Concussion & How To Make Contact Sports Safer

May 5

Typically when we think of concussion prevention in sports like football, lacrosse, hockey or even soccer we think of better helmets, better diagnosing on the sideline to remove those from play who might have had a concussion, mouth guards, and maybe some extra padding on the head or helmet during practice.

These strategies often work to help decrease the risk of concussion in some ways, but many of them have shown to be ineffective at significantly reducing the risk of concussion when entering the field of play.

With an estimated 1.8 million kids from the age 0-18 suffering from a concussion each year and up to 400,000 of them being sports related, concussion prevention needs to be re-assessed and improved.

Luckily in a nearby city, Cincinnati, and around the world some amazing research is being done looking at what we can do to help prevent concussions. Before we get started on how we think concussion prevention should be addressed lets first touch lightly on concussion.

Concussion

A concussion can occur from a direct hit (coup injury) to the head or through a whiplash type motion that causes the brain to bounce off the inside of the skull, called a coup-contrecoup injury. (Right Picture)

Concussions are unique for everyone. Some individuals recover quickly with no side effects or long term issues; while other individuals can have one concussion and have their life changed forever.

While concussions are unique for everyone there are ways to predict who might be at a higher risk for concussion.

This brings us to the first part of how to make contact sports safer. Establishing a Pre-Season baseline.

Pre-Season Baseline

Some individuals are at a higher risk of getting a sports related concussion than others. These individuals suffer from one or a combination of the following.

Dizziness
Neck Pain
Headaches
Previous Concussions
ADHD/ADD
Diagnosed Depression

Implementing a pre-season baseline test would allow for the discovery of current issues impacting players that could increase their risk of concussion.

Based off of that pre-season evaluation interventions can then be put in place before the season starts to improve these issues and hopefully reduce the risk of concussion.

Why do the above issues increase the risk for concussion?

The above issues, dizziness, neck pain, headaches, previous concussion, ADHD/ADD and diagnosed depression might increase the risk of concussion since many of these issues occur with or because of sensory processing disorders and/or sensory integration problems in the brain. Since these individuals already have sensory processing/integration issues and these areas are often the parts of the brain that are negatively affected due to a concussion individuals with these issues might be more susceptible to a concussion injury.

How do we establish a pre-season baseline and discover what underlying issues might predispose an athlete to a higher risk of injury?

Pre-Season Baseline Test

mCTSIB - Modified Clinical Test of Sensory Balance and Integration.
This test evaluates the three systems that are helping the body stay stabilized and balanced, the proprioceptive system, the visual system and the vestibular system. This test is not used to diagnose but rather see where the individuals currently is with their ability to stay balanced and what areas aren’t operating optimally.
Cervical Challenge Test - The Cervical Challenge Test puts an individual through 10 different neck and head positions to determine which position when held negatively affects balance and which position increases dizziness in those that have dizziness. Determining which position of the head and neck negatively affects balance can then be used to provide more specific care based on that individual.
Headache & Neck Pain Questionnaire (Oswestry & Disability Index) - Questionnaires allow us to add subjective information about the individual and what they’re feeling this can help determine the extent of how neck pain and/or headaches are affecting the individual and will help to put interventions in place to decrease the intensity and frequency of the neck pain and headaches specific to that individual.
Neuro-Visual Assessment (NVA) - The NVA is less of a baseline test and more of an assessment to see where weaknesses could be present in the visual system. Assessing the visual system during the pre-season allows for proper therapy to be incorporated throughout pre-season to strengthen the present weaknesses.

*Other test… There are literally hundreds of test that are in the process of getting validated or are have been thrown-out due to lack of validity or reproducibility. Along with that there is currently no standardized pre-season baseline test for contact sports. The above combination is what I believe to be a solid foundation for identifying underlying issues that could increase the risk of concussion. The above combination can also be used to help create a specific plan of action for those in pre-season activities.

Creating a Plan of Action

After a pre-season baseline a plan of action needs to be put in place to address weak areas and prepare the body for the season. Once pre-season baseline testing is finished athletes essentially fall into two categories.

Individuals who have indicators for a higher risk of concussion (IC).
Those who don’t have indicators for a higher risk of concussion, non-indicators for concussion (NIC).

