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Running Head: Sports Related Concussions
Sports Related Concussions
Nadeem Qurbani
Professor
FNES 705
December 14, 2016
Abstract
The number of sports related concussions continues to rise in this country. Several journals have been identified to discover the effects of those concussions, mainly on high school and college players. Quantitative data consists of cognitive and physical effects on those who were studied and quantitative analysis discovers the emotional effect concussions have on retired hockey players after playing for several seasons.
Understanding the effects of this particular head injury will assist in creating a better environment for players before they get to the field. Though the advent of the helmet occurred in the 1970s, it has not stopped players from pushing themselves even after they might have been severely injured. Concussions were then studied to estimate the amount of time it takes for a player to heal. We determine the physical effects of a concussion among several studies as well as the long term psychological and emotional damage after a player has retired from a contact sport.
Sports Related Concussions
After Will Smith released his controversial movie Concussion last year based on the NFL suppressing medical information regarding their players and their head injuries. The public looked to the professional organization for answers, but it seems the issue has been swept under the rug. Sport-related concussions are a large problem across the board. Since 1997, sports-related concussions in high school has risen by 15% (Boden et al., 2007). That number continues to grow steadily every year. Research has been done the number of concussions, which sports are the biggest contributors to head injuries, what has been done to prevent the severity of injuries, and long-term effects of sports-related concussions. The increase of concussions in sports has had a profound impact on athletes and should be further evaluated for safety and scientific research.
Many of the studies that have been done regarding sports related concussions have been quantitative (2013). In order to get good qualitative information each athlete would have to be extensively interviewed in order to get their history and then each would have to be compared. Finding a suitable sample across the board would not represent all of those with head injuries. The studies researched will focus on the number of those affected and how many of them had adverse symptoms due to their concussions. Some of those studied are as young as 14 years old to retired hockey players in their 40’s and 50’s who have undergone extreme damage.
There is a qualitative study in this collection that discusses the emotional stress of athletes. Specifically, it is retired hockey players who have suffered several concussions through their careers and what they had to endure. “Specifically, this retrospective study investigated the various thoughts, feelings, emotions, and experiences of these participants with respect to concussions” (Caron et al, 2013). These athletes had suffered decades of being hit in the head. But there are also studies that discuss the recovery period of high school students in comparison to collegiate students. The more they suffer these injuries, the less likely they will heal completely. Also, if they are a star player, they might not get the sufficient time to heal (2007).
Research Methods
The research found during this period reflected two major types of information. One being quantitative that can be broken into 2 categories: meta-analysis or the journal’s own lab study. The second being qualitative being an analysis of a small selection of people who are interviewed regarding their experiences with concussions.
Quantitative: Meta-analysis
Meta-analysis, systematic review, or assessments of journals represent a specific goal in which they gather several other academic resources to come to their final conclusion. Specifically, just as the information for this paper was discovered, they researched keywords in order to find those resources that pertained to their final goal. In this instance, sports concussions is an extremely broad topic. Because the topic has been placed under a microscope for the past decade, many statisticians, researchers, and so on wanted to find specific effects on sports concussions based on research that had been conducted for almost the last 20 years. One journal referenced finding articles pertaining to their goal dating back to 1974 (Broglio, 2008).
Discovering the effect of the cognitive function was the main goal of many of the meta-analytic journals. One method suggested being better than the other as there was a lack of human error in detecting a time lapse in response from the test subjects. Prior to computers, researchers utilitzed a pen and paper method watching those being tested, and timing their response time. Since then, the information has become more accurate because computers have the ability to pin point the exact time a test taker makes a move. “To remedy this shortcoming, the Standardized Assessment of Concussion (SAC) was developed as a brief concussion screening tool for sideline administration and has proven effective in the assessment of acutely concussed athletes” (Brolio & Puetz, 2008). Even those athletes with the slightest bit of injury could be assessed and studied without human error.
