section name header

Basics ⬇

Author: Marc P.Hilgers, MD, PhD, FAAFP

Description

  • Sport-related concussion (SRC) is a traumatic brain injury (TBI) induced by biomechanical forces.
  • The clinical signs and symptoms cannot be explained by drug, alcohol, or medication use; other injuries (e.g., cervical injuries, peripheral vestibular dysfunction); or other comorbidities (e.g. psychological factors or coexisting medical conditions).
  • Several common features that may be used in clinically defining the nature of a concussive head injury include:
    • SRC may be caused either by a direct blow to the head, face, neck, or elsewhere on the body with an impulsive force transmitted to the head.
    • SRC typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously. However, in some cases, signs and symptoms evolve over a number of minutes to hours.
    • SRC may result in neuropathologic changes, but the acute clinical signs and symptoms largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies.
    • SRC results in a range of clinical signs and symptoms that may or may not involve loss of consciousness (LOC). Resolution of the clinical and cognitive features typically follows a sequential course. However, in some cases symptoms may be prolonged (1).
    • Synonym(s): mild TBI; minor head trauma; commotio cerebri; MTBI; mild TBI, SRC

Epidemiology

  • 207,830 emergency department (ED) visits for nonfatal sports-related TBIs per year between 2001 and 2005 (2)
  • In 2012, an estimated 329,290 children (age 19 yr or younger) were treated in U.S. EDs for sports and recreation-related injuries that included a diagnosis of concussion or TBI (3).
  • 1.6 to 3.8 million concussions per year in the United States; falls, motor vehicle accidents, and assaults being the most common etiologies
  • 20% are sports related, but percentage is higher in adolescents.
  • Adolescents (aged >11 yr) percentage of concussions related to sports activity is much greater (41%) than for younger children (8%) (4,5,6,7).
  • Before age 10 yr, children tend to sustain concussions primarily from non–sports-related falls and then transition to sports-related injuries after age 10 yr (4,5,6,7).
  • Limitations in that data only evaluate certain organized sports and do not include all sports or recreational activities.
  • There might also be some overreporting of concussions because many athletes, parents, health care providers do not know what exactly a concussion is, and therefore might make that diagnosis when something else is more likely.
  • The incidence may be higher because athletes, coaches, or medical providers may fail to recognize the signs and symptoms of a concussion or athletes try to minimize the symptoms in order to continue to play (8,9).
  • Self-reported concussion rates have not changed significantly, but the rate at which athletes report suspected concussions has increased significantly (78.6% in 2013 vs. 47.3% in 1999 to 2002) (10).
  • In a study of high school and collegiate athletes, almost 3/4 withheld information about a concussion because they did not think their symptoms needed medical care. Almost 2/3 wanted to avoid being withheld from play, and a little >1/3 simply lacked understanding of concussion (10).
  • Possible underreporting of concussion especially in children because many do not seek medical care (9)
  • Some evidence of a higher reported incidence of concussion in female high school and college athletes even when comparing the same sports; the reason is unclear but could be due to more honest reporting of concussion in females (9,11).
  • 572 concussions per year for college athletes between 1988 and 2004 (12)
  • 54.8% of the total concussions during that period of time occurred in American football (12).
  • Women’s soccer, men’s ice hockey, men’s soccer, and women’s basketball each represented between 5% and 7% of total college concussions for the same time period (12).
  • Given the limitations in epidemiology, more research is necessary addressing SRC in all populations.

Etiology and Pathophysiology

  • Complicated pathophysiology that is incompletely understood (9,13,14)
  • Impact and resulting forces create shear injury to vessels and neurons (9,14).
  • Biochemical chain reactions are set in place, some of which may involve the release of excitatory amino acids (9,14,15).
  • Resulting decrease in cerebral metabolism occurs (9,14,15).
  • Temporarily decreased cerebral blood flow
  • Alternatively, the blow may create immediate neuronal depolarization followed by a refractory period where neural transmission does not happen (14).

