Key points 

• Concussions are common in sports and recreation, posing risks to brain health.
  
  
• Prevention is crucial and involves understanding intrinsic and extrinsic risk factors. 
  
  
• Primary prevention includes awareness campaigns, education, and safety protocols. 
  
  
• Secondary prevention focuses on early diagnosis and standardised management. 
  
  
• Tertiary prevention emphasises rehabilitation to mitigate long-term consequences. 
  
  
• Education, rule changes, and protective equipment are effective prevention measures. 
  
  
• Neck strengthening and proper training in tackling techniques show promise. 
  
  
• Challenges persist in raising awareness and changing sports culture, but ongoing research offers hope for minimising concussion risks. 

Introduction 

Sport-related concussion is among the most frequently reported injuries in sport and recreation. A sport-related concussion (SRC) is “a complex pathophysiological process affecting the brain, induced by biomechanical forces with several common features that help define its nature.” 

When it comes to concussions and traumatic brain injury, prevention is the key to maintaining optimal brain health. The reason it remains the best point of intervention is because it can be difficult to repair and reverse any brain damage incurred from those incidents, not to mention the increased susceptibility to secondary injuries.  

Concussion prevention strategies can reduce the number and severity of concussions in many sports. Taking precautionary steps towards safety in all aspects is the best way to approach the subject. 

Concussion risk factors 

Many sport-related concussions are predictable and, ultimately, preventable.  
 
A clear understanding of modifiable risk factors is required to design, implement, and evaluate appropriate prevention interventions to reduce the risk of SRC. Additionally, psychological and sociocultural factors in sport play a role within the uptake of any injury-prevention strategy and require consideration. 

The two risk factor categories for concussion are: 

• Intrinsic risk factors – internal factors specific to the individual, or 
• Extrinsic risk factors – external factors associated with the environment or sport 

 Early recognition of these factors is a part of an individualised, client-centred approach to the prevention of concussion. 

Intrinsic risk factors of concussion 

Intrinsic risk factors are variable, for example there may be some factors that make someone more likely to get a concussion can be changed (like how well they control their muscles) or can't be changed (like their history of past concussions, gender, age, and genetics). Similarly, if someone has had a concussion before, they might be more likely to get another one. 

There is no clear answer about whether being male or female affects the chances of getting a concussion. The risk of getting a concussion from sport tends to increase as people get older, especially during the teenage years, but then it starts to decrease in their early twenties. 

How well someone plays their sport and their specific skills can also affect their risk of getting a concussion. In high-level rugby, most concussions when making the tackle. If someone is moving fast and makes contact with their head, they are susceptible to suffering a concussion. 

Extrinsic risk factors of concussion 

Sports where players bump into each other a lot, like rugby, American football, and hockey, are particularly associated with concussion.

Concussion prevention strategies 

There have been numerous methods that have been proven to be effective in preventing the risk of concussion. They are as follows: 

Education 

Unfortunately, you can't always stop concussive injuries from happening. It's important to teach everyone who takes care of athletes about concussion to help prevent them. This can involve teaching people involved in sports the right techniques and following the latest advice. When people know more about concussion, they can recognize the signs and symptoms better. Also, doing tests to check brain functionafter any injury happens can help stop more serious injuries caused by going back to playing too quickly. 

Rule changes 

In February 2024, New Zealand’s ACC (Accident Compensation Corporation) introduced National Concussion Guidelines. Starting from the 2024 winter sports season, new rules aim to make community sports safer by setting a standard way to deal with concussions. These rules give guidelines for everyone involved in sports, like players and doctors, to handle concussions the same way every time. Two important changes are: first, players with concussions need at least 21 days off from full games, and second, they must get permission from a doctor before they can play again. 

Fair play 

Research conducted on youth and high school sports indicates a correlation between following the rules of the game and promoting fair play with reduced injury rates, particularly concussions. Instances of greater head accelerations and numerous concussions tend to happen during rule violations, unexpected collisions, or when athletes employ incorrect techniques. Consequently, employing appropriate coaching methods and adhering to the rules of the game could potentially lower the occurrence of concussions overall. 

Protective equipment 

While protective gear plays a vital role in mitigating brain impact, numerous studies indicate that such equipment may not entirely prevent concussions but can be effective in averting other types of injuries. Ensuring the proper choice and correct fitting of protective gear can, however, lower the chances of sustaining a concussion. 

Headgear 

Helmets are instrumental in decreasing the likelihood of severe traumatic injuries, commonly associated with skull fractures, bleeding, and other structural damages. However, it's important to note that concussions primarily occur due to the movement of the brain inside the skull, which helmets may not entirely prevent. Empirical research about the effectiveness of helmets in reducing the risk of concussion is in real-world settings is lacking 

The adoption of protective headgear in sports aligns with media coverage highlighting researchers' findings suggesting that modern football helmets could decrease translational and rotational accelerations, while soccer headgear might reduce peak impact forces. 

The majority of marketing efforts and research and development initiatives have concentrated on improving helmets and mouthguards. Some innovations include the integration of sensors aimed at monitoring players for possible concussions. Additionally, new products like protective collars are being introduced to help shield players during intense impacts. 

Sensors 

Recognising that concussions can occur even when helmets are worn, researchers and manufacturers have explored technological solutions to alert players and coaches about potentially concussive impacts. These sensors trigger an alert when an impact surpasses a specified threshold, enabling the identification and evaluation of affected players. Additionally, the technology maintains a database of individual players' impact patterns, facilitating intervention in training and technique as necessary. This strategy holds promise for reducing the occurrence of harmful impacts in the future. 

