Concussions: Being Smart About Your Child’s Brain

The New York Times
Frank Bruni Frank Bruni DEC. 19, 2015
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PROBABLY no one tracks concussions among young athletes in the United States more closely than Dawn Comstock, and in many ways, she’s encouraged by what she sees.

It’s now less common for a player whose head has collided violently with a ball, a wall, the ground or another player to return to competition right away. It’s now more common for him or her to get medical attention.

But Comstock, an epidemiologist at the Colorado School of Public Health, is frustrated by stubborn gaps between truly safe behavior and the status quo. She told me that more than half of the high schools with football teams don’t have a full-time athletic trainer, so there’s no immediately available person with the specific mission of preventing and treating injuries.

There are also sports other than football — and trauma other than concussions — that don’t attract nearly the vigilance they should, she added. Above all, there’s an enduringly strange, dangerous relationship between parents and sports, specifically between parents and coaches.

“What I would love to see is parents taking as much time to investigate their child’s coach, the league that they’re putting their child into and the officials officiating the game as they do a day care center when their child is young,” she told me. “They don’t have trouble challenging a teacher, even a pediatrician. But somehow they have trouble challenging a sports league.”

This coming week, the major Hollywood movie “Concussion” opens. It stars Will Smith as a scientist who sounded the alarm about the long-term impact of repetitive head injuries in professional football.

And it reflects a storm of attention over the last decade to the serious, sometimes fatal damage done to the vulnerable brains of football players of all ages — and of soccer players, too. We’ve learned, for example, that soccer carries a greater risk of concussion for girls than it does for boys.

But the talk of a “concussion crisis” and the pronounced concern about football and soccer are blinding us somewhat to a larger picture, a broader lesson: Our veneration of sports, our adulation of athletes and our ethos of toughing it out put kids needlessly at risk of all sorts of preventable injuries in all kinds of improvable sports.

“I worry that we’ve been so focused on football that parents are pushing their kids out of that and into something else and not realizing that there are dangers there, too,” said Kevin Guskiewicz, one of the directors of the Matthew Gfeller Sport-Related Traumatic Brain Injury Research Center at the University of North Carolina at Chapel Hill. “We need to improve safety in all the sports that children play.”

Did you know that while the incidence of injuries in cheerleading is much lower than in the majority of high school sports, nearly a third of those injuries are concussions? The reason, Comstock explained, is a shocking lack of common sense and caution in monitoring an activity that isn’t automatically associated with violence.

 

“We’ve seen cheerleaders who’ve sustained concussions because they were practicing on the asphalt in the parking lot or on the cement sidewalk — or in the school cafeteria on a tiled floor,” said Comstock, adding that grass or mats would be infinitely more appropriate. “Why on earth would parents let that happen?”

Guskiewicz drew my attention to a study published just a few months ago in The American Journal of Sports Medicine that determined that among college athletes, concussions were most likely in wrestling, followed by men’s ice hockey and then women’s ice hockey. And women’s soccer and women’s basketball, in that order, were right behind football in terms of the danger of concussion.

Comstock, who supervises an ongoing national inventory of athletic injuries among high school students, said: “I have 22 sports in my surveillance system, and concussions have been reported in all but one of them. That includes swimming.” A distracted kid will swim head-on into the wall or into someone coming from the other direction. The sport without concussions, she said, was tennis.

BUT head injuries are just one peril, and not necessarily the chief one, even in football. There are many more deaths among football players of all ages from indirect trauma, including heatstroke and cardiac arrest, than from such direct trauma as head and spinal-cord injuries.

Douglas Casa, the chief executive officer of the Korey Stringer Institute at the University of Connecticut, said that from 2000 through 2009, which was the last full decade studied, such indirect-trauma deaths outnumbered direct-trauma deaths by 108 to 41.

Casa, who monitors and compiles that data, told me that he knows of 14 deaths among football players below the college level since July 1, which is about when practice for the fall season usually begins. Four were from cardiac arrest and two were from heatstroke.
“Anytime you hear about a kid dying from heatstroke in high-school football, it was 100 percent preventable,” he added. And he said that there are an even greater number of preventable cases of severe heatstroke that leads not to death but to prolonged or permanent health complications.

Last August, for instance, a 16-year-old in Riverhead, N.Y., who developed heatstroke during practice ended up in the hospital, where he spiked a 108-degree fever, was treated for serious kidney damage and spent the next five weeks.

Casa said that heat acclimatization — or the incremental acceleration of practices during a season’s start — can guard against heatstroke. But while many leagues and teams have implemented that, many haven’t.

Players’ posture can affect the likelihood of head injury but often isn’t studied and adjusted. And Comstock said that there’s no widespread, dependable monitoring of the nature and incidence of injuries among athletes in elementary and middle school.

