Introduction

Traumatic Brain Injuries – as they are now known – have been a part of basketball since it first became popular in the first part of the twentieth century. Unfortunately, ignorance of the risk of these injuries has also plagued the sport at all levels. The first National Basketball Association All-Star Game was created to raise funds for a great player who suffered a blow to a head during a game and subsequently lapsed into a coma.

Maurice Stokes was an elite power forward who could score, rebound and pass. He was one of the first athletes in the sport who combined tremendous strength with quickness, agility and explosiveness. In a game near the end of the 1958 season, Stokes drove to the basket and hit his head on the floor. He was knocked unconscious for several minutes and returned to the game after he was revived with smelling salts. Three days later, on a flight after playing in a play-off game, Stokes collapsed on a team flight, suffering from post-traumatic encephalopathy.

He lapsed into a coma for three weeks and awoke a quadriplegic with no speech function. Years of rehab, assisted by teammate Jack Twyman enabled Stokes to communicate and perform some basic tasks. Stokes died in 1970. In a three-year career, he averaged sixteen points, seventeen rebounds and five assists per game. Contemporaries said that had his career continued, he would have been known as one of the top ten basketball players of all time and he was inducted into the Hall of Fame in 2004 (Carter, 2004).

Hopefully, if an injury like Stokes’ were to occur today, teammates, coaches and trainers would be more aware of traumatic brain injuries and provide the injured athlete with the support and resources to make a full recovery.

Definition

A concussion is caused by a blow to the head which shakes the brain inside the skull. A mild traumatic brain injury (M.T.B.I.) causes cells in the brain to discharge electricity (normally utilized to activate neurons) at once, destroying short-term memory and confusing the victim. Although visible signs, such as a bruise on the head, may not be visible, the victim could be suffering from a range of physical, mental and emotional symptoms (Ogilvie, 2011).

M.T.B.I.s can be caused by a single blow to the head or a number of small impacts over the course of a game or a sport season. As the head accelerates and decelerates along with the rest of the body, the brain – suspended in fluid – continues moving and collides with the inside of the skull.

Thirty thousand Canadians are diagnosed with a concussion annually although researchers believe that the number is much higher (Ogilvie, 2011). The concussion rate among Canadian junior hockey and high school football players is much higher than previously thought and many adolescent athletes may suffer from M.T.B.I.s that are not diagnosed.

Basketball and Head Trauma

Despite an overall twenty percent decline in basketball emergency room visits for children and adolescents in the past fifteen years, concussions have increased seventy percent. The increase is a combination of a greater awareness of M.T.B.I.s and their effects and a sport that grows bigger, faster and stronger every year (Hutchison, 2010).

Among youth sports, basketball is second in terms of concussion rate, accounting for nine percent of all concussions. It ranks behind football but ahead of soccer, hockey and baseball. The high number of M.T.B.I.s can be attributed to basketball’s high participation but the concussion rate is still rising. In the past ten years, the concussion rate for boys has doubled, whereas it has tripled for girls (Barker-Pope & Bradford, 2010).

Youth and Head Trauma

Children and adolescents are more likely suffer a concussion from a blow to head (in basketball, concussions are caused by collisions with another athlete, the floor or the ball) than a fully-developed adult (Richards, 2011).  Young people heal from concussions slower than adults and a head injury can impact them throughout their teen years and into adulthood (Metzl, 2010).

Student-athletes may suffer headaches, nausea, and confusion which hamper their academic performance.  M.T.B.I.s make it hard to learn and study as the brain activity in class triggers the same painful symptoms as exercise (Hammer, 2011). Also, high school student-athletes are more susceptible to reduced verbal and visual memory, reduced processing speed and slower reaction time. Decreased cognitive functions in adolescents commonly last from seven to fourteen days (McClincy, Lovell, Pardini, Collins, & Spore, 2006, p. 36).

Symptoms

After a suspected head injury, the athlete should be removed from play and examined by a coach or trainer.  Coaches must be especially attentive and observant since young athletes may conceal how they feel in order to continue to play or because the symptoms have not yet taken effect (McClincy, Lovell, Pardini, Collins, & Spore, 2006, p. 33).

