Running head: TRAUMATIC BRAIN INJURY 1

A Public Health/Aggregate Problem: Traumatic Brain Injury/Concussion*

Within the Adolescent and Young Adult Population: Associated with Football

Holy Family University

*A concussion is a type of traumatic brain injury. This paper uses the terms interchangeably.
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Abstract

The following paper examines one of the most serious public health issues facing the

adolescent and young adult population, which is traumatic brain injuries (TBI’s) related to

contact sports, such as football. “The Centers for Disease Control and Prevention estimate that

between 1.6 and 3.8 million sports-related TBI’s occur every year in the United States” (Lowrey,

2015). “A concussion is a type of traumatic brain injury—or TBI—caused by a bump, blow, or

jolt to the head or by a hit to the body that causes the head and brain to move rapidly back and

forth. This sudden movement can cause the brain to bounce around or twist in the skull,

stretching and damaging the brain cells and creating chemical changes in the brain” (CDC,

2015a). Through researching many articles on this topic, there were prevention strategies found

that could be taken to reduce the number of TBI’s occurring each year. When a TBI does

happen, the way it is treated and the rehabilitation afterwards have a great impact on the success

of the person affected. This paper also discusses the barriers to the resolution of the problem,

nursing interventions, and how cultural diversity impacts the problem. Vulnerable populations

can be affected by TBI’s; but different economic and biological variables can also be associated

with the problem. Ultimately, in order for prevention strategies and improved outcomes to occur,

this paper will discuss supportive multidisciplinary resources, leadership principles, and

legislative efforts.

Keywords: traumatic brain injury, TBI’s, adolescent, young adult, concussion, sports,

football, prevention, laws

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A Public Health/Aggregate Problem: Traumatic Brain Injury/Concussion

Within the Adolescent and Young Adult Population: Associated with Football

A serious public health issue facing the adolescent and young adult population in the U.S.

is TBI’s related to contact sports, such as football. “During the last decade, emergency

department visits for sports and recreation-related TBI’s among youth, including concussions,

increased by 62%” (CDC, 2015a). “The risk of concussion is highest in the 15-19-year-old age

group nationally regardless of gender” (CDC, 2015a). A concussion can happen anywhere or

anytime, but especially in contact sports, such as football, people are constantly tackled and

pushed down. Concussions can occur in all sports but, football has the highest incidence and as

many as 50% of concussions may go unreported (Harmon et al., 2013). Concussions are a major

issue because many players may not report them or say they are fine to get back out on the field,

but measures should be taken to ensure this does not happen. While doing a needs assessment I

found, “studies demonstrate that athletes, parents, and coaches lack the knowledge needed to

make informed decisions about concussion and education of medical personnel, coaches,

athletes, and parents can enhance the identification of concussions and improve treatment and

prevention” (Harmon et al., 2013). The purpose of this paper is to identify preventative measures

which can promote a decrease in TBI’s in the adolescent and young adult population as well as

using nursing interventions to increase the positive outcomes for the person affected. This paper

will also identify barriers to resolving the issue of TBI’s and cultural, economic, and biological

variables associated with TBI’s will be discussed. Multidisciplinary resources along with

leadership principles and legislative efforts taken to reduce fatalities with TBI’s will be
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discussed. TBI’s can have long-term or lifelong effects, such as the ability to return to work or

school, and sustain relationships with family, friends, and the community (CDC, 2013b).

As nurse’s, there are many interventions which help in the care of people with TBI’s.

There are ways to prevent concussions, but when they cannot be prevented, the way in which

they are treated is critical. TBI’s are “a life-threatening emergency that requires early and

continuous assessment to prevent mortality and morbidity and early detection and treatment is

essential and can significantly affect patient outcomes or make the difference in saving

someone’s life” (Lavagnilio, 2011). Whether a person comes into the emergency department

with a concussion or more serious TBI, each case should be taken with serious caution. A

concussion from a football game could start as nothing serious then in an instant develop into

something critical. There are interventions that nurses can do such as initial and on-going

assessments, which include the Glasgow Coma Scale and vital signs. The Glasgow Coma Scale

helps nurse’s assess the patient’s mental status, neurologic findings, and pupillary reaction

(Lavagnilio, 2011). The nurse can evaluate the Glasgow Coma Scale by interpreting the scores

the patient received. The scale includes eye opening, best motor response, and best verbal

response. A normal score is 15 indicating that the person is functioning to their fullest ability and

a score of less than 8 indicates damage has been done and they need immediate medical help.

