Concussions in Surfers

Overview

Head and neck injuries are the most common type of surfing injury, accounting for 37% of all injuries (Nathanson et al., 2002). The majority of these are superficial trauma or lacerations, but more severe injuries such as concussions represented 16% of injuries to the head and neck in Nathanson’s survey-based study. It is suspected that the true incidence of concussions is somewhat higher. Under-reporting may be attributed to several factors. First, surfers may not recognize the symptoms of a concussion, and assume that because they did not lose consciousness, they did not have one. In addition, they may not seek medical attention for symptoms associated with a mild concussion, such as headache or fatigue.

Mechanism of Injury

The most common mechanism of injury for head injuries in surfing is direct contact from one’s own board or another surfer’s board. An informal poll of any group of surfers will reveal that the vast majority of them have at least had the experience of hitting their head on their surfboard. Contact with the sea floor, especially when it is comprised or rock or reef, is another mechanism of injury.

Concussions

There is no universally accepted definition of concussion. The American Academy of Neurology (AAN) defines a concussion as “any trauma-induced alteration in mental status that may or may not include a loss of consciousness.” This definition is important because many people assume that a concussion must involve loss of consciousness. A concussion is a clinical diagnosis, encompassing any one of the following domains: symptoms, (headache, feeling dazed), physical signs (loss of consciousness, amnesia), behavioral changes such as irritability, cognitive impairment such as slow reaction times, and sleep disturbances (McCrory et al., 2009). If any of these signs or symptoms is present, a concussion should be suspected and managed accordingly.

Concussions can have deadly consequences for surfers because of the increased risk of drowning during a period of time where the surfer may be confused, disoriented or unconscious. In fact, in Nathanson et al., 6 of the concussions reported (or 8%) resulted in near-drowning episodes. Once the surfer has been brought safely to shore, it is also important to rule out cervical injury. Always assume cervical spine injury in any unconscious person, and take appropriate precautions to immobilize the head and neck.

For the majority of concussions, head imaging is not recommended, as it does not, by definition, reveal any abnormalities. However, if there is presence of any focal neurological signs (facial asymmetry, focal weakness, speaking difficulty) or prolonged or progressive alteration in consciousness—which may be suggestive of a delayed subdural or epidural hematoma—it is important to transfer the patient immediately to a medical facility for brain imaging and management. Other reasons for obtaining head CT include: if the surfer is taking anticoagulants or has known bleeding tendencies, the surfer is under 16 years of age, over 60, or is intoxicated.

For a suspected concussion, the injured surfer should not be left alone; serial monitoring for neurologic deterioration is very important in the first several hours after an injury. Most importantly, the surfer should not return to surfing that day. In addition, the surfer should be advised to avoid alcohol or sedatives, avoid driving, and to adhere to physical and cognitive rest (e.g., limiting video game playing, texting, prolonged reading or any activity that requires concentration or attention.)

During surfing competitions, a useful “sideline” tool for evaluating and monitoring athletes with suspected concussion is the Sport Concussion Assessment Tool (SCAT). This helpful tool is included in the document, Consensus Statement on Concussion in Sport.

Most concussions resolve spontaneously over a period of days. The current guidelines recommend that any athlete who has suffered a concussion should not be allowed to “return to play” on the day of injury. The primary goal of this is to prevent second impact syndrome, which is rare, but has serious consequences. Second impact syndrome can occur in athletes with prior concussion who experience a relatively minor second impact before the symptoms of the first concussion have resolved. Although relatively uncommon, the consequences are severe, leading to a rapid shift in brain arteriole chemistry, causing brain edema, herniation and rapid death.

The long-term consequences of sustaining a concussion are still being investigated. Although symptoms typically abate within a week, a person who has had a concussion is more at risk for future concussive injuries than a person without concussion history (Guskiewicz, et al., 2003). These subsequent concussions tend to take longer to resolve. Repeated concussions can lead to dementia pugilistica, a syndrome of early dementia and parkinsonism that was first recognized in boxers who receive repeated blows to the head. In addition, there may be an increased risk of depression later in life.

Prevention of Head Injury in Surfers

For sports in general, there is no good clinical evidence that protective equipment will prevent concussion (McCrory et al., 2009). However, research on the biomechanics of head trauma has found a reduction in impact forces transmitted to the brain while wearing helmets, even if this does not result in any reduction of concussion incidence. However, in specific sports, such as skiing, cycling, and horseback riding, it has been shown that helmets do prevent other forms of head injury, such as skull fractures. There has not been any such study performed among surfers.

As it currently stands, protective helmets are rarely worn by surfers. One survey of 668 surfers examined the perceptions of surfboard riders regarding the need for protective headgear, and found that only 1.9% of surfers reported regular use of helmets (Taylor et al., 2005). 10.2% reported occasional use. Interestingly, nearly 75% of surfers believed that protective headgear would decrease the risk of injury. The most frequently cited reason for not wearing headgear was “no need.” Other main reasons included discomfort, claustrophobia, and effects on the senses and balance interfering with surfing. One-third gave vague or poorly defined reasons. Certain groups of surfers who should consider wearing helmets are beginners, children, persons with previous head injury, or while surfing in dangerous conditions such as shallow reef/rock bottom or crowded breaks.

Conclusions

Although surfing is generally considered a safe sport, head injury in surfers is relatively common and can lead to serious consequences, such as drowning, devastating neurological injury, or susceptibility to repeated concussions. Incidence of concussion in surfers is probably underreported. Protective headgear may be useful but it is largely underutilized, and protective benefit has not been proven. Until surfers begin to perceive that head injury is a real threat, and chose to limit that risk, helmet use will probably continue to be low. Advancement in helmet design could make helmets more surfer-friendly and therefore more likely to be worn by surfers. Research into the protective benefits of helmet use for surfers should be undertaken.

References:

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McCrory, P. Meeuwisse, W. Johntson, K. Dvorak, J., Aubry, M. Molloy, M. Cantu, R. Consensus Statement on Concussion in Sport Held in Zurich, November 2008. Clinical Journal of Sports Medicine, 2009; 19:185-200.

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Taylor, KS. Zoltan, TB. Achar, SA. Medical Illnesses and Injuries Encountered During Surfing. Current Sports Medicine Reports. 2006, 5:262-267.

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Written by:

Margaret Donlon, MD, MPH
Department of Physical Medicine and Rehabilitation
University of Medicine and Dentistry of New Jersey
margie.donlon@gmail.com