Risk-Factors

  • The most consistent risk predictor of slower recovery is the severity of the acute and subacute symptoms. Subacute headaches (HAs) or depression is likely a risk factor for persistent symptoms lasting a month or more. Preexisting mental illnesses also appear to have a greater risk for persistent symptoms. Contrary to prior belief, a learning disability or ADHD does not appear to carry a substantially greater risk. Teenage years, in particular high school, might be the most vulnerable time period for having persistent symptoms, with greater risk for girls than for boys (16); participation in contact and collision sports (2,8,9,12)
  • An athlete with more than one previous concussion may be more likely to have a repeat concussion or any other injury than an athlete without a history of a concussion (8).
  • Improper technique (e.g., leading with the head, or “spearing,” in football) (12), heat exposure (17)
  • Investigations ongoing as to the significance of apolipoprotein (Apo) E4, ApoE promoter gene, tau polymerase, and others in concussion (13,14)

General Prevention

  • Helmets are not designed to prevent concussions but instead to prevent skull fractures.
  • Mouth guards do not prevent concussion but do decrease dental and orofacial injuries (9,13,18).
  • Rules that promote safe and proper techniques (e.g., outlawing “spearing” in football, leading with the head, and head-to-head contact) should be coached and enforced to limit concussion (12,13,15).
  • Encourage fair competition but discourage violent behavior in sports, especially among young athletes (13).

Diagnosis ⬆ ⬇

  • SRC is a TBI induced by biomechanical forces.
  • The diagnosis of a concussion is a clinical assessment.

History

  • Direct blow to the head, sudden rotational or acceleration–deceleration force to the head in the absence of direct trauma, or transmitted force to head from blow to other body parts (19)
  • Athletes often fail to recognize or report their symptoms. Concussion should be considered in anyone demonstrating signs of a concussion (1,9).
  • Standardized symptom checklists such as the one found in the Sport Concussion Assessment Tool 5 (SCAT5 or Child SCAT5) that allow the athlete to score his or her complaints on a scale of 0 to 6 may be useful when evaluating the concussed athlete (1,13)[C].
  • Athletes may complain of any of the following: HA or neck pain; feeling off-balance or dizzy; nausea or vomiting; problems with vision or hearing including ringing in the ears; confusion; slowness, fatigue, or sleepiness; irritability or other emotional problems; concentration difficulty; memory problems; “dinged”; “dazed”; or “don’t feel right” (8)[B].
  • Prospectively validated symptoms include HA, dizziness, blurred vision, attention deficit, memory problems, and nausea (8)[A].
  • On-field:
    • Use of SCAT5, providing standardized on-field and off-field assessment of SRC
    • Address airway, breathing, and circulation (ABCs) (9)[C].
    • Consider cervical spine (C-spine) immobilization (all unconscious athletes should have C-spine immobilization) (9)[C].
    • In general, do not remove the helmet in football or ice hockey players if C-spine injury is suspected (19)[C].
    • Prehospital helmet removal might be indicated if (20):
      • The helmet and chin strap fail to hold the head securely.
      • The helmet and chin strap design prevent adequate airway control, even after facemask removal.
      • The facemask cannot be removed.
      • The helmet prevents adequate proper immobilization for transport.
    • Assess level of consciousness with the Glasgow Coma Scale (GCS) as part of the SCAT5 (19)[C].
    • Evaluate for other trauma such as skull fractures (including basilar skull fractures) or lacerations (19)[C].
    • Perform a neurologic exam, including cognitive evaluation and balance assessment (19)[C].
    • Conscious athletes in whom C-spine trauma is not suspected may exit the field and undergo a more thorough exam (19)[C].
    • Immediately transfer athletes with prolonged LOC, focal neurologic deficits, including asymmetric pupils and declining GCS or worsening symptoms, athletes with comorbidities (e.g., hemophiliacs), and those with persistent vomiting (8)[C].

