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The 12 cranial nerves are a vital part of any advanced neurological assessment, yet many people struggle to remember them. The "Face of Cranial Nerves" can help! It is a visual tool for cranial nerve order that reminds you of their functions.

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The GCS is the most common scoring system used to assess level of consciousness. It is a reliable an objective way to recording the initial and subsequent level of consciousness in a person after a brain injury.

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Bacterial meningitis is a rare but potentially fatal disease. Several types of bacteria can first cause an upper respiratory infection and then travel through the bloodstream to the brain. It can also occur when bacteria invade the meninges directly. It can cause stroke, hearing loss, and permanent brain damage.

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PD is a progressive nervous system disorder that affects movements. It usually starts gradually with a barely noticeable tremor and progresses over time. Cardinal symptoms include tremor, slowed movement, rigid muscles, and impaired posture and balance.

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GBS is a rare autoimmune disorder in which a person's own immune system damages the nerves. Most people fully recover, but some may have permanent nerve damage.

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*NEW* Holly's Journey : From Guillain-Barre Syndrome to Happily Ever After (Extended Version)

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A CVA (stroke) occurs when the blood supply to part of the brain is interrupted. It can be hemorrhagic (due to a bleed) or ischemic (due to a clot). Most strokes (>80%) are ischemic. A stroke is a medical emergency and prompt treatment is crucial to reduce brain damage and other complications.

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A brain aneurysm occurs when part of a vessel wall weakens, allowing it to abnormally balloon out. Often there are no symptoms, but a rupture of the aneurysm can be fatal.

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An SCI is caused by damage to the cells and nerves that send messages to and from the brain to the rest of the body. It is often caused by trauma, but can also be the result of a disease process.

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National Institute of Neurological Disorders and Stroke

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Types of spinal cord injury

The National Institute of Neurological Disorders and Stroke ( ), a component of the National Institutes of Health ( ), is a primary funder of research on the brain and spinal cord. NIH is the leading supporter of biomedical research in the world.

The Brain Research through Advancing Innovative Technologies® (BRAIN) Initiative brings multiple federal agencies and private organizations together to develop and apply new technologies to understand how complex circuits of nerve cells enable thinking, movement control, and perception. SCI research as part of the BRAIN Initiative includes:

More information about spinal cord injury research may be found using , a searchable database of current and past research projects supported by NIH and other federal agencies. RePORTER also includes links to publications and resources from these projects.

For research articles and summaries on spinal cord injury, search , which contains citations from medical journals and other sites.

Learn About Clinical Trials

Clinical trials are studies that allow us to learn more about disorders and improve care. They can help connect patients with new and upcoming treatment options.

Consider participating in a clinical trial so clinicians and scientists can learn more about SCI. Clinical research uses human volunteers to help researchers learn more about a disorder and perhaps find better ways to safely detect, treat, or prevent disease.

All types of volunteers are needed- those who are healthy or may have an illness or disease- of all different ages, sexes, races, and ethnicities to ensure that study results apply to as many people as possible, and that treatments will be safe and effective for everyone who will use them.

For information about participating in clinical research visit NIH Clinical Research Trials and You . Learn about clinical trials currently looking for people with spinal cord injury at Clinicaltrials.gov , a searchable database of clinical trials.

Spinal cord injury and rehabilitation research centers maintain registries of people interested in participating in ongoing or future clinical studies. A multi-site network supported by the Christopher and Dana Reeve Foundation called the NeuroRecovery Network (NRN) accepts volunteer research participants.

Where can I find more information about spinal cord injuries?

The following organizations and resources help individuals, families, friends, and caregivers of people living with a spinal cord injury:

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A spinal cord injury (SCI) is damage to the tight bundle of cells and nerves that sends and receives signals from the brain to and from the rest of the body. SCI can be caused by direct injury to the spinal cord itself or from damage to the tissue and bones (vertebrae) that surround the spinal cord.

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A TBI is a sudden injury that causes damage to the brain. It can be caused by either blunt or penetrating trauma and is a major cause of death and disability in the United States.

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NINDS supports TBI research through grants to major medical institutions across the country and conducts TBI research in its intramural laboratories and Clinical Center at NIH in Bethesda, Maryland. The Center for Neuroscience and Regenerative Medicine (CNRM) is a TBI research collaboration between intramural NIH and the Uniformed Services University for the Health Sciences (USUHS).

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A seizure is abnormal electrical activity within the brain. It can be focal (affecting a portion of the brain) or generalized (affecting the entire brain). A seizure can be a single one-time event, or it can become a recurrent disorder known as epilepsy.

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Neurological nursing is out of my league, I admit. But I coached my daughter's soccer team in the fall and did a little research about head injuries. So here it is...

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There are an estimated 1.7 to 3.8 million traumatic brain injuries each year in the United States, according to the CDC, of which 10 percent arise due to sports and recreational activities. Amongst American children and adolescents, sports and recreational activities contribute to over 21 percent of all traumatic brain injuries. Sustaining an injury while playing sports can range from a mild physical trauma such as a scalp contusion or laceration to severe TBI with concurrent bleeding in the brain or coma. It is important to recognize when a head trauma is severe or has resulted in a TBI because it is crucial to seek immediate medical attention. While most brain injuries are self-limiting with symptoms resolving in a week, a growing amount of research has now established that the sequelae from recurrent minor impacts is significant in the long term.

