Running head: SPORTS INJURY AND LONG TERM EFFECTS ON MENTAL STATUS

Sports Injury Related to Long Term Effects on Mental Status

A Review of Literature
Natalee Bommer, Tracy Geiselman, Stephanie Hawkins, Brianna Triplett
Youngstown State University

NURS 3749: Nursing Research

Dr. Kim Serroka
April 13th, 2015

SPORTS INJURY AND LONG TERM EFFECTS ON MENTAL STATUS

Abstract
This literature review of current nursing research explores how concussions can lead to longterm changes in mental status. These long-term changes focus on diagnosed traumatic brain
injuries (TBIs) but also include changes in behavior, psychological changes, and development of
chronic traumatic encephalopathy. In addition to possible long-term effects, this review includes
recent research into nursing assessment tools for concussions and traumatic brain injury that may
soon come into popular use in emergency departments across the country. Before implementing
treatments in order to lessen or prevent long-term effects on mental status, adequate assessment
techniques and tools must be used and documented by the nurse to pinpoint specific signs and
symptoms of TBI. By identifying recent strides of research into advanced assessment methods
for traumatic brain injuries and the gaps in which assessment could be improved, this research
will ideally inspire nursing researchers in particular from various professional backgrounds
toward a desire for improved outcomes and assessment for TBI patients.

SPORTS INJURY AND LONG TERM EFFECTS ON MENTAL STATUS

Introduction
In the past, researchers have assumed that children and adolescents were less susceptible
to concussions than adults on the basis that more force is needed to injure a young brain, which
generally has more plasticity. However, research has shown that not only is that untrue but youth
sports players are more susceptible to head injuries that can lead to chronic mental illness
(Norton, Feltz, Brocker, & Granitto, 2013). As the term head injuries can be associated with
several types of injuries, it is important to define the specific types of head injuries that will be
discussed throughout this paper. According to the British Journal of Sports Medicine, a
concussion is defined as a traumatically induced transient disturbance of brain function and
involves a complex pathophysiological process (p. 15). Furthermore, the term concussion has
been used interchangeably with the term minor traumatic brain injury (mTBI), or just traumatic
brain injury (TBI), which refers to an injury that results from a forceful jolt to the head causing
the brain to collide with the skull (Norton et al., 2013). The significance of this type of injury can
be completely subjective. Although the injury happens mostly during sports such as football or
boxing, where contact and injury is applauded, the effect of the injury may not be readily
recognized in the above and even less physical sports. There has been inclusiveness about what
assessment tools can recognize if any injury has occurred. In discussing TBIs and association
with long-term illness, there are two points to consider. First, when a TBI occurs, there may be
no sign or symptoms of neurological injury, the patient may or may not lose consciousness, and
may report feeling fine after a few minutes. Once again, because this information is subjective
and the patient may not be completely honest, a health assessment at the time of injury may bring
inconclusive results. Secondly, considering that repeated TBIs can cause neurological deficit, it is
important to understand that brain injury may or may not show immediately on brain scans.

SPORTS INJURY AND LONG TERM EFFECTS ON MENTAL STATUS

When the injury occurs, it is vital that the patient is professionally assessed by a skilled
medical professional such as a nurse. Considering a baseline assessment is the cornerstone of
nursing care, it provides vital information about patient status that can be used as a comparative
tool if changes occur. Detailed assessment is an important nursing skill when dealing with TBI
because any signs or symptoms may be subtle and not recognized by untrained staff. Due to the
delayed symptoms of TBI, the patient needs to have a follow up assessment with a medical
professional after the acute time period has ended. In the field of nursing, it is important to have
a standard for assessment skills related to acute TBIs. According to Norton et al. (2013), Nurses
use the nursing process as the framework for assessment, prevention and education which is
invaluable when working with patients that are at risk or have already experienced a TBI. In
American society, the acknowledgment of the seriousness of repeated TBIs in adolescents is
ignored and the children are less likely to receive proper treatment. As nurses, there is a need to
determine if there is research proving the seriousness of chronic mental illness related to repeat
TBIs. There is also a need to identify what assessment tools are available for use in order to
recognize and document acute injury, furthering the documentation of the progression of
symptoms over time.
The following literature review will look at previous articles related to TBIs, long-term
effects of chronic mental degenerative illness, and nursing assessment tools to assist in the
recognition of chronic illness.
A Review of Literature
Symptoms of a concussion include memory problems, vertigo, dizziness, and headaches;
the latter is the most commonly reported concussion symptom. Post-traumatic migraines, a