3364 potential abstracts identified and screened
89 articles reviewed for relevancy
3275 abstracts excluded as irrelevant (e.g. review articles, abstracts, case studies and editorials)
50 articles excluded:
22 = insufficient data
17 = data exceeded 14 days post- injury
9 = no baseline assessment or control group
2 = subject data reported in more than one study
39 articles included in the meta-analysis: 34 = neurocognitive
14 = self-report symptoms 6 = postural control
Fig. 1. Selection of sport concussion manuscripts. Some articles included in the analysis reported more than one assessment technique of the concussed athletes (Broglio & Puetz, 2008)
The above figure discusses the process in selecting data in the meta-analysis. They got through thousands of documents to find the ones suitable for the study they wish to accomplish. The problem with the quantitative tests is there are so many athletes affected by concussions. “Between 1.6 and 3.8 million sport-related concussions occur in the US annually, with an estimated 250 000 in high-school football alone” (Brolio & Puetz, 2008). This does not include the number of collegiate or professional athletes that suffer a similar injury. The meta-analysis journals discuss the time measured from when an athlete experiences a concussion and how long it takes them to either report the injury or go back into the field to play. There is much controversy facing coaches on the amount of time they allow their athletes to rest. With that being the case, the athlete’s cognitive function is in question. According to Belanger and Vanderploeg’s study of neurosphycological impact on sports related concussions (2005), most athletes recover 7-10 days after being injured. Overall, the study discusses what was found in their research. This does not account for those who have been injured several times and whether it had a long-term effect on their recovery time.
What is most controversial according to Belanger and Vanderploeg (2005) is most patients do suffer acute cognitive functions that effect their response time. With meta-analysis research, the study is restricted to those that they find. If they want to search more deeply in the their findings, they would have to conduct a study on their own but they might not have the same sample as those that they research thus potentially leaving them with different results.
Quantitative: Controlled Lab Setting
Finding an appropriate sample for researchers conducting their own tests would possibly the most difficult when it comes to getting accurate results. Eckner, Kutcher, Brolio, and Richardson (2014) utilized a computerized method to measure the response time of athletes with sports related concussions. Very similar to the meta-analysis studies, they reported results that could coincide with doing vast amounts of research over several journals. Their study gathers athletes from two Universities and one high school to measure their response time in cognitive functions. The problem with this sample is that it is not random. The results could be skewed in regards to their particular coaches, the environment, and upbringing. The similarity came with the recovery time after a reported concussion being one to two weeks (Eckner et al., 2014).
Another study regarding cognitive function purely focused on the age difference and recovery time between high school and college students. “Participants underwent evaluation of symptoms (Graded Symptom Checklist), cognition (Standardized Assessment of Concussion, paper-and-pencil neuropsychological tests), and postural stability (Balance Error Scoring System). Athletes were evaluated pre-injury and followed serially at several time points after concussive injury: immediately, 3 hours post-injury, and at days 1, 2, 3, 5, 7, and 45 or 90 (with neuropsychological measures administered at baseline and 3 post-injury time points) (Nelson et al., 2016). High School students were less able to recover as quickly as the college students due to their developing minds and bodies. They were affected more by a concussion long term.
The amount of recovery was determined in another found in the Journal of Athletic Training (2016), in which some coaches push the recovery time for some athletes to be shorter to get them back in the game. Also, athletes do not report any symptoms in hopes that withholding that information will allow them to play again. Out of 140 athletes, almost half of them did not report any symptoms of concussions. One of the reasons is that they either wanted to withhold the information or they did know the symptoms were related to their injuries.
Finally, in addition to researching cognitive functions, the ability to keep up with balance was also researched. A journal article published in the Scandanavian Journal of Medicine and Science in Sports (2012) studied three groups over a course of randomized static and dynamic exercises. They gave each group the same exercises to do under varying levels to measure their ability to keep up. According to the journal, everyone in the group had the same amount of athletic skill, were the same height, and same weight so that the results would be directly related to their abilities. They had a control of those without concussions and a variable of those with a concussion thus giving them the results they had initially expected which was those with concussions lacked the ability to keep up in the high intensity work out.
Qualitative
Most of the research done on concussions is quantitative because it is difficult to really catch the effects of the head injury on every person through every sport. Some studies reference about 12 sports that an athlete could receive a concussion (Pfister et al., 2016). Though this is the case, researchers do want to personalize and add another layer to what happens to an athlete after they receive a concussion. In the study by Caron, Bloom, Johnston, and Sebastian questions five hockey players regarding their experience with concussions during their career and after (2013). All of the players in questions had been retired for at least four years and were asked to discuss their emotional and physical inabilities due to their injuries. The players were given pseudo names for the report thus protecting their identities. Overall, the interviews were analyzed to find similarities among their experiences.
