Concussion in sport is a controversial topic and one where advice is likely to change over time. Whilst research into this area is increasing, there are still many unknowns as to the longer-term outcomes of concussion on brain function and degenerative brain disease, including chronic traumatic encephalopathy (CTE).
Having been involved in managing concussion in elite sports since 2002, I have personally observed concussion to be generally well managed by specialist sports medicine doctors, as it continues to be. Despite this observation, ongoing adherence to “best practice protocols” and latest scientific evidence is critical. Doctors are not immune to mistakes, pressure, or other influences, and the concussion debate may also be skewed by commercial interests, litigation, and the media, including social media. The ongoing Australian Senate inquiry into “Concussion and repeated head traumas in contact sports” continues to investigate this issue.
I’ve heard, and read, many definitive statements about concussion and the consequences of concussion from multiple sources that, whilst logical, may not have adequate scientific evidence to establish as fact. In the medical field, there is also a large amount of advice and information that is essentially “expert opinion”.
I’m adding my “expert opinion” to this but that doesn’t mean I’m right. My aim is to try to balance the discussion, and to focus on concussion prevention.
There is increasing scientific evidence that repeated documented concussions are associated with degenerative brain disease. What should be stated is that there are many confounders to this, with multiple other factors potentially contributing, and this may explain why some athletes develop degenerative brain disease and others do not. Remember that degenerative brain disease, sadly, is also relatively common in the non-athletic population with ageing. I’m not saying that the association is not there, just that other influences may contribute and should be considered.
Whilst degenerative brain disease, including chronic traumatic encephalopathy (CTE), is associated with concussion, other factors that possibly contribute include:
· genetic predisposition (e.g. apoE4 gene marker)
· other trauma through a lifetime (e.g. falls, or motor vehicle accidents)
· medications, drugs, and alcohol (e.g. drug and alcohol abuse, smoking and vascular/ blood vessel disease, sedative/ sleeping pill abuse, or multiple general anaesthetics with surgical procedures)
It appears obvious that repeated concussions in sport may cause degenerative brain disease, but they may not, and they may not necessarily cause this in everyone.
As has been said, “if medicine were logical, it would be easy.” It is neither.
With so many unknowns, prevention of head trauma and concussion should always be the priority but is not entirely possible in life, as in sporting activities. Sporting activities, including contact sports, have many physical, mental, and social benefits for the individual athlete and, in general, sports participation should be encouraged. So, with this in mind, what may assist in increasing safety, and preventing concussion in sport?
There is no conclusive scientific evidence for any measure definitively reducing personal episodes of concussion. Despite this, having the best available medical care is useful for when injuries occur, and assessment of individual risk factors such as tackling technique or playing style may be worthwhile pursuing.
Rule changes, and enforcement of rules around head contact (e.g. head-high tackling, and head slams into the ground), should reduce overall head impact episodes across competitions. Padding hard surfaces such as goal posts, or surrounding fences or other hard structures, is a practical preventative measure.
There is also increasing scientific evidence that repetitive heading of the soccer ball/ football may increase the overall rate of dementia in later life and, as a result there should be sensible limits around heading in young players regarding age of starting heading (currently suggested starting age 12 years old), and frequency, intensity, and duration of heading drills in training. Coated soccer balls/ footballs minimise waterlogging with increased ball weight and should reduce concussion episodes.
Neck muscle strengthening is a relatively simple method to potentially reduce impact force transmission to the brain with contact injuries, but this evidence is mainly from animal studies (e.g. primates/ chimpanzees).
Mouth guards can reduce the rate of dental and facial injuries, and theoretically may reduce force transmission from the jaw to the brain, but there is no conclusive evidence in reducing concussion.
Soft headgear can reduce scalp lacerations/ cuts but do not reduce concussion episodes.
In sports with use of hard projectiles (e.g. baseball, cricket) or played on hard surfaces (e.g. ice hockey, gridiron/ American football), helmets can reduce overall traumatic head injuries although not necessarily episodes of concussion. Helmets may, in fact, increase the overall head surface area and potentially increase rotational forces on the brain. Wearing a helmet may also increase risk taking playing behaviour and increase the number of blows to the head and, perhaps, this is why there is such a high rate of chronic traumatic encephalopathy (CTE), a degenerative brain disorder, associated with repeated concussions in American football/"gridiron". It should be noted that the American Academy of Science in 2022 ruled that there was a causal link between repeated concussions and chronic traumatic encephalopathy (CTE) whereas the Concussion in Sport Group (CISG) that represents FIFA and the IOC has not currently endorsed this view.
Specifically in boxing, having the apoE4 gene marker is a risk for poor outcomes after sustaining moderate to severe brain injury, and is also a risk factor for developing chronic traumatic encephalopathy (CTE). Screening for the apoE4 gene is uncommon but could possibly assist in personal education about risks associated with head injury in sports.
For more information, including concussion management, see the "Concussion" section in the FixitDoc app.
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