SPORTS INJURY AND LONG TERM EFFECTS ON MENTAL STATUS

specific type of post-concussion headache, are associated with poor outcomes and longer
recovery following concussion. Monitoring these headaches may prove to be a challenge in
adolescents and children who may not be able to recall detailed list of symptoms experienced
after a concussion. The Headache Electronic Diary for Children with Concussions is an article
written by a team of nurses, with varying education levels, which explores a new assessment tool
to be used with children post-TBI. In this study, the team created an electronic diary, initially
referred to as the prototype, using iPad technology. This study used both quantitative and
qualitative methods of collecting the data, as well as interview and pain assessment tools. In the
first phase of the trial, the appearance of the interface was chosen largely based on the opinions
of the children who would be using the diary. Interviews included assessment questions about
the children's headache symptoms in order to develop choices used to describe symptoms that
were experienced. These choices then appeared on the assessment prototype, later renamed the
Headache Electronic Diary for Children with Concussion (HED-CC). (Pasek, Locasto,
Reichard, Sumrok, Johnson, & Kontos, 2015)
During the second phase, the iPad was sent home with the children to be tested. While
neurocognitive testing is imperative to managing post-concussion symptoms (eg, difficulty with
concentration, feeling slow) during recovery and return to play, clinicians must realize that selfreport remains the criterion standard for pain assessment (pg. 87). The goal of the prototype
created for this study was to implement an assessment tool that could track post-concussion
symptoms accurately and in real time. The prototype offers a calendar view of when symptoms
started, their progression, and possible regression of symptoms. Although this idea is a great
interactive tool for young adults who prefer technology, it is important to consider the limitations
of this study, the first being the subjectivity of the pain assessment. According to Pasek et al.

SPORTS INJURY AND LONG TERM EFFECTS ON MENTAL STATUS

(2015), we assumed that the participants provided thorough responses to the interview questions
about their headache pain and honest feedback. Pasek states that, twice during interviewing,
two sets of parents commented that they could feel their childs frustration with searching for
words. During these times, the parents tried to help their child articulate thoughts (pg. 82). The
need for parental guidance may cause bias in the childs subjective description of their injury. So
although the child may have difficulty articulating a thought, it is important to document the
findings as objectively as possible without a guardian's opinion. (Pasek et al., 2015)
An important consideration when looking at the study is how the prototype was received
by the children and to determine if the tool would be successful in current medical practice. The
opinion of the children was a very important factor considering that children would be the target
customers if the tool is eventually implemented into practice. One child stated, this is pretty
cool actually. It would help doctors understand their patients lots of kids are getting
concussions these days (pg. 86), while another stated, when I come to the doctor, I report how
I feel now, not over the past days or months. This requires less talking. You could come to your
appointment and just hand this (the final page) to your doctor (pg. 86). It can be inferred that
the children find the tool useful, however, it is important to get the parents opinion of the
prototype because parents are an active part in their childs plan of care. One parent states, this
supports these stages the doctor gave me (referring to a stepwise return to play standard of care).
Its not totally up to me now. (pg. 86) Another parent states, when I come in here (clinic), I
cant remember anything about her headache, when she went to school, whole days or half days
due to headaches. This would be great to help parents remember things (pg. 87). The study has
been successful in appealing to the patient and the families who would be using the tool,
however, it is important to identify if this prototype would be useful to nurses and the medical

SPORTS INJURY AND LONG TERM EFFECTS ON MENTAL STATUS

field in general. In the article, the author states the HED-CC [the prototype] did not adequately
handle time and headache trending, nor did it provide for the correlation of headache with
activities of daily living. Furthermore, the author states that in the future further reliability
testing will be conducted with a larger sample of children to establish clinical application
benefits. Although the author did not prove the tool had clinical use in the first study, this
assessment tool developed by nurses is beneficial in tracking post-concussion symptoms in
children and may lead to a successful way in not only tracking symptoms in TBI patients but
other patients with chronic illness not related to TBIs. (Pasek et al., 2015)
That fact that over 1.7 Americans report the experience of traumatic brain injury yearly
shows that the exploration of additional tools, like the HED-CC, for assessment of post-TBI
complications would be of great benefit to hospitals nationwide. TBI, unlike stroke, Alzheimers
dementia, and other neurological disorders, is most common among those of 0-4 years of age and
15-19 years of age (Kimbler, Murphy, & Dhandapani, 2013). These statistics only include those
who have sought emergency treatment, overlooking a large amount of victims who have failed to
seek medical assessment of their injuries. Despite knowing the prevalence, only a small amount
of research has been allocated to the treatment of TBI. As nearly a quarter of all wounded
soldiers returning from Operation Iraqi Freedom, a high concussion risk event, have experienced
at least one TBI while in service, there has been at least some increased awareness and research
interest into the effects of this type of neurological injury (Kimbler, Murphy, & Dhandapani,
2013). However, this continues to overlook the vast amount of patients in the adolescent athlete
demographic that could benefit from improved long-term research and assessment of their TBIs.
Concussion cases among those of 14-19 years of age requiring emergency treatment and