The group that the individual test into will determine whether the individual receives rehabilitation training or resilience training.

Rehabilitation Training focuses on strengthening the areas that are weak, bringing the body back to balance and working to decrease pain, frequency and intensity in individuals who have headaches or neck pain.

Resiliency Training focuses on utilizing therapies that have been shown to help decrease the risk of concussion. These therapues are focused on strengthening the neck, improving balance and improving the neuro-visual processing and integration.

The Nuts & Bolts

Rehabilitation Training & Resiliency Training both utilize similar therapies but for different reasons. Individuals in both groups would undergo neck strengthening exercises, balance improvement and neuro-visual therapy.

For the individuals in the Rehabilitation Group their therapy would be focused on improving the areas that are found to be weak.

For the individuals in the Resiliency Training Group their therapy would be focused on further improving the strength of the neck, balance and neuro-visual processing. The individuals in the Resiliency Training Group would also receive the above therapies in a manner that works to strengthen areas that are strong but considered weak in comparison to the other areas.

Now let’s dive into these therapies and how they work.

Neuro-Visual Therapy

For sports like football, lacrosse, hockey, soccer, etc., our ability to process information is key. For instance imagine a wide receiver going across the middle of the field for a pass. While the receiver goes across the field he is using his central vision to watch what is in front of him and his peripheral vision secondarily to watch what is around him. If this individual has deficient central vision or peripheral vision on the right or left it might decrease his chance of catching the ball and not allow him the time to brace for impact or contort their body to decrease their chance of a major collision. A Neuro-Visual Assessment done in the pre-season would find deficiencies in vision during the off-season that would then allow for specific rehab to improve these deficient areas. Now back to our scenario.

In this scenario their is typically a player from the other team (linebacker or safety) that is going to tackle the receiver pretty soon after catching the ball. An individual who has a good ability to process visual information (neuro-visual processing) should be able to see the linebacker and then be able to make adjustments with their body to either brace for impact or move their body in a way to decrease the amount of impact, but an individual with good neuro-visual processing might have missed seeing the safety and not not be able to react to them as well. An individual with great neuro-visual processing would most likely be at a less risk for injury and an individual with poor neuro-visual processing would most likely be at a higher risk for injury.

What’s The Research Say about Neuro-Visual Therapy?

Lucky for us in a nearby city amazing research is being done by PhD Joseph Clark in cooperation with the University of Cincinnati football team looking at the impact Neuro-Visual Therapy has on their athletes. This is what they’ve found so far.

Division 1 Baseball Players that underwent 6 weeks of NVT 3 times a week showed an improvement in batting average from 0.251 to 0.285, an increase of .034, while the rest of the conference didn’t undergo any NVT and saw a decrease in overall batting average by .034 .
Division 1 Football Players that underwent NVT during pre-season training and once a week in-season showed a decrease in concussion rates from 9.2 concussions per 100 player seasons(individuals that didn’t recieve NVT) to 1.4 concussions per 100 player seasons (individuals that received NVT).

Neck Strength Training

Neck strength training for concussion reduction is still being debated. However, each year more and more studies show that increasing neck size and strength can be a protective factor in reducing the risk of concussion. Let’s examine what some of the latest research says on neck strengthening and concussion prevention.

In 2018 a high school football team went through a 7 week preseason training protocol that included neck strengthening exercises. During the 2018 season only 4 concussions occurred, this is significantly less then the prior seasons where a neck strengthening program wasn’t implemented. 12 concussions occurred in 2017 and 7 concussions occurred during the 2016 season.
A 2014 study found that for each 1 pound increase of neck strength the odds of concussion decreased 5%.

Neck strength training can be a low cost, low risk way to help improve the strength of the neck and help decrease the risk of concussion.

Balance Training

Balance is one of the many things that can be negatively affected after a concussion occurs. Preseason evidence of balance issues and dizziness also point to a higher risk of concussion in-season. By incorporating balance training in the off-season and addressing what is causing the dizziness or balance individuals should see a decrease in the risk of concussion. Here’s what the research says.

Individuals who have poor dynamic balance are at a 3x higher risk for sustaining a concussion.
A preventative movement control program that incorporated balance training found that individuals that underwent this protocol saw a reduction in total injuries and concussions.

