Concussions in Youth Sports In Times of COVID-19

Is playing sports worth the risk of a concussion?

Despite concussion risks, the value of the free play of sports in our society is significant. This has become even more clear during the pandemic as kids and adults have been prohibited from engaging in their usual activities and many sports and recreation activities were limited or shut down for many months. 

What is a concussion?

A concussion is a mild traumatic brain injury.  According to the Center for Disease Control (the CDC), concussions are a bump, blow or jolt 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.

How does an athlete get a concussion?

The most common way a concussion is sustained in sport is through collisions. Think about two players colliding in mid-air when going for a header, or a basketball player being hit in the head during an aggressive rebound. As you know, collisions in sport are common occurrences. Concussions can be an unfortunate by-product of these collisions.

Are concussions more harmful to young athletes than to adults?

​Concussions can be equally harmful to both young athletes and adults, but each group may face different challenges. Young athletes' brains are still developing up until approximately age 25 and concussions can disrupt their normal development. Concussions can impact the way kids think, act, feel, and learn. Without medical personnel at a youth sporting event a concussion may go unnoticed or untreated. This then requires knowledgeable coaches, officials, and parents to respond to a suspected concussion. Without adequate and timely intervention, and because kids brains are still developing, the recovery time for kids might be longer than adults. Young adults, though, are more likely to suffer the consequences from multiple concussions.

How many young athletes get concussions from participating in sports?

According to a 2017 study, 2.5 million U.S. high school students reported having had a concussion from a sports or recreational activity over a 12-month time period (DePadilla L, et al.). Another published study from 2019, indicates that 12.1% of youth athletes sustained concussions, with an 18-year-old twice as likely to get a concussion than a 13-year-old (​​Tsushima, et al.).

Which sports have the most concussions?

Most research has concluded that the riskiest youth sports for concussions for boys are tackle football, lacrosse, and ice hockey. It is notable that the three boys’ sports with the largest occurrence of concussions are contact sports in which helmets are worn. While helmets may reduce the risk of head trauma, it does not eliminate the risk of concussions.
 
When it comes to comparable sports, a 2019 study concluded that girls are one and a half times more likely to sustain a concussion than boys (Tsushima, et al.). For girls, soccer was identified as the riskiest sport for sustaining concussions. Soccer is classified as a non-contact sport in which no helmets are required. Think about how often players collide with one another or how often a header is used to play the soccer ball.

But players do not even need to hit their heads to get a concussion. Remember a concussion is a bump, blow or jolt that shakes the brain. This means there does not even need to be actual contact with an athlete’s head for a concussion to occur. For instance, two players’ bodies colliding with no head contact can still shake the brain and cause a traumatic brain injury. Without head contact, it is more difficult to identify a resulting concussion.

How is a concussion diagnosed?

Since a concussion is not visible on a CT, MRI or x-ray, medical professionals must use other means to diagnose a concussion. Generally, a medical professional will look for the signs and symptoms of a concussion. These symptoms may be physical (blurred vision, dizziness, fatigue), cognitive (confusion, slurred speech, amnesia), emotional (anxiety, depression, personality changes), or related to sleep (increased or decreased sleep).

How has COVID-19 made it difficult to recognize concussion symptoms?

Now we have to be concerned with how COVID-19 has complicated concussion identification and recovery. Many sports took a backseat during the pandemic so concussions were the furthest thing from the minds of most people. Although the priority  shifted to preventing transmission of COVID-19, as we return to play, now coaches, athletes, and parents need to be concerned with both COVID-19 and concussions.
 
For instance, it is important to understand that both COVID-19 and concussions have shared symptomatology. So let’s say that an athlete exhibits the symptoms of fatigue, headache, nausea, gastrointestinal issues, or a change in or loss of taste.  Does the athlete have COVID-19, a concussion, or something else? While it may be a good idea to rule out COVID-19 with a simple test, you cannot dismiss concussion as the cause of these symptoms.

