Orig Post journals.lww.com | Re-Post Duerson 8/25/15
Heads First: The number of children who sustain concussions is on the rise. Sports organizations are responding with stricter policies to ensure safer play. Here’s what parents and coaches need to know.
Cindy Parlow Cone kicked around a soccer ball almost before she could walk. By middle school, she was heading the ball regularly, and often saw stars afterward. “We thought it was just part of the game,” she recalls.
Her skills, honed as a child, made her one of the world’s best “headers” as an adult. Throughout her career, which included every game during the 1999 World Cup and three Olympic Games, Cone was the go-to player for longer kicks and punts; she scored more than 50 percent of her goals with her head.
Despite seeing stars and having repeated run-ins with the ball from middle school onward, Cone was never officially diagnosed with a concussion—until 2001, when she was hit so hard she lost consciousness. After that, she experienced headaches, fatigue, and jaw pain—symptoms that became exponentially worse after a second concussion knocked her out in 2003. For the first time, Cone started questioning the game. “I loved soccer my whole life, and I sacrificed so much for it, but I was secretly hoping I wouldn’t make the 2004 Olympic team,” she says.
In 2006, Cone retired from the game due to post-concussion syndrome, a condition in which concussion symptoms persist for weeks, months, or even years. These days, she is a coach with the Triangle United Soccer Association in North Carolina, and she has become an outspoken advocate for a campaign called Parents and Pros for Safer Soccer, which seeks to eliminate heading in soccer for players under age 14.
As part of this mission, Cone and a growing number of parents, coaches, and players are insisting on safe play protocols. Sports associations are also getting on board. Athletic organizations at every level, from Pop Warner football—a nonprofit program for kids aged five to 16—to the National Football League, are changing the rules that dictate when players can return to the field, what type of personnel must be on the sidelines at sporting events, and how to determine if an athlete is ready to lace up her cleats or needs to spend more time on the bench.
A NEW UNDERSTANDING
Today, sending players with post-concussion symptoms like Cone’s back into play is considered unacceptable. A spate of new studies suggests that head trauma incurred before brains have fully matured—which occurs in the mid-to-late 20s—can have long-term consequences ranging from poor academic performance to depression. And neurologists are paying attention. In fact, the American Academy of Neurology (AAN) recently issued an update to its guideline on concussion called “Summary of Evidence-based Guideline Update: Evaluation and Management of Concussion in Sports” with more rigorous recommendations. (For more information about the guideline and other sports concussion resources, browse the AAN’s Sports Concussion Toolkit at http://aan.com/practice/sports-concussion-toolkit.)
“We’ve come to appreciate that blows to the head can be more serious and require more lengthy recovery than anyone recognized even five years ago,” says Jeffrey Kutcher, MD, director of the Michigan NeuroSport Program, an associate professor of neurology at the University of Michigan Medical School, and a Fellow of the AAN. “We also know that a concussion can occur without a direct hit to the head, for instance when the head moves quickly in response to a blow to the body. There’s a greater understanding not only of the potential long-term effects of these injuries, but also of the complexities of evaluating, diagnosing, and managing injuries in real time.”
CHANGING THE CULTURE
Unfortunately, that understanding is lagging among parents and coaches, especially in soccer. “Parents want their kids to grow up strong and tough,” says long-time coach and referee Linda Hayden of Irvine, CA. “If they don’t see blood and their child doesn’t pass out, they push their kids to get up, brush it off, and get back in the game.”
In a 2013 report on sports-related concussion in youths, the Institute of Medicine—an independent, not-for-profit network of experts that provides information and advice on health and science policy—noted that this “play through it” culture continues to permeate organized sports. Hayden agrees, but says awareness is slowly changing, especially on the assessment front.
Indeed, more children are being evaluated for concussion than ever before. Between 2001 and 2010, the number of kids aged five to 14 who visited the emergency room for head injuries increased 43 percent, according to the US Centers for Disease Control and Prevention (CDC). And that doesn’t include kids who don’t seek medical attention and aren’t formally diagnosed, says Jay Alberts, MD, director of the Cleveland Clinic Concussion Center.
But don’t snatch the soccer ball away from your kids just yet. Sports teach children important life skills during a critical development period and present an opportunity for kids to develop leadership skills and build self-esteem, says Dr. Kutcher. Despite her injuries, Cone agrees. “I was a shy, quiet kid. Soccer helped me come out of my shell,” she says. “All of a sudden I was part of a group of people working toward a common aim, and I never had to apologize for wanting to be the best.”
