Concussions: Awareness

How Common Are Football-Related Concussions?

Whatever the cause, the number of reported head injuries in football varies widely, from between 4% and 20% of all player injuries. The discrepancy?  It may be because players fail to disclose injuries ("I do not want to be taken out of the game"), but also because head injuries like concussions are often hidden injuries, without easy to identify signs like bleeding or bruising.

Elbow-To-Head: Against The Rules

The International Football Association Board (IFAB) banned deliberate elbow-to-head contact, most commonly seen during heading duels. This rule change was instituted at the 2006 FIFA World Cup™ in Germany where referees were instructed to penalize these cases of elbowing with red cards. The result: there were fewer head injuries.

Don't Ignore The Neck!

Please be very conscious of the potential for neck/spine injuries in players suspected of having a concussive trauma. Proper medical safety protocols should be followed if a neck injury is suspected*.

* For more information, please go to FIFA's Medical Extranet site at https://extranet.fifa.com/medical/, sign up, and then go to the Publications section to find the Football Emergency Medicine Manual.

The SCAT 2

The SCAT 2 was designed to be used as a tool to help identify the presence of a concussion or another more severe head injury.

Each player should undergo the SCAT 2 test (or a similar test) in the preseason, to identify baseline levels that can be compared to any re-tests performed after an injury. In other words, it helps to evaluate changes that have occurred during the season, for example, as a result of a concussion.

SCAT 2 Test*  CLICK HERE >>

*Yes, there is an APP for this test.

Signs And Symptoms of a Concussion

Some signs and symptoms (such as behavioral changes) may include:

       ● headaches

       ● feeling "pressure in the head"

       ● neck pain

       ● nausea and vomiting

       ● dizziness

       ● balance problems

       ● blurred or double vision

       ● seeing stars or spots

       ● hypersensitivity to light

       ● hypersensitivity to noise

       ● feeling slowed down

       ● feeling like you're "in a fog" (shaking head "to clear the cobwebs")

       ● just "do not feel right"

       ● difficulty concentrating

       ● difficulty remembering

       ● fatigue or low energy

       ● confusion

       ● drowsiness

       ● trouble sleeping or falling asleep (if applicable)

       ● more emotional than normal

       ● irritability

       ● sadness or depression

       ● nervous or anxious

       ● ringing in the ears

       ● slurred speech

Other signs that you may see:

       ■ Loss of consciousness or unresponsiveness

       ■ Convulsing body movements or irregular movement postures like purposeless muscle tightening.

       ■ Balance problems or unsteadiness

              ● Ask a player to adopt the following positions, and then close his or her eyes (see SCAT 2 test for instructions):

                     ̵ Double leg stance

                     ̵ Single leg stance

                     ̵ Tandem stance—one foot in front of the other with heel touching toe of other foot

       ■ Coordination issues

              ● Ask the player to perform the following test seated with the eyes open (see SCAT 2 test for instructions):

              ̵ Finger-to-nose test (perform the movement 5 times)

Another useful test to evaluate more extensive brain trauma is the Glasgow Coma scale (recorded for all players, even for injured players without a loss of consciousness):

       ■ Checks for:

              1. Eye opening: Do the player's eyes open without cue or does it require something more, like talking to the player or causing the player pain?

              2. Verbal responses: How does the player respond to questions (appropriately, confused, inappropriately, incomprehensibly, or not at all)?

              3. Movement as a response to stimulation: How is the player moving? Normally and in response to commands, or is pain the only stimulus that causes movement? And what kind of movement (withdrawal from the pain, bending the body part, straightening the body part)? Or does the player not respond at all when unconscious?

How does the player respond cognitively? (see SCAT 2)

       ● Is he or she oriented to time, place, and situation?

       ● How does the player respond to a memory tests?Is he or she concentrating well; is he or she slow to answer?

       ● How is his or her short-term recall ability (upon repeating the memory test minutes later)?

The Pocket SCAT 2

There is a Pocket SCAT 2, an abbreviated form, for field side use to help the team medical staff, coaches, and trainers make quick decisions for return-to-play.

The Pocket SCAT 2*  CLICK HERE >>

* There is an APP for the Pocket SCAT 2 test too.

