The Neuropathology of Concussion

Willie Stewart, MBChB, PhD, FRCPath, explains what happens to the brain during a concussion and the lasting effects of TBI

Traumatic brain injury has been a subject of research for decades, and investigators are constantly learning more about the brain, effects of these injuries, and technologies to help in their assessment and treatment. While concussion, a type of mild traumatic brain injury, has increasingly gained attention within recent years, there is still much that researchers and health care professionals do not know about the damage caused to the brain. Dr. Willie Stewart, Consultant Neuropathologist and Honorary Clinical Associate Professor at University of Glasgow and ICS Scientific Advisory Board Member, outlines what we do, and do not know, about concussion and its effects on the brain and the body.

What happens to the brain during a concussion

The effects of moderate or severe traumatic brain injury are visible in brain imaging and recognizable in clinical exams. Patients with these more severe brain injuries occasionally die, allowing researchers to view the brain with a microscope and see structural changes.

The neuropathology of concussion is distinct from that of moderate or severe traumatic brain injury. “Concussion is much more challenging because there’s very little to see on imaging, unless you use really specific brain imaging techniques, which are at research level,” explains Dr. Stewart. “The clinical symptoms are heterogenous and often quite mild and hard to pin down. Patients don’t tend to die with acute, uncomplicated mild brain injury so we can’t look down a microscope and see exactly what’s happening to the brain.”

To illustrate what happens during a concussion, Dr. Stewart describes the brain as suspended as a semiliquid inside the skull. In all forms of brain injury, the skull moves rapidly, while the brain moves just slightly out of sync within it, causing the fine fibers in the brain to be stretched, pulled and, ultimately, damaged. “That damage interrupts the passage of signals in the brain, which leads to all the different symptoms people complain of,” Dr. Stewart says. The blood vessels and reactive cells within the brain can also be affected, contributing to those symptoms.

While severe brain injuries can be quantified using classification systems such as the Glasgow Coma Scale, there is no valid, objective assessment for concussion at this time. “There’s no blood test that can be done. No brain scan routinely performed. No clinical examination to elicit signs of concussion with any confidence. It’s all really subjective,” says Dr. Stewart. “And that’s where the problem, I think, lies in trying to figure out this disease. How do we recognize who really has a concussion?”

Possible long-term effects of concussion

While most people who suffer a single concussion will make a full clinical recovery within a short period of time, a small number will experience symptoms for months or longer. But long-term effects are generally believed to be a result of multiple concussions. “We don’t believe [a single concussion is] necessarily enough to lead to long-term problems. It requires the cumulative effect of exposure to multiple mild brain injuries or to one single moderate or severe brain injury,” Dr. Stewart says.

Researchers have recognized that exposure to repetitive brain injury can lead to long-term change in the brain. Dr. Stewart notes chronic traumatic encephalopathy (CTE), a degenerative brain disease found in people who have a history of traumatic brain injuries, as an example that has been captured in headlines in recent years, especially in the world of sports. However, while researchers can see physical differences when viewing a brain with a microscope, long-term effects such as psychiatric disease and personality syndromes are still difficult to define as directly associated with brain injuries.

So can the brain heal? The brain does have plasticity, which allows it to adapt to minor injuries when circumstances require it, says Dr. Stewart. “For milder forms or single injuries, some degree of recovery of function is undoubtedly capable. My concern is the cumulative effect of multiple injuries, one on top of the other. And that might not be repairable or recoverable.”

Weighing the health benefits and risks in sports

Despite the risk of head injury for athletes, Dr. Stewart also calls for balancing the concern for injury with a recognition of the health benefits of physical activity, including cardiovascular benefits and a decreased risk of obesity, diabetes and other diseases. This positive counterpoint may be overlooked due to a lack of information. “What we’re really lacking at the moment is any real understanding of what global, long-term brain health looks like in former athletes,” says Dr. Stewart. He points to his ongoing research with the FIELD study that aims to go beyond isolated cases of dementia in former athletes. Instead, it will take a broader view of the lifelong health of around 10,000 former soccer players, evaluating not only brain health but also other body systems and diseases, in order to more accurately weigh the risks and benefits of playing the sport.

But the message is clear: If in doubt, sit them out. It’s an initiative that health care providers and researchers in this field want the general public to take to heart. “If there’s any suspicion an athlete may have concussion, they should just be removed from play,” Dr. Stewart says.

While there’s so much left to learn about concussion, Dr. Stewart sees the increased public awareness of the long-term risks of exposure to brain injury as a positive sign. This awareness contributes to more researchers coming into the field, new ideas, emerging technologies for diagnosis and management, and studies that give further insight into how dementia develops. All of these new developments point to a clearer understanding of the brain and a world of possibility for the neuropathology of concussion.

