Investigative Series: Head Injuries in Contact Sports
For the past several years, a national discussion about sports concussions, particularly among young athletes, has been gathering steam, not only in the scientific community but in the national press, as the number of head injuries grows exponentially and new research casts doubts on traditional ways of analyzing the injuries.
Suffice it to say, as the number of injuries grows, so does the controversy, and, as each passing week seemingly brings to light new evidence, the dialogue is not about to abate anytime soon. Indeed, a trio of new studies is challenging the very notion of what causes most concussions, pointing to the accumulation of asymptomatic impacts, or "hits," over time rather than as a result of a single traumatic blow to the head.
There are a range of opinions on the matter, and the latest evidence is contested, or at least treated skeptically, by the neurological establishment, leading to three distinct, if cross-pollinated, theoretical camps.
On one end of the spectrum are those who embrace current protocols based on concussion management. While preventive efforts certainly play a role in this approach, the focus is more on managing a concussion after the fact, and making sure players are healthy and asymptomatic before they return to the field.
On the other end of the spectrum are those who say that collision and high-impact sports such as football should be banned altogether for young people. One of the nation's preeminent neurologists, Dr. Robert Cantu, is in that bloc - he says young people should not play collision sports until they are 14 - and others are perilously close, such as NFL legend Troy Aikman.
"I think that we're at a real crossroads, as it relates to the grassroots of our sport, because if I had a 10-year-old boy, I don't know that I'd be real inclined to encourage him to go play football, in light of what we are learning from head injury," Aikman told Bryant Gumbel on HBO's Real Sports earlier this month.
In the middle are those who believe that youth in younger grades - primarily between the fourth and eighth grades - can play but that hits need to be minimized in some fashion. That might include such things as contact-free practices, contact-free games, and even hit counts.
An enormous problem
While there is disagreement about what causes concussions and consequently how to deal with them, there's no controversy about the underlying problem. That concussions and head trauma have become a huge problem needing attention is a consensus.
Consider that, in the United States, about 3.8 million sports and recreation-related concussions occur each year. They happen to women as well as to men, they happen to young athletes as well as to older ones, and they take place in younger leagues as well as at higher levels of play.
It's not just anecdotal evidence, either. A 2010 study published in Pediatrics found that young people between the ages of eight and 19 went to emergency rooms 502,000 times for concussion treatment between 2001 and 2005. Almost half of them were sports-related, and 40 percent of those involved children between the ages of eight and 13. Fifty-eight percent of concussions in the eight- to 13-year-old group were sports-related, the study stated, while approximately 25 percent of all sports-related concussion visits to the ER among eight- to 13-year-olds occurred because of organized team sports.
And there was this startling fact, undercutting those who say an increase in concussions is simply due to better diagnosis and reporting: Between 1997 and 2007, concussions involving organized team sports doubled among eight- to 13-year-olds and rose by more than 200 percent among 14- to 19-year-olds, even though participation in team-related sports declined slightly overall.
All this has prompted a spate of new research, mostly involving neuroimaging and studying changes in brain activity. The results of that research have catalyzed new approaches to the issue and raised questions not only about the way concussions are handled but about the very nature of head injuries and their long-term consequences.
As that dialogue develops, the top priority, as it has been, is to develop ever better ways to recognize concussions and manage a player's return to active involvement. That has been particularly important in youth leagues because young, developing brains respond differently than older brains to traumatic injury.
Indeed, a study published this year in PM&R, the official scientific journal of the American Academy of Physical Medicine and Rehabilitation, underscored the need to continue improving the tools needed for recognition of concussions as well as for proper recovery - not to mention the challenge of determining readiness to return to play - because of the potential consequences of mismanagement and of subsequent injury.
"Evidence exists that children and adolescents take longer to recover than adults after a concussion, which underscores the need for a more conservative approach to management and return to physical and cognitive activities," the study, "Pediatric Sports-related Concussion," stated. "Concussion in the young athlete is of specific concern because of the continuing cognitive maturation, therefore, the recovery may be more difficult to track when using the standard assessment tools currently available. Until future studies can better delineate the mechanisms of, response to, and recovery from concussion in the young athlete, it is prudent to act in a conservative manner when dealing with pediatric athletes with concussion."
Concussion management today
That's where physicians such as Dr. Bill Melms of the Marshfield Clinic-Minocqua Center come into the picture.