Traumatic Brain Injury

A traumatic brain injury (TBI) is defined as a form of acquired brain injury from a blow or jolt to the head or a penetrating head injury that disrupts the normal function of the brain. TBI can result when the head suddenly and violently hits an object, or when an object pierces the skull and enters brain tissue. Symptoms of a TBI can be mild, moderate, or severe, depending on the extent of damage to the brain. Mild cases (mild, traumatic brain injury, or mTBI) may result in a brief change in mental state or consciousness, while severe cases may result in extended periods of unconsciousness, coma or even death. Individuals with TBI may experience one or more of the following:

Pain: Constant or recurring headache

Motor Dysfunction: Inability to control or coordinate motor functions, or disturbance with balance

Sensory: Changes in ability to hear, taste or see; dizziness; hypersensitivity to light or sound

Cognitive: Agitation; confusion; shortened attention span; easily distracted; overstimulated by environment; difficulty following directions or understanding information; feeling of disorientation and confusion and other neuropsychological deficiencies

Speech: Difficulty finding the "right" word; difficulty expressing words or thoughts; dysarthric or slurred speech

Concussions Concussions frequently affect athletes in both contact and non-contact sports, and are considered to be diffuse brain injuries that traumatically induce alterations of mental status. A concussion may result from shaking the brain within the skull and, if severe, can cause shearing injuries to nerve fibers and neurons.
The 5th International Conference on Concussion in Sport held in Berlin, Germany, in 2016 defined Sport-related Concussion as:

Sport-related concussion is the historical term representing low velocity injuries that cause brain 'shaking' resulting in clinical symptoms and that are not necessarily related to a pathological injury. Concussion is a subset of TBI and will be the term used in this document. It was also noted that the term commotio cerebri is often used in European and other countries. Minor revisions were made to the definition of concussion, which is defined as follows:

Sport related concussion is a traumatic brain injury induced by biomechanical forces. Several common features that may be utilized in clinically defining the nature of a concussive head injury include:

1. Sport related concussion may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an "impulsive" force transmitted to the head.

2. Sport related concussion typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously. However, in some cases, signs and symptoms evolve over a number of minutes to hours.

3. Sport related concussion may result in neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies.

4. Sport related concussion results in a range of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course. However, it is important to note that in some cases symptoms may be prolonged.

The clinical signs and symptoms should not be explained by drug, alcohol, or medication use, other injuries (such as cervical injuries, peripheral vestibular dysfunction, etc.) or other comorbidities (e.g., psychological factors or coexisting medical conditions).
To view peer-reviewed literature related to sports concussions, the Sports Concussion Library can be found here .

Grading the concussion can be a helpful tool in the management of the injury and depends on:

1. Presence or absence of loss of consciousness;

2. Duration of loss of consciousness;

3. Duration of posttraumatic memory loss; and

4. Persistence of symptoms, including headache, dizziness, lack of concentration, etc.

Some team physicians and trainers evaluate an athlete's mental status by using a five-minute series of questions and physical exercises known as the Standardized Assessment of Concussion (SAC). More recently, teams have employed , a 25-minute computer-based testing program specifically designed for the management of sports-related concussion. A player who has sustained a concussion is three to six times more likely to sustain another one. While the decision when an athlete is ready to return to play isn't straightforward - such as in this , when in November of 2013 a professional soccer player helped bring his team to victory despite having lost consciousness and dislocating five vertebrae - every player could benefit from baseline neurological testing before the season so that the results can be used for comparison in the event the athlete receives a blow to the head.

Note: There is no evidence to demonstrate all participants in contact collision sports should have baseline computerized neuropsychological (NP) tests. NP tools such as ImPACT/Cogsport, as well as SCAT3 have yet to be proven reliable or validated. These screening tests can be used only as a tool in the expert medical diagnosis and return to play decision-making process. Second Impact Syndrome (SIS) is an acute, sometimes fatal, brain swelling that occurs when a second concussion is sustained before complete recovery from a previous concussion. This repeat injury causes vascular congestion and increased intracranial pressure, which may be difficult or impossible to control. The risk for SIS is higher for sports such as boxing, football, ice or roller hockey, soccer, baseball, basketball and snow skiing.

The issue of concussion is covered further within another AANS Patient Information section. To view that page, click here .

refers to a profound or deep state of unconsciousness. An individual in coma is alive but is unable to respond to his or her environment. The unconscious state has variability and may be very deep, where no amount of stimulation will cause the person to respond or, in other cases, the person in a coma may move, make noise or respond to pain, but is unable to obey simple, one-step commands such as "hold up two fingers" or "stick out your tongue." Although higher brain functions like thinking are impaired, key functions like breathing and circulation remain intact in comatose patients. The process of recovery from coma is a continuum along which a person gradually regains consciousness.

For people who sustain severe injury to the brain and are comatose, recovery is variable. The more severe the injury, the more likely the result will include permanent impairment.

The Glasgow Coma Scale is administered upon admission to the hospital or by paramedic first responders to establish a baseline level of consciousness, motor function, and eye findings. Abilities are scored from 3 to 15 on the GCS, with higher scores correlating with less severe injuries. Frequent evaluations of the patient are imperative to help assess neurologic improvement or deterioration.

Brain-imaging technologies, particularly computerized tomography (CT or CAT scan), can offer important immediate information about a person's status. The purpose of performing an emergency CT scan is to rule out a large mass lesion (hematoma) that may be compressing the brain. A magnetic Resonance Imaging (MRI) can be used to image subtle changes that may not be captured by a CT scan.