Willie Stewart, MD, is a Scientific Advisory Board Member of the International Concussion Society. The International Concussion Society sponsored website Concussion.Org  is the number one destination for information related to concussion prevention, diagnosis and treatment. Our mission is to serve medical professionals, athletes, administrators, coaches, patients and the public by providing a central repository of accurate and scientifically vetted concussion research. Working alongside our world-class scientific advisory board, aims to be the most trusted global index on one of the most common, yet least understood, forms of traumatic brain injury. If you would like to be interviewed for an influencer profile, please fill out this form.

Neurological Complications of Repeated Concussions

Charles Adler, MD, PhD, speaks on the link between concussion and long-term neurological disorders

Immediately following a concussion, memory loss, blurry vision, loss of consciousness, and confusion are common. These symptoms can go away fairly quickly, making it easy for someone to think he or she has recovered. However, for those who experience repeated head injuries, there can be long-term neurological complications, says Charles Adler, MD, PhD, a neurologist in the Neurology department at the Mayo Clinic in Scottsdale and member of the International Concussion’s Scientific Advisory Board.

He recently spoke with us about the underlying damage that can be done after repeated head injuries, and how players can protect themselves from long-lasting effects.

How Repeated Injuries Affect Athletes

“Damage can be done to different parts of the brain, including the deep nuclei of the brain, which can lead to various Parkinson’s-like symptoms,” Dr. Adler says. “It can lead to damage of the cerebral cortex which can lead to cognitive and behavioral abnormalities.”

Dr. Adler says some abnormalities show up immediately after a head injury. Sometimes they don’t resolve at all, while in other cases they seemingly resolve but then evidence of neurodegenerative and behavioral disorders show up at a later date. There is also evidence for chronic traumatic encephalopathy, which can lead to both behavioral and neurodegenerative disorders.

Concussion in Young Children

While conversation around young children and head injury is common, people of every age are at risk.

“There is a lot of concern that younger age groups are at greater risk because the brain is still developing. Certainly, with young children, you have some reason to believe that there’s a potential increased risk. But I believe there’s a risk at any age of concussion, especially multiple concussions, leading to neurologic syndromes in the future,” Dr. Adler says.

What plays more of a role than age is activity level. Those who are very active or play contact sports are at greater risk of concussion, due to the nature of the activities. There is also an increased risk if someone resumes their activity level too soon after a head injury.

To prevent injuries, it’s important for parents and coaches to educate themselves on the key concussion indicators, as well as what to do after a suspected concussion and the importance of returning the athlete to competition after a concussion safely.

Signs and Symptoms

Difficulty with memory and other cognitive functions are common symptoms of neurodegenerative disorders, which can occur after repeated injuries. This can include the ability to concentrate, pay attention and multitask, as well as being able to comprehend when reading or hearing things, Dr. Adler says.

Additionally, difficulty with the following motor skills may also indicate the development of a neurodegenerative disorder: overall weakness, slow movements, tremor at rest, difficulty with walking, dragging a leg, shuffling the feet, and persistent and progressive twitching of muscles.

There are medications that can treat symptoms of cognitive impairment and Parkinson’s-like symptoms; however, there are currently no treatments that can cure or stop the progression of neurodegenerative disorders, Dr. Adler says. There are some medications that can potentially slow cognitive abnormalities, and researchers are currently studying medications that can slow the onset of motor abnormalities.

If an individual has already experienced multiple head injuries, there is currently nothing a healthcare provider can to do prevent the onset of a neurodegenerative disorder. Dr. Adler says this is why continuing research is invaluable and preventing concussion from the beginning is important.

Current Research

Researchers are currently working to understand how best to prevent neurological complications. This includes looking into when it is safe for athletes to return to play after an injury to reduce acute and chronic problems, clinical trials to improve function after an injury and research on biomarkers.

“There is a lot of work being done looking for biomarkers in the blood, spinal fluid or imaging biomarkers,” Dr. Adler says. “This could suggest improved safety, in terms of when somebody is less at risk for further damage.”

For additional information on concussion symptoms, diagnosis and treatment, visit our resource library.

Charles Adler, MD, PhD, is a Scientific Advisory Board Member of the International Concussion Society. The International Concussion Society sponsored website Concussion.Org is the number one destination for information related to concussion prevention, diagnosis and treatment. Our mission is to serve medical professionals, athletes, administrators, coaches, patients and the public by providing a central repository of accurate and scientifically vetted concussion research. Working alongside our world-class Scientific Advisory Board, aims to be the most trusted global index on one of the most common, yet least understood, forms of traumatic brain injury. If you would like to be interviewed for an influencer profile, please fill out this form.

Concussion, Your Child and You

What every parent needs to know about concussion risk

Concussions can happen anywhere. From a fall on the playground to a hard hit on the field, accidents that result in a concussion are especially common in children. For parents, the most important thing you can do is not underestimate just how serious they can be.