Another research analyzed the career of equipment personnel and their involvement in the safety of players specifically from getting serious concussions. This was done similarly to the hockey interviews as a selection of equipment personnel ranging in experience gave their synopsis of what day to day life was like while working for coaches and their input on what the players wore. Some of the findings were interesting as it seemed the equipment personnel had the players best interest in mind, however, the coaches had other ideas. In fear of losing their jobs, they humored the coaches’ requests. “Interviews occurred over the phone and lasted from 30 to 90 minutes depending upon how much detail was provided by the participant” (Oja & Bass, 2016). That information was later analyzed to, again, find similarities and differences in how each of the equipment managers handled their locker room.
The qualitative research gives a more in depth look as to how athletes handle concussions and what they might do to avoid them. However, it does not give a good depiction across the board as to everyone affected by the head injury.
Results
As previously discussed, several of the studies alluded to recovery time for athletes after a concussion was about 7-10 days. Though they vary in their findings on how long athletes specifically get healed, that time period is dependent on the amount of injury and how many times an athlete has been injured before.
Youth athletes are more susceptible to injury due to their larger head and body size ratio, weaker neck muscles and increased vulnerability to the developing brain (Pfister et al., 2016). Gender is also considered an important source on whether an athlete will recover quicker. It can also be suspected that because females have reduced neck mass in comparison to men (Pfister et al., 2016). The amount of concussions continues to rise as more athletes become active and coaches either do not address the injury.
Figure 3. Time since injury by cognitive domain by comparison group (Belanger & Vanderploeg, 2005)
The above figure discusses the amount of time it takes for a high school athlete to recover from an injury including their cognitive functions. Each column represents the amount of time the athlete was injured and which cognitive function they were asked to perform. It is apparent that after 7 days, their function improves for example “orientation” starts at 4.6 within 24 hours of a concussion and after 7 days, d is at 0 meaning the athlete had full orientation. This particular study used both the tradition pencil and paper method along with computerized methods to study. “Despite reports in the literature that computerized measures may be superior to or more sensitive than more traditional paper-and-pencil measures, the overall effect size associated with computer assessment was comparable to the overall effect size associated with more traditional measures” (Belanger & Vanderploeg, 2005). In comparing high school and collegiate athletes, concussed high school athletes performed worse than concussed collegiate athletes at certain times of the day ((Nelson et al., 2016).
Figure 1. Baseline and postinjury performance on the Graded Symptom Checklist. Higher scores reflect more severe symptoms. Error bars indicate 95% confidence intervals. (Nelson et al., 2016).
As shown in the figure below, their healing times were parallel but high school students suffered more than college students. The baselines were students who were not concussed. “While comparing a player to his or her own baseline performance is preferable to reduce extraneous variability not attributable to the concussion, effect-size estimates based on repeated administrations likely represent an underestimate of sports-concussion effects due to practice effects” (Belanger & Vanderploeg, 2005). They were the control group of the study, which were uninjured students. This particular study had a large sample of 621 concussed athletes and 150 non-injured controls. Thankfully, according to a study by the British Journal of Sports Medicine (2014), their study showed that there was no significant evidence of elevated heart rate from those who were concussed 10 days prior. The injuries seem to only effect the brain and cognitive function.
The argument that seems to be permeating the airwaves is the amount of recovery time after an injury. In the qualitative study “Effects of Multiple Concussions on Retired National Hockey League Players” (2013), some of the players discussed how they were not able to sit out of the game for the 7-10 days previously discussed or their athletic trainers might have ignored their symptoms. “However, on a few occasions he suffered major concussions that involved loss of consciousness, which he described as “unfortunate” because he felt medical personnel were more cautious returning him to play after each subsequent collision” (Caron et al., 2013). The figure below shows the amount of time players sat out of the game before they were pushed back to play.
Figure2 . Percentage of athletes cleared for return to contact over time based on removal-from-activity (RFA) group (Brenton et al., 2016)
According to a study done by Boden, Tacchetti, Cantu, Knowles, and Mueller, more catastrophic head injuries lessened after the advent of the helmet but that still does not stop the consistent injuries of players. They also completed an analysis of several peer-reviewed journals to discover the amount of injuries since the advent of the helmet. “There were 0.67 injuries per 100,000 high school and 0.21 injuries per 100,000 college participants for a risk ratio of 3.28” (Boden et al., 2007).
The stories told by the NHL players showed the lack of care from their coaches to get them back to the game was insensitive. “Days missed was defined as the number of days between the concussion-causing event and clearance for return to contact” (2016). It created a vehicle for researchers to utilize information from players themselves regarding their experiences in the field. One might argue that five players is not enough of a sample in order to get a good feel for all of the players in the NHL or any contact sport. Because of the amount concussions they endured, they were unable to quantify amount of times they were hit thus leaving a hole in the study. It can be said that they were hit several times but to what extent does the injury cause damage.
