Overview

Traumatic Brain Injuries (TBIs) are acute brain injuries caused by physical forces applying mechanical energy to the head. Causes include falls and accidents on the road but an area for concern is injuries due to sports that frequently lead to concussions.¹ TBIs have severe long-term consequences on brain function. TBIs lower processing speed and memory.² Sports that commonly lead to TBIs include contact sports such as American Football, Wrestling and Rugby. Basketball and Cycling cause brain injuries with cycling injuries resulting mainly from falls. A study showed that being kicked on Football or Rugby led to 38.1% of sports TBIs; falls led to 20.3% of injuries.³

TBIs lead to long and short-term effects. Long-term effects include chronic traumatic encephalopathy (CTE) which leads to an early onset of Parkinson’s disease and cognitive decline. TDP-43 proteins are deposited in CTE and are indicative of brain injuries and neurodegenerative conditions.⁴ In the short-term TBIs lead to concussions and decreased cognitive function which subsides after 72 hours.⁵ Preventative measures include using protective equipment and avoiding head-to-head collisions. These strategies and athlete guidelines will be explored alongside TBI mechanisms in sports.

Understanding TBI in sports

There are three main types of TBIs, concussions, contusions and second impact syndrome (SIS).⁶ Concussions are mild TBIs (mTBIs) and structural imaging is typically unaffected. Athletes are unconscious for half an hour in most cases. An individual’s overall mental state typically is affected for up to 24 hours and there is a small brain function alteration. The white matter in the frontal cortex is damaged and this has been shown through imaging of the brain. Lesions in this region typically correspond to mTBIs.⁷

Contusions refer to bruising on the brain. These are typically attributed to falls and lead to haemorrhages and damage to blood vessels in the brain. The haemorrhage can spread to white matter in the frontal cortex.⁸ Contusions progress in severity over a few days and previous blood clots can cause a secondary brain haemorrhage. Brain contusions are correlated to TBI deaths thus contusions are indicative of potential mortality.

Second impact syndrome (SIS) occurs when athletes suffer more than one traumatic event to the brain within a short time period. This is prevalent in American football due to the playing schedule with many players suffering multiple concussions within the same season.⁹ SIS causes cognitive impairment, hypertension and oedema. Brain 

swelling leads to high intracranial blood pressure. SIS can lead to fatalities within two to five minutes following the second impact and trauma to the brain. This is rare however confirmed SIS cases are low thus the actual SIS numbers may be higher.⁹

There are many short and long-term signs and symptoms of TBIs. In concussions decreased cognitive function and consciousness are short-term however multiple concussions can lead to CTE and other neurodegenerative conditions. Following all types of TBI headaches, memory loss and confusion are the main short-term symptoms with contusions having oedema as a long-term consequence and SIS having a very high chance of death.

Risk factors for TBI in athletes

There are many risk factors for TBIs in athletes. Contact sports lead to the highest TBI incidences. Cycling and gymnastics also have a high TBI prevalence due to the falls being associated with contusions and concussions.³ Age is another risk factor, mortality is correlated to age and TBIs have a more severe impact in older individuals.¹⁰ In older athletes, amnesia lasts longer and there is less grey matter in the brain. Gender is another risk factor for TBI in athletes, males are twice as likely to sustain a TBI than females however the difference in mortality rate between patients who have suffered from a TBI is negligible between genders.¹¹ Men are more likely to suffer from TBIs as men participate in more contact sports than women. Poor weather affects playing surfaces therefore the environment is a key factor in TBI likelihood, particularly in sports such as cycling where falls are likely in adverse conditions.¹² Protective gear prevents injury likelihood as helmets reduce forces on the head and the brain collides with the skull at a slower rate. This decreases axon damage. In American Football helmets vary in protectiveness due to increased padding therefore headgear needs to be used regularly by athletes. Newer helmet technology will revolutionise preventative strategies.¹³

Prevention strategies

Preventative measures are gradually being introduced to protect athletes. In American youth sports coaches receive concussion training and videos can test if officials understand the safety rules. Disciplining officials who do not enforce the rules can reduce TBIs.¹⁴ Balance and coordination exercises are an excellent prevention strategy. A slide-and-step programme significantly reduces coordination loss and balance difficulties following a TBI in comparison to traditional muscular training. Socio-economic background is linked to TBI awareness therefore providing all athletes, coaches and parents of athletes with education can lower the risk of TBI susceptibility.¹⁵ Wearing headgear and other forms of protection can reduce TBI risk. 