Recognizing the symptoms and knowing the right steps to take are crucial to ensuring your child receives the proper care. John Leddy, MD, FACSM, FACP, a Professor of Clinical Orthopedics and Rehabilitation Sciences and Director of the University at Buffalo Concussion Management Clinic, explains the common symptoms of concussion, how to treat youth concussion properly and ensure your child returns to school and sports safely.

What is a concussion?

“A concussion is a temporary disturbance of brain function that occurs when traumatic forces are transmitted to the head, either directly or indirectly,” explains Dr. Leddy. This means that a concussion can occur from forces other than a direct blow to the head. A hit to the body can jostle the brain, causing it to collide with the skull and result in a concussion. But what makes concussions so scary for parents is that they aren’t always visible.

“Most concussions do not occur with loss of consciousness,” says Dr. Leddy. “In fact, concussion often occurs despite the individual not being unconscious. This is particularly true in sports, where loss of consciousness is unusual.”

What are the common symptoms of concussion?

Concussion results in the fairly rapid onset of a series of symptoms such as headache, dizziness, blurred vision, trouble with concentration, memory or balance. “A concussion typically evolves over a period of 24 hours or so, and it may continue to evolve or be persistent, depending on how bad the injury is,” Dr. Leddy states.

Symptoms of concussion are the same across age groups; children 10 and younger will experience the same symptoms as high school athletes. “What’s different is that children under 10 may not know how to articulate their symptoms,” says Dr. Leddy. “They’ll say, ‘I feel weird’ or ‘I’m tired,’ but they might not know how to express feeling more irritable, off-balance or recognize that their blurred vision is what’s giving them a headache. Young children have a hard time describing how severe their symptoms are because you need life experience to do that.”

My child is under 10, how can I tell if they have a concussion?

Keep an eye out for any changes in behavior.

“Anything out of the ordinary, such as being less active, more tired or more irritable, is important to note,” says Dr. Leddy.

Think about a possible cause of injury.

If your child just came back from football practice or was climbing on the jungle gym after school, they might have been injured there. “Inquire as to the possible mechanism of injury earlier in the day or the day before.”

Ask leading questions.

If you notice something’s off and know they were playing earlier, ask the child, “Hey, did you hit your head?” or “Did you fall down and bump your head, or did you get kicked in the head?” It’s important for parents to start the conversation since young children might not know what to say.

Dr. John Leddy quite about common cause of concussion in children under 10

What should I do if I think my child has a concussion?

“The first step is to make sure that the injury is not something more serious,” says Dr. Leddy. “If your child is saying, “My headache is really bad,” he or she is vomiting or isn’t answering questions appropriately, it may be a brain injury that is more severe than concussion and you need to take your child to the emergency room.” These symptoms could be the sign of something more severe such as bleeding in the brain.

However, if the symptoms are more standard, such as a personality change, non-worsening headache, feeling foggy or trouble with balance, an emergency room visit may not be necessary. “You can choose to bring your child to an ER or urgent care center if you’d prefer to–that’s OK!” he explains. “As long as things are not getting worse within the first 24 to 48 hours, a hospital visit is generally not necessary. At a minimum, however, within the next day or so bring the child to the primary care physician or to a concussion clinic in your area.”

How long should my child sit out of sports and school?

The first two days are crucial in terms of caring for children with concussion. “The first few days after a concussion are going to be difficult for the child or young adult, and school or other activities will only exacerbate their symptoms,” Dr. Leddy states. “Most kids with concussions should not go to school the first day or two immediately following the injury. Absolutely no sports during this period. We try to get kids back to school, with accommodations, as soon as possible after those first few days”

Staying home from school with a concussion does not mean lying in bed all day. “We don’t treat concussions by keeping patients in a dark room anymore,” he explains. “It’s better to move around, interact with others and perform low-level activities. Of course, they shouldn’t do anything that exacerbates their headache or dizziness. If anything makes their symptoms worse, they should stop and rest. Getting relative rest—which means staying below symptom-exacerbation thresholds—and taking it easy is important for the first 48 hours.”

Is screen time OK when a child is recovering from a concussion?

Once symptoms have stabilized or started to improve after the first few days, you can start to reintroduce activities to your child’s routine. “They can text their friends and have minimal screen time,” Dr. Leddy says, “but they shouldn’t be looking at a screen for an hour.” Kids should do things in small chunks of time, 10 or 15 minutes each, and take scheduled breaks. “I like the ‘15-5 rule’ for the first days after concussion: do cognitive activity for 15 minutes, or stop sooner if symptoms increase, and then take a 5 minute break. Keep repeating this cycle until you complete your task”.

How can I manage my child’s pain at home?

“Using Tylenol in the first few days is fine,” says Dr. Leddy. Try to avoid aspirin or other anti-inflammatories, as these can thin the blood. “Try not to use medicines more than four days a week. Taking headache medications too frequently can cause rebound headaches.”

Do helmets help prevent concussion?