Physical Exam

  • The suspected diagnosis of SRC can include one or more of the following clinical domains:
    • Symptoms: somatic (e.g., HA), cognitive (e.g., feeling like in a fog), and/or emotional symptoms (e.g., lability)
    • Physical signs (e.g., LOC, amnesia, neurologic deficit)
    • Balance impairment (e.g., gait unsteadiness)
    • Behavioral changes (e.g., irritability)
    • Cognitive impairment (e.g., slowed reaction times)
    • Sleep/wake disturbance (e.g., somnolence, drowsiness)
  • Remove a player who shows any signs or symptoms of an SRC:
    • The player should be evaluated by a physician or other licensed health care provider on site using standard emergency management principles, and particular attention should be given to excluding a C-spine injury:
      • The appropriate disposition of the player must be determined by the treating health care provider in a timely manner. If no health care provider is available, the player should be safely removed from practice or play and urgent referral to a physician arranged.
      • Once the first aid issues are addressed, an assessment of the concussive injury should be made using the SCAT5 or other sideline assessment tools.
      • The player should not be left alone after the injury, and serial monitoring for deterioration is essential over the initial few hours after injury.
      • A player with diagnosed SRC should not be allowed to return to play (RTP) on the day of injury (1).
  • The SCAT5 was developed by the 5th International Conference on Concussion in Sport and incorporates two prospectively validated tests, the Maddocks score and the Standardized Assessment of Concussion (SAC), into a comprehensive tool (8,13,21).
  • The on-field includes a C-spine assessment, GCS, Maddocks, and observable signs.
  • The off-field includes history, GCS, SAC with now 5 to 10 words, the Modified Balance Error Scoring System (m-BESS) and a new neurologic screening exam, as well as disposition recommendations, RTP, and Return to learn sections (1).
  • The SCAT5 should not be used as the only tool to diagnose concussions, to determine whether recovery has occurred, or to decide when to allow an athlete to RTP (13,21)[C].

Differential Diagnosis

  • Subdural hematoma, which may be acute or subacute (22)
  • Epidural hematoma, which can result in rapid deterioration after a “lucid interval” (22)
  • Intraparenchymal hemorrhage (22)
  • Diffuse axonal injury (DAI) or shear injury to white matter that leads to prolonged LOC and often causes residual deficits (22)
  • Second impact syndrome (SIS) is a rare yet often fatal process that occurs when an athlete who has not recovered completely from one concussion sustains a second blow to the head. Cerebral edema and increased intracranial pressure result. The patient can decline rapidly as cerebral herniation occurs (9).
  • Other medical conditions, including trauma-induced migraine, peripheral vestibular dysfunction, C-spine injury, medical or psychological comorbidities

Diagnostic Tests & Interpretation

Initial Tests (lab, imaging)

  • Research conducted on more severe head injury suggests that many genetic and cytokine factors are induced (23).
  • As yet, the significance of these factors in concussion is not fully known, and no routine laboratory testing is recommended (23).
  • Cranial computed tomography (CT) scan: useful in acute imaging to rule out intracranial bleed. Consider if prolonged LOC or if symptoms are worsening or failing to resolve in a timely manner (1,8,13)[C].
  • The Centers for Disease Control and Prevention (CDC) recommends against routine CT scans (in pediatric patients) (24).
  • Imaging usually contributes little to routine concussion management (1,8,13).
  • Magnetic resonance imaging (MRI) modalities such as gradient echo and perfusion and diffusion imaging may diagnose structural lesions better than CT scan, but routine use of MRI does not add to concussion evaluation (1,13)[C].
  • Functional MRI (fMRI) may illustrate degree of symptoms and their resolution but is not yet part of standard concussion management (1,13).
  • Experimental imaging technology includes positron emission tomography (PET), diffusion tensor imaging, MRI spectroscopy, magnetoencephalography (MEG), and functional connectivity (1,13).

Diagnostic Procedures/Other

  • Neuropsychological (NP) testing can be used to assess cognitive function and help with RTP decisions (1,13)[A].
  • Usually, but not always, conducted when the athlete is asymptomatic as a final measure before clearance for RTP (8)[C]
  • Cognitive function often resolves after other symptoms, so NP evaluation can add helpful information but sometimes athletes will have normal NP tests despite being symptomatic (1,13)[A].
  • Should not be used as the only factor in deciding if an athlete should RTP (1,8,13)[C]
  • Consider in the case of a concussion with modifiers/risk factors (1,13)[C].
  • Computerized NP tests facilitate administration and interpretation (1,8).
  • Most computerized test results include a postconcussion symptom scale, attention, memory, processing speed, and reaction time measures (8).
  • Comparing preinjury NP baseline testing with postinjury testing is helpful but not necessary. Using a test that accounts for confounding factors (e.g., a practice effect) that occur with serial tests is critical (1,8,15,25)[C].
  • The Reliable Change Index describes test–retest reliability and is a feature available with computerized tests (25).
  • A neuropsychologist may administer other formal NP testing if necessary; neuropsychologists are typically the most qualified to interpret NP tests (1,13)[C].
  • Vestibular testing may add valuable information, especially when the athlete is showing signs of postural instability (13)[A].
  • The BESS evaluates the ability of a person to hold without “error” three positions (legs together, single-leg stance, and tandem stance) with eyes closed and hands on the hips. The test is conducted on a firm and a foam surface and can be performed on the sideline or in the training room (8).
  • BESS has been prospectively validated (8)[A].
  • BESS has a demonstrated practice effect.
  • An m-BESS is one component of the SCAT5.
  • More advanced, computer-based vestibular testing can be done in an office setting for more objective data.