Melms practices in the center's urgent care department, but is also in charge of coordinating concussion management for Lakeland Union High School and Northland Pines through Marshfield Clinic's sports medicine department, and he has recently become LUHS's medical advisor.
Melms and his medical counterparts are the crucial front-line troops in concussion management because they are the ones evaluating the players and helping make determinations about when they must leave the field and when they can return.
These days, Melms says, concussion management starts with a 2009 document, the Zurich Consensus Statement on Concussion in Sport, produced from the Third International Conference on Concussion in Sport, which itself followed a series of international symposia on the topic.
"The current approach is really based on consensus which is based on data from studies," Melms said. "The new approaches that are being looked at have to do with things like neuroimaging, specifically dynamic MRI scanning, and what that can tell us about the brain. So we look at concussions not just from the standpoint of symptoms but from the standpoint of how the brain functions after a concussion. Those are kind of the new realms of concussion research."
In its most basic formulation, the Zurich protocol is based on answering a seemingly simple question: Has a player suffered a concussion? If so, that player does not return immediately to the field, and the concussion is managed until the player can safely return.
"Our current approach is that if you have what is termed a bellringer hit you are absolutely not going to return that day," Melms said. "That's part of our guidelines and part of most people's guidelines and in fact will be part of the law when the (state) Senate passes (proposed) legislation, possibly next week."
It's not as simple as all that, of course, as the Zurich consensus statement points out. Though the document defines in rather specific terms what a concussion is - "concussion may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an 'impulsive' force transmitted to the head" and typically results in "a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course" - determining whether a player has suffered a concussion, as well as decisions relating to the management of it, has its subjective and individualized elements.
"While agreement exists pertaining to principal messages conveyed within this document, the authors acknowledge that the science of concussion is evolving and therefore management and return to play decisions remain in the realm of clinical judgement on an individualised basis," the document states.
The Zurich consensus includes a Sports Concussion Assessment Tool to help guide evaluations.
"The panel agreed that the diagnosis of acute concussion usually involves the assessment of a range of domains including clinical symptoms, physical signs, behaviour, balance, sleep and cognition," the document states. "Furthermore, a detailed concussion history is an important part of the evaluation both in the injured athlete and when conducting a pre-participation examination."
Some of the clinical symptoms include a feeling of being in "a fog," drowsiness, irritability, headache, amnesia, and slower reaction times.
Gradual return to play
Once a concussion is diagnosed, concussion managers then prepare a protocol for returning to play, and the Zurich consensus operates on a defined set of principles, in addition to the core rule that, except in rare cases, a player does not return to play on the same day a concussion is incurred.
"The cornerstone of concussion management is physical and cognitive rest until symptoms resolve and then a graded programme of exertion prior to medical clearance and return to play," the Zurich consensus states. "The recovery and outcome of this injury may be modified by a number of factors that may require more sophisticated management strategies."
Practically speaking, with some possible modifying factors such as loss of consciousness, amnesia and depression, the Zurich protocol follows a calibrated and progressive return-to-play-strategy.
"When we evaluate someone for a concussion, we must determine that they are ready to return to their sport," Melms said. "We look at a couple of different things. Number one, they have to be symptom free. Number two, they have to return to base line in the neurocognitive testing. Anybody who is in an impact-prone sport in our high school has a baseline neurocognitive test and we keep that on file and if they get concussed we do repeated followup tests until they return to baseline."
In general, according to the Zurich consensus, a concussion is a short-term event.
"The panel however unanimously retained the concept that the majority (80-90%) of concussions resolve in a short (7-10 day) period, although the recovery time frame may be longer in children and adolescents," the document states.
On the other hand, Melms says, there are fewer concussions to deal with at the younger levels.
"If you go to college down to high school down to middle school down to grade school, what we can see is that, as we go down, the total number of concussions per player per year goes down," he said. "There are more concussions in college, by far, than there are in middle school and grade school. What also changes during that time is the duration of time for those concussion symptoms to resolve, for that individual to heal."
While the healing time might be seven to 10 days in high school, it's more in the 14- to 21-day range for a 12 year old, Melms said.
"So kids get concussed less frequently but their concussions take more time to heal and the theory on thinking that is the developing brain requires longer to heal," he said.