There’s no scientific evidence to prove that helmets prevent concussions. “That doesn’t mean that your child doesn’t need to wear a helmet in football or hockey,” he says. “Helmets are very good at doing what they were designed for, and that’s preventing skull fractures. However, a helmet isn’t going to prevent the brain from getting shaken up. Any kid who hits his or her head while wearing a helmet during sports should be assessed and potentially treated for a concussion.”

How common are concussions in kids?

“The most common cause for concussions in children under 10 isn’t sport––it’s falling on the playground, falling off their bike or running into somebody at school,” Dr. Leddy explains. “On the other hand, sports are the number one cause of concussion in adolescents.”

It’s estimated that over half of student-athletes will sustain at least one concussion before they graduate high school. “The most dangerous thing an athlete can do is to continue to play with concussion symptoms or return to the playing field too soon, which puts them at increased risk of additional damage to the brain,” says Dr. Leddy. Educating children, coaches and parents about the signs and symptoms of a concussion is vital to ensure they are treated properly before returning to play.

For more breaking news and resources in the field of concussion, make sure to follow Concussion.Org on social media.

How to Be Your Child’s Health Care Advocate

Knowing common signs and symptoms of concussion is invaluable

As a parent, one of the most important things you can do is be an advocate for your child when it comes to concussion safety. After all, more than 800,000 children seek treatment for mild traumatic brain injury, or concussion, each year.

Being an advocate for your child means knowing how to help him or her avoid a mild traumatic brain injury. It also means being aware of the signs and symptoms of concussion and speaking up if you don’t think your child is receiving appropriate medical care. Below, you’ll find specific steps you can take to ensure you’re acting as your child’s best health care advocate.

Concussion Signs and Symptoms

The first step you can take to be your child’s health care advocate is educating yourself on concussion, which can occur following a hard blow to the head or body, according to the Mayo Clinic.

The signs and symptoms of a concussion vary, as does their onset. Some children will have symptoms immediately following the injury, while others won’t show symptoms for days or weeks, the Mayo Clinic says. Some common symptoms of concussion in children include headache, a feeling of pressure in the head, dizziness, nausea, confusion, slurred speech, fatigue and brief loss of consciousness.

Recently, the Centers for Disease Control and Prevention (CDC) released specific guidelines for treating concussion in children. If your child participates in contact sports, it’s especially important to read up on these guidelines so that you can ask the appropriate questions. Read these guidelines over to get a firm understanding of the latest protocol in concussion treatment in children.

How to Avoid Traumatic Brain Injury in Youth Sports

Youth sports are a great way for children to make friends, get active and be competitive. But with youth sports, especially contact sports, there is a risk of injury. There are a handful of steps you can take to make sure your child is safe before entering the game:

  1. Talk to your children. Teach your children about the signs and symptoms of concussion, as well as the importance of speaking up if they ever feel like they have these symptoms.
  2. Visit your pediatrician. Getting a physical is an important step in preparing your child for athletics, as it will ensure your child is healthy before his or her first game. Visiting the pediatrician can also allow you to speak with your health care provider about any additional preventive concussion measures your child can take before starting a new sport.
  3. Purchase the correct protective equipment. This step is crucial, as ill-fitting equipment can increase the chances of injury. The CDC offers specific equipment and helmet guidelines for various sports, including baseball, football, hockey, skiing, lacrosse and more.

What to Do If Your Child Is Injured

If your child is injured and you believe he or she might have a concussion, there are steps you can take to ensure your child gets the care needed to be on the path to a safe recovery. Take the following steps if you think your child might have a concussion:

  1. Remove your child from play. If your child has been hit in the head, take him or her out of play immediately. Although there is a good chance that he or she has not sustained a concussion, it’s always best to be cautious.
  2. Assess your child’s symptoms. Take inventory of how your child is feeling. Does he or she have any of the common symptoms of concussion?
  3. Consult a health care professional. Immediately following the blow to the head, call your primary care provider to discuss the injury. It’s best to be safe and have your child cleared by a medical professional before returning to play. If your child begins exhibiting any symptoms of concussion, take him or her to the doctor immediately.
  4. Watch for signs. Remember: Concussion symptoms might not present for days or weeks. Keep an eye on your child in the weeks following a blow to the head, and be alert for key concussion indicators.

For the latest information on concussion symptoms, treatment and more, visit the International Concussion Society’s resource library.

Animal Models of Concussion and Post-Traumatic Headache

Frank Porreca, PhD, explains how animal models may be used to improve understanding of pathophysiology of post-traumatic headache and to develop better treatments

In the U.S. each year, there are 1.6 to 3.6 recreational or sports-related concussions. And approximately 29% of people who experience a concussion have long-term effects, which typically includes post-traumatic headache. The American Headache Society defines post-traumatic headache as occurring within seven days of concussion or regaining consciousness after concussion. Symptoms are described as migraine-like and can include pulsing pain, light and noise sensitivity, memory problems, dizziness, and insomnia.

