When we discuss school athletes at risk for concussions, the first sports that usually come to mind are high-impact ones—especially football. In a 2020 study from the Michigan-based Henry Ford Health System’s Sports Medicine Research team, records of 357 high school athletes who sustained concussions between ages 14 to 18 were studied between 2013 and 2016. The researchers found that of those students (62% of which were male), 27.7% of the reported concussions were related to football. That’s slightly more than a quarter of the cases. Where were all the other concussions happening?
Concussion Rates by School Athletic Activity
The Henry Ford study, published in the journal Orthopedics, had some surprising concussion statistics. The sports with the highest incidences of concussions in among the students studied were:
- Football: 27.7%
- Hockey: 21.8%
- Soccer: 17%
- Basketball: 9%
- Cheerleading: 4.2%
For comparison, and earlier study from 2019 examining 9,542 reported high school concussions had a somewhat similar breakdown. Data originated from the National High School Sports-Related Injury Surveillance System. The data came from the 2013–2014 to 2017–2018 academic years and originated from a random sample of approximately 100 high schools. Of the reported incidents examined, these were the top sports with the highest concussion rates per 10,000 athlete exposures:
(Infographic courtesy of our friends at ImPACT Applications, Inc.)
Concussions Don’t Need Player-on-Player Collisions to Occur in Athletics
In the previously mentioned Henry Ford study, an eye-opening 20.3% of concussions happened in various “other” team sports—meaning sports other than the ones that typically come to mind when we think of head injuries, meaning football, hockey, soccer, basketball, cheerleading. This makes sense when you consider another study reported in Pediatrics that looked at the types of impacts causing traumatic brain injuries (TBIs) in student athletes and was conducted by researchers from the Department of Exercise and Sport Science at the University of North Carolina at Chapel Hill. While approximately 62% of concussions were attributed to contact with other players, not all were. An additional 17.5% of concussions were associated with contact with a surface, and another 16% were a result of contact with equipment. It’s clear that head injuries can occur in any school sport, and that the protocols we utilize for assessment and treatment are equally as important regardless of the nature of the trauma.
Concussions in Cheerleading Are More Frequent Than Many Would Think
“It is a bit alarming to see that the researchers in the Pediatrics study found the concussion rate for the cheerleaders in the study were lower during competitions than during practices,” says Dr. Vincent Schaller, M.D., DABFM, CIC, founder of Mid-Atlantic Concussion Alliance. This did not happen in any other sports that the study looked at. “I think there are two big takeaways from that. One, we should be evaluating the safety measures that are in place during cheerleading practice: the location, protective surfaces, protective equipment, adult supervision, etc. Two, cheerleaders should be baseline tested prior to the start of pre-season practice to make sure we have a healthy brain “roadmap” to compare to in the event of a head injury.”
What Is a Concussion?
The word concussion comes from the Latin “concutere” which means to shake violently. A concussion is a traumatic brain injury that occurs as a result of a bump, blow or even jolt to the head (as in whiplash). The sudden movement can cause a release of chemicals from nerve cells that temporarily affect how the brain functions. Contrary to what some might think, student athletes don’t have to be knocked unconscious to have a concussion. And, unfortunately, even mild concussion (mild traumatic brain injury, or mTBI) can result in long-term health issues if the concussion isn’t properly diagnosed and treated.
Is there a difference between TBI and mTBI?
“Concussions were initially classified as mild traumatic brain injuries, or mTBI’s. But with the latest technologies including BrainScope One EEG, RightEye infrared eye tracking and neurocognitive testing with ImPACT and CBS Health testing, we now can quantify objective measurements documenting visual, vestibular, ocular and cognitive deficits months—and even years—after injury,” Says Dr. Schaller. “So it must be clearly understood that all concussions are indeed traumatic brain injuries, and if the notably measurable objective deficits from the concussion are long term—weeks, months or years—then the TBI is not really ‘mild’.”