There’s a better way to prevent sports concussions, experts say, and that involves educating parents, coaches, and players to err on the side of brain health rather than staying in the game at any cost. It also involves teaching children about concussions and brain health, and emphasizing the importance of identifying and reporting symptoms, says Teshamae Monteith, MD, an assistant professor of clinical neurology at the University of Miami School of Medicine and a member of the AAN and the Neurology Now editorial board.
Here’s some additional advice for keeping kids safe.
KNOW THE RISKS OF CONCUSSION
Parents are largely unaware of the significant consequences of concussions, says Hayden. “I’ve seen parents yell at seven-year-olds for ducking rocket shots instead of heading the ball.” She believes youth sports organizations should require parents to complete concussion awareness training before their child can participate in a game.
Parents should know that kids and teens have physiological differences that make them more susceptible to head injury, says Harry Kerasidis, MD, medical director for the Center for Neuroscience at Calvert Memorial Hospital in Prince Fredericks, MD, founder of XLNTbrain LLC, a sports concussion management program, and a member of the AAN. Compared to adults, adolescent necks are weaker and have less fatty material coating the nerves, so their tissues are more vulnerable to impact, he says. Shake up a cranium during this stage of development, and the results can be catastrophic. “The brain is like the yolk in an egg. It’s bathed in cerebrospinal fluid, but if you shake it hard enough it’s going to slosh inside,” he says.
Fibers connecting one nerve cell to the next can tear and swell from the force, cell membranes may become leaky, and the glucose that fuels brain cells has trouble entering the cells and supplying the energy required for repair. “The brain requires huge amounts of energy to restore its equilibrium, and at the same time it’s suffering from a fuel deficit,” Dr. Kerasidis explains.
While the whole brain is vulnerable, the frontal and prefrontal cortex—the locus of judgment, decision making, attention, and impulse control—are at greatest risk because of their proximity to the skull. That’s even more troubling for kids, since their frontal lobes don’t reach maximum density until age 25 or 30, which may be one reason teens take longer to recover from concussions than adults.
Kids and teens are sustaining a bigger hit in a region of the brain that’s still under construction, and that may alter the trajectory of their brain development. “It’s not just how a child’s brain immediately responds to injury. It’s that the brain was developing day to day up until the concussion, and then it had to pause in its development,” says Frances Jensen, MD, chair of the department of neurology at the University of Pennsylvania, a member of the AAN, and author of The Teenage Brain: A Neuroscientist’s Survival Guide to Raising Adolescents and Young Adults (Harper Collins 2015).
START WITH A PRE-SEASON EVALUATION
Nowadays, many advocacy groups encourage or require parents to have their child evaluated before the playing season begins to establish a baseline measure of brain function. One such test, called Immediate Post-Concussion Assessment and Cognitive Testing, or ImPACT, evaluates memory, motor speed, and reaction time. Players take the test at the start of the season and periodically thereafter, and again if they’re injured. The caveat: Athletes shouldn’t take the test unless they’re symptom-free, since it requires sitting in front of a bright computer screen, which is off-limits following a concussion.
TAKE YOUR CHILD TO A NEUROLOGIST
The key to determining whether post-concussion brain changes will be life-altering or just temporarily mind-numbing is to ensure that every child who gets hit—whether knocked out or not—receives a comprehensive neurologic evaluation, including an assessment of cognition, balance, and coordination, a physical exam, and a complete medical history, including family history of neurologic conditions such as migraines. Unfortunately, in the vast majority of concussion cases, that isn’t being done, says Dr. Kutcher.
Even with a post-concussion evaluation, the impact of injury isn’t always easy to assess. A concussion doesn’t cause bleeding or bruising, and diagnostic imaging tests like computed tomography scans and magnetic resonance imaging almost always come back normal. In many cases, kids aren’t knocked out. That makes diagnosis difficult, says Dr. Kerasidis—especially from the sidelines.
Take Luke Bolster, for example. The 16-year-old high school basketball player, a nephew of Neurology Now’s managing editor, was smacked on the bridge of his nose by another player as he was shooting a layup. He took a couple of minutes to compose himself during a time out, then scored two free throws.
“From the stands, it didn’t look like a serious blow, so we thought he was fine,” says his father, Jim. “But as the game progressed, his teammates noticed he seemed confused, and the trainer sidelined him. When he got home that night and turned on the computer, he couldn’t focus. He had a headache, and the light bothered him.” Turns out, he had a mild concussion.
Bolster’s experience isn’t unique. Only 10 percent of concussions result in a loss of consciousness, so in 90 percent of cases, parents, coaches, and staff need to watch for symptoms such as confusion, balance problems and slurred speech, as well as headache, nausea, and vomiting, says Dr. Kerasidis.