Until recently, there have been very few animal models of concussion and post-traumatic headache. Frank Porreca, PhD, a researcher at the University of Arizona and at the Mayo Clinic, Arizona and member of the International Concussion’s Scientific Advisory Board, is working on one of the first. He recently spoke with us about his research and the benefits of using animal models to better understand concussion and post-traumatic headache.

The Benefits of Animal Models

Dr. Porreca is currently working with researchers at the University of Arizona and Mayo Clinic to identify mechanisms that promote post-traumatic headache and to develop ways to intervene to prevent long-term effects after a concussion including persistent post-traumatic headache.

“We want to know what kind of triggers will be important in precipitating post-traumatic headaches,” he says. “With athletes, for example, they have a traumatic brain injury. Should they return to playing sports, should they have the stress of academic studies, should they exercise, should they stay in a dark room, should they be exposed to light?

While it’s still early to discuss findings, the lab has been able to induce an experimental traumatic brain injury in a mouse. These injuries are similar to concussions that might occur in an athlete’s day-to-day life. The researchers measure the outcomes of the injury, which “can help us to learn mechanisms that we think may be relevant to post-traumatic headache,” Dr. Porreca says.

Over the course of their research, Dr. Porreca and his team have observed changes that occur in terms of the excitability and sensitivity of mice. When inducing the injury in the mice, “there’s no obvious sign of damage to the head of the mouse,” he says. “We’re trying to model the kinds of sports injuries that occur often.”

Following the injury, the team allows the mice to recover and then exposes them to a stressful situation to see if they develop hypersensitivity that might be consistent with the headache phenotype.

How Post-Traumatic Headache Presents in Mice

While there are many benefits to using animal models, there are constraints as well. In addition to measuring the long-term effects of headache, Dr. Porreca is trying to measure pain; however, mice do not convey pain in the same way humans do.

“Post-traumatic headaches present with migraine phenotypes, and so in humans we know that they’re having pain episodes because they tell us,” he says. “Humans are verbal creatures, and animals, of course, are nonverbal. We have to use surrogate measures in order to interpret behavior or outcomes that suggest the animals are in pain.” In order to measure pain more effectively in mice, the researchers are using von Frey filaments that produce touch stimuli that are normally not painful.

“Mice that have been exposed previously to traumatic brain injury become hyper-responsive to these touch stimuli,” Dr. Porreca says. That is interpreted as a pain response, which may be indicative that the animal might be experiencing a post-traumatic headache. Most of the pain responses are seen in and around the head of a mouse, which might be consistent with a headache phenotype.

Research is still ongoing; however, Dr. Porreca hopes to find better treatments and approaches to relieving and eliminating post-traumatic headache in individuals by using animal models to test mechanisms by which therapeutics may be developed.

For more information on concussion signs and symptoms, treatment and diagnosis, visit the International Concussion Society’s resource library.

Frank Porreca, PhD, is a Scientific Advisory Board Member of the International Concussion Society. The International Concussion Society sponsored website Concussion.Org  is the number one destination for information related to concussion prevention, diagnosis and treatment. Our mission is to serve medical professionals, athletes, administrators, coaches, patients and the public by providing a central repository of accurate and scientifically vetted concussion research. Working alongside our world-class scientific advisory board, aims to be the most trusted global index on one of the most common, yet least understood, forms of traumatic brain injury.

King-Devick Test Proves Useful in Outpatient Concussion Assessment

University at Buffalo researchers further validate King-Devick Concussion Test in adolescents

With 90% of sports-related concussions occurring without loss of consciousness, it’s important that sideline tests be as accurate as possible to prevent an athlete from continuing play with a traumatic brain injury. The King-Devick Test in association with Mayo Clinic (K-D Test) is a common sideline concussion test used by medical professionals, as well as trained parents and coaches. The test compares a subject’s baseline with repeated test results to identify worsening physical and functional conditions that may indicate a concussion.

A new study conducted by researchers at the University at Buffalo, including John Leddy, MD, FACSM, FACP, President of the International Concussion Society, sought to evaluate the effectiveness of the K-D Test in young athletes and kids.

What is the King-Devick Test?

The K-D Test is a portable, two-minute assessment of an individual’s eye movements, attention and language. The K-D Test evaluates saccadic eye movements, or rapid movements with both eyes, as well as processing speed and visual tracking. The test times each patient and tracks their errors as they read single-digit numbers displayed on an electronic tablet.

After first establishing a baseline prior to the start of the season, trained parents and coaches can conduct the K-D Test as part of their concussion protocol. The test software will then compare the results with the baseline, searching for any declined saccadic function–a common indicator of concussion.