“Don’t get me wrong: I’m not against sports,” she said. “I was a three-sport player. And I played contact sports. I played rugby for 13 years.” She and Guskiewicz both stressed that, at a time when too many kids are obese or diabetic, they want more of them to play sports.
But they also want more prudence in the mix. Some parents obsess about a high school’s success or failure in getting kids into Ivy League colleges but know nothing of the school’s athletic teams’ safety protocols. Some question the amount of homework more readily than the number of laps athletes run on a 95-degree day.

Some shop for lenient physicians who will declare their child healed and let him or her back out on the field. Athletic glory beckons.

“Sports has achieved an almost mythologized place in our country,” Comstock said. She’s wrong about the “almost.” She’s right about this: It’s not concussions per se but an unquestioning worship of sports that puts young lives in jeopardy.

Concussions In Young Athletes Remain A Mystery

The Huffington Post

AP  |  By By LAURAN NEERGAARD  10/30/2013

WASHINGTON (AP) — No one knows how often the youngest athletes suffer concussions. It’s not clear if better headgear is the answer, and it’s not just a risk in football.

A new report reveals big gaps in what is known about the risk of concussion in youth sports, especially for athletes who suit up before high school.

The Institute of Medicine and National Research Council on Wednesday called for a national system to track sports-related concussions and start answering those questions.

Despite a decade of increasing awareness of the seriousness of concussions, the panel found young athletes still face a “culture of resistance” to reporting the injury and staying on the sidelines until it’s healed.

“Concussion is an injury that needs to be taken seriously. If an athlete has a torn ACL on the field, you don’t expect him to tape it up and play,” said IOM committee chairman Dr. Robert Graham, who directs the Aligning Forces for Quality national program office at George Washington University.

“We’re moving in the right direction,” Graham added.

But the panel found evidence, including testimony from a player accused by teammates of wimping out, that athletic programs’ attention to concussions varies.

Reports of sports concussions are on the rise, amid headlines about former professional players who suffered long-term impairment after repeated blows. Recent guidelines make clear that anyone suspected of having a concussion should be taken out of play immediately and not allowed back until cleared by a trained professional.

Although millions of U.S. children and teens play school or community sports, it’s not clear how many suffer concussions, in part because many go undiagnosed.

But Wednesday’s report said among people 19 and younger, 250,000 were treated in emergency rooms for concussions and other sports- or recreation-related brain injuries in 2009, up from 150,000 in 2001.

Rates vary by sport.

For male athletes in high school and college, concussion rates are highest for football, ice hockey, lacrosse and wrestling. For females, soccer, lacrosse and basketball head the list. Women’s ice hockey has one of the highest reported concussion rates at the college level.

College and high school sports injuries are tracked, but there’s no similar data to know how often younger children get concussions, whether on school teams or in community leagues, the IOM panel said.

“One thing that parents question is, ‘Well, should I let my son or daughter play this sport they’re asking me to play?'” said sports injury specialist Dawn Comstock of the University of Colorado, who reviewed the report. “If we don’t have that type of data on the national level, it’s very difficult” to know.

Could safety gear prevent kids’ concussions?

Some equipment ads make that claim. But there’s little scientific evidence that current sports helmet designs or other gear, such as face masks or headbands for soccer, really reduce the risk, the panel cautioned.

Still, it stressed that youngsters should wear helmets and other sport-appropriate safety gear, because they guard against other injuries, including skull fractures and face injuries.

“Parents deserve to know how safe their children’s safety equipment really is,” said Sen. Tom Udall, D-N.M., who is pushing legislation to curb false advertising and encourage improvements to sports equipment standards.

“While we can’t reduce every risk, we should do everything we can to stop misleading advertising that gives parents a false sense of security.”

The report found that every state except Mississippi has passed a concussion law since Washington started the trend in 2009, prompted by a 13-year-old who suffered permanent disability after returning to a football game despite a concussion.

The laws address such things as criteria for removal from play and standards for return-to-play decisions, but the report said most are in the early stages of being implemented.

It’s not always easy to spot a concussion — symptoms might not be obvious right away — yet most young athletes practice and play without routine access to a professional trained to check them, the panel said. That can leave the decision to bench players up to coaches and parents.

That’s especially true before high school and in community leagues, said Tamara Valovich McLeod with the National Athletic Trainers’ Association, which long has pushed for concussion education.

Without training, people may not realize you can have a concussion without losing consciousness, or that you can still have symptoms despite a clean CT scan, she said.

Typically, youth athletes recover from a concussion within two weeks. But in 10 percent to 20 percent of cases, symptoms can persist for weeks, months, occasionally even longer, the report found. A second blow before full recovery is especially dangerous.

Nor is the concern only about physical activity.

The American Academy of Pediatrics this week said teachers may need to ease students back into learning after a concussion.

There’s increasing evidence that too much mental activity can prolong recovery, too. Sensitivity to light, headaches or memory difficulties may require breaks or extra time on assignments when the student returns to class, the pediatricians’ policy says.

The IOM report also said:

—Youths who’ve already had a concussion are at higher risk for subsequent ones.

