Expected Performance After Head Injury – How to Approach an Invisible OpponentNo Opinions
Sports related head injuries (e.g., concussions) affect one’s ability to concentrate, make decisions, foster learning, and perform both individually and collaboratively as part of a team (Asplund, C., Mckeag, D., & Olsen, C., 2004). Furthermore, head injuries have the potential to become more dangerous over time if not understood properly and taken care of in an appropriate manner (Senthinathan, A., Mainwaring, L., Psych, C., & Hutchison, M., 2017). While the threat of personal injury is overwhelmingly important, many coaches and/or athletes may lose sight of this by sacrificing recovery over return-to-play [RTP*] (Wallace, J., Covassin, T., & Lafevor, M., 2016). This sacrifice not only puts the athlete at risk for more severe injury but puts the coaches, affiliated school/organization and team in a position of responsibility should anything happen to the injured athlete. As a result of this threat, a mutual understanding of what head injuries are and how they affect performance is imperative. In addition, a better understanding of the rehabilitation associated with head injuries may assist in reducing future unintended harm and reduce repeated rehabilitation. This, in turn, may increase athletes’ self-confidence, expedited return to optimal performance, and create greater team cohesion.
Before getting into a discussion regarding RTP, it is important to gain a basic understanding about brain injuries. Traumatic brain injuries (TBI) and mild traumatic brain injuries (mTBI), more often referred to as concussions, occur when there is a sudden acceleration and deceleration of the head. This results in one’s brain moving with an abnormal force. Subsequently, the brain will experience what is called axonal shearing (Asplund et al., 2004). Put in simple terms, a concussion is a force, either internal or external, that results in one’s brain moving in a sudden and rapid manner which commonly results in internal damage to the brain (Kissick & Johnston, 2005). As with all injuries, there are symptoms. Common symptoms associated with traumatic brain injuries include, but are not limited to: amnesia, loss of consciousness (LOC), headaches, confusion, difficulty concentrating, and visual impairment (Asplud et al., 2004). There has been debate over which symptom has the most influence regarding the severity of TBI an individual may have sustained, but for the purpose of this article, we will not be addressing debate.
The main dangers surrounding TBIs are that the majority of the symptoms are not external. This means, as coaches, we must trust the athlete to report any uncomfortable symptoms after sustaining a head injury. Granted, there are exceptions that coaches can see in order to make more sound judgment calls (e.g., heavy hits, falls, and penetrating injuries). This process of revealing possible symptoms to a coach or trainer is what is called the initial reporting process. The reporting process is the timeframe from which an athlete may have initially sustained an injury, but the symptoms may not yet severe enough to be overly apparent. Common symptoms in this category are headaches, dizziness, and/or nausea. This time is crucial because it gives coaches the opportunity to remove the athlete from activity that may compound the injury and make it more severe.
What is to say my athlete will hide these symptoms in order to avoid losing ‘play’ time? This question is a primary obstacle that coaches may face when it comes to self-reported injuries. The first thing to consider when trying to develop a remove-from-play (RFP) strategy may be by simply asking oneself: “are my athletes aware of the dangers that head injuries pose?” If the answer is no, than the answer may be as simple as exposing your athlete’s to what TBI(s) are and the dangers they pose. Moreover, educating athletes about compound concussions resulting from underreported symptoms may hold the key in getting athletes ‘on-the-fence’ of reporting to come forward. It is a coach’s responsibility, to help educate athletes both on and off the field. This includes information about the sport of which they play, and the dangers of which the athletes will be exposed to.
Another way to approach the difficulty of unseen injuries is through continuing education for coaches and staff. There are a wide variety of sources one can use to educate their coaches and staff. Sources include, but are not limited to: online education, seminars, workshops, and medical training. These approaches, while more time consuming, may enable coaches to identify some of the smaller external factors that pair with TBI(s) (e.g., stumbling, slurred speech, abnormal eye movement). In the end, the end goal of continuing education should aim at providing coaches with a broader knowledge of the symptoms of TBI. This, in turn, may enable coaches to make better decisions regarding RFP and RTP moving forward.
So what about an RTP plan? Currently, there are no universal RTP plans that are in place specific to brain injuries. The main reason is due to the complexities that are associated with head injuries. How hard one hits his/her head, susceptibility, repeated concussions, and post-concussive syndrome (PCS) are just a few of the factors that have shown to have an influence on TBI severity (Asplund et al., 2004; Senthinathan et al., 2017). When it comes to head injuries, it is up to the on-site medical provider to provide guidance from which route is best for the athlete. However, this is not to say coaches are helpless in assisting his/her athletes.
As a coach, a potential starting point for determining whether or not to address a potential TBI is to ask the following questions:
- How did the athlete hit his/her head?
- Was the impact violent in nature (e.g., head snap forward and backward)?
- Has the athlete shown visible TBI related symptoms (e.g., confusion, LOC, inability to keep eye contact, difficulty concentrating)
- ASK THE ATHLETE!
- Did it take a longer than average amount of time for the athlete to get up?
When in doubt, the best thing a coach can do if he/she is concerned about an athlete is to consult a medical professional. Athletes are the first line of defense in protecting themselves. Coaches are there to provide authoritative guidance when necessary and ultimately have the power to initially remove athletes if they are concerned. However, most coaches are not medical professionals or experts in the field of TBI. As a result, it is their responsibility to report an injury regardless of the consequence to team performance. Concussions remain dangerous regardless of the stage/severity. Research and media reports show that TBI(s), if gone unchecked, have the ultimate severity of, in rare cases, death (Senthinathan et al., 2017).
In the end, the expectation that athletes are supposed to be tough and perform, regardless of circumstance, may be harmful. Athletes should be expected to perform, but they should be expected to perform by the safest means possible to maintain their performance. In other words, athletes should not be placed in a situation where the game/competition/practice comes before personal safety. After all, an athlete who has cognitive performance deficiencies related to a head injury is not an effective athlete. We, as coaches, owe it to our athletes to assist them in performing to their fullest potential by keeping them healthy and educating them about how to keep themselves healthy in the future. Our ability to perform pends on their ability to perform. Optimal performance begins and ends with optimal health.
* RTP refers to the process of rehabilitating individuals who have suffered a head injury and returning them to full sport participation (e.g., practice and competition).
Asplund, C., McKeag, D., & Olsen, C. (2004). Sport-related concussion: Factors associated with prolonged return to play. Clinical Journal of Sports Medicine, 14, 339-343.
Kissick, J., & Johnston, K. (2005). Return to play after concussion: Principles and practice. Clinical Journal of Sports Medicine, 15, 426-431.
Senthinathan, A., Mainwaring, L., & Hutchinson, M. (2017). Heart rate variability of athletes across concussion recovery milestones: A preliminary study. Clinical Journal of Sports Medicine, 27(3), 288-295.
Wallace, J., Covassin, T., & Lafevor, M. (2016). Use of stepwise progression return-to-play protocol following concussion among practicing athletic trainers. Journal of Sport and Health Science, 1-6.
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About Michael Mellinger
Michael Mellinger serves as a Study Coordinator for the world's largest concussion study - the Concussion Assessment Research and Education (CARE) study - at the United States Naval Academy (USNA). He performs both military and sport psychology related consulting specific to cognitive performance enhancement strategies. Contact 'firstname.lastname@example.org' for questions surrounding his work and/or consulting.