p>
<p>Similarly, the death of a young NSW rugby player, Jake Kedzlier, after being struck in the face by a player’s knee led to statements about having weight classes for leagues and it being a “<a href="http://www.foxsports.com.au/nrl/rugby-league-hard-man-tommy-raudonikis-devastated-by-grandsons-death-in-rugby-league-accident/story-e6frf3ou-1226614898982">freak accident</a>”, as though injuries were not inherent in that contact sport.</p>
<p>After controlling for the number of participants in each sport, a <a href="http://www.ncbi.nlm.nih.gov/pubmed/21345432">2012 study from Victoria</a> found motor sports, fishing, equestrian activities and swimming all led to more deaths in a year than boxing, which didn’t even make it into the top ten. <a href="http://www.ncbi.nlm.nih.gov/pubmed/10688484">Another study found</a> motor vehicle accidents and falls were far more likely to kill people than boxing or any other sport. </p>
<p>It may be that the seemingly inhumane aim of causing your opponent to lose consciousness by punching them separates boxing from other sports. And, for some reason, the relatively rare fatalities seem to get far more press than the insidious long-term effects of a career in boxing or other contact or combat sports. </p>
<p>If you’re evaluating the safety of a sport, you have to consider the whole gamut of potential injuries they cause, not just death. Major traumatic injuries, frequently to the head and face, <a href="http://www.ncbi.nlm.nih.gov/pubmed/16076230">are also much more common</a> in motor sports, cycling, skiing, hockey and equestrian activities than in boxing. </p>
<p>Some sports put participants at risk of acute injuries that resolve with proper care (a fractured arm, for instance, or a simple single concussion), while others last for years or a lifetime (damaged knees, or moderate to severe brain injuries). And others still put the person at risk for degenerative illnesses, such as Alzheimer’s disease, which is what faces many boxers. </p>
<p>Some boxers who have suffered numerous blows to head or face that rattled their brain develop what’s called <a href="http://www.ncbi.nlm.nih.gov/pubmed/10949160">dementia pugilistica</a>. This leads to serious problems with memory, attention, speech, balance and emotion regulation. It can cause premature death.</p>
<h2>Responding well</h2>
<p>So why might someone become a professional boxer? Well, professional athletes earn some money, but they also get recognition and the satisfaction that comes from perfecting a physique and skills. And, of course, most people like winning. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/75315/original/image-20150319-1588-1q6dl5f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/75315/original/image-20150319-1588-1q6dl5f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/75315/original/image-20150319-1588-1q6dl5f.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/75315/original/image-20150319-1588-1q6dl5f.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/75315/original/image-20150319-1588-1q6dl5f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/75315/original/image-20150319-1588-1q6dl5f.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/75315/original/image-20150319-1588-1q6dl5f.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">Spectators get caught up in the emotion evoked by the spectacle of sports, such as boxing.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/ennuiislife/3458443298">Kate Gardiner/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span>
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<p>And why might someone pay to watch as two men or women bash each other? Perhaps the boxing crowd gets caught up in the emotion evoked by the spectacle, and any thoughts about civilised behaviour go out the window as they watch what is taboo in other settings. There is no reflection on what the spectacle might mean for those involved when it ends.</p>
<p>The positive emotional experience of the spectator, especially in a crowd, was aptly <a href="http://www.just%20or.org/stable/2763073?seq=1#page_scan_tab_contents">described by social psychologist George Elliot Howard</a> in 1912:</p>
<blockquote>
<p>In the spectator crowd … very undisciplined social instincts or desires … well up from the deep abyss of the unconscious or the subconscious … the elemental gaming instinct slips its leash … the social person (at the boxing match) … is a group of sentiments attached to a symbol. </p>
</blockquote>
<p>Boxing and other spectator sports are commercial enterprises designed to fuel these social psychological needs of the spectator. And some sporting spectacles (think rugby, AFL, for instance, or motor racing and horse racing) with significant financial implications are linked to symbols of national or local pride. These get a pass when it comes to moral or safety issues, even when eventual impairment may be so great that the ex-participants cannot even attend future spectacles.</p>
<p>Finally, is it the role of government to save adults from themselves or should we as a society allow spectacles that include the risk of death? We tend to tolerate the occasional tragedy in recreational activities, such as skydiving or hang-gliding, and even more common favoured sports, such as cricket, rugby or gridiron. </p>
<p>We also defend against thoughts about the true risks involved for all participants, possibly because our psychological or social needs met by the sport outweigh the loss of one combatant. </p>
<p>We might rationalise a tragic event as rare or atypical, blame the person who died for not having sufficient skill, conjure up examples of others in the same sport who never got hurt or focus on the heroic features of the athlete’s history to somehow make the loss meaningful. All these act as defences against accepting that our favourite sport, which symbolises something important for our own sense of self, may actually be brutal and dangerous.</p>
<p>Some people continue to cling to the myth that aggression in sport acts as catharsis for both the combatant and the spectators. And that this aggression would otherwise be expressed elsewhere. But this <a href="http://psycnet.apa.org/psycinfo/1999-13741-004">idea has been wholly refuted</a>.</p>
<p>Rather than banning boxing, a more sensible solution may be to better manage the physical and social environment risk factors posed by it. This may decrease the brutality that attracts some people to the sport, but it will increase the opportunities for life after it for those risking life and limb by participating.</p><img src="https://counter.theconversation.com/content/38907/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr James F. Donnelly has received funding in the past from the Sylvia and Charles Viertel Foundation to develop concussion management programs for schools..</span></em></p>The death of a 23-year-old boxer has prompted a call by the Queensland branch of the Australian Medical Association for the sport to be banned in Australia.James F. Donnelly, Lecturer in Psychology, School of Health and Human Sciences, Southern Cross UniversityLicensed as Creative Commons – attribution, no derivatives.