Chronic Traumatic Encephalopathy

Chronic traumatic encephalopathy (CTE) is a progressive degenerative disease typically found in individuals who have sustained repeated head injuries in the past, including concussions during contact sports. The symptoms of CTE usually develop over several years to decades after repeated injuries and consist of cognitive deficits such as learning disabilities, disinhibition, memory disturbances, and mental illnesses such as depression, anxiety, and suicidal ideation. As the disease progresses, some patients may experience progressive dementia and motor symptoms such as balance instability and extrapyramidal disorders.

A research study conducted in 2017 at Boston University examined 202 brains from deceased football players and found that 177 of them (87%) had signs of chronic traumatic encephalopathy from repeated blows to the head.

The U.S. Consumer Product Safety Commission (CPSC) tracks injuries through its National Electronic Injury Surveillance System (NEISS).

According to CPSC data, there were an estimated 454,407 sports-related head injuries treated at U.S. hospital emergency rooms in 2018. This number represents a decrease of nearly 32,875 sports-related injuries from the previous year. Of all the sports noted below, most of them posted a decrease in the number of injuries treated from 2017.

The actual incidence of head injuries may potentially be much higher for two primary reasons. In the 2018 report, the CPSC excluded estimates for product categories that yielded 1,200 injuries or less, those that had very small sample counts and those that were limited to a small geographic area of the country. Additionally, the system does not track many less severe head injuries treated at physicians' offices, immediate care centers, or are self-treated. Sports/recreational activities, in addition to the equipment and apparel used in these activities are included in these statistics. For example, swimming-related injuries include the activity as well as diving boards, equipment, flotation devices, pools, and water slides.

The following sports/recreational activities represent the categories contributing to the highest number of estimated head injuries treated in U.S. hospital emergency rooms in 2018.

The top 10 sports-related head injury categories among children ages 14 and younger: *Note: Reported incidence is known to be significantly under-reported (up to 50%, McCrea Clin J Sports med 13:13-17, 2004) and do not reflect those that are treated by family doctors or other para-medical professionals.

Anyone with signs or symptoms of moderate to severe traumatic brain injury should receive medical attention as soon as possible. Although little can be done to reverse the brain damage, stabilizing the individual with TBI and preventing further injury is very important. Most studies indicate that once brain cells are damaged, they do not regenerate for the most part. However, recovery after brain injury can take place as the surrounding tissue of the brain sometimes makes up for the injured areas by rerouting the information and functions of the damaged tissue.

With mild traumatic brain injuries, individuals should be monitored closely at home for any persistent, worsening or new symptoms. Indications for returning to work, school or physical activities are based upon the physician's recommendations.

Moderate to severe traumatic brain injuries may require emergent medical care to ensure that the individual has proper oxygen supply to the brain and the rest of the body, adequate blood flow and a normal blood pressure. Further medical management may be required based on the patient's symptoms, e.g. people who develop seizures after their injury may be given anti-seizure medications. If the patient is severely injured, a neurosurgeon may need to remove or repair hematomas (ruptured blood vessels), contusions (bruised brain tissue) or skull fractures.

Most people with a significant brain injury will require some form of rehabilitation to relearn basic skills and perform their daily activities. The type and duration of rehab depends on the severity of the injury and what part of the brain was injured.

Information on Specific Sports

Boxing

Over time, professional and amateur boxers can suffer permanent brain damage. The force of a professional boxer's fist is equivalent to being hit with a 13-pound bowling ball traveling 20 miles per hour, or about 52 times the force of gravity.

According to the Journal of Combative Sport , from January of 1960 to August of 2011, there were 488 boxing-related deaths. The journal attributes 66 percent of these deaths to head, brain or neck injuries; one was attributed to a skull fracture.

There are boxers with minimal involvement and those that are so severely affected that they require institutional care. There are some boxers with varying degrees of speech difficulty, stiffness, unsteadiness, memory loss, and inappropriate behavior. In several studies, 15-40 percent of ex-boxers have been found to have symptoms of chronic brain injury. Most of these boxers have mild symptoms. Recent studies have shown that most professional boxers (even those without symptoms) have some degree of brain damage.

Cheerleading

Cheerleading has changed drastically in the last 20 years, with increasingly difficult acrobatic stunts performed. A number of high school and college level schools have limited the types of stunts that can be attempted by their cheerleaders. Rules and safety guidelines now apply to both practice and competition.

According to 2010 cheerleading data from the CPSC, head and neck injuries accounted for 19.3 percent of total cheerleading injuries. Additionally, in the 2010-2011 school year head injuries were associated with 1579 concussions, 361 contusions and 2,292 internal injuries; neck injuries accounted for 118 contusions, 16 fractures and 1,301 sprains/strains.

In its Catastrophic Sports Injury Report for fall 1982 through spring 2011 , the National Center for Catastrophic Sport Injury Research at the University of North Carolina (UNC) noted that there was one direct high school cheerleading catastrophic injury during the 2010-2011 school year. A high school cheerleader collided with another cheerleader during practice and elbowed in the temple. The result was two skull fractures, seizures and a medically induced coma. Recovery at the time was incomplete.
UNC also reported that college cheerleading was not associated with any direct injuries during the 2010-2011 school year.

A 2009 study by the Center for Injury Research and Policy of The Research Institute at Nationwide Children's Hospital yielded the following head-injury statistics:

The majority (96 percent) of the reported concussions and closed-head injuries were led by the cheerleader performing a stunt.

Nearly 90 percent of the most serious fall-related injuries were sustained while the cheerleaders were performing on artificial turf, grass, traditional foam floors or wood floors.

A 2012-2013 RIO study by the Nationwide Children's Hospital yielded the following statistics about high school cheerleading:

Cheerleading yielded 0.73 injuries per 1,000 athletic exposures in the 2012-2013 school year.