King-Devick test quote from

The Study

The University at Buffalo researchers studied adolescent patients–kids age 10-19–who were diagnosed by a doctor with a sport-related concussion within ten days of injury. Patients of the same age without concussions served as a comparison control group. Across two clinical visits a week apart, patients received K-D testing before and after exercising on a graded treadmill test to their symptom limitation (the Buffalo Concussion Treadmill Test).

The young patients with concussions performed significantly worse than their counterparts on the pre-exercise K-D Test, demonstrating that the K-D test is a useful tool in distinguishing healthy controls from concussed patients in an outpatient clinical setting.

After exercising on the treadmill, concussed patients who performed better on the K-D test when compared with their pre-exercise times had a typical concussion recovery time of seven to ten days and were recovered by the second visit. Conversely, concussed patients with delayed recovery–who required more than two weeks to recover–showed no significant difference in their K-D Test results after exercising when compared with their pre-exercise performance. The authors concluded that a lack of improvement on K-D Test scores after exercising on the Buffalo Concussion Treadmill Test predicted which adolescent patients would have a delayed recovery from a sport-related concussion.

“Not only does the study support the utility of the K-D test as part of outpatient concussion assessment, lack of improvement in K-D test performance after exercise may be an indicator of delayed recovery.”

What this Means

The study’s results indicate that the K-D Test is a useful component in concussion management by helping to identify those patients who are at risk of delayed recovery after sport-related concussion. The ability to help predict how long a child’s recovery from sport-related concussion has the potential to help doctors, parents, teachers and coaches plan for the child’s return to school, not to mention a safe return to sports. This is groundbreaking insight for patients and their support systems.

For more breaking news and resources in the field of concussion, make sure to follow Concussion.Org on social media.

5 Tips for Preventing Concussion in Skiing and Snowboarding

What to know before hitting the slopes

Skiing and snowboarding can be great ways for families to bond in the wintertime, as the slopes can provide memories that will last for years to come. But it’s important to have concussion safety in mind to ensure everyone is both happy and safe. Knowing these best practices is particularly important if you or your child participates in skiing or snowboarding competitively.

Below, you’ll find a series of tips that will ensure everyone is as safe as possible when lacing up and hitting the mountains this season:

1. Get the proper equipment

Wearing right helmet and gear is key to preventing an injury. The Centers for Disease Control and Prevention (CDC) offers specific guidelines regarding protective equipment and helmets for skiing and snowboarding. Refer to these guidelines for specific information on fit and sizing. In general, helmets should fit snugly, with no space between the head and helmet.

A properly fitting helmet can reduce head injuries by between 30 and 50 percent, according to UPMC. In addition to fitting properly, a helmet should always be well-maintained, age-appropriate, worn consistently and certified for use. If you’re unsure about the fit, head to your local ski shop for an expert opinion and adjustment.

2. Purchase the right attire

When deciding on the best slope attire, you should first look for fabric that is both wind- and water-resistant, which can keep you warm during harsh winter weather. In addition, the National Ski Areas Association notes that you should purchase attire that has wind flaps for zippers, collars that can be fastened up to the chin, drawstrings that can keep out cold winds, and secured cuffs at the wrists and ankles.

Wearing the correct attire can help ensure you’re as safe as possible in the event of a fall or unpredictable weather conditions.

3. Take a lesson from a qualified instructor

This step is crucial if you or anyone you are with is new to the slopes. Taking a lesson from a qualified instructor can ensure you will be well on your way to becoming a good (and safe!) skier, according to the National Ski Protocol (NSP). Building the proper fundamentals will help you avoid bad habits that could lead to an injury now or in the future.

4. Be prepared for weather changes

Weather can be deceiving. It may appear sunny at first, but it can cool down rapidly—leading to icy conditions. The opposite can also happen: It might be very cold, and then the sun will pop out. Being prepared for these weather changes can ensure you are as safe as possible. Be sure to pack gloves, and a headband or hat so that you’re prepared for anything. You should also have goggles on hand, as well as sunglasses to avoid being blinded by sudden sunny conditions.

5. Know the U.S. Skiing concussion policy

If you or your child skis or snowboards competitively, you should review the concussion policy from U.S. Skiing. Reading the policy in full is a good idea for anyone who practices either sport competitively at any level. Worth noting is the policy’s requirement that anyone suspected of having a mild traumatic brain injury, or concussion, should be removed from play immediately and kept out of play until he or she has been cleared by a medical professional.

If you think you or someone you’re with might have sustained a concussion, stop activity immediately. Contact ski or snowboard patrol to remove you from the slope. For the latest information on concussion symptoms, treatment and more, visit the International Concussion Society’s resources library.

How to Prepare Your Children for Winter Sports

No matter if you are hitting the slopes or stepping on the ice, follow these tips to prevent a sports-related injury during the cold-weather months

Winter activities and sports such as skiing, sledding, hockey and ice skating can increase a child’s risk for concussion. In fact, one 2009 study showed that there were more than 17,000 head injuries due to winter sports in the U.S. Nearly 7,000 of those injuries occurred in children under 14. Help your child avoid concussion due to winter activities and sports with the following tips.