Education, Awareness and Management of Concussions in School Sports
Concussions are a possibility in any school sport. Regardless of what activities were going on when they occurred, it’s important that TBIs be properly addressed so that student athletes fully recover before resuming play. While most concussions will resolve withing a week to ten days, some take several weeks or months more. Sometimes symptoms can even take longer than that to resolve. Reinjury during the period when the brain is still healing can mean an increase in the risk of:
- Persistent post-concussive symptoms and long-term issues
- Permanent brain injury
- The rare, but usually fatal second impact syndrome
Perhaps thanks to a population of better-informed coaches, athletic trainers, parents and the young athletes themselves, rates of repetitive concussions in student athletes seems to be dropping. The Pediatrics study reported a reduced rate of recurrent sports-related concussions was found from 2013 to 2018. This is a positive trend that Dr. Schaller thinks may be also partially attributed to better state-legislated concussion guidelines, closer monitoring of athletes and more clinical evidence being utilized when it comes to return-to-play decision making.
“Years ago, there was no real protocol when it came to concussions, but we have made great inroads with our schools, athletic trainers and parents, who are more aware of our focus on safety,” notes Dr. Schaller. “Better access to baseline testing gives us a comparative tool to help make return-to-play decisions more accurate.”
Concussion Awareness is Growing
According to the Society of Health and Physical Educators (SHAPE) every state in this country has some form of legislation regarding sports-related concussion and requires medical clearance before student athletes may return to play. This is a good start.
Unfortunately, many state return-to-play requirements are too ambiguous. SHAPE’s website notes that while all states require medical clearance before a student may return to play, what kind of healthcare professionals are legally allowed to provide medical clearance varies from state to state. Additionally, only some states specify that such clearance must be given in writing, while many states do not.
Brain Rest with Gradually Increased Physical Activity is Common Concussion Protocol
Sometimes athletes hesitate to honestly admit to their coaches that they are experiencing symptoms. In these instances, the athlete, if not pulled from play, can risk a repeated concussion before the brain is properly healed, resulting in possible long-term damage.
“At MAC Alliance, we actively treat concussion so the brain has adequate time to heal following the guidelines of the UPMC Sports Medicine Concussion Program,” says Dr. Schaller. While brain rest protocol normally includes resting the brain by refraining from taxing mental work (such as academics, gaming and internet surfing), Dr. Schaller also notes, “Some form of exercise, under the direction of a medical professional, is also important. We encourage walking, getting outdoors, limited driving, etc., to keep our patients moving. We also advise our post-concussion patients: no jogging, no sweating, no prolonged travel, no excessive heat or light exposure, etc.”
5 Basic Stages of Post-Concussion Physical Rehabilitation
When it comes to athletes, medical providers consider post-concussion physical rehabilitation to have five basic stages. They include:
- Participating in light aerobic activity (walking, stretching)
- Slightly more strenuous light aerobic activity (brisk walking, for instance or strength training)
- Moderate training (no head impact activities)
- Non-contact physical training or heavy exertion
- Full return to play
Post-Concussion Management Is Not One-Size-Fits-All
Concussion management for student athletes means teamwork between the athlete, parents, school trainers and medical professionals. While taking time off from an activity is helpful and a majority of concussions will heal within about two weeks, keep in mind that student athletes may take longer to recover than adults. The amount of cognitive and physical rest, and ultimate return to full physical activities, is best determined by medical professionals with comparative brain health tools. Be sure to give your medical team the feedback and cooperation necessary for a full recovery.
Dr. Schaller feels strongly that student athletes should not be cleared for return to play unless they can clearly demonstrate improvement in post-injury neurocognitive testing. “Whether your child is a football player, a cheerleader or a golfer, we need to take into consideration not just self-reported feelings of being ‘back to normal,’ but brain health testing scores to determine whether complete recovery has been fully met,” says Dr. Schaller. “We all want kids to get back to the sports and activities they love, but we need to make sure it’s safe to do so.”
— reporting by Faith R. Foyil