SPORTS INJURY AND LONG TERM EFFECTS ON MENTAL STATUS

later exhibiting signs and symptoms of TBI, were three times more common in 2007 than in
1997 (Mitka, 2010). Due to a number of factors, including a federal government push for
increased physical activity, an increased number of competitive sports programs for both male
and female adolescents, and the popularity of professional contact sports, adolescent
involvement in competitive sports has been on the rise and is continuing in a similar trend. So as
expected, along with increased participation in combative sports, there has been a parallel
increase in the number of concussions and traumatic brain injuries (Kimbler, Murphy, &
Dhandapani, 2013). Although traumatic brain injury is not something to take lightly, its
symptoms can seem mild, leading to complacency among youth athletes, parents and coaches.
This can not only lead to a second brain injury, compounding previous damage, but permanent
damage that could have been prevented with early diagnosis and prompt treatment.
A number of retired NFL players, prime candidates for study of the long-term effects of
contact sport-related TBIs, have reported symptoms of neuropsychiatric disorders including
increased aggression, erratic behavior, and suicidal thoughts or actions. Although the specific
cause is under investigation, the common theme among these behavioral symptoms is TBI. In
1994, the NFL formed the Mild Traumatic Brain Injury (mTBI) committee to study the long-term
effects of concussion in professional football players. The formation of this committee lead to a
redesign of NFL helmets, mouthpieces, and ban on helmet-to-helmet contact (Kimbler, Murphy,
& Dhandapani, 2013). It has been found that repetitive TBIs over the course of years, such as
during a professional sports career, may result in the development of chronic traumatic
encephalopathy (CTE), a progressive degenerative brain disease. Upon the study of post-mortem
brain tissue donated by former NFL and NHL athletes, this condition has been found in over a
dozen of the retired athletes (Kimbler, Murphy, & Dhandapani, 2013). Even amateur collegiate

SPORTS INJURY AND LONG TERM EFFECTS ON MENTAL STATUS

athletes have been found to be affected by CTE, after post-mortem study of suicidal collegiate
football players. As adolescent athletes are not exempt from the type of combative contact that
can occur during game-play in competitive sports, these initial long-term studies of adult athletes
show the risk of the long-lasting neurological deficits of concussion. The need for life-long study
of traumatic brain injury in adolescent athletes is a critical and relevant research front in both the
fields of medicine and nursing. As the accurate and skilled assessment of the registered nurse is
so important to the improvement of TBI patient outcomes and the rate of aforementioned sportsrelated brain injuries continues to increase, the need for research into advanced long-term
nursing assessment methods becomes more important as time progresses.
Conclusion
It can be concluded that a relationship does exist between repeated traumatic brain
injuries and long-term effects on mental status. Research has shown that these injuries are
usually sports-related and furthermore, can be prevented with proper head protection and nonbiased, on-field assessment despite the rising popularity of contact sports. The effects of TBIs are
usually chronic and can happen insidiously. Furthermore, it is not always accurate for a medical
professional to rely on the subjective data provided by a concussed patient. Therefore, in a
worsening situation or additional head injury, there is often a lack of sufficient data, which could
be useful for patient care. During the literature review, it was learned that a group of clinical
nurse specialists created a tool that can track childrens cognitive systems over time called the
Headache Electronic Diary for Children with Concussion, or HED-CC, which is extremely
useful in assessing symptoms over time. While considering ways to follow patients symptoms
over time, this assessment tool could possibly fill the gap between accurate data collection and

SPORTS INJURY AND LONG TERM EFFECTS ON MENTAL STATUS

10

contribute to finding more specific precipitating factors of mental health issues in patients with
TBIs.
Luckily, there has been more, although still insufficient, research into improved tools for
post-concussion assessment thanks to the prevalence of TBIs among wounded soldiers and sports
icons, even though the long-term effects are often too late to reverse at this point. Since a nurse is
likely to have the most contact with a newly concussive patient while still being able to utilize
assessment tools that require at least a nursing skill set, advanced post-concussion assessment
tools such as HED-CC are a very necessary and promising topic for not only medical but nursing
research. Finally, if the post-concussion assessment of a patient becomes more accurate, better
treatments can be provided, leading to better patient outcomes and less incidence of long-term
effects of traumatic brain injuries such as chronic traumatic encephalopathy. Through review of
current literature, it was found that the best prevention for increased long-term effects of sportsinjury related traumatic brain injuries is not only proper head protection but improved nursing
assessments, better tools for those assessments, and further research of post-TBI patients over the
life span.

SPORTS INJURY AND LONG TERM EFFECTS ON MENTAL STATUS

11

References
Harmon, K. G., Drezner, J. A., Gammons, M., Guskiewicz, K. M., Halstead, M., Herring, S.A.,
Roberts, W. O. (2013). American medical society for sports medicine position statement:
Concussion in sport. British Journal of Sports Medicine,47(1), 15. Retrieved from
http://search.proquest.com/docview/1239853894?accountid=29141
Kimbler, D. E., Murphy, M., Dhandapani, K. M. (2011, December). Concussion and the
adolescent athlete. Journal of Neuroscience Nursing. Retrieved from
http://www.ncbi.nlm.nih.gov
Mitka, M. (2010, December). Reports of concussion from youth sports rise along with awareness
of the problem. Journal of the American Medical Association, 304(16),1775-1776.
Norton, C., Feltz, S. J., Brocker, A., Granitto, M. (2013). Tackling long-term consequences of
concussion. Nursing2013, 43, 50-55.
Pasek, T.A., Locasto, L.W., Reichard, J., Sumrok, V., Johnson, E.W., Kontos, A.P. (2015). The
headache electronic diary for children with concussion. Clinical Nurse Specialist, 29(2),
80-88.