Vital signs which include heart rate, blood pressure, temperature, pain, and respirations help the

nurse establish a baseline for the patient and to see if they remain stable or become unstable. The

nurse can evaluate the vital signs by knowing their normal range such as heart rate being

between 60-100 bpm and blood pressure being near 120/80. If those values are out of normal
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range then the nurse knows that interventions need to be done to help correct the situation. The

nurse can evaluate pain by using a 0-10 scale and then once the patient receives medication, the

nurse can re-evaluate the pain level after. Implementation and evaluation are other nursing

interventions which can be done, which include giving the prescribed medication to the patient,

contacting the physician if needed in a timely manner, and documenting the patient’s progress

and response to treatment from the time they come into the hospital until they are discharged

(Lavagnilio, 2011). Implementing the plan of care and evaluating how the patient responds to

that plan of care is crucial in the recovery and rehabilitory effort. A third intervention which can

be done is teaching, for example, the patient who comes in with a concussion from a football

game as well as parents, coaches, sports league officials, and school professionals can learn a lot

from helmet safety to the signs and symptoms of a concussion and when to get prompt treatment

(CDC, 2015a). The nurse can evaluate if teaching has been effective by asking athletes, parents,

and coaches to do a return demonstration, such as the application of a football helmet. Also,

asking the people who were educated questions and receiving feedback and seeing if they have

any other questions. To improve outcomes for a person with a TBI, they should be taught the

signs and symptoms of a concussion and when to obtain prompt treatment, rather than waiting

and delaying treatment.

Healthy People 2020 states that “injuries are the leading cause of death for Americans

ages 1 to 44, and a leading cause of disability for all ages, regardless of sex, race and ethnicity,

or socioeconomic status” (Healthy People 2020, 2016a). Each year more than 1 million serious

sports-related injuries occur among adolescents 10 to 17 (Healthy People 2020, 2016a). The

impact of injuries such as TBI’s can have lasting effects such as brain injury, poor mental health,
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and disability, but even worse is the fate of death. In order to help prevent and deal with the

consequences of TBI’s determinants that should be looked at are individual behaviors, the social

environment, and improvements in product safety (Healthy People 2020, 2016b). There are also

grand scale ways to help promote change and prevention regarding injuries such as legislation

and enforcement and education. An objective of Healthy people 2020 is to reduce fatal and

nonfatal traumatic brain injuries. One goal of Healthy People 2020 is to “prevent unintentional

injuries and violence, and reduce their consequences” (Healthy People 2020, 2016b).

There many barriers to the resolution of the problem of TBI’s in the adolescent and

young adult population. One of the barriers is the actual game of football, “some students are

hesitant to report symptoms because they do not want to risk being pulled out of a game, while

coaches reported pressure from parents to keep children in the game” (CDC, 2015a). This barrier

could be helped by increasing awareness of the issue of concussions to athletes and their parents.

Another barrier is the access to healthcare services, some athletes can get medical care right on

the field, but if they need to see a specialist, they cannot always travel to another part of the city

or state. The barrier of money makes a big difference because there are not always resources

available at games or schools to be able to monitor and evaluate athletes. Some resources that

would be needed are “staff time, stakeholder capacity, and financial resources” (CDC, 2015a).

“The cultural diversity of football players has at least made it clear that sport concussions

are an ‘equal opportunity’ injury” (Webbe & Salinas, 2013). “The diverse representation of

athletes at all levels makes the issue of cultural competence in concussion management

important” (Webbe & Salinas, 2013). There have been pre and post-concussion impact
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performances compared between African American and Caucasian high school and collegiate

athletes, most of whom played football (Webbe & Salinas, 2013). The findings from that

comparison “indicated equivalent baseline performance, but African American athletes

evidenced poorer processing speed and were 2.4 times more likely to have an impaired domain

1-week post-concussion” (Webbe & Salinas, 2013).

Vulnerable populations who have an increased risk of TBI’s and the long-term effects

associated with them are adolescent and young adults who play contact sports such as football,

people who have a pre-existing condition such as learning disorders, ADD/ADHD, and migraine

headaches, and people who have already sustained a concussion previously. “Research indicates

that the risk is greatest for young, developing brains and that girls have more symptoms and a

longer recovery period” (Lowrey, 2015). When people have a pre-existing condition, this can

complicate the diagnosis and management of a concussion. “A history of a concussion is

associated with a 2 to 5.8 times higher risk of a sustaining another concussion” (Harmon et al.,

2013). When an athlete has had a concussion and then sustains another one, the brain takes an

even longer time to heal because it has already had something traumatic happen to it.

