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First things first, concussion is a type of traumatic brain injury categorized as a “mild” brain injury because concussions are usually not life-threatening. In general all tests and images are normal. It is not a structural injury but a functional injury, and the effects of a concussion can be serious.

A recent study showed that concussions constitute 8.9% of high school athletic injuries and 5.8% of collegiate athletic injuries. Meaning that if we round these numbers, almost 1 out of 10 injuries that happens playing sports in high school, and 1 out of 16 injuries in college kids is a concussion.

With this high incidence and potential for significant problems is very important to identify risk factors.

History of concussion, multiple studies has shown a history if prior concussion as a risk factor for subsequent concussion. In high school athletes, a greater than-twofold increase in concussion rate was seen even when adjusting for sport contact level, grade and body mass index. This association was strongest for football. Non-professional rugby has similar findings. For college athletes there is 3 times higher risk of repeat concussion with a history of 3 or more concussions.

Sports, it is hard to compare owing to varied methods for calculating incidence; however, several findings are evident. For individual sports boxing has the highest incidence compared to martial arts. Collision team sports (football, ice hockey, rugby) have the highest rates of concussion in men at multiple levels of competition. For women, soccer consistently has the highest risk. Wrestling, men’s soccer, basketball and lacrosse also put scholastic athletes at risk for concussion. In most sports, the rate of concussion is significantly higher in games than practice.

Positions, appears that football linebackers, defensive backs and offensive linemen, soccer goalkeepers, defensive field players; and rugby midfield backs sustain more concussions than other positions.

Age, is still unclear but there are some evidence that a younger age is associated with an increased risk of concussion.

Sex, female sex confers an increased risk of concussion. This is suggested by most of the studies when sports are examined where men and women’s games are similar (including soccer and basketball); female’s athletes have a higher risk.

Migraines, there are a lot of unanswered questions here, but appears that migraine is associated with an increased risk of sport-related concussion.

Genetics, little evidence exists for the role of family history and genetics as risk factors for concussion. There are multiple studies going on the implication of the APOE gene.

Equipment, football helmets reduce the acceleration of the head from collisions and decrease severe head injuries, but the rate and severity of concussion are not affected. Similarly, ice hockey helmets decrease severe head injuries but not concussion rate. Headgear in rugby shows mixed results without conclusive evidence for a protective effect on concussion. Mouth guards in multiple sports and face shields in ice hockey decrease dental and orofacial injuries but have no effects on concussion risk.

Over the past 2 decades, the rate of concussion in American high school football demonstrated an alarming upward trend. Concussion have been referred as a “silent epidemic”. While associated problems are often not visible, they may lead to profound consequences, including long term mental, physical or occupational sequelae. While the number of skull fractures has dramatically declined with modern helmet design, concussion have persisted at concerning rates.

The National High School Sports-Related Injury Surveillance system (HS RIO) analyzed first-time concussions sustained during participation in high school football for 9 seasons from 2005-06 to 2013-14 nationwide. Each concussion report documented concussion symptoms and helmet characteristics, including whether the athletic trainer (AT) believed the helmet fit correctly at the time of injury and type of inner helmet liner.

4580 concussions sustained over 9 seasons were analyzed. When separated into groups above or below mean values (age, height, weight) there was no difference in numbers of symptoms according to age or weight but players taller than 70 inches had more severe concussions than shorter players.

Data regarding helmet fit were included in 3172 reports. Athletic trainers reported that 101 helmets did not fit properly and 3070 did. Athletes with helmets that did not fit properly had greater rates of drowsiness, irritability and sensitivity to noise as well as more symptoms in average. Also, they experience symptoms for longer than 1 week more often than players with properly fitted helmets.

The helmet liners were also compared either with an interior air bladder lining or helmets lined with either a foam or gel. Players that had a concussion while wearing helmets with an air bladder had more sensitivity to light or to noise. Athletes with a gel or foam helmet liner had greater rates of loss of consciousness and drowsiness. Somehow the air lined helmets protect more with regular concussions but don’t make a difference with higher energy collisions.

Newer helmets with additional thick padding over the cheek bone and mandible improves the helmet fit and helps prevent concussion in high school football. With a proper fitted helmet head and neck acts together as a single unit. But, if the helmet is not secured properly the head acts as a separate unit, the neck muscles may not be able to dampen the forces. Especially rotational forces, which are then transmitted from the helmet to the brain. A loose helmet also may delay the cervical muscle contraction response to an impact since the direction of the force to resist may not be detected until it reaches the head.

Maintaining a properly fitted helmet throughout the season is challenging because of mismatches between helmet size and athlete’s head. Helmet fit can also vary when players sweat or play in rainy conditions. Additionally, high school players may dramatically alter their hair styles (e.g. Shaving their heads) or what they wear under a helmet (e.g. adding internal layers of clothing for warm) over the course of the season. Last, air bladder systems may leak, resulting in insufficient inflation.

According to rules published by the NFHS, no supervising individual is specifically responsible for ensuring proper helmet fit prior to athlete participation. Prior to each game, coaches are required to verify that all athletes are wearing a helmet that meets NOCSAE standards and all helmets have an exterior warning label. This label mentions avoidable causes and risks of head and neck injuries but not mention helmet fit.

It is often the responsibility of the athlete to recheck helmet fit, inflate a loose air bladder during the season, or bring problems with helmet fit to the attention of team officials.

The 2012 NFHS Helmet Rule mandates that any player with a helmet completely dislodged must leave the game for 1 play and adjust their helmet. Unfortunately, did not adequately addressed this problem since concussions were of greater severity after the 2012 rule change, and frequency with which symptoms lasted more than 1 week increased.

The NFHS helmet rule does not force athletes to adjust their helmets until after they have sustained a potentially major impact.  Thus, supervisors of high school football teams should mandate that coaches, AT’s, or equipment managers verify adequate helmet fit among all players prior and throughout the football season.