Injuries to the head/face accounted for 36.5 percent of all cheerleading injuries in the 2012-2013 school year.

The National Cheer Safety Foundation offers comprehensive resources and safety information specific to cheerleading, including news articles such as .
Cycling

Every year, more than 500,000 people visit emergency rooms in the U.S. with bicycle-related injuries. In 2009, nearly 85,000 of those were head injuries. There are about 600 deaths a year, with two-thirds attributed to TBI. It is estimated that up to 85 percent of head injuries are preventative with proper use of helmets, such as those approved by The Snell Memorial Foundation , American National Standards Institute (ANSI) or American Society for Testing and Materials (ASTM). It is essential that the helmet fit securely while the user is riding or if he or she takes a fall. According to Safe Kids Worldwide , more children from ages five to 14 visit emergency rooms for biking-related injuries than from any other sport. Helmets can reduce the risk of severe brain injuries by 88 percent. However, approximately 55 percent of children are reported not always wearing a helmet while bike riding.

The following facts/statistics are from Safe Kids USA :

Head injury is the leading cause of wheeled sports-related death and the most important determinant of permanent disability after a crash.

Without proper protection, a fall of as little as two feet can result in a skull fracture or other TBI.

Approximately 50 percent of U.S. children between 5- and 14-years own a helmet, and only 25 percent report regularly wearing it while bicycling.

Universal use of bicycle helmets by children ages 4 to 15 could prevent 45,000 head injuries.

Helmets reduce the risk of head injury by at least 45 percent, brain injury by 33 percent, facial injury by 27 percent, and fatal injury by 29 percent. Eight states and the District of Columbia require children to wear a helmet while participating in wheeled sports such as riding scooters, in-line skates, or skateboards.

One study found that the rate of bicycle-helmet use by children ages 14 and under was more than twice as high in a county with a fully comprehensive bike-helmet law than in a similar county with a less comprehensive law.

Safe Kids Worldwide further reported that in 2010, 112 children under the age of 19 died while riding a bike. This is the smallest number of deaths since 1999, and a 56-percent reduction in the number of deaths since, with a 59-percent decrease in the death rate.
Football

The National Center for Catastrophic Sport Injury Research (NCCSIR) also tracks a number of statistics for "catastrophic" football injuries, which it defines as those that resulted in brain, or spinal cord injury, or skull or spine fracture. Recent findings in the Annual Survey of Catastrophic Football Injuries, 1977-2012, include the following:

A few football injuries also have resulted in fatalities, according to the National Center for Catastrophic Sport Injury Research's Annual Survey of Football Injury Research, 1931-2012 :

There were two fatalities directly related to football during the 2012 football season. Both fatalities were in semi-professional football. There is only one other year where there were no direct fatalities in high school and college football and that was in 1990.

The rate of direct fatal injuries is very low on a 100,000 player exposure basis. For the approximately 4,200,000 participants in 2012, the rate of fatalities was 0.04 per 100,000 participants.

The rate of direct fatalities in high school (grades 9-12) was 0.00 per 100,000 participants. The rate of direct fatalities in college was 0.00 per 100,000 participants. The rate for all other areas of football was 0.06 per 100,000 participants.

Most direct fatalities usually occur during regularly scheduled games, and in 2012 this was true with both direct semi-professional fatalities occurring in games.

According to the same report by NCCSIR, a number of the players associated with brain trauma complained of headaches or had a previous concussion prior to their deaths.
The National Federation of State High Schools released the following statement on February 23, 2010: "Effective with the 2010 high school football season, any player who shows signs, symptoms or behaviors associated with a concussion must be removed from the game and shall not return to play until cleared by an appropriate health-care professional." The new concussion language is now in all NFHS rules books as well as the "NFHS Suggested Guidelines for Management of Concussion."

More recently, the long-term implications of concussion have been discussed at length in the media, sparked by the controversy between the and its former players. An ESPN from early November 2013 covered the chronic traumatic encephalopathy (CTE) diagnosis of three ex-NFL players. Additionally, ESPN also reported that last year UCLA tested five other former players and was able to diagnose all five as has having signs of CTE, marking the first time the disease has been recognized in living patients.

Rule Changes in College Football to Prevent Head and Neck Injuries

The National Athletic Trainers' Association (NATA) and the American Football Coaches Association (AFCA) Task Force, headed by Ron Courson, director of sports medicine for the University of Georgia, has focused on two primary problems associated with head contact.

Head-down contact still occurs frequently in intercollegiate football

Helmet-contact penalties are not adequately enforced

Rule changes implemented by the National Collegiate Athletic Association (NCAA) related to head-down contact and spearing in collegiate football have been distributed to all coaches and officials throughout the country. The objective is to eliminate injuries resulting from a player using his helmet in an attempt to punish an opponent.
With the rule changes and more diligent enforcement of the rules, there is hope that a significant reduction in head and neck injuries will result.

The NCAA revised its 16-year-old guidelines on treatment of concussion in the NCAA Sports Medicine Handbook to better provide member institutions with appropriate responses to concussion injuries and procedures for returning athletes to competition or practice. According to page 59 of the 2013-2014 edition, "...Any athlete who is diagnosed with a concussion must not return to play or practice that day and must be cleared by a healthcare professional before returning to play or practice."