There are economic variables related to TBI’s such as money. In order to have the right

equipment for football players such as helmets, which take the brunt of the impact of a

concussion, resources have to be available. There are many factors that come into play when

choosing a helmet such as finding a good fit based on the athlete’s head size, the coverage of the

helmet, making sure their vision is available through the helmet, and that the chin straps are the

right fit (CDC, 2015a). Money comes into play because after so many years a helmet has to be
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replaced either because of the child growing or if it gets damaged. Education is important to

athletes, coaches, and parents because if the helmet is cracked, if parts are missing, or if it is

severely damaged it should be replaced. It takes money to develop new technologies, such as

newly designed helmet impact sensors or accelerometers, which provide real-time monitoring of

head impact exposure to identify high-risk impacts and alert sideline personnel that a concussion

assessment is warranted (Lowrey, 2015). Companies are working to fine tune their products

based on pilot data and the NFL could soon be using accelerometer devices on their helmets

(Lowrey, 2015). Also, the biggest problem with legislation such as the Lystedt Law is “the costs

of implementing such a program which would include athletic trainers present at all practices and

games as well as physician coverage for games. In many areas of the country, this is not

financially or logistically possible” (Doolan, Day, Maerlender, Goforth, & Brolinson, 2011).

There are biological variables associated with TBI’s such as age and gender. Age is a

huge variable because the adolescent and young adult population is at a greater risk for a TBI.

High school athletes exhibited a protracted recovery period following a concussion when

compared to collegiate and professional athletes (Webbe, 2013). There are also risk factors

between men and women such as women having a “weaker musculoskeletal support for the

head, which exacerbates the acceleration of the head and brain induced by an externally applied

force” (Webbe & Salinas, 2013). There are other factors that contribute to biological variables,

such as “time to evaluation and education received regarding physical and cognitive rest, poor

compliance, premorbid conditions; sociocultural factors” (Webbe & Salinas, 2013).

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There are many multidisciplinary resources which discuss information about concussions

such as educational programs. One of the resources is by the CDC and is called “Heads Up:

Concussion in Youth Sports” which provides teaching to athletes, parents, and coaches who can

view videos regarding concussions and learn about different topics such as the signs and

symptoms of a concussion, when to get prompt treatment, and preventative measures that should

be taken. A recent evaluation of this program “demonstrated that a relatively small sample of

coaches of youth sports were able to recognize and respond to sports-related concussions after

reviewing the materials, suggesting that such efforts aimed at training for coaches can be

effective at improving concussion recognition and management” (Lowrey, 2015).

Leadership principles make a big impact when it comes to preventing or dealing with a

concussion. There are many types of leaders, but the two leadership styles that would help with

the vision of preventing and dealing with TBI’s are a democratic and transformational leader. A

democratic leader “encourages staff participation in decision making, involves staff planning and

developing new ideas and programs, and communicates effectively, and provides regular

feedback” (Cherry & Jacob, 2014, 291). The staff in this instance would be the athletes, coaches,

parents, school officials, legislators, law makers, and professional organizations such as the NFL.

People have to advocate for laws and legislation, such as the Lystedt Law in Washington State.

A transformational leader “identifies and clearly communicates vision and direction, empowers

the work group to accomplish goals and achieve the vision, are admired and emulated, and

provide mentoring to individual staff members based on need” (Cherry & Jacob, 2014, 291).

Nurses and NFL players can be transformational leaders because they are role models. They can
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influence and mentor athletes, coaches, and parents. Nurses can advocate for legislation, people

affected by TBI’s, and make sure they are educated about concussions. NFL players have a

vision of the goals their team wants to achieve and in order to do that, the players need to wear

the correct gear and play by the rules. If young athletes notice professional players abiding by the

rules, then they would want to follow their lead.

Concussions have become a major public health issue and there have been many news

stories and reports specifically pertaining to football. Many legislative efforts have been put forth

to help show athletes, parents, teachers, coaches, school officials, and professional sports

organizations that something needs to be done to prevent and reduce the morbidity and mortality

of sports-related concussions. “In 2009 Washington State led the way with the passage of the

Lystedt Law, named for Zacahary Lystedt, a middle school football player who suffered a severe

brain injury after returning to a game in which he had sustained an earlier concussion” (Lowrey,

2015). The Lystedt Law, had the backing of the National Football League (NFL) and other

influential stakeholders, and became a model for other state legislative activity which resulted in

rapid and widespread passage of public health legislation across the nation (Lowrey, 2015). “As

of April 2014, every state and the District of Columbia, has enacted a law that addresses youth

sports concussion” (Lowrey, 2015). “The Washington State Law was the first state law to require

a ‘removal and clearance for Return to Play’ among youth athletes” (CDC, 2015a). These laws

are made to help prevent and reduce the number of concussions and reduce the effects that can

come along with sustaining a concussion. Most sports laws concerning concussions include 3

action steps which are 1) educating coaches, parents, and athletes 2) removing the athlete from
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playing and 3) obtaining permission to return to play (CDC, 2015a). The NFL has even

developed sideline tools which can determine if an athlete is a “No-Go” and they have a policy

where once an athlete is removed from the game or practice, they should not return until they are

fully asymptomatic, has a normal neurological exam, normal neurophysical testing, and has been

cleared by the team physician and independent neurological consultant (Doolan et al., 2011).