—Calls for a “hit count” to limit the number of head impacts in a week or a season make sense, but there’s no evidence to say what that number should be.

—Sports officials should examine if there are age-specific rules to make play safer, such as Canadian youth hockey’s no-checking rule for the youngest players.

But the report shouldn’t scare parents into pulling their kids out of sports, injury expert Comstock stressed.

“The positives of sports as a physical activity still far outweigh the negatives,” she said. “We just need to make it as safe as possible.”

“Concussions May Be More Severe in Girls and Young Athletes”

The New York Times

Concussions May Be More Severe in Girls and Young Athletes

By ANAHAD O’CONNOR

May 10, 2012, 12:00 pm

New research has found that younger athletes and those who are female show more symptoms and take longer to recover from a concussion than athletes who are male or older.Joe Paull/The Ledger-Enquirer, via Associated Press
 
New research has found that younger athletes and those who are female show more symptoms and take longer to recover from a concussion than athletes who are male or older.

During a soccer game two years ago, Megan Wirtz, a goalie for her high school team, was bending down to pick up a ball when an opposing player mistakenly kicked her in the face.

Her face swollen and bleeding, Megan was taken to an emergency room and stitched up. No one realized she had suffered a severe concussion until three weeks later, when a player ran into her during another game and she fell to the ground, suffering a seizure on the field. Doctors believe she experienced what’s known as second impact syndrome, a sequence of events in which a child or teenager sustains a hit before a concussion fully heals, which can cause the brain to bleed or swell, even if the second impact is a moderate one.

“In retrospect, we hadn’t thought as much about her brain as we clearly should have,” said her mother, Barbara Wirtz, a nurse in East Lansing, Mich. “She doesn’t have lingering problems like some players do. We were very lucky in that regard. But the reality is if she continues to play, it could happen again.”

New research in the latest issue of The American Journal of Sports Medicine shows that athletes like Megan may be particularly susceptible to the damaging effects of a concussion. The research found that younger athletes and those who are female show more symptoms and take longer to recover from a concussion than athletes who are male or older.

More than 1.6 million Americans suffer a sports-related concussion every year, and a growing number occur among high school and college athletes. According to federal statistics, more than 150,000 teenage athletes sustained concussions on the playing field from 2001 to 2005, though that figure accounts for only those who were taken to emergency rooms, so the true number, experts say, is likely to be much higher.

While researchers have known that girls run a greater risk of suffering concussions than boys playing the same sports, the new study is among the first to look at the effect of both age and sex on a range of symptoms.

The findings suggest that because of anatomical differences that make them more vulnerable, female athletes, and younger athletes in particular, may need to be managed more cautiously after a concussion, said Tracey Covassin, an associate professor of kinesiology at Michigan State University and the lead author of the report.

“Parents need to understand that if their daughter has a concussion, that they may potentially take longer to recover from that concussion than their son who is a football player,” she said.

Over the course of two years, Dr. Covassin and her colleagues followed a large group of high school and college athletes from California, Michigan, Louisiana and Tennessee. At the start of the study, the athletes were given baseline tests that looked at memory and other cognitive skills. Those who suffered concussions in the two years that followed, about 300 in all, were given three different postconcussion tests commonly used in professional sports.

Over all, after concussions, the high school athletes performed comparatively worse for their age than older college athletes on measures of verbal and visual memory, and female athletes reported more symptoms and showed greater declines in visual memory compared with their male counterparts. The cognitive impairments were also more likely to persist over time in younger athletes, lasting an average of 10 to 21 days after concussion in high school students. That is about two to three times as long as the five- to seven-day period of persistent symptoms that has been documented in college athletes.

Researchers say that younger athletes may be at greater risk of damage from concussion because their brains are not fully developed. There is also some evidence that young women may suffer more symptoms than young men because of higher estrogen levels, which may exacerbate brain injury, as well as greater rates of blood flow and higher metabolic needs in the brain, which may make symptoms more pronounced. But, says Mark Hyman, author of “Until It Hurts: America’s Obsession With Youth Sports and How It Harms Our Kids” (Beacon Press, 2009), girls may also just be more willing than boys to admit to injury and seek treatment.

“We don’t expect girls to be indestructible, as we do boys,” who may be more likely to play through pain to avoid being sidelined in their sport, he said. “Attitudes are changing about that. But not fast enough.”

The findings also highlight the dangers of treating children and teenagers as “miniature adults,” he added. “The brain and head of a small child are disproportionately large for the rest of the body,” he said. “The result is that their heads are not as steady on their shoulders. When they take a big hit in a football game or are slammed with an elbow in a soccer game, their brains move inside their skulls. That’s when concussions occur.”

As for Megan, she continues to play soccer, but under strict rules. Her parents attend every game, and are more alert to potential problems.

“I think we’re better at assessing the symptoms of a concussion now,” Ms. Wirtz said. “We’re a little more watchful and demanding that coaches don’t keep her in if there’s any question at all that she got knocked around.”

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