Treatment ⬆ ⬇

  • Base treatment on an individual basis according to the burden, nature, and duration of symptoms and other individual factors (e.g., other preexisting medical and psychological factors, sport, position).
  • On-field management as above (1,8,13,19)[C]
  • Patient monitoring:
    • A patient should not be left unsupervised following a concussion (1,13)[C]. There is no indication for the need to wake up the patient from sleep, which had been recommended historically.
    • A patient should be monitored for the following: focal neurologic deficit, declining mental status or LOC, and uncontrolled vomiting (8)[C].
    • Emergent medical care should be sought if any of the preceding occur (8)[C].

Ongoing Care ⬆ ⬇

Follow-up Recommendations

  • After sustaining a concussion, an athlete should be evaluated by a medical professional prior to RTP (19)[C].
  • Acetaminophen may be used to treat HA or other pain, but nonsteroidal anti-inflammatory drugs (NSAIDs) and aspirin should be avoided initially.
  • Athletes also should avoid sedating medicines or substances such as alcohol that may affect cognitive function. There is currently insufficient evidence that prescribing complete rest achieves the desired objectives. After a brief period of rest during the acute phase (24 to 48 hr) after injury to ease discomfort and to promote recovery by minimizing brain energy demands, patients can be encouraged to become gradually and progressively more active while staying below their cognitive and physical symptom-exacerbation thresholds (i.e., activity level should not bring on or worsen their symptoms). It is reasonable for athletes to avoid vigorous exertion while they are recovering. The exact amount and duration of rest is not yet well defined in the literature and requires further study (21).
  • After the symptoms have started to resolve without the use of medicine to mask complaints and an athlete sees a medical provider, a gradual RTP process as well as a return to academics is typically recommended. It is important to be honest about the presence of symptoms because there is some evidence that if someone is incompletely recovered from a concussion and sustains another blow to the head, SIS, a rare yet often fatal process, can occur (9,21,26).
  • The 5th International Concussion in Sport Consensus Statement reviews RTP and return to academics (1).
  • RTP/return to academics:
    • At present, it is reasonable to conclude that the large majority of injured athletes recover, from a clinical perspective, within the 1st mo of injury (1).
    • A six-step graduated RTP protocol is endorsed in the work of the Concussion in Sport Group and by the American College of Sports Medicine (1,13,15,27,28)[C].
    • Athletes progress through each step for a period of at least 24 hr. Before moving forward in the protocol, athletes must be asymptomatic and not taking any drugs that would change or hide their symptoms.
    • If symptoms develop at one stage, the athlete should stop the attempt. Another attempt to progress to the next level can occur the following day.
    • The six steps are as follows: no activity, light aerobic exercise, sport-specific training, noncontact training drills, full contact practice, and RTP.
    • A similar step-by-step protocol should be used to reintroduce academics into the concussed patient’s life. One of those protocols could include (each involving no [increased] symptoms for at least 24 hr):
      • Passive participation for a half day, passive participation for a full day, own note taking, taking homework, untimed tests, full participation.

Prognosis

  • For most athletes, cognitive deficits, balance, and symptoms improve rapidly during the first 2 wk after injury. There is a sizeable minority of youth, high school, and collegiate athletes who take much longer than 10 days to clinically recover and return to sport.
  • 70% of school-aged children show symptom resolution in 28 days (29).

