A concussion is a mild traumatic brain injury (TBI) caused by an impact to the head or a sudden jolt that may or may not involve lost consciousness. In athletes, the effects reach past physical symptoms: headache, dizziness, and nausea usually present first, while cognitive, emotional, and social effects can last longer, and cognitive deficits sometimes persist after physical symptoms resolve. That is why computerized cognitive tests play a role in concussion treatment and recovery.
Approximately 69 million people experience a TBI every year. Of those TBIs, many are concussions, which are incredibly prevalent in sports, with an entire subfield of sports medicine focused on concussions and TBIs. Concussions in sports are particularly prevalent in youth sports, among children and young athletes. The Centers for Disease Control and Prevention (CDC) found that approximately 283,000 children under the age of 18 went to U.S. emergency departments for sports-related TBI each year.
In healthcare settings, brain scans may be used after a TBI if there is a concern about swelling, bleeding, or a skull fracture. However, brain damage resulting from a milder concussion is unlikely to show up in a scan. To get a complete picture, providers often require concussion assessment tools to measure cognitive, mental health, and behavioral health symptoms associated with head injuries.
Cognitive tests measure processes such as short term memory, reasoning, and concentration. They are an important part of treating any sports concussion, from screening and diagnosis to recovery and return to play.
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Traumatic brain injuries account for approximately 10–15% of all sports-related injuries. Another study found that 70% of all reported sports-related concussions came from patients 19 years old and younger.
Which sports contribute the most concussion cases depends on location. One study done in South Carolina found that the "most common mechanism of sports-related TBI was being kicked in football or rugby," which accounted for 38% of all reported sports concussions. Sports-related falls and off-road vehicular sports were other leading causes of sports concussions.
A study on team sports in Canada found the following breakdown across the team sports studied:
| Sport | Share of concussions |
|---|---|
| Ice hockey | 44% |
| Soccer | Approximately 19% |
| Football | 13% |
Any contact sport carries an increased risk of concussion.
Concussions come with a range of symptoms and effects, which will be different for every person. Traumatic brain injuries can also be accompanied by neck injuries, which can affect range of motion in concussion patients.
Concussions often affect balance and coordination, which are significant concerns for athletes. Struggles with balance can lead to falls and repeated injuries. A patient's reaction time may also be affected, which would have a similar effect on their performance and safety in their sport.
If an athlete returns to play too early, loss of balance and reaction time can lead to potential repeat concussions. While exercise and other physical activity have been found to be good for overall brain health, overexertion can worsen concussion symptoms and lengthen recovery time.
Headache, dizziness, and nausea typically present immediately post-injury, but the cognitive, emotional, and social effects can be less visible. Symptoms like depression, fatigue, and irritability can lead to issues in school, sports, and other aspects of a patient's social life.
To help an athlete recover and return to their desired quality of life and level of sport performance, physicians ideally need to address every aspect of health as they treat concussions.
Physical symptoms, including balance and coordination, often resolve first. The most common physical symptoms include:
Balance and coordination can be tested with simple tasks, and are usually tested on-site, immediately post-concussion. Symptoms can be assessed using self-report symptom questionnaires, such as the Rivermead Post-Concussion Symptoms Questionnaire (RPQ) or the Sports Concussion Assessment Tool (SCAT-5). The SCAT-5 is designed to be administered by a healthcare professional to a patient immediately after a sports injury, and tests both self-reported symptoms, as well as coordination and balance.
If an athlete has experienced any head and neck injuries, they should seek immediate medical attention. However, the first hurdle to a patient receiving care is detecting the concussion in the first place.
Many athletes who have suffered a concussion experience memory loss, and may not remember sustaining an injury at all. As well, patients might fear that reporting the injury would lead to them not being able to return to work, school, or play. Other patients might not even be aware they should seek medical care for head trauma. It's therefore crucial for clinicians to inform their patients about the importance of cognitive health.
Several sideline concussion screening tools can be used to screen for and diagnose concussions, and many are designed to be used on-site. Self-report symptom questionnaires like the RPQ can also be useful, especially when used in conjunction with objective cognitive assessment tools that test brain function.
While concussion symptoms for some athletes may dissipate in a few weeks, many people still experience symptoms for a year after the initial injury.
What makes a concussion last longer? Certain factors such as age, sex, other health conditions, and status pre-injury have been shown to have an effect. Symptoms may resolve quickly, but persistent post-concussion symptoms that have not resolved after three months are described as post-concussion syndrome.
Multiple concussions will also have a significant impact on patient symptoms and recovery, and athletes are at a particularly high risk of repeated head impacts. A second concussion is likely to come with more and longer lasting symptoms.
An important stage in an athlete's concussion recovery is return to play. According to one meta-analysis, the average time for return to play for young athletes was nearly 20 days. However, the analysis found that if an athlete who has had a concussion returns to play or activity sooner than they should, this may lead to a risk of reinjury, or of symptoms persisting longer.