In conclusion, the U.S. has a rising number of TBI’s each year related to contact sports,

such as football. The most as risk population is the adolescent and young adult. Nurses are

important in helping with is issue because a lot of teaching can be done in the community and at

schools as well as at hospitals. There are prevention strategies which can be taken and

educational programs available to learn how to deal with a concussion when it happens. Healthy

People 2020 promote reduction of fatal and nonfatal traumatic brain injuries. Barriers such as

money and pressure for not wanting to be pulled out of the game should be talked about and

resolved. From a cultural perspective, it does not matter about race or ethnicity; a concussion

can happen to anyone. Access to good healthcare could really help with the identification,

treatment, and rehabilitation of the athlete affected. The prevention and management of TBI’s

involve using a multidisciplinary approach which involves education and programs to raise

awareness of this issue. There are economic and biological variables that can increase or

decrease the outcome for the athlete affected, such as money, age, gender, and pre-existing

conditions. Legislative efforts such as the Lystedt Law help with giving the proper treatment to

athletes affected with a concussion and gives time for the person to rehabilitate before returning

to play. A study has shown “significant brain abnormalities in a large group of living active and
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retired professional football players” (Amen et al., 2011). The same study also suggested “that

playing professional football is associated with a significantly higher risk for permanent brain

damage” (Amen et al., 2011). Most high school football players go on to play football in college,

and then some players are drafted for the NFL and this is at a young age. The long term effects

of a TBI can be severe but can be reduced if preventative measures are taken and education is

provided to an athlete at a young age.

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Resources

Amen, D. G., Newberg, A., Thatcher, R., Jin, Y., Wu, J., Keator, D., &

Willeumier, K. (2011). Impact of Playing American Professional Football

on Long-Term Brain Function. The Journal of Neuropsychiatry and

Clinical Neurosciences, 23(1), 98-106.

Centers for Disease Control and Prevention. (2015). What is a Concussion? Retrieved

from http://www.cdc.gov/headsup/basics/concussion_whatis.html

Centers for Disease Control and Prevention. (2013b). CDC: Grand Rounds: Reducing

severe traumatic brain injury in the United States. MMWR, (62)27, 549-552

Cherry, B., & Jacobs, S. R. (2014). Contemporary Nursing: Issues,

Trends, and Management (6th ed.). St. Louis, MO: Mosby & Elsevier.

Doolan, A. W., Day, D. D., Maerlender, A. C., Goforth, M., & Brolinson, P.

G. (2011). A Review of Return to Play Issues and Sports-Related

Concussion. Biomedical Engineering Society.

Harmon, K. G., Drezner, J., Gummons, M., Guskiewicz, K., Halstead, M.,

Herring, S., . . .Roberts, W. (2013). American Medical Society for Sports

Medicine Position Statement: Concussion in Sport. Clinical Journal of

Sports Medicine, 23(1), 1-18.

Healthy People 2020. (2016). Injury and Violence. Retrieved from

https://www.healthypeople.gov/2020/leading-health-indicators/2020-lhi-

topics/Injury-and-Violence
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Healthy People 2020. (2016b). Injury and Violence Prevention. Retrieved from

https://www.healthypeople.gov/2020/topics-objectives/topic/injury-and-violence-

prevention/objectives

Lavagnilio, C. L. (2011). Traumatic Brain Injury: Improving the Patient's

Outcome Demands Timely and Accurate Diagnosis. Journal of Legal

Nurse Counseling, 22(3), 3-10.

Lowrey, K. M. (2015). State Laws Addressing Youth Sports-Related

Traumatic Brain Injury and the Future of Concussion Law and Policy.

Journal of Business & Technology Law, 10(1), 61-72.

Webbe, F. M., & Salinas, C. M. (2013). It’s Not Just White Male Adults

Playing Football and Hockey: Concussion Management with Diverse

Athelete Populations. Bulletin of the National Academy of

Neuropsychology, 27(2), 23-27.