Complications

  • Mental illness (depression has been most frequently studied) is reported in retired former professional football players at higher incidence in those with a history of three or more concussions compared with those without (13,30,31,32).
  • Mental health issues are common in adolescents and young adults, and often present at this time, despite no involvement in contact or collision sport.
  • Chronic traumatic encephalopathy or cognitive impairment is more common in the brains of retired National Football League (NFL) players who donated their brains postmortem (33).
  • A small number of patients may develop postconcussion syndrome (PCS) (14,34).
  • There are limited data on the incidence and characterization of PCS, especially with respect to sports-related concussions (14,35).
  • PCS is characterized by persistent cognitive trouble (concentration deficits, memory difficulty), physical complaints (HA, fatigue), or emotional disturbances (irritability, depression) (22,34).
  • NSAIDs and antidepressants are used commonly to treat PCS, and psychological treatment might become necessary (35).
  • Athletes should not RTP when still symptomatic (1,8,9,13,15,27,28).
  • No evidenced-based guidelines exist for temporary or permanent disqualification after concussion (21).
  • Retirement from sports participation may be considered in the case of continued symptoms or objective exam findings, situations where a lesser impact creates concussion symptoms and the athlete takes longer to recover, or when an athlete sustains multiple concussions (21). These decisions must be individualized.

Additional Reading ⬆ ⬇

References ⬆ ⬇

Inter-Association Task Force for the Appropriate Care of the Spine-Injured Athlete. Prehospital care of the spine-injured athlete. http://www.nata.org/statements/consensus/NATAPreHospital.pdf. Accessed November 14, 2018.