The "Concussion Diagnosis and Management" section details circumstances in which an athlete should be withheld from competition pending clearance by a physician. Football-related Head and Neck Injury Prevention Tips

Horseback Riding While head injuries comprise about 18 percent of all horseback riding injuries, they are the number one reason for hospital admission. A 2007 study by the Centers for Disease Control and Prevention found that horseback riding resulted in 11.7 percent of all traumatic brain injuries in recreational sports from 2001 to 2005, the highest of any athletic activity. Of the estimated 14,446 horseback-related head injuries treated in 2009, 3,798 were serious enough to require hospitalization. Subdural hematomas and brain hemorrhages comprised many of the serious injuries. According to the Equestrian Medical Safety Association, head injuries account for an estimated 60 percent of deaths resulting from equestrian accidents.

There are factors that may increase the risk of falling, such as a green horse, slippery footing or bareback riding, but it is the height from which the rider falls that most significantly affects the severity of the injury. According to the Ontario Equestrian Federation , a rider sitting on a horse is elevated eight feet or more above the ground: a fall from just two feet can cause permanent brain damage. Riders ages 10-14 are most likely to be involved in an accident with a horse.

While serious head injury can occur while wearing a helmet, the data very clearly shows the severity of the head injury can be decreased with helmet wear. According to the New England Journal of Medicine, helmets can reduce head and brain injuries by 85 percent. While helmets are required in equestrian sports that involve jumping, including eventing and show jumping, in high-level dressage competitions, the riders generally wear top hats, which provide no protection. Accidents are less common in competitive dressage, but accidents can occur. While most dressage riders do not wear helmets even when practicing, they are allowed during practice and competition.

The U.S. Equestrian Federation strongly encourages all riders while riding anywhere on the competition grounds to wear protective headgear with harness secured which passes or surpasses ASTM (American Society for Testing and Materials)/SEI (Safety Equipment Institute) standards for equestrian use and carries the SEI tag.

Snow Skiing/Snowboarding

According to a John Hopkins Medicine-led study , approximately 10 million Americans ski or snowboard in the United States each year, with about 600,000 injuries reported annually. Severe head trauma accounts for about 20 percent of all skiing- and snowboarding-related injuries, and of those head injuries, 22 percent are severe enough to cause loss of consciousness or concussion. Head injuries are the most frequent cause of death and severe disability among skiers and snowboarders.

According to the National Ski Areas Association's (NSAA's) 2012-2013 National Demographic Study, 70 percent of skiers and snowboarders wore helmets during the most recent ski season. This shows a 5-percent increase from the 2011-2012 season. Among those interviewed, helmet usage has increased by 180 percent since the 2002-2003 season, when only 25 percent of skiers and snowboarders reported wearing helmets.

More importantly, 80 percent of skiers and snowboarders age 17 and under reported wearing helmets on the slopes during the 2012-2013 ski season. The NSAA National Demographic Study was compiled from more than 130,000 interviews of skiers and snowboarders nationwide.

The 2012-2013 NSAA study also revealed that:

89 percent of children 9 years old or younger reported helmet usage in the 2012-2013 ski season

83 percent of children between the ages of 10 and 14 reported wearing helmets

81 percent of adults over the age of 65 reported helmet usage

Skiers and snowboarders ages 18-24 have traditionally represented the lowest percentage of helmet use among all age groups. In the 2012-2013 season, 60 percent of all 18 to 24 years olds interviewed wore helmets, a 13-percent increase from the 2011-2012 season, when only 53 percent wore helmets.

NSAA recently launched a revamped Lids on Kids website designed to provide parents with pertinent helmet-safety information; it includes simple helmet-sizing instructions to help ensure a proper fit.
Helmet Usage

In 2011, New Jersey became the first state to require those under the age of 18 wear a helmet while skiing or snowboarding. Currently, there are no other state laws mandating helmets for skiing or any winter sports. Ski resorts in Aspen, Colo., mandate skiers under age 12 wear helmets. Following the high-profile skiing-related deaths of Michael Kennedy in December of 1997, Sonny Bono in January of 1998 and Natasha Richardson in March of 2009, an increase in the number of skiers wearing helmets has been noted in several studies.

Meanwhile, helmet use has been mandatory for snowpark users in Quebec, Canada, since the winter of 2006-2007, according to the Quebec Ski Areas Association (ASSQ). And in January of 2010, the Canadian Ski Council (CSC) issued the following national policy:

"The Canadian Ski Council recommends wearing helmets for skiing and riding. Skiers and snowboarders are encouraged to educate themselves on the benefits and limitations of helmet usage. The primary safety consideration, and obligation under the Alpine Responsibility Code, is to ski and ride in a controlled and responsible manner."

The policy developed after research undertaken by the CSC showed that helmet usage in Canada is increasing steadily, with more than 50 percent of Canadian skiers and boarders wearing helmets. Usage is much greater among youth, reaching 90 percent in many areas. To ensure compliance with this initiative, the CSC notes that Canadian ski areas have invested heavily in making the sport safer, with improved signage, better grooming, and safer equipment; areas have purchased more than 50,000 rental helmets to include in their rental packages, which are available at nearly all Canadian ski areas.

In a February 2010 release from Quebec's Trauma Centres and the ASSQ, Dr. Tarek Razek, director of the Montreal General Hospital Trauma Program, said, "Wearing a helmet reduces the risk of head injuries in skiers and snowboarders by approximately 35 percent." Dr. Razek also advocates helmet use in other sports, including cycling and rollerblading.

As part of a survey of 80 Canadian ski areas:

Area operators estimated that 55 percent of all skiers and boarders wore helmets. Quebec had the highest rate of usage at 65 percent, with the lowest rate in Western Canada at 50 percent.

The Grade 4/5 Snowpass program, which had 41,000 youth participants in 2008-2009, provides reduced-cost lift tickets and other specials for participants. Fifty-four percent of the parents of Snowpass holders reported wearing helmets regularly, and 93 percent of youth participants reported wearing helmets on a regular basis.