Final Thoughts

The risk for concussion in every contact sports is always going to be there. However, each year we learn a little more about the body and how to work with it to make it more resilient and help it heal. When it comes to concussion this is true as well.

Neuro-Visual Therapy, Neck Strengthening, and Balance Training all have been shown to decrease the risk of concussion in multiple studies. However, at this time no study has been done looking at combining all three to reduce the risk of concussion. Implementing preseason baseline test and implementing performance and rehabilitative therapy into contact sports has the potential to not only reduce the risk of concussion and other injuries as well as improving the performance of the athletes.

References

Moira K. Pryhoda, Kevin B. Shelburne, Kim Gorgens, Aurélie Ledreux, Ann-Charlotte Granholm & Bradley S. Davidson (2020) Centre of pressure velocity shows impairments in NCAA Division I athletes six months post-concussion during standing balance, Journal of Sports Sciences, 38:23, 2677-2687, DOI: 10.1080/02640414.2020.1795561

Schneider, K. J., Meeuwisse, W. H., Kang, J., Schneider, G. M., & Emery, C. A. (2013). Preseason reports of neck PAIN, dizziness, and headache as risk factors for concussion in male Youth ice hockey players. Clinical Journal of Sport Medicine, 23(4), 267-272. doi:10.1097/jsm.0b013e318281f09f

Satoshi Nobusako, Atsushi Matsuo, Shu Morioka, "Effectiveness of the Gaze Direction Recognition Task for Chronic Neck Pain and Cervical Range of Motion: A Randomized Controlled Pilot Study", Rehabilitation Research and Practice, vol. 2012, Article ID 570387, 13 pages, 2012. https://doi.org/10.1155/2012/570387

Clark, J., Selmanovic, E., Drewry, T., Mangine, R., Keuhn-Himmler, A., Hasselfeld, K., . . . Divine, J. (2019). Observational study of prevention and intervention strategies that help Speed return to Play Post-Concussion in Division I college football. Neurology, 93(14 Supplement 1). doi:10.1212/01.wnl.0000580916.40209.58

Rotto T, Kraus E, Fredericson M. A NECK STRENGTH TRAINING PROTOCOL IN HIGH SCHOOL FOOTBALL PLAYERS FOR CONCUSSION RISK REDUCTION. Orthopaedic Journal of Sports Medicine. April 2020. doi:10.1177/2325967120S00165

Clark, J., Betz, B., Borders, L., Kuehn-Himmler, A., Hasselfeld, K., & Divine, J. (2020). Vision training and Reaction training for improving performance and Reducing injury risk in athletes. Journal of Sports and Performance Vision, 2(1). doi:10.22374/jspv.v2i1.4

Clark, J.F., Colosimo, A., Ellis, J.K., Mangine, R., Bixenmann, B., Hasselfeld, K., Graman, P., Elgendy, H., Myer, G., Divine, J. Vision Training Methods for Sports Concussion Mitigation and Management. J. Vis. Exp. (99), e52648, doi:10.3791/52648 (2015).

Clark JF, Ellis JK, Bench J, Khoury J, Graman P. High performance vision training improves batting statistics for University of Cincinnati baseball players. PLoS ONE 2012;7(1):e29109.o

Johnston W, O'Reilly M, Duignan C, Liston M, McLoughlin R, Coughlan GF, Caulfield B. Association of Dynamic Balance With Sports-Related Concussion: A Prospective Cohort Study. Am J Sports Med. 2019 Jan;47(1):197-205. doi: 10.1177/0363546518812820. Epub 2018 Dec 3. PMID: 30501391.

Hislop MD, Stokes KA, Williams S, et al Reducing musculoskeletal injury and concussion risk in schoolboy rugby players with a pre-activity movement control exercise programme: a cluster randomised controlled trial British Journal of Sports Medicine 2017;51:1140-1146.

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Sittikraipong, K., Silsupadol, P., & Uthaikhup, S. (2020). Slower reaction and response times and impaired hand-eye coordination in individuals with neck pain. Musculoskeletal Science and Practice, 50, 102273. doi:10.1016/j.msksp.2020.102273

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Jacob Coffman