Children who sustain concussions may also experience an emotional knock-back. It may not happen right away, but four to five days afterwards, kids may experience mood swings, sleep problems, anger, and anxiety, says Dr. Kerasidis. The causal relationship, though, is hard to establish. Head injuries may impact parts of the brain involved with regulating mood, but sadness and anxiety may also be a natural response to the shock of a traumatized brain—or an athlete’s reaction to being sidelined from his or her favorite sport.
ENFORCE A REST PERIOD
Repairing and reorganizing a shaken brain requires significant energy—a resource that’s in short supply following a head injury. So it makes sense that rest is the cornerstone of concussion treatment. Mental and physical rest ensures that kids don’t add to the demand on already taxed neurons and instead allow their brains time to recover and refuel.
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“No screens, no reading, no physical play,” advises Dr. Kerasidis. Concussed kids who skip that prescription in favor of roaring applause from the sidelines when they return to play are more likely to develop the post-concussion syndrome that Cone still battles.
When Natalia Mepham, 14, sustained a concussion during a soccer match, she needed no incentive to rest. In fact, after she was discharged from the hospital and sent home, she slept for 19 hours straight. Even still, headaches, dizziness, and sensitivity to light—both artificial light from screens and natural sunlight—sidelined her for three weeks.
Bolster, too, understood the importance of rest after his injury. His school’s athletic trainer and his doctor dictated not only what he could and couldn’t do on the basketball court, but also at home and in the classroom. “Luke followed post-concussion protocol for two to three days,” his father says. “He didn’t read. He didn’t go to school. He didn’t watch TV. He couldn’t even listen to books on tape [because it required too much cognitive effort].”
KEEP YOUR CHILD SIDELINED WHILE SYMPTOMATIC
“Letting athletes play when they’re symptomatic may delay recovery, even without further physical contact,” says Dr. Jensen. One reason, according to the AAN guideline, is that the symptoms of concussion, such as loss of coordination and delayed reaction time, make staying out of harm’s way more challenging.
The recovering brain is also more susceptible to additional damage from a second concussion. Yet 59 percent of middle-school soccer players reported playing with concussion symptoms, according to the American Medical Association, with less than half being assessed by a doctor or another qualified medical professional.
Unfortunately, there aren’t much data regarding the degree and duration of physical and cognitive rest needed to promote recovery, or the best timing and approach for returning to play, according to the AAN and the Institute of Medicine. The updated AAN guideline expressly states that “there is no set timeline for safe return to play” and that athletes should be assessed individually by a licensed health care professional trained in concussion.
In the past, that decision rested with the athlete, parents, and coaching staff. Now, thanks to guidelines like the AAN’s, nearly all 50 states require a medical professional to clear kids before they can get back in the game—which includes meeting their baseline cognitive testing level.
ENCOURAGE A SAFE AND GRADUAL RETURN TO PLAY
Research hasn’t defined a protocol for resuming play post-concussion, but the AAN guideline recommends a gradual return once the acute symptoms are gone. That’s the approach Mepham took. Each weekday, she met with an athletic trainer who was also in close contact with her physician.
“Before I started playing soccer again, the trainer had me do simple exercises,” Mepham says. “I started on an elliptical machine for 20 minutes and gradually worked my way up to getting back in the game.” Doctors focused on ensuring that Mepham had no symptoms before allowing her to return to competition. And while it took Mepham five to six weeks to regain her “soccer legs,” today she’s still free from symptoms.
BE AWARE OF SUSCEPTIBILITIES
There is moderate evidence to suggest that concussion symptoms and cognitive impairment last longer in younger athletes—high school level and below—than older athletes, according to the AAN guideline, but it’s hard to isolate age from level of play. “There’s so much happening during puberty in terms of hormones and enhanced synaptic processing and activity,” says Dr. Jensen. “It makes sense that the teenage years would be a period of unique vulnerabilities as well as strengths.”
Girls are especially vulnerable, but many parents still perceive girls’ sports as less dangerous, says Dr. Alberts. “Parents might not let their sons play football, but they have no qualms about their daughters playing lacrosse, field hockey, or soccer,” he says. Yet according to a study published this year in Primary Care, females are actually more prone to brain injury and take longer to recover.
While girls might simply report more concussions than boys, the gender gap could also reflect hormonal and even structural differences in male and female bodies, says Dr. Alberts. Females have thinner, more supple necks, for instance, which allow for more movement of the head during impact, especially if the blows are repeated.
Genetics may also play a role. “When we evaluate kids with post-concussion syndrome, we often see a pre-existing family history of migraine headaches, mood disturbances, other brain network disorders, and sleep problems,” says Dr. Kutcher.