The quantitative studies are a good indication of how the patients were affected but only in what is measurable such as their cognitive functions or ability to stabilize themselves. When following the injury immediately, functions are all out of sorts and the athlete might not come to consciousness right off the bat. “While comparing a player to his or her own baseline performance is preferable to reduce extraneous variability not attributable to the concussion, effect-size estimates based on repeated administrations likely represent an underestimate of sports-concussion effects due to practice effects” (Brolio & Puetz, 2008). The more seasoned an athlete gets, the more likely they are to perform even though they have a concussion. In this matter, it is about practice and how they are able to perform again. This, unfortunately, is used to the coach’s benefit. Also, the inability for the equipment manager to get the appropriate safety items for each player and their uniform also has an effect on their safety.
In the qualitative study regarding the equipment managers, it was more about the landscape of the locker room. Each player needed to size to the correct equipment which was a tedious job for the managers (Oja & Bass, 2016). Not having the right size helmet would make the player for susceptible to injury so they would request the coaches to have the players wear the helmets a few times prior to playing in a serious game. Because of the aesthetic needs of the NFL, some coaches would give the players new helmets right before the game, giving the equipment managers no time to have them fitted appropriately thus causing a scenario that regardless of the players wearing protection, they were susceptible to getting injured.
Discussion and Conclusions
It is unfortunate the amount of concussions occurs every year with that number rising. With the NHL and NFL consistently looking for more ratings, athletes tend to be the ones who get the brunt of pain. Some of them are psychologically conditioned to want to go back on the field regardless of their condition, to play through the pain. There have been some rules that were changed mostly because of the studies performed and how organizations like the NFL are under the scrutiny of the public. ““For example, the National Football League (NFL) has adjusted its rule pertaining to kick offs. The kick-off was thought to be football’s most dangerous play” (Oja & Bass, 2016). Similarly, college football has taken some measures in order to follow suit in the way they handle defenseless players like those whose helmets come off during a game. Equipment managers still attempt to voice their opinions but might fear the coaches just as much as the players as they have to adhere to the same politics as everyone on the team. Coaches do seem to have the stronghold of the athletes but they still have to take into consideration their health.
A good example would be to tell the stories of the NHL players who had suffered concussions for many years. It could potentially be the social pressures of having a good game and ensuring the fans and shareholders are happy. The NHL players in the study discussed would talk about the emotional trauma they are left after they retire in their inability to remember simple things that could affect their relationships (Caron et al., 2013). They also do experience paranoia. For the amount of times these players are hit, there is no telling what kind of damage has been done to their normal, cognitive functions. There is simply no recovery. “One significant implication of these findings relates to educating athletes and coaches. “ Athletes are sometimes motivated to hide their symptoms because of both internal and external pressure to perform” (Asken et al., 2016).
Athletes are getting concussions as early as high school since they are still developing; they are not able to heal as quickly as a college player. Knowing the potential these players have in getting into professional teams is likely for a few but there has to be something said about those high school players that experience concussions early on and are never really able to recover from those injuries.
Most of the quantitative studies do not discuss the long-term effects after 14 days since the initial injury occurred. It is implied that after there is no evidence of the injury, there is not much more to study. Those that do experience some cognitive difficulty show an acute inability to comprehend some of the tasks but nothing so daunting that it is worth noting. The physical ability of those with concussions is apparent but again depending on the severity of the injury. They have poor reliability and are significantly affected by mid-impact and heavy impact exercise, which is a fundamental component of most sports that carry a risk of concussion (Schneiders et al., 2012). Athletes with concussions do train themselves over time in order to overcome their latencies in their inability to perform because of their injuries and their coaches want them to be on the field. It seems the passion for their sport tends to overtake their health regardless of the impact it has on the player.
Will Smith had the great idea of using his celebrity to put sports related concussions under a microscope so that society could see what organizations like the NFL and the NHL were sweeping under the rug. By studying both quantitative and qualitative scientific results, the increase in concussions continues to hold some ground in getting noticed by researchers and professionals alike. More qualitative research with a larger sample would be needed in order get a good grasp of the psychological effects on the athlete. This, in turn, might cause a little bit more of a stir than a film by a celebrity. Also, it will help to continue to create better rules such as requiring helmets to be tested prior to a game in order to help those equipment managers whose job is to ensure that the players are safe.