Contact Sports, Brain Health, and Concussions: Answers to Parents' Top Questions.

Policymakers, parents, and athletes are talking about the risks of concussions more than ever before—partly because of growing public awareness of the relationship between concussions and the neurologic condition chronic traumatic encephalopathy (CTE). 

CTE can be a fatal brain disease associated with traumatic brain injuries and dementia, along with various mood and behavior changes. The disease has been in the spotlight as the subject of the 2015 movie “Concussion” starring Will Smith and Brett Favre’s recent PSA campaign against youth tackle football. 

As CTE continues to be studied, research shows that people who experience repeated concussions and sub-concussive blows (hits to the head that don’t result in a concussion) can develop CTE later in life. This is why concussion care early in life is so important. Better treatment may reduce the long-term risk.

While concussions—mild traumatic brain injuries caused by a trauma directly or indirectly to the head—are most often caused by falls and car accidents, repeated concussions typically occur in people who play contact sports. 

With fall sports such as football and soccer in full swing, let’s discuss the most common questions parents of student athletes typically ask this time of year.

Q1: What sports have high rates of concussions?

All contact sports include the risk of concussion, from basketball to volleyball. In middle and high schools, concussions occur most frequently in football, soccer, and hockey.

The position a student athlete plays is an important consideration. Goalies, for example, have higher rates of concussions because they’re constantly using their bodies to block people and objects. A 2019 study of concussion trends in 20 U.S. high school sports found that most concussions were caused by contact with: 

• Another person (62%)
• A surface (17%)
• Equipment (15%)

Good news from the study: Rates of recurrent concussions across all 20 high school sports have decreased, as have football practice-related concussions. But in almost every sport, concussion rates were higher during competition play than practice—and concussions sustained during football games increased. 

In sports with quarters or halves, nearly 55% of concussions were reported during the last half or quarters of a game. This is probably because players are more tired, which makes them more likely to engage in reckless or sloppy play and less likely to defend themselves against possible collisions. 

For college football players, however, growing evidence shows that concussions may occur more often during practice, which we typically think of a safe environment, and this may be an area for greater risk reduction.

Q2: What are common symptoms of concussions?

Concussion symptoms can appear within hours or days after a head injury, so it’s important to remain vigilant after a concussion. Signs of a concussion include:

• Blurred vision
• Confusion
• Dizziness
• Headache
• Light sensitivity
• Lost consciousness 
• Memory loss
• Mood or personality changes
• Nausea
• Vomiting

The effects of concussion symptoms on students’ academic performance have been studied more in recent years. Research published in 2020 shows that high school students exhibiting signs of a concussion experienced more difficulty in language, math, and science classes. Students ages 11-17 required up to 21 days after a concussion to recover cognitive skills, and emotional instability in students ages 10-17 lasted up to five weeks following the injury.  

Neuropsychological testing, which analyzes brain functions such as concentration, mood, problem-solving, and memory, is one of the best ways to assess these symptoms—especially if your child has had recurring concussions. 

Q3: What should I do if my child is showing signs of a concussion?

Every concussion should be taken seriously; take your child to the emergency room if they lose consciousness, become increasingly sleepy, or have persistent or worsening symptoms after a head injury.

Contact your child’s regular health care provider to discuss the injury and symptoms. They may recommend making an appointment for further evaluation or monitoring the symptoms over the next several days. It’s never a wrong decision to be cautious and request an evaluation.

The MedStar Health Concussion Clinic offers specialized care for people who experience long-term concussion effects. Providers can recommend timing and accommodations for returning to school and sports. They offer treatments such as physical and vestibular therapy, which can help your child restore movement and balance and safely get back into their sport.

Concussion recovery care is also available at the MedStar Health Orthopedic and Sports Center at Lafayette Centre, where providers specialize in sports-related injuries.

Q4: How soon can my child return to sports after a concussion?