Sideline Treatment

On the sidelines, coaches and athletic therapists evaluate a suspected athlete by asking questions. If a question is too generic, an athlete could guess at the correct response (such as “where are you?” and “what day is it?). Ask questions that force the athletes to access their memory (Cantu & Hyman, 2013, p. 17):

• Do you remember the play where you were injured?
• What quarter is it? What’s the score?
• Do you remember what happened? Tell me what you recall?
• Memory: Give a six-digit sequence and ask the athlete to repeat it forwards and backwards.
• Balance: Stand with both feet together, on one foot, then the other, then with eyes closed.

When in doubt, sit the player out and err on the side of caution.

Duration of Symptoms

The length of time that the athlete is affected by symptoms indicates the severity of the concussion. Those who exhibit more than five minutes of on-court mental status changes have longer post-concussive symptoms and greater memory decline. High school athletes who fall into the former group may be ready to return to play in about a week but those in the latter category will need longer (Lovell, et al., 2003, p. 302).

Multiple Concussions

High school players who sustained a previous concussion were three times more likely to have a second concussion during the same season. The concussion symptoms on the court were more severe and a longer recovery time was necessary (Collins, Lovell, Iverson, Cantu, Maroon, & Field, 2002, p. 1175). Young people who have sustained multiple concussions reported significantly more symptoms and reduced memory scores on baseline tests (Iverson, Gaetz, Lovell, & Collins, 2004, p. 440).

Treatment

Treat a suspected concussion as a T.B.M.I. unless shown otherwise and remove the player from the game. If they have show symptoms of a concussion, they should not play again in the game or the rest of the day (in the case of a tournament). The athlete may need to consult a physician; encourage them to return with a written diagnosis (most doctors have standard forms for head injuries that detail the grade of the concussion and a timeline for returning to activity).

Coaches should monitor the athlete for worsening symptoms, including seizures, which indicate bleeding in the brain or a more severe injury.  Someone should check on the athlete for the next twenty-four hours to monitor them.  The athlete can go to sleep but should be awoken every two to three hours to ensure they are recuperating (ThinkFirst-SportSmart, 2010).

Concussion Grade

Concussions are graded from one (least serious) to three (most serious).  Although more serious grades of concussions are more likely to present more acute effects of greater intensity at the time of the injury, these symptoms are not the only distinguishing trait. Symptoms may persist longer for the higher grades. Recovery times for high school athletes do not appear correlated to the severity of the concussion (McClincy, Lovell, Pardini, Collins, & Spore, 2006, p. 37).

Second Impact Syndrome

It is important to give youth plenty of time to recover from their injury before they return to play; someone who comes back too soon is at a greater risk of an M.T.B.I. which may compound the severity of the symptoms. Less severe impacts could aggravate the swelling caused by the first concussion and may lead to a worse injury or even death. The majority of the victims of second impact syndrome are high school student athletes aged thirteen to eighteen, perhaps due to greater sensitivity to M.T.B.I.s for that age group or because of incorrect diagnosis (Lovell, et al., 2003, p. 295).

Recovery Timeline

Athletes must progress through a series of steps symptom-free before they can resume contact sports. In case post-concussion syndrome returns after the activity, the athlete must be symptom free for the remainder of the day. Proceed through each step one day at a time (ThinkFirst-SportSmart, 2010).

Gradually increase the duration and intensity of the activity as the athlete recovers.  Consult a physician if symptoms return at a later stage.

How Teammates Can Help

It can be challenging for the athlete who is at home missing school and their favourite sport. Peers and teammates can be an important source of support by visiting at home, sending occasional texts and keeping in touch. Even if a parent has taken away a phone for a time, seeing the messages when they get the phone back (for a limited time) can be an emotional boost. Teammates should try to listen and be supportive, rather than asking too many questions or placing took many demands on their friend (Cantu & Hyman, 2013, p. 73).