A survey of 1,500 attendees conducted at the Toronto Ski Show in October of 2008 found that 55.3 percent of men and 57.6 percent of women wore helmets all or most of the time. Older skiers and boarders had a higher usage of helmets than younger adults.

Meanwhile, according to the 2012-2013 National Demographic Study of Skiers and Boarders, the National Ski Area Association in the U.S. found the following;

Seventy-one percent of survey respondents were wearing a helmet when interviewed, up six percent in the previous season.

Helmet usage increases with ability level, rising from 26 percent usage by beginners, to 38 percent by intermediates, to 55 percent by advanced/expert participants.

Helmet usage is higher for children ages 9 and under (89%) and 10-14 (83%), and adults ages 55-64 (76%) and 65+ (81%) than for other age groups. Helmet usage is lowest among 18-24-year-olds (62%).

Soccer Protection against head injuries in soccer is complicated since heading is an established part of the game, and any attempt to protect against head injuries must allow the game to be played without modification. Several head guards have been developed to reduce the risk of head injuries in soccer. One independent research study found that none of the products on the market provide substantial benefits against minor impacts, such as heading with a soccer ball.
A McGill University study found more than 60 percent of college-level soccer players reported symptoms of concussion during a single season. Although the percentage at other levels of play may be different, these data indicate head injuries in soccer are more frequent than most presume.

According to CPSC statistics, 40 percent of soccer concussions are attributed to head to player contact; 10.3 percent are head to ground, goal post, wall, etc.; 12.6 percent are head to soccer ball, including accidents; and 37 percent are not specified.

Prevention Tips

Buy and use helmets or protective headgear approved by the ASTM for specific sports 100 percent of the time. The ASTM has vigorous standards for testing helmets for many sports; helmets approved by the ASTM bear a sticker stating this. Helmets and headgear come in many sizes and styles for many sports and must properly fit to provide maximum protection against head injuries. In addition to other safety apparel or gear, helmets or headgear should be worn at all times for:

General Tips

Resources for More Information

Author Information

Nitin Agarwal, MD
Rut Thakkar
Khoi Than, MD, FAANS

The AANS does not endorse any treatments, procedures, products or physicians referenced in these patient fact sheets. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific neurosurgical advice or assistance should consult his or her neurosurgeon, or locate one in his or her area through the AANS' Find a Board-certified Neurosurgeon online tool.

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​What kinds of sports result in the most head injuries? How are those injuries diagnosed and treated? Learn more in this neurosurgeon-edited guide.

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Spinal Cord Fatalities in US HS & College Football Players (2005-14)

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Spinal Cord Fatalities in US HS & College Football Players (2005-14)

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Kristen L. Kucera, PhD ¹; Rebecca K. Yau, PhD ¹,2; Johna Register-Mihalik, PhD ³; Stephen W. Marshall, PhD ²; Leah C. Thomas, MS ¹; Susanne Wolf ¹; Robert C. Cantu, MD ⁴; Frederick O. Mueller, PhD ¹; Kevin M. Guskiewicz, PhD ³ ( View author affiliations)

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Summary
What is already known about this topic?
Fatalities resulting from catastrophic brain and spinal cord injuries occur infrequently among high school and college football players.
What is added by this report?
During 2005-2014, a total of 28 traumatic brain and spinal cord injury deaths in high school and college football were identified (2.8 deaths per year). The most common playing positions of those fatally injured were running back and linebacker. Approximately 18% of identified high school brain injury deaths were preceded by an earlier concussion, which might have led to second impact syndrome.
What are the implications for public health practice?
Implementing enhanced safety measures to prevent fatalities from catastrophic brain and spinal cord injuries among high school and college football players has the potential to reduce the number of these fatalities. Continued surveillance is important to monitor the circumstances of these deaths and develop risk scenarios to improve prevention measures.

An estimated 1.1 million high school and 75,000 college athletes participate in tackle football annually in the United States. Football is a collision sport; traumatic injuries are frequent ( 1, 2), and can be fatal ( 3). This report updates the incidence and characteristics of deaths caused by traumatic brain injury and spinal cord injury ( 4) in high school and college football and presents illustrative case descriptions. Information was analyzed from the National Center for Catastrophic Sport Injury Research (NCCSIR). During 2005-2014, a total of 28 deaths (2.8 deaths per year) from traumatic brain and spinal cord injuries occurred among high school (24 deaths) and college football players (four deaths) combined. Most deaths occurred during competitions and resulted from tackling or being tackled. All four of the college deaths and 14 (58%) of the 24 high school deaths occurred during the last 5 years (2010-2014) of the 10-year study period. These findings support the need for continued surveillance and safety efforts (particularly during competition) to ensure proper tackling techniques, emergency planning for severe injuries, availability of medical care onsite during competitions, and assessment that it is safe to return to play following a concussion.

NCCSIR has been conducting catastrophic injury surveillance at the national level for high school and collegiate football since 1965 ( 5) and for all sports since 1982 ( 6). Deaths were identified through ongoing and systematic monitoring of public media sources (e.g., online search engines and news search engines) and individual reports from national and state-level organizations, clinicians, school authorities, and researchers. Once a death was identified, NCCSIR researchers contacted family members or school staff members to gather additional details. When possible, NCCSIR obtained medical examiner reports. Information was collected about the athlete's age and level of play; player position and activity; and injury type, medical care, and cause of death.