In any event, the majority of scientists in the field believe that, once healed, there are no lasting effects in most cases. To make that point, Melms points to research conducted at the University of Pittsburgh Medical Center Sports Medicine Concussion Program, which is the largest ongoing clinical and research program focusing on the diagnosis, evaluation and management of sports-related concussion in athletes.
"One of the most prevalent theories and thoughts about concussion and this is the thinking and mantra out of the University of Pittsburgh, where there is a huge center for concussion management, and that is, if you recover fully, meaning you are completely asymptomatic, you have demonstrated normal neurocognitive testing, you've returned to play and continue to be asymptomatic, then, basically, the clock resets at zero as far as your brain goes. You're fine at that point, you may participate and you may or may not get another concussion."
Beyond Zurich, beyond Pittsburgh
Still, as mentioned earlier, a number of neuroscientists don't believe that's the case at all. They offer up a decidedly different take, and that involves the accumulation of "hits" over time.
While a single blow might cause a concussion, to be sure, scientists such as Cantu, a major consultant to the NFL on concussions, and others say new studies show nonsymptom-causing repetitive impacts take a toll over time, making concussions more likely and exposing players to long-term degenerative brain conditions such as Chronic Traumatic Encephalopathy.
The Zurich protocol itself points to the need for more research in brain trauma and acknowledges the new research, though it does not yet embrace it.
"The consensus panellists recognise that research is needed across a range of areas in order to answer some critical research questions," the document states, including but not limited to pediatric injury and management paradigms and long-term outcomes.
The document also gives a nod toward chronic traumatic brain injury caused by repetitive concussions over time.
"Epidemiological studies have suggested an association between repeated sports concussions during a career and late life cognitive impairment," the document states. "Similarly, case reports have noted anecdotal cases where neuropathological evidence of chronic traumatic encephalopathy was observed in retired football players."
The Zurich scientists reached no consensus on that research but said doctors needed to be "mindful of the potential for longterm problems in the management of all athletes."
For his part, Melms says the research on repetitive hits is simply too nascent to be useful right now, though he says new evidence could change thinking in the field 180 degrees. But, he said, that time has not yet come.
"We truly just don't know enough about how safe or unsafe these sports are just yet," Melms said. "As clinicians you get bombarded with all this data from different directions from different areas. I've taken a tremendous interest in concussions in the last year and a half. You tend to trend toward a particular camp of thinking. If there are conflicting types of thinking, you listen to everything that comes in, but when there are conflicts you tend toward how you feel things work out best. and right now my line of thinking is, based on the Zurich consensus, based on the thinking that is going on at the University of Pittsburgh, our job is to identify concussions and to protect that kid until they are symptom free and we know functionally, based on neurocognitive objective testing, that they are back to normal, and then in a careful, coordinated way put them back into sports. That's my line of thinking and that's our line of thinking in our concussion management program."
And his message to parents and the community?
"My advice generally is that we need to take concussions seriously," Melms said. "They're not just bellringers anymore. They are serious injuries. When in doubt you take your kid to your health care provider. I think you listen to the advice of your health-care provider and the athletic trainer at the school."
Next: A closer look at new research suggesting that nonconcussive repetitive hits lead to concussions and long-term brain degenerative conditions, and what that might mean for football and other high-impact sports, particularly for young people.
Richard Moore may be reached at firstname.lastname@example.org
Posted: Monday, February 27, 2012
Article comment by:
My State Representative Joan Ballweg sent me this article as she thought I would be interested in reading it.
I have a 13 year old son who received a concussion back in September of 2011 during a football game. What I hoped to be a quick recovery and a short "time off" of football turned into six months and counting of therapy and numerous doctor visits. My son has been diagnosed with Post Concussion Syndrome, PTSD, ADD, Anxiety, and depression. He never did finish his football season and it is likely he will never play football again. On top of that he can only attend 1/2 days of school due to the continued headaches he gets on an almost daily basis.
The doctors are not sure if this was my son's first concussion or one of many as he has been playing football for four years and at his level the knowledge of concussion is lacking. There also is no IMPACT testing done at the middle school level, so needless to say we had no baseline to go off of.
As a mother I can not tell you the stress this has caused on our family. I have a son who loves the sport of football and now may be watching on the sidelines.
Continued education on concussions is a must for schools and coaches. My son's case may be an extreme case but this is exactly the reason more needs to be done to educate, not only for prevention but also on the recovery of concussions.