  • Sled in an area with a clear path and avoid obstacles such as fences and trees.
  • Sled feet-first instead of head-first, and have children sit up instead of lying flat.
  • If appropriate, consider having your child wear a helmet while sledding.
  • Dress young children in several thin layers of clothing to keep them dry and warm during outdoor activities. Always remember to pack boots, a hat and gloves.

Skiing and Snowboarding

  • If your child is new to a winter sport, sign them up for lessons taught by a qualified instructor before hitting the slopes. If it’s been a while since your child participated in one of these activities, have them take a brush-up lesson.
  • Ensure your child has a helmet that is well maintained, age appropriate, worn correctly and certified for use.
  • All children skiing or snowboarding should wear helmets and protective eye gear. Additionally, children who ski should have their safety bindings adjusted every year, and children who snowboard should wear gloves with built-in wrist guards, the AAP advises.
  • The CDC offers specific guidelines for skiing helmets. To ensure a ski helmet fits your child properly, make sure it sits low enough in the front to protect the forehead—about an inch above the eyebrows. The back of the helmet should not touch the top of the neck. The CDC also recommends that children try on their helmet to assess fit with the goggles they plan to wear skiing before venturing out.


  • Children should wear helmets that fit properly, are age appropriate and certified for use. Helmets should be replaced after a serious fall or crash, as some helmets are only built to withstand one impact.
  • Ensure your child’s additional ice hockey equipment, such as skates and protective gear, also fit appropriately.
  • The CDC offers specific guidelines for hockey safety. In addition to a properly fitting helmet, hockey players should wear a cage or facemask, throat protector and chin strap. To make sure a helmet fits your child properly, the CDC advises making sure the helmet sits flat on the head and that the rim of the helmet is one finger width above the eyebrow.

Ice Skating

  • Before setting foot on the ice, scope out the skating rink to be aware of any obstacles.
  • Always skate in the same direction as the crowd, avoid quickly skating across the ice, and don’t chew gum or eat candy while skating, according to the AAP.


  • No children under 6 should ride in snowmobiles or ATVs, and only children 16 or older should drive them, according to Brainline.
  • Avoid pulling sledders or skiers using a snowmobile or ATV.
  • Wear appropriate gear. This includes helmets, goggles, waterproof snowmobile suits, waterproof gloves and rubber-soled boots.
  • Only drive when it’s light outside, and stay on marked trails.


Before setting out, it’s important to educate yourself on the common signs and symptoms of concussion. Early signs of concussion, according to the Mayo Clinic, can include headache or a feeling of pressure in the head, temporary loss of consciousness, dizziness, confusion, nausea, vomiting and fatigue. Changes in behavior, mood and personality can also occur. Seek medical attention if you think your child might be experiencing concussion.

By keeping these safety tips in mind, you can rest assured that your child will be as prepared as possible for winter sports.

The Female Brain and the Anatomy of Concussion

Doug Smith, MD, PhD, discusses the distinct anatomy of the female brain and the lasting effects of concussion

Female athletes are shown to have higher rates of concussion and longer recovery times, compared to their male counterparts in the same sport. While the higher rate of concussion may be due to women being more likely to report symptoms, researchers are taking a more in-depth look at why women typically take longer to recover and have poorer overall outcomes.

Dr. Doug Smith—Director of the Center for Brain Injury and Repair, Professor of Neurosurgery at the Perelman School of Medicine, University of Pennsylvania, and founding member of the International Concussion Society’s Scientific Advisory Board—explains how differences in the male and female brains may shine a light on new ways to diagnose and treat concussion.

The Anatomy of the Female Brain

At the moment of impact, when a head collides with another person or object, the brain’s movement can cause stretching and damage to nerve fibers called axons. Researchers think this internal structural damage in the brain—rather than the external impact or variables such as neck strength—is what causes symptoms of concussion.

“It seems like the predominant pathology is going to be something called diffuse axonal injury,” says Dr. Smith. “It’s damage to nerve fibers called axons that travel from one part of the brain to the other and form the white matter. We know that they are selectively vulnerable to become injured upon head impact.”

Dr. Smith likens the brain’s network of axons to an electrical grid. In the case of a concussion, the signals transferred across this network are disrupted. That insight drove him to take a closer look at the difference in female axons in comparison to male axons.

“What we recently discovered is that there’s a difference down to the nanoscale between the nerve fibers of these axons in male and female brains. And females might have a more complex network in their brain than males, but the skull is smaller from females to males,” explains Dr. Smith. “Maybe to get a similarly large or maybe even larger network in a smaller box, so to speak, what was changed was the architecture and size of the axons on average. If they’re on average smaller in the female brain, given the same mechanical force, that means they’re more likely to have damage to the internal skeleton.”