The events included in this study were defined as fatal traumatic brain and spinal cord injuries that occurred during a scheduled team activity (game, practice, or conditioning session) and were directly related to football-specific activities (e.g., tackling or being tackled). Each fatality report was manually reviewed for inclusion and classification. Fatality rates per 1 million players were calculated using National Federation of State High School Associations and National Collegiate Athletic Association participation statistics as the denominators. The causes and potential strategies to prevent these injuries were described in association with the 10 Haddon energy damage countermeasures ( 7). All procedures were reviewed and approved by the Institutional Review Board of the University of North Carolina at Chapel Hill.

During 2005-2014, a total of 24 high school and four college football-related traumatic brain and spinal cord injury fatalities were identified, for a combined average of 2.8 fatalities per year. Among the 24 high school fatalities ( Table 1), 22 (92%) involved head/brain injuries. All four college fatalities involved a brain injury. Subdural hematoma was the most common diagnosis for both high school and college fatalities (46% overall). Four (18%) of the 22 high school players who died from brain injuries had sustained a concussion within 4 weeks of the event, and second impact syndrome (in which a second concussion occurs before a first concussion has properly healed, causing rapid and severe brain swelling) was implicated in three of these four events.

Among the 24 high school fatalities (Table 1), 20 (83%) occurred during a game and during the regular season; 17 (71%) involved tackling or being tackled. Among the four college fatalities, two occurred during a regular season game, and two occurred during spring football. The most common player positions among those fatally injured were running back (32% of players overall) and linebacker (21%). Of the 28 deaths, head first/head down contact was identified in eight deaths. Six illustrative cases provide associations with the Haddon energy damage countermeasures and extensions to football recommendations for preventing traumatic brain and spinal cord fatalities ( Table 2).

The average number of high school deaths per year was 2.4 (standard deviation [SD] = 2.2) and ranged from zero to seven deaths annually. The average number of deaths among college players per year was 0.4 (SD = 0.7) and ranged from zero to two deaths annually. For 2 years (2007 and 2012) of the 10-year study period, no traumatic brain or spinal cord injury deaths were reported among either high school or college football players. Fatality rates over the study period were 5.96 fatalities per 1 million college football players (95% confidence interval [CI] = 0.12-11.81) and 2.18 fatalities per 1 million high school football players (CI = 1.31-3.06) ( Figure). All four of the college deaths and 14 (58%) of the 24 high school deaths occurred during the last 5 years (2010-2014) of the 10-year study period.

Discussion

The finding of an annual average of 2.8 brain and spinal cord injury deaths for high school and college football combined is consistent with a previous report of 3.1 brain injury fatalities annually during 1990-2010 ( 4). Also consistent with previous studies ( 3, 4), most brain and spinal cord injury deaths occurred during competition, among players at running back and linebacker positions, and as a result of tackling or being tackled.

Head first/head down contact was identified as contributing to eight of the 28 deaths. This emphasizes the importance of instruction in proper tackling techniques (both delivery and receipt of tackles) for all players, but particularly for running backs, linebackers, and defensive backs. A previous evaluation of football tackling programs among youth league football players indicated a reduction in concussions in practice and games when education of coaches was combined with practice contact restrictions ( 8), providing evidence that these programs might have a positive impact on reducing nonfatal head injuries among youth league players. However, it is unclear whether older players who learned high risk methods can be retrained in new techniques. Football is a collision sport played at high velocity, and players must act and react quickly. In such situations, new techniques might be difficult to deploy, resulting in players possibly reverting to past behaviors and reactions unless coaches routinely intervene to correct their technique.

The finding that 18% of high school players with fatal traumatic brain injuries had a concussion <4 weeks earlier is consistent with a previous study that found 16% of football players who died from traumatic brain injuries over a 20-year period had a previous concussion within 30 days of death ( 4). This finding supports the importance of recognition, reporting, management, and adherence to recommended return-to-play protocols after a concussion. All 50 states and the District of Columbia currently have concussion education and safety laws in place that include appropriate medical evaluation by a trained medical professional, no same-day return to play, and return to play only after medical clearance. All laws include education for various stakeholders about concussion symptoms and management. However, for the laws to be effective, athletes must report their concussion symptoms, and medical professionals must be able to accurately assess symptom resolution and full recovery from the concussion before allowing an athlete to resume contact. The implementation and impact of these laws are an important area for future inquiry.

The cases described in this report illustrate the importance of emergency preparedness, recognition, and access to medical services. All schools should have written emergency action plans specific to their school and venue that are rehearsed annually by coaches and staff ( 9). The availability of medical professionals onsite who are trained to recognize and act in emergency situations is critical in catastrophic football injury events. Many schools employ certified athletic trainers, and for competitions, have emergency medical services onsite. However, nationally, 30% of public high schools do not have access to an athletic trainer, and 50% do not have athletic trainers present at practices ( 10). One of the deaths in this report occurred during a junior varsity football scrimmage when emergency medical services were not onsite and arrival of emergency medical services took 15 minutes because of traffic. Current best practices include access to athletic trainers for practices and competition and maintaining emergency medical services onsite during competitions ( 9).

The findings in this report are subject to at least four limitations. First, most events were captured through publicly available media sources, and it is possible that some football deaths were missed. Second, football participation numbers are representative of National Federation of State High School Associations and National Collegiate Athletic Association-affiliated schools and likely underestimate the actual number of football participants. Third, whenever possible, medical diagnoses and medical examiner report causes of death were used, however, the exact diagnosis was unknown for seven of the traumatic brain injury deaths. Information availability might be hampered by the sensitivity surrounding a fatal event, potential litigation, and inability to talk with persons involved. Finally, public interest and media attention about sport-related deaths and traumatic brain injuries increased during the study period, and it is unknown how this might have affected the identification of fatal injuries over time.