The Doctor's Tests

In addition to the information obtained from the SCAT 2, a doctor may perform other tests on the field, field-side, or in the office (eye/pupil responsiveness, neck range of motion, reflex testing, et al...) to help determine the presence of a concussion and to rule out other injuries (i.e. fractures, paralysis, bleeding, dislocations) that could put a player's health at risk*

* In some cases, an athletic trainer will be the first responder to evaluate a player. Proper referral to the doctor and/or hospital is an essential part of the trainer's role.

Please follow up with your doctor for more complete medical testing such as:

       ■ Neuropsychological testing: a more extensive look at behavior/responses that reveal how the brain is functioning or how the brain interacts with the world - things like attention, memory, speed of thinking, problem-solving, and reaction time.

       ■ Neuroimaging: your doctor will also determine if any emergency neuroimaging is required - if a more severe brain injury is suspected [Figure 1].

Figure 1 SOME PHYSICAL SIGNS THAT YOU MAY REQUIRE MORE EXTENSIVE TESTING     ● Loss of consciousness     ● Repeated vomiting     ● Increasing headaches     ● Evidence of seizures     ● Unsteady walking     ● Slurred speech or any altered speech patterns     ● Weakness or numbness in the limbs     ● Unusual behavior     ● Signs of a skull fracture or any cuts to the head     ● Glasgow Coma Scale score of less than 15.

 

Usually if extensive testing is done, it's done to rule out more severe brain injuries that may be life-threatening. Tests might include computerized tomography (CT) scans; magnetic resonance imaging (MRI) using gradient echo, perfusion, or diffusion; and others.*

* Researchers continue to work on developing tests that may one day reveal the presence of a concussion and how recovery after a concussion is proceeding. Some examples of promising tests:

         ■ Blood tests that look for specific biomarkers or indicators of brain trauma.

         ■ Functional MRIs that show brain activity patterns correlating with severity and recovery of symptoms.

         ■ Tracking of eye movements using a device that can detect elements of movement like smoothness, accuracy, and speed as an indicator of brain trauma recovery.

Young Children Uniquely Considered

Below the age of 10 years old, children report concussion symptoms different from adults and therefore require a more age-appropriate symptoms checklist for assessment, such as:

       ● changes in eating patterns

       ● a lack of interest in favorite toys

       ● increased fussiness/crankiness

       ● a lack of energy/listlessness

       ● changes in personality.

Children may also be more susceptible to concussions. Some explanations include:

       ■ Children have developing brains that may be more vulnerable to injury as nerves continue to make connections with each other. Any disruption in this process has the potential to be harmful.

       ■ Children have less playing experience on the pitch that might otherwise prevent head injuries.

Brain Trauma: More Than Just A Contact Injury

Not all damage in a concussion is from contact of the brain with the skull.

We also know that an abrupt movement of the head generates movement of the skull in advance of the brain. This sudden change in head speed on an initially immobile brain may create a cascade of shearing forces (two forces in opposite directions and parallel to each other) that act on the brain, causing blood vessels or nerve fibers (or other tissues) to tear. The injury that results may often be damage to more than one area or region of the brain, producing a variety of signs and symptoms.

It has been suggested that females who, in general, have thinner and weaker necks compared to their male counterparts may be at greater risk for these types of injuries. Players with these characteristics, as well as those with a longer neck length, may fail to prevent the head and neck from spinning and shifting rapidly after contact, which allows the forces to influence the brain more severely and leads to concussive injury. This inadequate control is also an issue in children, whose larger heads relative to their body size and weaker necks compared to those of adults may expose them to similar risks.

It's What You Don't See: "Internal" Bleeding

Bleeding in and around the brain can cause compression of or damage to delicate brain tissue, especially in the days immediately after an injury. Unfortunately, this bleeding is usually hidden from view. That's why parents and friends should always watch over a player after a concussion.*  It is important to look for changing signs and symptoms (i.e. increasing headache or decreasing responsiveness) that might expose these "silent killers" [Figure 2]. Identified players should be taken immediately to an emergency room for evaluation.