One of the most challenging things about COVID-19 is that we are still discovering all the short-term and long-term harm the virus causes to a body. Think about all the things we may not yet know. We need to question whether COVID-19 can have an impact on concussions or vice versa.  Consider the following questions:

• Can catching COVID-19 while recovering from a concussion complicate, delay or prevent recovery from a traumatic brain injury?
• Can a COVID-19 vaccination increase concussion symptoms?
• Can a COVID-19 long-hauler ever return to play or will their prolonged symptoms put them at a greater risk of head injury?
• Will we adequately be able to observe signs of a concussion in the behavior of an athlete who is masked, socially distant or wearing a helmet?
• Will symptoms of dizziness be dismissed as a complication of wearing a protective face mask and ignored as a symptom of a concussion?

How has COVID-19 reduced concussion risks?

Perhaps one of the few positive consequences of COVID-19 is it it likely gave athletes who were suffering from sport related concussions sufficient time to rest and heal from their traumatic brain injuries. The break from play may have prevented some athletes from brain swelling from second impact syndrome. Second impact syndrome is when an athlete sustains another concussion before recovering from a first concussion, an incident that is often fatal.

Another strategy to deal with COVID-19 led to a slow return to play in sports. Athletes focused more on skills and drills and less on competitive play. Less competition and reduced contact provided a benefit to concussion recovery and concussion prevention.

How has COVID-19 increased concussion risks?

The singular focus to reduce the spread of COVID-19 has left little time, thought or energy towards the physical and mental readiness of those returning to play. This hyper focus on COVID-19, coupled with the enthusiasm to return to play, may cause coaches to neglect adequately preparing athletes to avoid concussions.

How can you prevent concussions?

Approximately, 15% of athletes sustain concussions.  So what can be done to prevent them?

1. Coaches must ensure their athletes are ready to play their sport. It is rare that  athlete will remove themselves from competition due to a lack of physical or mental preparedness. The world was surprised when gymnast Simone Biles withdrew from competition at the Tokyo Olympics because she was not in the right state of mind to compete. Her response likely saved her from a concussion. This is an example of risk avoidance. More athletes should be encouraged and supported to withdraw from competition when they do not feel physically or mentally ready to compete.
2. Focus on drills, skills and conditioning and minimize full contact during practices.  Recognize that following COVID-19’s cancellation of sport, athletes may not have the same physical or mental readiness to resume play at the same level as before. A player that is neither physically or mentally ready to play is more likely to get injured, which could include a concussion.
3. Neck strengthening exercises are important.  For example, in tackle football, strong neck muscles are key to support the head and heavy helmets. Strong neck muscles can help an athlete better control jostling to their head that might otherwise contribute to a concussion.
4. Use properly fitted helmets that meet safety standards. Helmets should be regularly maintained and inspected. If they are defective, they should be repaired or replaced. Officials should enforce the safety rules and make sure  each athlete is wearing an approved helmet that is not damaged and that fits properly.
5. A helmet's chin strap should be securely fastened. In the Tokyo Olympics many televised skateboarders and BMX bikers wore helmets with loose fitting chin straps. While helmets may not save all athletes from a traumatic brain injury, a properly fitting helmet that stays in place can lessen head trauma in the event of a fall or collision.
6. Spend extra time reminding players of the rules of sport, emphasizing those rules that affect safety and can minimize the risk of concussions. This is particularly important for younger or inexperienced kids.
7. Communication and consistent enforcement of safety rules is important. Some sports have modified their rules to help prevent traumatic brain injuries. For example, U.S. Youth Soccer eliminated heading for players under age 11, and limits heading in practices for 11 to 13-year-olds. USA Hockey has eliminated checking for 11 and 12-year-old players, and introduce intentional contact at age 13. Whereas, U.S. Lacrosse changed the rules for U14 so that any check involving the head and any stick-to-head contact is now a penalty. Tackling safety rules in football include no helmet-to-helmet hitting and leading a tackle with your shoulders, rather than your head. Coaches should remind players of safety rules before each practice and game and officials should enforce the safety rules during play.
8. Delay the start of tackle football until at least until an athlete is 14 years of age. Some youth sport programs offer tackle football programs for kids as young as 5 years of age. However, an early start to tackle football does not necessarily predict athletic success in higher levels of play as many successful professional football players never played tackle football before high school. In fact, premature exposure to tackle football may increase the risk of traumatic brain injuries, which in turn may compromise an athlete’s future success.
9. Remind athletes that wearing a face mask to protect from COVID-19 limits a person’s ability to see well. Many COVID-19 protocols require athletes, coaches, staff and officials who are not in active play to wear a face mask to reduce the likelihood of the transmission of COVID-19. This, however, can increase the likelihood of collisions and trip and falls, which may in turn increase the likelihood of concussions. Young athletes in particular may need to be reminded how to prevent these sideline incidents while wearing face masks.