The worst thing we can do for athletes immediately after a head injury is send them back into the game, as older athletics will anecdotally tell you happened frequently. The best thing we can do is provide individualized neurologic care and allow them to recover. 

If a basketball player breaks their arm but continues to play, they’re going to further damage that arm. Brains are the same; if a brain is hurt and then hit again, it’s only going to get worse. Most students need a brief period of rest, followed by individualized, symptom-guided progression back to their sport, with full symptom resolution before entering a contact situation—with their doctor’s approval.

Based on research and experience, a gradual, sub-symptomatic return-to-play protocol is the safest, most effective method. In the past, all-or-nothing recovery was often recommended with long rest periods—no movement, no schoolwork, no regular activities for at least two weeks. But that can make a return to sports feel overwhelming and take away a vital part of the athlete’s life.

The University of Michigan demonstrated that supervised exercise can significantly increase our ability to gauge student athletes’ physical and cognitive symptoms and determine readiness to return to play. This means having the athlete work out at a clinic with an athletic trainer or physical therapist, and using the data collected to guide recovery.

In a supervised setting, providers gradually gave students more schoolwork and exercises to do while watching for signs of improvement, confusion, and frustration. They also tracked behaviors, moods, neurologic exams, and heart rates during exercise to ensure they had a view into the students’ overall health. This approach helped parents feel more comfortable about their children’s recovery and is one way to better prevent long-term effects of concussions.

Q5: Should I let my kids play contact sports?

The answer to this question is personal for every family. On one hand, kids have growing brains and can be very susceptible to head injuries. On the other hand, the benefits of exercise and teamwork can last a lifetime.

Studies have shown that young athletes who participate in contact sports in high school or college were not more likely to meet criteria for CTE-like symptoms, compared to those in non-contact sports or who played no sport at all.

At the same time, a Boston University study on the relationship between amateur and professional football players and CTE found that the risk of CTE doubles for every two and half years of play. This translates to other sports as well and represents a cumulative effect as players sustain injuries over time.

Recognizing societal impact.

As a society, we always expect our athletes to be at their best—even from an early age. I often feel that professional athletics, for some, serve the function of a modern Roman Colosseum: although a much safer version, risk is still present, and the effects trickle down to student athletes as well.

While all 50 U.S. states now have youth concussion legislation in place, one study analyzed the speed of certain states enacting these laws. It found that states with more high school football participation—and a strong college football presence—passed concussion laws later than states with less focus on football.

The pressure on performance may also factor into underreported concussions among young athletes. Several studies discovered two primary reasons students ages 13-18 do not report their concussion: a desire to remain in the game and a fear of the effect their report could have on their relationship with their teammates and coaches. Concussion education didn’t increase their desire to report.

The future of concussion care.

As health care experts collaborate more with families, organizations, and policymakers, we strive to develop better solutions, including improved diagnostics and treatments, and to improve education for student athletes, coaches, and parents.

Three key areas of research I expect to conduct and see more of in the future will help me do this more effectively:

• Standardized care: An extensive study of post-concussion management research concluded that we need to develop dependable guidelines to help health care providers better manage head injuries. I’m involved in ongoing studies that are reviewing electronic medical records to determine which types of treatments may work best for patients with certain characteristics and which factors may predict concussion outcomes in specific populations.
• CTE treatment: Today, CTE can only be diagnosed after death. Until effective detection and treatment methods are developed, we can base care only on a patient’s risk factors (a history of brain injuries) and symptoms (memory loss, confusion, personality changes). Diagnosing CTE in living patients, potentially through blood tests or spinal fluid analyses, could make a considerable difference in their quality of life. 
• Concussions and CTE in female athletes: Women make up a huge number of athletes of all ages, but they have been underrepresented in these studies—even though the limited data that exist show female athletes are more likely to get concussions.

Sometimes, the more data we discover, the more questions we raise. Asking questions helps us learn and better care for patients. There are no easy answers to many questions about concussion care—but it’s important to keep asking so we can continue to improve our understanding of this common condition.