This damage can affect how signals are transmitted and block the transport of proteins down thin structures called microtubules. When these proteins cannot be transported, they can build up, which can lead to swelling and ultimately a disconnection of the axon.

“We think that the damage to these axons may contribute to delayed recovery,” Dr. Smith says.

Treatment protocols for concussion are continually evolving, so there isn’t a general recommended protocol yet, let alone a female-specific one. For example, in recent years, a treatment called “cocooning”—in which a person avoids lights, electronics and other stimulation for a certain period—was often used. But that’s changing as we learn more about concussion and the brain. “We’re turning toward active rehab or sub-threshold training, where you do some exercise to the point of feeling discomfort, just below that threshold and get the blood moving,” says Dr. Smith. Once a person starts this type of protocol, their rate of recovery can be used as an individualized “control” to guide further treatment.

Ongoing Concussion Research

While research on concussion is making progress, this field of study is still in its early stages. Researchers are looking to examine a wide range of individuals to gain a better and broader understanding of the brain. “Why do some who experience a concussion do well later in life, but others seem to have issues earlier?” asks Dr. Smith.

Identifying genetic differences between the sexes, as well as more subtle genetic markers, will help researchers pinpoint what makes one person more at risk for a delayed recovery, poorer outcome or even degenerative effects than another. “We would like to have some kind of screening tool, whether it’s genetic or otherwise, to identify individuals who would be most at risk,” says Dr. Smith.

In the meantime, Dr. Smith acknowledges that participating in sports can provide physical health benefits, a sense of teamwork and a mental boost. However, he also encourages coaches and athletes to look for ways to reduce the risk of concussion, such as penalizing aggressive play. Being aware of the risks and doing what’s possible to prevent brain injury is the first step, as the research on concussion, its effects and treatments continue.

Doug Smith, MD, PhD, is a Scientific Advisory Board Member of the International Concussion Society. The International Concussion Society sponsored website Concussion.Org  is the number one destination for information related to concussion prevention, diagnosis and treatment. Our mission is to serve medical professionals, athletes, administrators, coaches, patients and the public by providing a central repository of accurate and scientifically vetted concussion research. Working alongside our world-class scientific advisory board, aims to be the most trusted global index on one of the most common, yet least understood, forms of traumatic brain injury. If you would like to be interviewed for an influencer profile, please fill out this form.

How to Prevent Concussion During Winter

Follow these tips to protect yourself from slips and falls in the cold-weather months

There are many hazards associated with winter weather that can pose an increased risk for mild traumatic brain injury, or concussion. Everyday activities like driving the kids to school and shopping for groceries can become more dangerous when ice and snow are involved. Take extra precaution this winter to lower your risk for concussion with these 10 tips.

1. Wear appropriate shoes.

Purchase non-slip shoes with traction to avoid slipping on the ice or snow. The Military Health System recommends shoes with rubber soles that have treads or a raised pattern on the bottom.

2. Be careful when entering and exiting your vehicle

The University of Pittsburgh Medical Center (UPMC) suggests leaning on your vehicle and using it as support if you need to.

3. Keep an ice scraper in your vehicle.

Maintaining a clean, clear windshield will make driving conditions as safe as possible. Use a wintertime formula for your windshield washer fluid and replace tires with all-weather or snow versions if necessary.

4. Clear your sidewalks and driveway.

Work slowly when doing outdoor chores like shoveling to avoid slipping and falling. If you live somewhere where ice and snow are common, purchase rock salt to have on hand before a snowstorm approaches. The CDC notes that sand and cat litter can also be used for de-icing.

5. Don’t carry too much when running errands.

UPMC advises people to avoid carrying too much or walking with their hands in their pockets during icy or snowy conditions. Doing either of these things could make it difficult to regain your footing if you slip.

6. Make sure your clothes fit properly.

This is especially important if you’re participating in any winter activities like ice skating or skiing, as loose or baggy clothing can pose a fall risk.

7. Walk like a penguin.

The CDC notes that many cold-weather injuries happen due to sidewalks, steps, driveways and porches that are covered in ice. One way to avoid slipping is to walk like a penguin. This means maintaining your balance and center of gravity by walking with your feet and arms spread wide in a “waddle” fashion. Point your feet outward, spread your legs, walk flat-footed, take short steps and use your arms for balance.

8. Watch for black ice.

If ice appears wet on the surface, it might be black ice. Be mindful of this when driving, as black ice can make road conditions more dangerous.

Know the signs and symptoms of concussion. Because slips and falls occur so commonly in the wintertime, it’s important to know when a fall may have led to concussion. Symptoms of concussion vary, but some early signs include headache or a feeling of pressure in the head, temporary loss of consciousness, confusion, dizziness, nausea, vomiting, slurred speech and fatigue, according to the Mayo Clinic.

Keep these tips in mind during the winter season to prevent concussion in yourself and those around you.