Some studies argue that headgear is not effective in reducing concussions in Rugby however in ice hockey and American Football headgear is beneficial. In sports where headgear is ineffective, redesigning helmets may significantly reduce TBI risk.¹⁶

Rules within sports can reduce TBI risk. Since 2023 tackles in rugby must be below the waist to prevent head collisions.¹⁷ Tackling rules are a good preventative measure and in British Football the FA has banned heading in youth football as heading is linked to CTE. Enforcing dangerous play rules leads to a lower TBI frequency and many organisations have taken precautions. Neck strengthening exercises can reduce concussions as neck muscles absorb the kinetic energy of the collision therefore preventing the head from colliding with the skull to a high degree.¹⁸ Sideline assessments where cognitive ability, as well as nerve function and balance in conjunction with a neurology examination, is used to determine whether an athlete can continue to play following a suspected head injury.¹⁹ Injury surveillance systems such as intracranial pressure monitors can assess swelling and contusions during matches. Qualitative data allows comparisons between different injuries to be drawn thus providing useful data to keep athletes safe.²⁰

Guidelines for athletes post-TBI

Immediate response and management are necessary post-TBI. Immediately after a suspected injury a neurological exam can assess the extent of an injury. The patient may be ventilated if there is any risk of hypoxia due to TBI.²¹ The spine should be examined. Athletes should not be medically cleared for any major physical activity for at least 24-48 hours after a TBI. There are return-to-play protocols in place for athletes. The general return to play protocol is firstly symptom-limited activity followed by aerobic exercise, there will then be sport-specific exercise and drills without contact. Finally, full-contact practice must be completed.²² Healthcare professionals make decisions based on the return to play protocols and carry out neurological examinations therefore they are important in allowing a safe return. Long-term monitoring and support take place after a TBI. Temporary post-concussion symptoms such as headaches and dizziness subside quickly however post-concussive syndrome (PCS) means symptoms last months. PCS hinders memory and learning and is more common than recorded. Assigned Counsellors can help athletes who are affected in the long-term with TBI therefore helping with the psychological and learning difficulties faced by athletes in these circumstances.

Role of stakeholders in TBI prevention

Athletes, coaches, sports organisations and healthcare providers are stakeholders in TBI prevention. Athletes must be educated about the risks associated with 

their chosen sport. In America, the CDC educates athletes and the public on these issues. Younger athletes appear to be more aware of the complications with concussions thus this needs to be spread to older age groups.²³ Coaches teaching proper techniques and how to stay safe is a very effective measure in preventing TBI. Organisations such as the NFL have launched initiatives such as the Head Health initiative which focuses on technology and research post-TBI.²⁴ Investing in this type of technology is a good method of prevention and healthcare providers can educate the public on prevention and recovery techniques for athletes.

Case studies and success stories

TBI prevention programmes will set the standard for the near future in TBI prevention. The Safe Stars Act in Tennessee regulated safety standards and ranked programmes according to their safety in youth sports. Since 2017 when this Act was introduced there has been a 70% increase in Safe Star Status thus demonstrating that this initiative has led to higher safety in youth sports.²⁵ The NFL has a concussion protocol which has been funded and has been successful thus far. Helmets will also be redesigned for athletes. These initiatives show that investment and education in safety can lead to long-term benefits for athletes. The CDC has a heads-up initiative, designed for high schools to diagnose concussions. Many schools have agreed to this therefore awareness of TBIs has increased greatly.²⁶

Summary

It is key to prevent TBIs in sports through education, research and preventative measures such as wearing protective equipment and rule enforcement. With increasing knowledge and awareness of the issues that can be caused to athletes, particularly long-term because of TBIs there have been efforts to prevent this from occurring. CTE is a very prominent issue and TBI prevention will ensure that this can hopefully be less prevalent in the future. There must be continued focus on safety and initiatives such as the Safe Stars Act and regulations around coaching and officiating are key steps in ensuring that safety is the main priority. Increased funding into research regarding brain health is encouraging to say the least and healthcare providers can work in conjunction with athletes, organisations and the general public so that TBI can be a less prevalent phenomenon.