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Prevention and Control Strategies

The Haddon Matrix (below) is a useful tool for organizing the factors involved in sport-related concussion and identifying possible interventions. This matrix takes into consideration the three phases of injury: pre-injury, at the point of injury, and post-injury. It also considers factors of the human player, the vehicle, which is the other player that delivers the blow, and the physical and socio-economic environment. This matrix was mainly developed to represent adolescent football, but it could be applied to other adolescent contact sports, too.

Haddon Matrix.jpg

Haddon also identified ten strategies for determining approaches to injury prevention. These strategies can be applied to sport-related concussion in adolescents as follows:

1. Prevent the creation of the hazard in the first place.
Prohibit all contact sports among adolescents.

2. Reduce the amount of the hazard brought into being.
Use legislation to restrict age groups that are allowed to participate in contact sports.

3. Prevent the release of the hazard that already exists.
Allow traditional contact sports to only be played as non-contact sports (e.g. touch football).

4. Modify the rate or spatial distribution of release of the hazard from its source.
Modify sports to eliminate high-risk, forceful contact between players.

5. Separate, in time or space, the hazard and that which is to be protected.
Only allow certain types of contact, avoiding contact that is likely to deliver a blow to the head or result in sudden movement of the neck.

6. Separate the hazard and that which is to be protected by interposition of a material barrier.
Enforce use of advanced helmet technology and continue to develop effective protective gear.

7. Modify basic relevant qualities of the hazard.
Only allow adolescents of similar sizes to play contact sports together.

8. Make what is to be protected more resistant to damage from hazard.
Incorporate neck muscle strengthening exercises into team workouts, and teach players the safest posture and position to take at time of impact.

9. Begin to counter the damage already done by the environmental hazard.
Ensure that players, coaches, and athletic trainers recognize the symptoms in order for the injured player to receive immediate medical attention, rather than return to the game.

10. Stabilize, repair, and rehabilitate the object of the damage.
Enroll the injured player in rehabilitation care to address cognitive deficits from the injury.

Despite the risk of concussion, it is unlikely that parents, adolescents, and schools would be willing to eliminate contact sports or even adjust them through age restrictions or adjustments to the rules. Due to the nature of sports like soccer and football, it would also be difficult to control the types of contact that occur because the velocities and masses of players cannot be controlled. Therefore, strategies six, eight, nine, and ten are likely to be the most appropriate and feasible.

Much of the current literature on sport-related concussion stresses the importance of strategy nine, education to recognize concussions, rather than focusing on preventing the injury from occurring. The “Heads Up” program was developed in 2004. This program seeks to educate coaches, players, and parents about the risks and signs of concussion (1). However, since the inception of this program, no assessment has been done to determine its effectiveness. Such data would be useful to guide future educational programs.

Image: CDC

Education can be supplemented by equipping teams with tools to properly assess suspected concussions. Moorhead High School implemented a software program called ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) that allows coaches, trainers, and physicians to make educated decisions about return to play calls (10). Using the software, each athlete completes neurocognitive tests at the beginning of each season to create a baseline score. Following an injury, the player retakes this test, and his or her scores are compared to the baseline to assess whether a concussion has occurred.

Image: ImPACT

Studies have found that protective headgear may prevent concussions in head-to-head collisions (9). Helmets and other forms of protective headgear are not entirely effective because they protect the skull and brain from direct contact, but cannot protect the brain from contact with the skull. For instance, an individual wearing a helmet who suffers a violent blow to the head will be protected from fracture of the skull, but may still move their head in a manner that allows the brain to collide with the skull.

However, new technology is being developed to better design helmets for protecting against concussion. Riddell produced an advanced helmet with extra padding on the side of the head and around the face. A study of this technology found that use of this helmet reduced the incidence of concussion in high school football players (11). This research represents the importance of strategy six. Although this technology cannot entirely prevent concussion, the significance of reducing the incidence of concussion cannot be ignored. It would be useful to expand upon this research by testing whether adding protection to the neck, thus lessening sudden motions of the head, would also reduce the incidence of concussion.

Strategy eight, which would incorporate neck muscle strengthening exercises into team workouts, as well as teach safe contact postures, would make seek to make the player’s body more resistant to damage. In suggesting this strategy it is assumed that neck strength and player posture are associated with the motion of the head and neck upon contact. More research should be done to determine the strength of this association and whether such a strategy would be effective.

Strategy ten, rehabilitation of the injured player, is important for assessing when it is appropriate for the adolescent to return to play. Coaches often attempt to make rushed sideline calls regarding possible concussions, but given the risk of subsequent injury to concussed players it is crucial to make sure that the player is fully rehabilitated before returning to play. Although there is no treatment for concussion, rehabilitating the player should include assessing their memory and other cognitive functions. This can allow for accommodations to made at school and for appropriate return to play calls to be made.

Education is the best means for controlling the effects of concussion following the injury. The downside of this strategy is that it requires active participation of players, coaches, and athletic trainers. However, concussions can be well treated when recognized and are far more dangerous when they go undetected. Especially for school-aged adolescents, the effects on memory and concentration can be quite prominent in the classroom environment. Also, individuals who have experienced a concussion are far more likely to experience a second concussion.