Mouthguard 

 Mouthguards are essential for preventing dental injuries as well as facial and skull fractures. However, it's important to note that currently, there are no mouthguards designed to prevent athletes from experiencing concussions6. The suggested advantage of wearing a mouthguard lies in its ability to alter the jaw's position, thereby potentially reducing the force transmitted to the skull upon impact. Recent studies indicate a significant reduction of over 50% in the likelihood of sustaining a concussion with mouthguard usage. 

Neck strengthening 

Neck strengthening has emerged as a novel approach in the prevention of sports-related concussions. Recent research underscores the potential of enhancing cervical musculature to diminish head impacts and safeguard athletes against neck injuries. Several studies have explored the relationship between neck strength and concussion susceptibility, suggesting that neck strength may be a factor amenable to change. 

The hypothesis posits that concussions frequently result from linear and rotational head accelerations, such as those experienced in whiplash scenarios. Strengthening the neck muscles may prove advantageous in mitigating concussions by enabling athletes to better manage whiplash-like movements induced by high-impact sports. By not only generating force but also absorbing shock, stronger neck muscles potentially empower athletes to exert control over such movements, thereby reducing the risk of concussion. 

Tackle training strategies 

An analysis of tackle mechanisms has pinpointed collisions between players' heads, whether intentional or accidental, as posing the greatest risk of head injuries. The second most common cause of head and neck injuries involves one player using their arm or hand to impact another player's head. Norwegian studies on head injuries highlight heading duels as the most frequent cause of injury, constituting 60% of cases, with 41% attributed to head contact with elbows or hands and 32% to head-to-head collisions. 

Understanding proper sports techniques is crucial in preventing concussions. Spearing, a dangerous form of tackling involving leading with the helmet in a head-down position, poses significant risks of concussions and other severe injuries. This technique generates axial loads through the head and spine, potentially causing cervical spine injuries and increasing the likelihood of concussions. 

Emphasising tackling with the head up is vital for injury reduction. Teaching correct techniques from a young age can establish proper habits that persist into later stages of athletic development. Additionally, limiting collision practices in youth football may decrease the frequency of head impacts during both games and practice sessions. 

Neuromuscular training warm-ups 

A study revealed a significant reduction of over 50% in the risk of concussions in rugby players after implementing neuromuscular training warm-up strategies at least three times per week throughout a season. Similarly, preliminary findings in youth soccer suggest a comparable reduction of over 50% in concussion risk with the adoption of neuromuscular training programs10. 

Vision training 

Vision therapy, also known as Oculomotor Therapy, is considered a promising approach in concussion prevention. As per research findings, optimal vision enables football players to efficiently utilise their eyes and brain to process peripheral visual information, enabling quicker reactions to the surrounding environment and thereby reducing the likelihood of injury-inducing collisions11. This therapy focuses on enhancing functional abilities such as eye-tracking, focusing, eye teaming (coordination between the eyes), hand-eye coordination, and more. 

The challenges of preventing concussions 

While progress has been made in promoting, implementing, and, in some cases, evaluating the prevention strategies described above, many challenges remain, particularly in concussion knowledge and awareness, and in the culture of sports. 

Knowledge and awareness of concussion risk factors 

 Awareness and knowledge regarding the risks, recognition, and management of concussions have seen an increase. However, studies indicate that a considerable number of young athletes fail to report their concussion symptoms, continue to play despite experiencing symptoms, or return to play prematurely. Often, young athletes and their parents lack familiarity with concussion signs and symptoms, as well as state concussion laws or school/league protocols dictating return-to-learn and return-to-play guidelines. Additionally, coaches may struggle to identify subtle signs of concussions and may not grasp the importance of managing both physical and cognitive activities post-concussion. 

Sports culture 

The attitudes and behaviours of young athletes regarding concussions are shaped by the prevailing "sports culture," which is influenced by parents, coaches, teammates, spectators, and the athletes themselves. This culture is partly formed by the discussions among parents and coaches regarding what constitutes acceptable behaviour within the team and how to ensure safe play and adherence to sports rules. Such a culture significantly impacts how concussions are reported and managed by both athletes and coaches. Positive reinforcement from coaches regarding concussion reporting tends to encourage athletes to accurately report their symptoms. 

Conclusion 

Managing the risk of concussions in fast-paced, physically intense contact sports remains challenging, and ongoing research explores the efficacy of external interventions in minimising the impact or severity of such injuries. Measures such as proper conditioning, year-round neck strengthening, adherence to correct tackling and rucking techniques, compliance with sports rules, appropriate equipment usage, and understanding and implementing concussion policies among players, coaches, referees, and supporters can significantly mitigate risks. While protective equipment like helmets, headgear, and mouthguards may reduce the risk of concussion, the evidence is inconclusive. Researchers and manufacturers continue to work towards enhancing or redesigning existing equipment to lower the incidence of concussions across various sports. 

Prevention strategies for concussions are rooted in an understanding of injury mechanisms, with a majority of concussions occurring due to body contact with other players or during tackling. Therefore, primary prevention strategies that focus on refining body-contact and tackling skills, along with improved secondary prevention measures centred on adhering to return-to-play protocols, hold significant value.