Traumatic Brain Injury

Between 1.6 million-3.8 million traumatic brain injuries are seen in sports each year in the United States.  The types of traumatic brain injuries include cerebral concussion, diffuse brain injury, second impact syndrome, subdural hematoma, and epidural hematoma.  Although cerebral concussions rarely cause death they can be the starting point for other deadly brain injuries.  Athletes under the age of 15 represent the majority of traumatic brain injuries. Also, in every age group males show a higher rate of traumatic brain injuries than females.


According to the 4th International Conference on Concussion in Sport held in Zurich, November 2012, a concussion is defined as:

“Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces. Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilized by defining the nature of a concussive head injury include:

  • Direct blow to the head, face, neck, or anywhere on the body that produces an “impulsive” force to the head
  • Signs and symptoms are typically rapid in onset and result in short-lived neurological impairment.
  • The clinical symptoms of a concussion reflect a functional disturbance rather than a structural injury, however, neuropathological changes can develop
  • A concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the signs and symptoms typically follows a sequential course, but in some cases, symptoms may be prolonged”

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How do you prevent traumatic brain injury?

The only way to completely prevent a traumatic brain injury (TBI) from occurring during sport is not to participate.  But the other injuries and illnesses that occur due to lack of exercise could have major health implications also.  With that consideration in mind, safe participation in sport by minimizing risks for TBIs from occurring is the best method of prevention.  In terms of prevention of death secondary to TBI, prompt and appropriate recognition, removal from play, and initial monitoring and treatment are the best ways to minimize the risk of death due to TBI during physical activity.

Concussion safety laws for sports are becoming a national trend.  These laws usually mandate appropriate education on recognition and immediate response to injury for coaches, administrators and/or medical staff.  They also commonly require evaluation to be done by appropriate medical staff, which should include athletic trainers and physicians.

Some states also mandate pre-participation (baseline) evaluation for concussion.  This important step takes into account concussion history and other predisposing factors which may make an athlete more prone to future TBIs.  They can help identify athletes who are at high risk for TBI, and disqualify those who are at too high a risk for some sports.  This should be part of a standard pre-participation physical examination (PPE) and can lead to a brief educational opportunity for the athlete on basic signs and symptoms, as well as future problems if a TBI occurs.

For medical care providers, of the mechanisms of injury, how to recognize, treat, and return an athlete to play are of primary relevance for prevention of death due to TBI.  Although appropriate care providers should already have the necessary information for this type of injury, this resource sponsored by the CDC and NFL is comprehensive, and aimed at keeping health care providers up to date on all the most recent and important information related to concussion.

Based on the most updated consensus statement created by a committee of sports medicine professionals at the International Conference on Concussion in Sport, the following steps were recommended for TBI prevention:

  • Protective Equipment- Protective equipment (including mouth guards, helmets, and helmet modifiers) has not been shown to adequately prevent a concussion from occurring.  However, this equipment has a role in preventing other head, face, and neck injuries that could increase an athlete’s risk for death.
  • Rule Change/Risk Compensation- Rule changes related to heading in soccer, tackling and other contact technique, equipment usage, and those relating to medical assessment may be protective in nature.  Rule changes which allow appropriate medical assessment and treatment are imperative for preventing death due to TBI.
  • Aggression/Violence- Appropriate competition and the aggressive nature of some sports is not discouraged, however unnecessary violence or other aspects should be evaluated based on the merit they provide in the sport.  Some aggression or violence, which increases the risk of concussion, could be addressed and discouraged by sporting organizations.
  • Education- The ability to detect and deal with a TBI is enhanced when everyone on the field is looking out for the safety of the athletes.  Education should include the athletes themselves, coaches, administrators, and parents.  It should cover basic tools for recognition, what to do if they suspect a concussion, and the process of treatment and returning to participation.


What puts an individual at risk for traumatic brain injury?

  • Previous concussions: A previous history of a concussion increases the risk of sustaining another concussion on the order of 2-5.8 times greater risk
  • Number, severity and duration of symptoms: Evidence has shown that those who report a greater number of symptoms, or report a greater severity of symptoms or duration may experience a longer recovery than those who experience less severe symptoms.
  • Sex: Research has shown that females experience a higher incidence of concussion in addition to reporting a increased number/severity/duration of symptoms, and prolonged recovery.
  • Age: Young athletes may experience a prolonged recovery from a concussion and may be due to the differences in the developing brain of a child/adolescent compared to that of an adult brain
  • Sport, position, and style of play: Depending on the sport, position, and the athlete’s style of play increases the risk of concussion. In sports where there is player-to-player contact, the risk of concussion increases. The table below outlines the incidence the risk of concussion for various sport.
  • Mood Disorders: Mood disorders such as depression, anxiety, and irritability may complicate both the diagnosis and management of a concussion
  • Learning disabilities and attention disorders: Learning disabilities such as ADD/ADHD or others that result in some form of cognitive dysfunction can complicate the management of a concussion and may lead to a longer recovery time post concussion


Look for these symptoms in athletes when traumatic brain injury is suspected:

A suspected concussion may include any of the above-mentioned points and the associated signs and symptoms of a concussion may include any of the following areas:

  • Physical Signs
  • Behavioral Changes
  • Cognitive Impairment
  • Sleep Disturbance
  • Mechanisms
    • Direct blow to the head
    • “Impulsive forces” on other parts of the body which are transferred to the head
  • Initial signs and symptoms


Signs Symptoms
  • Disorientation, confusion
  • Retrograde/anterograde  amnesia
  • Loss of consciousness
  • Automatism
  • Unequal pupil size
  • Combativeness
  • Slowness to answer questions
  • Loss of balance
  • Atypical behavior/personality changes
  • Vacant stare
  • Nystagmus
  • Headache
  • Nausea
  • Balance issues/dizziness
  • Tinnitus (ringing in the ears)
  • Diplopia (double vision)
  • Blurred vision
  • Trouble sleeping
  • Trouble concentrating
  • Memory issues
  • Irritability, sadness,
  • Sensitivity to light or noise

How do you know if this is traumatic brain injury?