* Many experts feel that bleeding is of greatest concern in the first few hours after head trauma. That's why, after being evaluated by a doctor, it is often recommended that players with a suspected concussion stay awake during these initial hours (it is difficult for family and friends to evaluate a "sleeping" person). In other words, it can help observers more easily evaluate changes in signs and symptoms that might require an immediate trip to the emergency room. Nevertheless, general observation for up to 48 hours (allowing for sleep) is still recommended as the bleeding can occur slowly and little by little create dangerous pressure on the brain or decrease the necessary flow of oxygen to the brain.

Figure 2 SOME REASONS FOR URGENT REFERRAL TO A HOSPITAL Any player who has or develops the following: 1. A fractured skull. 2. Deterioration in conscious state following injury. 3. Focal neurological signs (physical or mental signs that point to damage to a particular part of the brain, spinal cord, or other nerve) 4. Confusion or impairment of consciousness for more than 30 minutes. 5. Loss of consciousness for more than 5 minutes. 6. Persistent vomiting or increasing headache post-injury. 7. Any convulsive movements with neurological signs. 8. More than one episode of concussive injury in a match or training session. 9. Children below the age of 10 with head injuries. 10.High-risk patients (e.g. hemophilia, anticoagulant use). 11.Inadequate post-injury supervision. (Football Emergency Medicine Manual, FIFA, pg. 60)

 

What You Can Do: Prevention

Technique:

Some thoughts about prevention techniques (things to consider before going on the pitch):

  ■ Learn about concussions: all soccer personnel (including players and parents) must increase their awareness about concussion signs, symptoms, common causes, and treatment protocols

  ■ Inform the team: players should always tell the coach and the team medical staff about any previous concussions (as previous concussions have been found to increase the risk of suffering a second concussion)

  ■ Strengthen the neck muscles: in an attempt to better absorb forces and to develop greater control of head movement after contact

  ■ Gain or provide proper education in heading techniques: to help avoid dangerous contact with other players. Some examples include…

      ● learning to head the ball with your forehead supported by your neck and trunk during movement (you have a better chance to see your opponent with this technique)

      ● learning to create a protective space around your body with your arms while heading, making sure not to use your arms as weapons (if you do not create the protective space or if you move your head outside of the protective space, you put yourself at greater risk for injury)

  ■ Do not return to play until full recovery from a concussion has occurred and your doctor has given you clearance to play: early return to play increases the risk that a second concussive injury, even an injury with a lower amount of force associated with it, can result in more severe, sometimes life-threatening, problems

Equipment:

Part of injury prevention is making sure that you are using the correct equipment whenever possible. The same is true for concussions. While heading balls has not been found to cause concussions, it is still always best to use a ball that's in proper playing condition. Always check for:

  ■ Ball air pressure:

     FIFA Regulations* = 0.6 to 1.1 bar or 8.7 to 16 psi (pounds per square inch).**

     * The ball pressure required will vary with category of play (i.e. Outdoor, Futsal, and Beach Soccer) and may vary by manufacturer. The ball's pressure can also be affected by temperature, humidity, and air pressure.

     ** "FIFA APPROVED" testing standard for outdoor footballs = 0.8 bar or 11.6 psi (at ~20°C and 65% humidity).

  ■ Size of ball (for different ages):

       ●Size 3 - Under 8 years old (not included in FIFA Guidelines)

       ●Size 4 - 8-12 years old

       ●Size 5 - 13 years old and over

It's also important to avoid balls that take up too much water, increasing the weight of the ball. Here are the FIFA specs for a size 5 ball:

   ■ For "FIFA Approved" balls: The water uptake can increase the ball's initial weight by an average of 10% or less, with the maximum uptake not to exceed 15%.

   ■ For "FIFA Inspected" balls: The water uptake can increase the ball's initial weight by an average of up to 15%, with the maximum uptake not to exceed 20%.

For more information on football design and parameters, please go to:

  ■ FIFA Quality Concept For Footballs: http://footballs.fifa.com/

  ■ FIFA Ball Standards:  CLICK HERE >>

For FIFA's regulations regarding football "Qualities and Measurements", please go to:

  ■ FIFA's Laws of the Game (page 15): http://www.fifa.com/mm/document/affederation/generic/81/42/36/lawsofthegame_2011_12_en.pdf

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