Legal Responsibilities

Coaches and organizations have a duty of care towards the athletes participating in basketball programs. The standard of care to be provided is based on what a reasonable coach at that level would do, written standards and common sense. The risk of harm from concussions must be appropriately managed; given the recent news coverage of M.T.B.I.s and their effects, failure to exercise any care in this regard would constitute negligence on the part of the coach and place the organization in a position of vicarious liability (Corbett, Findlay, & Lech, 2008, p. 29).

Coaching Certification

Most youth coaches are unfamiliar with the symptoms of a concussion and correct treatment. Only a handful of coaches use an assessment tool although about half would be willing to do so if one was made available. Common misconceptions can lead to premature return to play decisions and an increased risk of second impact syndrome (Valovich-McLeod, Schwartz, & Bay, 2007, p. 141).

Emergency Action Plan

In Canada, it is the responsibility of Canadian coaches to plan for possible crises, such as building evacuations and catastrophic injuries (Corbett, Findlay, & Lech, 2008, p. 230). A detailed Emergency Action Plan should include contingencies for when a concussion is suspected – for example listing who will render first aid and test the injured player – to ensure prompt and thorough treatment and prevent second impact syndrome.

The National Collegiate Athletic Association requires all member schools to have a concussion-management plan in order to treat players, reduce the occurrence of second impact syndrome injuries and make sound Return to Play decisions (Amber, 2010).

Baseline Tests

Composite baseline tests can roughly determine the extent of an athlete’s injury although pen and paper tests like the Sports Concussion Assessment Tool are less reliable than more expensive computerized tests. Although they are used by many National Hockey League and National Football League clubs, costly interactive tests like imPACT are not a feasible option for most school and community teams (McClincy, Lovell, Pardini, Collins, & Spore, 2006, p. 38).

Proper Instruction

Failing to teach a skill is required to perform a sport at that level – even allowing athletes to perform a skill incorrectly – could be a legal liability for a coach if it leads to an injury (Richards, Game Misconduct: Violence, Abuse and Young Athletes, 2011). When coaches develop physical performance factors such as explosiveness, strength and speed, they must be equal conscious of instructing skills lacking in adolescents, such as balance, body awareness and agility (Reynolds, 2011). If one athlete is going to explode towards the rim at high velocity, others must be able to see what will happen and protect themselves.

Managing Aggression

During a game, fouls, screens, hand-checks and other forms of contact will occur. These common plays could escalate to the point of recklessness or assault, causing a serious injury, possibility an M.T.B.I.. Acts of violence are judged based on what a reasonable competitor would do: if the act exceeds the parameters of a normal game, there may be grounds for criminal or civil proceedings.

Coaches must not only instruct the technical aspects of the sport-specific movements in order minimize injury to the player and the opponents but help athletes manage their aggression throughout the game and amidst instinctive reactions (Corbett, Findlay, & Lech, 2008, p. 41). Players must know how to defend and foul safely because a hard foul could lead to a collision and a concussion.

Return to Play Guidelines

Every organization should have a Return to Play policy for athletes who have suffered (or are suspected to have suffered) a concussion. Young athletes badly want to play and do not understand the risks of returning to play too soon. In a worst case scenario, players or parents may conceal symptoms in order to play or coaches and organizations may overlook medical advice in order to win. A black and white policy is clear, easy to follow and takes the personal element out of the situation.

Students who take their time as they recover make better progress than those who push themselves. St. Michael’s College School created a “Return-to-Learn” program which emphasizes student health over athletics. The six-level program begins with bed rest at home and gradually reintroduces class time, time online and homework. A student must be symptom-free for a week in order to move on to the next level (Hammer, 2011). At the University of Toronto, athletes must wait twice the duration of the symptoms plus twenty-four hours before returning to play (Richards, Return-to-Play Guidelines, 2010).

Conclusion

Basketball is becoming safer and safer each day. It is an excellent way for young people to stay fit, make friends and have fun; physical inactivity is a far greater risk that any sport-specific injury (Richards, 2011). Parents and coaches should not prevent youth from participating in the sport but become aware of how it is evolving. Concussions are a critical issue in all sports in the twenty-first century and it is paramount to be fully aware of the signs and symptoms and the proper care for M.T.B.I.s.