On-Field/Sideline Evaluation:

If a concussion is suspected in an athlete during participation in activity, the following steps should be taken:

  • Any athlete suspected of a concussion should be removed from play immediately and evaluated by a licensed healthcare professional who is trained in the evaluation and management of concussions
  • Recognition and diagnosis of a concussion should be driven by the initial signs and symptoms, cognitive assessment (using tools such as the SCAT3), balance assessment, and further neuropsychological testing
  • Cognitive assessment, using the SCAT3 for example, should include assessment of the Glasgow coma scale, Maddocks Score, Standardized Assessment of Concussion (SAC): immediate memory, concentration, and delayed recall, balance testing (using a modified BESS test), and coordination test (using the finger to nose test)
  • The athlete suspected of a concussion is not permitted to return to activity on the same day as injury
  • Continued monitoring of an athlete evaluated of having a concussion is necessary in order to observe any deterioration of physical or mental status (which warrants transport to local healthcare facility)


Emergency Room or other Medical Care Facility:

If an athlete has sustained a suspected concussion and the first point of contact is at either a medical facility or emergency department, the following steps should be taken for evaluating the injury:

  • The medical evaluation should include a detailed history of the injury, mechanism, signs and symptoms, a detailed neurological examination, cognitive assessment, and assessment of mental status
  • Determining the status of the patient and whether or not mental status has deteriorated sign initial insult of injury. It may be necessary to get information from persons present at the time of injury (coaches, parents, teammates, other witnesses)
  • Determining whether or not the athlete needs further neuroimaging to rule out a more severe brain injury (subdural/epidural hematoma, skull fracture, etc)


  • Orientation
  • Cranial Nerves
  • Sensation
  • Coordination
  • Balance
  • Memory
  • Gait
  • Exertional Provocative Test


What else could this be?

  • Intracranial hemorrhage
  • Subdural hematoma
  • Epidural hematoma
  • Skull Fracture
  • Second impact syndrome
  • Heat illness
  • Drug overdose or interaction


How do you treat an individual with traumatic brain injury?

  • Physical and Cognitive rest: Physical and Cognitive activities that result in an increase in symptoms should be avoided during the acute phase of concussion treatment
  • Medications that mask the symptoms of a concussion (NSAIDS, Aspirin, stimulants, and antidepressant) should be avoided, especially in the acute phase of the injury.
  • The use of acetaminophen may be considered in treating symptoms such as headache but should be used after the acute phase of the injury
  • Athletes sustaining a concussion should have a follow-up appointment with their general practitioner to evaluate the mechanism of injury, the course of symptoms, and any previous history of concussive injuries.


When can the individual return to activity?

Return to play following a concussion should follow a graded return to play protocol. This protocol should consist of 5-7 stages and take 5-7 days to complete (if there is no recurrence of symptoms). The graded return to play protocol should begin once the athlete has a cessation of symptoms for at least 24 hours. An athlete must be prohibited from returning to activity if they are still experiencing symptoms.

The goal of the return to play protocol is to progressively increase the duration and intensity of exercise to ensure that there is no return of symptoms with physical exertion. See the table below to see an example of a 6-stage return to play protocol.


Table 2. Adapted from: Mihalik JP, Guskiewicz KM. Brain Injuries. In: Casa DJ, ed. Preventing Sudden Death in Sport and Physical Activity. Sudbury, MA: Jones & Bartlett Learning. 2012: 79-100.

Rehabilitation Stage

Functional Exercise at each Stage of Rehabilitation

1.  No activity Complete physical and cognitive rest
2.  Light aerobic exercise Walking, swimming, or stationary cycling keeping intensity <70%
No resistance training
3.  Sport specific exercise Skating skills in ice hockey, running drills in soccer,
No head impact activity
4.  Non-contact training drills Progresion to more complex training drills (eg: passing drills in football and ice hockey)
May begin progressive resistance training
5.  Full-contact practice Following medical clearance, participate in normal training activities
6.  Return to play Normal game play


If at any point during the return to play protocol the athlete experiences a return of any symptoms, that particular stage should be terminated and the athlete should regress to the previous asymptomatic stage the following day and then work forward.

In the instance of returning to school, if an athlete experiences an increase in symptoms with the increased cognitive stress associated with school, the athlete may be considered for academic accommodations, which may include:

  • Reduced workload
  • Extended test-taking times
  • Shortened school day


Recommended Equipment List

  • Prevention
    • Properly fitted helmet
    • Custom mouthguard
  • Testing/Management
    • Baseline testing software
    • Pen light
    • Foam pad (balance testing)
    • Reflex hammer


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