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Overview
Recent research indicates that head impacts occur quite commonly during contact sports (most commonly in American Football), in which visible signs/symptoms of neurological dysfunction may not develop despite those impacts having the potential for neurological injury. The associated cumulative impact burdens throughout a career are equally, if not even more important. Clinical studies have also identified athletes with no readily observable symptoms but who exhibit functional impairment as measured by neuropsychological testing and functional MRI (fMRI), which are further corroborated by diffusion tensor imaging (DTI) and, most excitingly via blood biomarker studies, demonstrating axonal injury in asymptomatic athletes at the end of a season. These emerging biomarker data have demonstrated significant axonal injury, blood-brain barrier permeability, and evidence of neuroinflammation, all in the absence of behavioural changes.
Such data suggest that subconcussive level impacts can lead to significant neurological alterations, especially if the blows are repetitive.1.
Brain trauma doesn't require great distance and speed.
Nuts and Bolts
Brain trauma among football players across all codes—and athletes in other contact sports such as lacrosse and ice hockey—may be less a result of violent collisions leading to concussions and more the consequence of the cumulative impact of repetitive head injuries (RHI). This discovery has prompted growing calls from experts to implement measures at all levels of sport, from professional leagues down to youth programs, to reduce exposure to such repetitive trauma. However, a shrinking minority, including some within major US professional and collegiate sports, continue to advocate for a more cautious approach until further research provides clearer, definitive evidence.
While scientists have long suspected that RHI could cause brain damage—particularly in boxers—a 2010 study by Purdue University researchers on high school football players marked a breakthrough. The study revealed a previously unknown group of athletes who, despite showing no clinically observable signs of concussion, exhibited measurable impairments in neurocognitive functions (especially visual working memory) on computerised tests. Additionally, these players demonstrated altered brain activation patterns on advanced neuroimaging tests (fMRI), highlighting the subtle yet significant effects of repeated head impacts.1.
Indeed, researchers found that the players with the most impaired visual memory skills were not those diagnosed with concussions but rather those who, in the week leading up to the study, had experienced a large number of repetitive head impacts (RHI)—around 150 hits—mostly in the 40 to 80 g range of linear acceleration. While linear acceleration plays a role, it is believed that rotational forces are the primary cause of significant brain injury.
Regardless of the number of hits or the force involved, the key takeaway is that "undiagnosed" and "untreated" concussions can lead to serious long-term issues if proper "Return to Play" (RTP) decisions are not made.
In Summary
1. Escaping detection. Because they have not suffered damage to areas of the brain associated with language and auditory processing, they are unlikely to exhibit clinical signs of head injury (such as headache or dizziness) or show impairment on sideline assessment for concussion, all of which test for verbal, not visual memory.
2. Didn't know they were injured. If working memory deficits are sufficiently small, a player may not be aware of the additional effort required to complete everyday tasks and, therefore, not think to bring the problem to anyone's attention.
3. Facing an uncertain future. Even though the players in the original Purdue study who suffered short-term cognitive impairment from repeated sub-concussive blows exhibited results on fMRI and ImPACT tests administered before season 2. comparable to the baseline results before season #1, their return to baseline did not necessarily mean that there was 100% recovery, as several of the subsequent Purdue studies demonstrated. The damage may only be known over the long term, years later.
Side note
Patients with moderate and severe brain injuries often have focal deficits and occasionally profound brain damage. However, it should be noted that the severity of the initial injury does not correlate linearly with the severity of the brain damage. They may need ongoing cognitive and vocational rehabilitation, case management, and pharmacological intervention to return to their highest level of function.
Similarly, with 'mild' cases, the level of blow does not correlate with the level of injury.
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