GUARD AGAINST REPEATED BLOWS
Traditionally, people viewed concussion as occurring from a single blow to the head. But new research suggests that a series of milder hits—getting tackled weekly in football, diving headfirst into a pool, and, yes, heading a soccer ball—may be equally risky. While most adolescent brains can compensate for the potential long-term effects of one or two concussions by relying on cognitive reserve, or the brain’s ability to cope with damage while maintaining adequate function, repeated blows may be more problematic—especially if they aren’t being diagnosed as concussions.
That’s what researchers at Purdue University found when they monitored 21 high school football players at Jefferson High School in West Lafayette, IN. Players wore helmets equipped with sensors that transmitted data to a device on the sideline during each play. A review of the data showed that athletes who had never been clinically diagnosed with concussion exhibited changes in information-processing patterns similar to those of their concussed teammates. The findings, which were published in the Journal of Neurotrauma in 2010, suggest that more players are suffering brain injury than are currently being detected—and often, those players remain in the game and continue to take hits, risking future neurologic injury, according to the study authors.
The data also showed that teens who endured up to 50 hits to the head a week had a 50/50 chance of reversing those brain changes during the off-season, but those who sustained 60 hits or more had only a 6 percent chance of recovery. It’s not clear why those extra 10 hits take such a toll, but the study authors suspect it’s because the brain doesn’t have time to recuperate between blows. The researchers noted that 50 to 60 blows per week is not uncommon in sports like football. In fact, high school football players may sustain up 1,600 hits a season.
And the damage isn’t just physical, says Dr. Alberts. Many athletes with head trauma struggle academically and emotionally, too.
KEEP RISK IN PERSPECTIVE
The vast majority of concussed kids will fully recover—90 percent, in fact, recover within 30 days—and experts and athletes alike say the benefits of sports far outweigh the risks.
And pulling a player off the field can have its own negative consequences. Tell a concussed athlete that he or she has to walk away from a beloved sport, and you run the risk of creating significant emotional symptoms, many of which are similar to those from the concussion itself. So while complaints of depression, headaches, sleep problems, and difficulty in school are classic signs of post-concussion syndrome, they may also stem from prohibiting play—and that’s important to keep in mind and respond to accordingly, says Dr. Kutcher.
“Sometimes pulling athletes permanently out of their sport is the right decision, but in many, if not most cases, you’re taking away something that defines them. They no longer have a sense of self, and that’s a huge problem,” he says. Getting athletes off the field is the right decision if a comprehensive neurologic evaluation shows evidence of brain dysfunction, he adds.
ENLIST AN ATHLETIC TRAINER
Unlike parents, coaching staff, or volunteers, athletic trainers know how to block out environmental distractions during games to assess an injury properly—and they’re trained to be objective when evaluating athletes. (According to the National Athletic Trainers Association, athletic trainers must hold a bachelor’s or master’s degree.)
“It’s easy for us to say ‘get them off the field,’ but when a 12-year-old who has traveled five hours to play in a weekend-long soccer tournament has an incident during the first match, that’s a tough sell,” says Dr. Alberts. With such high stakes, players and parents simply aren’t good at reporting concussion symptoms. That’s why having an impartial athletic trainer on the field is essential.
More than 70 percent of concussed athletes return to play when athletic trainers aren’t at the game, says Dr. Alberts. Yet only 37 percent of high schools across the country have full-time athletic trainers on staff, according to the American Medical Society for Sports Medicine—and only 22 percent of states meet the recommendation that every school or organization that sponsors athletics develop an emergency action plan for managing serious injuries.
MAKE SAFE PLAY A TOP PRIORITY
Perhaps the best strategy to reduce concussions is to minimize the risk through new policies and attitudes, experts say.To that end, Pop Warner football has eliminated full-speed, head-on blocking and tackling in drills and practice; USA Hockey has banned checking for kids younger than 13 (the American Academy of Pediatrics has called for the minimum age to be 15); and many youth soccer teams limit heading during practice for older kids and no longer allow the youngest kids to head the ball at all.
If those policies were in place when Cone was playing, she may not have hung up her cleats at the age of 24 because of lingering post-concussion symptoms.
“Sure, eliminating heading changes the game, but I believe it changes it for the better,” says Cone. “Kids spend more time working on other technical skills.” But most importantly, studies show that eliminating heading in vulnerable age groups reduces their risk of concussion by 30 percent.
“We need to protect our youngest, most vulnerable kids,” says Cone. “Each child has only one brain, and the effects of concussion, particularly repeated concussions, can last a lifetime.”