List of Resources

• Amber, D. (2010, May 4). Second Impact Syndrome, Preston Plevretes. Retrieved November 18, 2011, from E:60: http://espn.go.com/video/clip?id=5163151
• Barker-Pope, T., & Bradford, S. (2010, September 13). In Basketball, Danger of Head Trauma. Retrieved November 15, 2011, from New York Times: http://well.blogs.nytimes.com/2010/09/13/in-basketball-danger-of-head-trauma/
• Cantu, R., & Hyman, M. (2013). Concussions and Our Kids. New York City: First Mariner Books.
• Carter, B. (2004, September 13). Stokes’ life a tale of tragedy and friendship. Retrieved November 11, 2011, from ESPN Classic: http://espn.go.com/classic/biography/s/stokes_maurice.html
• Collins, M. W., Lovell, M. R., Iverson, G. L., Cantu, R. C., Maroon, J. C., & Field, M. (2002). Cumulative Effects of Concussion in High School Athletes. Neurosurgery , 51 (5), 1175-1181.
• Corbett, R., Findlay, H. A., & Lech, D. W. (2008). Legal Issues in Sport. Toronto: Edmond Montgomery Publications Limited.
• Hammer, K. (2011, November 2). How a school got smart about concussions. Retrieved November 16, 2011, from The Globe and Mail: http://www.theglobeandmail.com/news/national/toronto/the-academic-impact-of-concussions/article2223368/
• Hutchison, C. (2010, September 13). Basketball and Concussions. Retrieved April 23, 2011, from ABC News: http://abcnews.go.com/Health/WellnessNews/basketball-concussions-head-injuries-rise-teen-sports/story?id=11603847
• Iverson, G. L., Gaetz, M., Lovell, M. R., & Collins, M. W. (2004). Cumulative effects of concussion in amateur athletes. Brain Injury , 18 (5), 433-443.
• Lovell, M. R., Collins, M. W., Iverson, G. L., Field, M., Maroon, J. C., Cantu, R., et al. (2003). Recovery from mild concussion in high school athletes. Journal of Neurosurgery , 98 (2), 295-301.
• McClincy, M. P., Lovell, M. R., Pardini, J., Collins, M. W., & Spore, M. K. (2006). Recovery from sports concussion in high school and collegiate athletes. Brain Injury , 20 (1), 33-39.
• Metzl, J. (2010, August 10). Concussion Care Guidelines. (S. Sy, Interviewer)
• Ogilvie, M. (2011, April 8). Why a blow to the head is a big deal. Retrieved November 16, 2011, from Toronto Star: http://www.healthzone.ca/health/newsfeatures/article/971546–why-a-blow-to-the-head-is-a-big-deal
• Reynolds, G. (2011, April 20). Are Gawky Adolescents More Injury Prone? Retrieved November 15, 2011, from New York Times: http://well.blogs.nytimes.com/2011/04/20/sports-injuries-and-the-teenage-brain
• Richards, D. (2011, May 24). Game Misconduct: Violence, Abuse and Young Athletes. Retrieved November 13, 2011, from Faculty of Physical Education and Health: http://www.physical.utoronto.ca/news/11-05-26/Youth_in_sport_need_better_protection_Experts.aspx
• Richards, D. (2010). Return-to-Play Guidelines. Retrieved November 15, 2011, from University of Toronto/Toronto Rehab Varsity Athlete Concussion Program: http://www.physical.utoronto.ca/Concussion/Return_to_Play_Guidelines.aspx
• ThinkFirst-SportSmart. (2010, May). Concussion in Sport. Retrieved November 16, 2011, from Concussion Education and Awareness Program: http://www.thinkfirst.ca/downloads/concussion/concussion-card-physicians.pdf
• Valovich-McLeod, T. C., Schwartz, C., & Bay, R. C. (2007). Sport-Related Concussion Misunderstandings Among Youth Coaches. Clinical Journal of Sport Medicine , 17 (2), 140-142.