Traumatic brain injuries occur infrequently in baseball and softball, but the effects can be devastating. Yet players often fail to wear helmets and many do not comply with return-to-play guidelines following a concussion, according to a new research paper published online Monday in the journal Frontiers of Neurology.
The findings, which reported injuries ranging in severity from mild to immediate death, have prompted the authors to call for all baseball and softball players, including recreational players, to use helmets.
"Some of these injuries can be quite catastrophic, and a helmet would prevent things like a skull fracture or bleeding in the brain," said lead author Michael Cusimano, a neurosurgeon and scientist at St. Michael's Hospital in Toronto.
The systematic review, which received funding from the Canadian Institutes of Health Research, examined 29 studies that involved a total of 242,731 baseball and softball-related traumatic brain injuries from 1982 to 2015. The players ranged from children to athletes in major and minor leagues. It found that while helmets are mandatory in all formal baseball leagues, recreational baseball players rarely used them. Moreover, up to 55.6 per cent of baseball and softball players who experienced concussions did not comply with return-to-play guidelines.
The review noted that baseball and softball had the lowest rates of concussion among 15 other sports, including ice hockey and American football. The average rate of injury was 0.13 per 1,000 athletic exposures. (By comparison, the rates of traumatic brain injury were reported to be 0.75 per 1,000 athletic exposures in American football and 0.74 per 1,000 athletic exposures in ice hockey, according to one study cited in the review.)
In spite of the low injury rates for baseball and softball, Dr. Cusimano said he specifically studied these sports after seeing multiple patients who had been hit in the head with a ball or a bat.
"You don't have to see too many people with bleeding in the brain and severe injury to say, 'Hey, what can we do to hopefully prevent this?' " he said.
In seven studies cited in the review, injuries were generally mild, with more than 28 per cent of players making a full recovery within a week. But around 14 per cent were severe, requiring surgery or resulting in disability or persistent symptoms. One study that focused on 26 catastrophic cases found five players died from severe cerebral bleeding immediately after a head injury.
The review noted that studies involving high school and collegiate teams generally found poor compliance for the use of helmets. Among baseball-related traumatic-brain-injury cases that were seen in a hospital emergency department, only 6.7 per cent reported the use of a helmet.
The authors pointed out that a recent review showed helmets did not protect against concussion. But, they said, helmets do provide clear protection against other brain injuries, including open skull fractures and intracranial hemorrhage.
"As such, we believe that it is important to enforced [sic] and encourage the use of helmets among all baseball and softball players," the authors wrote.
They also suggested athletes, parents and coaches should be educated about the symptoms of traumatic brain injury, and the importance of preventing and reporting injuries.
When it comes to adhering to post-concussion return-to-play guidelines, sports teams in Canada have generally taken "a step in the right direction," said Michelle McDonald, executive director of Brain Injury Canada. But she says these guidelines need to be enforced further.
"There needs to be some regulations that … training [on concussion guidelines] has to be mandated for all coaches or all league heads, and that it has to be mandated for school boards as well," she said. "Prevention, obviously, is critical, but when a concussion does happen, following the right return-to-learn and return-to-play and recovery guidelines is essential."
Ms. McDonald said in baseball, children are already commonly required to wear helmets while batting and pitching, but it will likely be challenging to achieve more widespread helmet use, especially in recreational play.
"I would love for every child to be wearing a helmet when they're playing sports … but it'll be an uphill battle," she said.