  1. McCrory P, Meeuwisse W, Dvořák J, et al. Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med. 2017;51(11):838–847.
  2. Goldberg LD, Dimeff RJ. Sideline management of sport-related concussions. Sports Med Arthrosc Rev. 2006;14(4):199–205.
  3. Coronado VG, Haileyesus T, Cheng TA, et al. Trends in sports- and recreation-related traumatic brain injuries treated in US emergency departments: the National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP) 2001-2012. J Head Trauma Rehabil. 2015;30(3):185–197.
  4. Meehan WP III, Mannix R. Pediatric concussions in United States emergency departments in the years 2002-2006. J Pediatr. 2010;157(6):889–893.
  5. Bakhos LL, Lockhart GR, Myers R, et al. Emergency department visits for concussion in young child athletes. Pediatrics. 2010;126(3):e550–e556.
  6. Buzzini SR, Guskiewicz KM. Sport-related concussion in the young athlete. Curr Opin Pediatr. 2006;18(4):376–382.
  7. Karlin AM. Concussion in the pediatric and adolescent population: “different population, different concerns.”PM R. 2011;3(10Suppl 2):S369–S379.
  8. Meehan WP III, Bachur RG. Sport-related concussion. Pediatrics. 2009;123(1):114–123.
  9. McCrea M, Hammeke T, Olsen G, et al. Unreported concussion in high school football players: implications for prevention. Clin J Sport Med. 2004;14(1):13–17.
  10. LaRoche AA, Nelson LD, Connelly PK, et al. Sport-related concussion reporting and state legislative effects. Clin J Sport Med. 2016;26(1):33–39.
  11. Hootman JM, Dick R, Agel J. Epidemiology of collegiate injuries for 15 sports: summary and recommendations for injury prevention initiatives. J Athl Train. 2007;42(2):311–319.
  12. McCrory P, Johnston KM, Mohtadi NG, et al. Evidence-based review of sport-related concussion: basic science. Clin J Sport Med. 2001;11(3):160–165.
  13. Centers for Disease Control and Prevention. Nonfatal traumatic brain injuries from sports and recreation activities—United States, 2001–2005. MMWR Morb Mortal Wkly Rep. 2007;56(29):733–737.
  14. McIntosh AS, McCrory P, Finch CF, et al. Does padded headgear prevent head injury in rugby union football?Med Sci Sports Exerc. 2009;41(2):306–313.
  15. Aubry M, Cantu R, Dvorak J, et al. Summary and agreement statement of the First International Conference on Concussion in Sport, Vienna 2001. Recommendations for the improvement of safety and health of athletes who may suffer concussive injuries. Br J Sports Med. 2002;36(1):6–10.
  16. Iverson GL, Gardner AJ, Terry DP, et al. Predictors of clinical recovery from concussion: a systematic review. Br J Sports Med. 2017;51(12):941–948.
  17. Sakurai A, Atkins CM, Alonso OF, et al. Mild hyperthermia worsens the neuropathological damage associated with mild traumatic brain injury in rats. J Neurotrauma. 2012;29(2):313–321.
  18. Concussion (mild traumatic brain injury) and the team physician: a consensus statement. Med Sci Sports Exerc. 2006;38(2):395–399.
  19. McCrory P, Makdissi M, Davis G, et al. Value of neuropsychological testing after head injuries in football. Br J Sports Med. 2005;39(Suppl 1):i58–i63.
  20. Sport concussion assessment tool—5th edition. Br J Sports Med. 2017;51(11):851–858.
  21. Guskiewicz KM, Marshall SW, Bailes J, et al. Association between recurrent concussion and late-life cognitive impairment in retired professional football players. Neurosurgery. 2005;57(4):719–726.
  22. McCrea M, Meier T, Huber D, et al. Role of advanced neuroimaging, fluid biomarkers and genetic testing in the assessment of sport-related concussion: a systematic review. Br J Sports Med. 2017;51(12):919–929.
  23. Lumba-Brown A, Yeates KO, Sarmiento K, et al. Centers for Disease Control and Prevention guideline on the diagnosis and management of mild traumatic brain injury among children. JAMA Pediatr. 2018;172(11):e182853.
  24. Bailes JE, Cantu RC. Head injury in athletes. Neurosurgery. 2001;48(1):26–46.
  25. Broglio SP, McCrea M, McAllister T, et al; and CARE Consortium Investigators. A national study on the effects of concussion in collegiate athletes and US Military Service Academy members: the NCAA–DoD Concussion Assessment, Research and Education (CARE) consortium structure and methods. Sports Med. 2017;47(7):1437–1451.
  26. McCrory P, Johnston K, Meeuwisse W, et al. Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague 2004. Clin J Sport Med. 2005;15(2):48–55.
  27. Wojtys EM, Hovda D, Landry G, et al. Current concepts. Concussion in sports. Am J Sports Med. 1999;27(5):676–687.
  28. Zemek R, Barrowman N, Freedman SB, et al; for Pediatric Emergency Research Canada (PERC) Concussion Team. Clinical risk score for persistent postconcussion symptoms among children with acute concussion in the ED. JAMA. 2016;315(10):1014–1025.
  29. Kerr ZY, Marshall SW, Harding HP Jr, et al. Nine-year risk of depression diagnosis increases with increasing self-reported concussions in retired professional football players. Am J Sports Med. 2012;40(10):2206–2212.
  30. Gouttebarge V, Aoki H, Lambert M, et al. A history of concussions is associated with symptoms of common mental disorders in former male professional athletes across a range of sports. Phys Sportsmed. 2017;45(4):443–449.
  31. Manley G, Gardner AJ, Schneider KJ, et al. A systematic review of potential long-term effects of sport-related concussion. Br J Sports Med. 2017;51(12):969–977.
  32. Lee LK. Controversies in the sequelae of pediatric mild traumatic brain injury. Pediatr Emerg Care. 2007;23(8):580–586.
  33. Ryan LM, Warden DL. Post concussion syndrome. Int Rev Psychiatry. 2003;15(4):310–316.
  34. Kirkwood MW, Yeates KO, Wilson PE. Pediatric sport-related concussion: a review of the clinical management of an oft-neglected population. Pediatrics. 2006;117(4):1359–1371.

Clinical Pearls ⬆

  • No RTP while symptomatic
  • No RTP the same day
  • The younger the patient, the longer the likely recovery
  • Receiving a second blow to the head (even a minor one) while still suffering from the effects of the original concussion can lead to SIS, which results in severe brain swelling and often death.
  • A stepwise and gradual return to academic and physical activities should occur after the patient is no longer experiencing debilitating symptoms. Developing any symptoms during this program will require additional time before proceeding.
  • Sometimes additional testing such as balance testing or formal NP testing may be necessary.
  • Evidence exists that three or more concussions are associated with a general increase in injuries, mental illness, slowed and prolonged recovery, substance abuse, early Alzheimer. Athletes should consider this risk of cumulative brain injury from multiple concussions when deciding whether or not to RTP.
  • Although helmets cannot prevent concussions, proper headgear for sports should be worn to prevent other head injuries.
  • Learning safe fundamentals of a given sport, as well as following the rules, can help to reduce the occurrence and severity of concussions.