How do you keep concussion symptoms from getting worse?

Even when safety measures are complied with, accidents do happen, and athletes can sustain head injuries.  Many athletes with minor concussions can return to play within 2 to 4 weeks after following proper concussion protocol. But some concussed athletes may never fully recover or may even die. So, what can be done post-concussion to best minimize the risk to an athlete?

1. Concussion training must be provided to coaches, staff and volunteers to minimize post-concussive harm. Parents and athletes also benefit from this training, which is offered by the CDC and other organizations. Concussion training may even be required in your state.
2. Promote a pre-play physical examination to ensure that the athlete is physically healthy enough to participate. This should be more thorough than a simple COVID-19 test.
3. Encourage athletes to complete a baseline cognitive test by a qualified medical professional. This baseline test allows for future comparison testing of the before and after concussion conditions of a brain. This test helps medical professionals better assess when an athlete can return to play and is performed on kids as young as five-years-old. A medical professional may recommend that a concussion-free athlete repeat the baseline test every couple of years, and that a concussed athlete repeat the test more frequently.
4. Do not ignore or dismiss symptoms of a concussion. For instance, many may attribute anxiety or depression to teenage hormones or to the challenges of living through the pandemic. However, anxiety or depression can be triggered or heightened as a result of a concussion and may be resolved with proper treatment by a medical professional.
5. An athlete must completely recovering from a concussion before returning to play to avoid the risk of developing second impact syndrome. This condition occurs when an already concussed athlete sustains a second concussion. Even if it was a minor event that caused the subsequent concussion, the symptoms can be significantly worse, which may increase suffering, prolong recovery, and may be fatal. Our break from sports during COVID-19 likely saved some athletes from a devastating encounter with second impact syndrome.
6. Understand the risks of CTE, which stands for Chronic Traumatic Encephalopathy. CTE is a progressive and fatal brain disease associated with repeated traumatic brain injuries. This condition can only be diagnosed after death by an autopsy. Awareness of the seriousness of CTE reminds us of the importance of settling time aside before games and practices to encourage athletes to tell you about any possible concussion symptoms that they are experiencing.
7. Post information about concussions in locker rooms or other places where your athletes practice and compete. Let them know of the risks of concussions and the greater risks of multiple concussions, particularly before an athlete is fully recovered.
8. When a concussion is suspected immediately remove the athlete from play. Inform the athlete’s parents and medical provider. Follow the medical providers instructions for adequate brain rest. Only allow an athlete to return to play when sufficiently recovered and medically cleared.
   

What are the concussion return to play protocols?

All 50 states and Washington D.C. have laws to reduce the risk of traumatic brain injuries in sport. States may also have laws that outline how and when an athlete can return to play following a concussion. These protocols may outline informed consent of parents and athletes, removal from play, bench times, medical clearance, and training for coaches, parents, and athletes.

Each athlete’s health is more important than any practice or any game. Coaches, officials, staff, sports organizations, parents, and athletes all have a role in concussion prevention and symptom management. Consistent protocols should be in place before the athlete is allowed to return to play---with no exception. The recovery process generally means a period of complete rest, followed by a gradual return to limited physical activity, and ultimately to full activity and competition. These steps are important to keep athletes healthy in order to avoid secondary concussion syndrome, long term physical and mental problems, and so athletes can enjoy many years of healthy play and lifetime success.