These findings support continued surveillance and safety efforts to ensure proper tackling techniques, emergency planning, and medical care, particularly during competition, and adherence to protocols for safe return-to-play after a concussion. These measures will also reduce the risk for concussion and improve treatment and management after a concussion is sustained. CDC provides emergency action plan templates and guidance ( https://www.cdc.gov/niosh/docs/2004-101/emrgact/emrgact1.html) and information about concussions through the CDC HEADS UP program ( https://www.cdc.gov/headsup/). Information on state laws related to concussions is available at https://www.ncsl.org/research/health/traumatic-brain-injury-legislation.aspxexternal icon . Catastrophic sport injuries can be reported to the National Center for Catastrophic Sport Injury Research at http://nccsir.unc.edu/external icon .

Acknowledgments

Julie Gilchrist, MD, National Center for Injury Prevention and Control, CDC; R. Dawn Comstock, PhD, Douglas J. Casa, PhD, Tom P. Dompier, PhD, Jonathan A. Drezner, MD, Zackary Y. Kerr, PhD, David Klossner, PhD, Rebecca L. Stearns, PhD, Consortium for Catastrophic Injury Monitoring in Sport. The National Center for Catastrophic Sport Injury Research is funded by the following organizations: the American Football Coaches Association, the National Athletic Trainers' Association, the National Collegiate Athletic Association, the National Federation of State High School Associations, the National Operating Committee on Standards for Athletic Equipment, and the American Medical Society for Sports Medicine.

¹National Center for Catastrophic Sport Injury Research, Department of Exercise & Sport Science, University of North Carolina at Chapel Hill; ²Injury Prevention Research Center, University of North Carolina at Chapel Hill; ³Matthew Gfeller Sport-Related Traumatic Brain Injury Research Center, Department of Exercise & Sport Science, University of North Carolina at Chapel Hill; ⁴ Emerson Hospital and Boston University, Massachusetts.

TABLE 1. Traumatic brain and spinal cord injury fatalities among high school and college football players, by selected characteristics - United States, 2005-2014

Characteristic

College

High school

Total

No. (%)

No. (%)

No. (%)

Grade level

Activity

Season

Player action

Suspected cause

Body part injured

Position

Total 4 (100)24 (100)28 (100)

TABLE 2. Descriptions of six illustrative cases of deaths from traumatic brain and spinal cord injury among high school and college football players and associated Haddon energy damage countermeasures* - United States, 2005-2014

Year

Player action

Position

Activity

Narrative

Associated Haddon countermeasures

2005

Blocking

Kickoff coverage

Regular season game

A high school player aged 16 years was injured at the end of the second quarter of the game while blocking on a kickoff return. The athlete lowered his helmet into the chest of an opponent and appeared unconscious when he hit the ground. He was immediately attended to by emergency medical services and transported by ambulance to a hospital. Surgery was performed to relieve pressure on the brain, but the player never recovered consciousness. He died 1 week following the injury. Cause of death was a traumatic brain injury.

1. Prevent the creation of the hazard: Ban head first contact, regardless of intention, enforce ban. 4. Modify the rate or spatial distribution of the hazard from its source: Decrease the closing distance on kickoffs. 8. Make what is to be protected more resistant to damage from the hazard: Provide universal education about proper technique for blocking, strengthen neck muscles.

2013

Tackling

Cornerback

Regular season game

A high school player aged 16 years collapsed after making a "routine" tackle during a junior varsity scrimmage against a visiting team. Witnesses to the event reported that his head was up when he made the tackle and that his head hit his opponent's chest. Coaches and adults responded and found he was not breathing. They telephoned emergency medical services, which took 15 minutes to arrive at the suburban school. Emergency medical services began cardiopulmonary resuscitation and transported the player to the hospital, where he died shortly afterward. Autopsy confirmed C-3 cervical fracture from blunt force head and neck trauma.

8. (see above) 9. (see above) 10. (see above)

FIGURE. Fatality rates from traumatic brain and spinal cord injuries among high school and college football players - United States, 2005-2014

Suggested citation for this article: Kucera KL, Yau RK, Register-Mihalik J, et al. Traumatic Brain and Spinal Cord Fatalities Among High School and College Football Players - United States, 2005-2014. MMWR Morb Mortal Wkly Rep 2017;65:1465-1469. DOI: http://dx.doi.org/10.15585/mmwr.mm6552a2external icon .

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Traumatic Brain and Spinal Cord Fatalities Among High School and College Football Players - United States, 2005-2014

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Kristen L. Kucera, PhD 1; Rebecca K. Yau, PhD 1 ,2; Johna Register-Mihalik, PhD 3; Stephen W. Marshall, PhD 2; Leah C. Thomas, MS 1; Susanne Wolf 1; Robert C. Cantu, MD 4; Frederick O. Mueller, PhD 1; Kevin M. Guskiewicz, PhD 3 ( View author affiliations) View suggested citation What is already known about this topic?

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Chronic Traumatic Encephalopathy (CTE), degenerative brain disease found in people with a history of repeated head trauma, may be more common among football players than previously thought. In new findings published in JAMA, BU researchers identified CTE in 99 percent of brains obtained from NFL players, as well as 91 percent of college football players [...]

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Many neurological problems in children are congenital, meaning they are birth defects or conditions that develop in the womb. Other conditions develop later in a child's life. Neurological disorders at UCSF Benioff Children's Hospital are treated by specialists trained in the care of infants and children who have conditions ranging from brain tumors to stroke, including the most complex cases.