High levels of activity after a concussion have been shown to worsen cognitive performance and lengthen recovery time. This is true of both physical exertion and cognitive exertion.
Cognitive assessments can be used alongside symptom reports before making a return to play decision. In some cases, cognitive deficits persist longer than physical symptoms.
One Canadian study used advanced magnetic resonance imaging (MRI) technology to better see what happens to the brains of concussed hockey players. Even after clinical testing clears a player to return to the ice, there are still changes happening in the brain up to three months after the injury. On the positive side, an increase in neural connectivity in some areas suggests that the changes are due to the brain compensating for injuries.
There are many effects and long term consequences of a traumatic brain injury, which may present in a multitude of ways. It's important to be aware of and monitor all possible effects of a traumatic brain injury, using a range of tests and useful concussion assessment tools, by taking a whole person care approach to health care.
Concussion research on mental health consequences has increased in recent years, with studies showing that many aspects of a patient's mental health can be affected. Mild traumatic brain injuries (mTBIs, or mild TBI) can lead to a change in mood or behavior, and can also lead to an increase in mental health conditions. Reported effects include:
Clinicians can test for mental health effects with symptom questionnaires designed for specific conditions. For example, the Patient Health Questionnaire (PHQ-9) can be used to assess depressive symptoms in patients.
Cognitive impairments have been found to take longer to improve in some athletes. Cognitive skills are best tested with objective cognitive assessment tools. Several online cognitive tasks are available from Creyos, which test areas shown to be affected by concussions. These include:
One study found that members of the general population who had reported past concussions scored lower on the Double Trouble cognitive task, designed to test concentration and response inhibition. This study also found that the results of participants who reported having had a concussion were identical to the results of football players with a history of frequent head injuries.
As understanding of the severity of concussions in sports rises, so too do guidelines and rules put in place to help prevent them. Guidelines may include wearing a helmet, other protective equipment, or disallowed behavior. It's important for athletes to not only follow these guidelines during competition, but also during practices. Many harmful maneuvers that have a high rate of head injury have been disallowed in their sports, such as body checking into the boards in hockey and high kicks in soccer.
Immediately after an impact, there are ways to screen for a concussion, many of which do not require a professional to administer the test. One of the more common ones is the Standardized Assessment of Concussion (SAC), designed to be used on-site or for emergency room assessment.
To diagnose a concussion, healthcare professionals may benefit from using a variety of tests, including subjective and objective neuropsychological tests, along with physiological tests.
Computerized cognitive testing can play a key role in concussion treatment and can support a patient throughout all stages of the assessment and recovery process. Computerized tests improve upon traditional pen-and-paper medical evaluation, as they can be more consistent in their administration and scoring.
Patients can do computerized cognitive tests from their own home, without having a lengthy and potentially strenuous journey to a specialized clinic when injured. Testing can also be done in the same appointment and yield same-day results, without having to refer patients to another location. This can lead to a more accessible patient experience.
Athletes can be tested at the start of the season or before a concussion. Athletes can do cognitive tests in order to give an idea of normal brain function. These can give a good baseline to compare to if the athlete sustains a brain injury in the future. This can also help normalize concussion testing and the seriousness of brain injuries in athletic contexts.
Throughout concussion treatment, it's beneficial to continue testing cognitive function to monitor how patients are or aren't improving. Symptom questionnaires are useful for clinicians to hear how patients have been feeling, but cognitive tests are particularly useful for monitoring and tracking recovery. They can objectively and quantitatively show how a patient's cognitive performance is changing over time.
When compared to traditional neuropsychological testing, computerized tests can more efficiently measure symptoms during concussion treatment. Traditional testing often takes significantly more time, including referrals to external specialists, while computerized testing can be done in a fraction of the time, without having to refer patients out to other clinics.
Having a consistent healthcare team is not only important for ensuring patients with concussions can keep up with appointments, but is also important for continuity of care. In this way, a consistent team is always monitoring patient change and recovery, and is able to make changes to a treatment plan with full understanding of the patient's status.
In this article, we've discussed concussions in sports, and how they affect brain function. We've also outlined how cognitive testing, particularly computerized and online cognitive testing, can support treatment and recovery from sports-related concussions.
Computerized cognitive testing is a useful tool in concussion diagnosis and treatment, and can offer many improvements over pen-and-paper testing. It's important to also remember that other types of tests such as symptom questionnaires can be used to support and complement the results of cognitive tests, in order to get the most complete picture of a patient's cognitive health, mental health, and physical symptom recovery.
Reviewed by Mike Battista, Director of Science & Research at Creyos
Mike Battista specializes in brain health, cognition, and neuropsychological testing. He received his PhD in personality and measurement psychology at Western University in 2010 and has been doing fun and useful stuff in the intersection between science and technology ever since.