These days it's hard to find a neuroscientist who believes everything in the world of high-impact sports for young people is going well.
There's too many concussions, and the numbers are growing, for one thing. There's almost universal consensus on that. Then, too, emerging studies suggest nonconcussive hits may be as damaging as concussive impacts because their accumulation might trigger concussions down the road. Even some who don't embrace that theory acknowledge the "impressive" numbers of hits football players take to the head and voice concern about emerging evidence that chronic traumatic encephalopathy (CTE) is linked to repetitive brain trauma.
The march and pace of the research is as dizzying these days as a bellringing helmet-to-helmet clash. And there's a equally dizzying number of suggestions about how to deal with concussions.
There's the mainstream approach, for one: manage the concussion until the player is symptom-free, and until they have returned to an initial base line in neurocognitive testing (testing prior to playing).
That's increasingly a minority sentiment, however. Others embrace that protocol but believe coaches and players need to be retrained about how to play the game and condition young players. Different kinds of hits and training would minimize damaging impacts, they believe.
Still others go further, and advocate minimizing hits absolutely, using a variety of methods; some propose a "hit-count" similar to "pitch counts' used in youth baseball leagues.
Still others would ban the contact version of such sports as football altogether until at least the age of 14.
Keeping age groups together
As the evidence mounts, and the debate about the findings grows, there is underlying agreement on some practices.
For example, the idea that injuries increase because of weight differences - i.e., lighter players are more likely to be injured - has been scientifically dismissed. Instead, the prevailing view is that age differences are more likely to lead to injuries for younger players.
Specifically, a 1997 Mayo Clinic study found that age groupings and not weight groupings were the best predictor of injuries and safety in youth football. The Mayo Clinic studied a large youth football league of 915 players ages nine to 13 in grades four through eight. All of the teams were grouped by grade; weight categories were not used.
While the study minimized the risk of participating in youth football programs - "youth football injuries are uncommon" and "most injuries are mild," the study included - it nonetheless found a rising injury risk factor with age. The risk of injury for an eighth grader was four times the risk of injury for a fourth grader, the researchers determined - the higher the age, the higher the chance of injury.
"Risk increases with level of play (grade in school) and player age," the study stated. "Potential contributing factors include increased size, strength, speed, and aggressiveness. Analysis of body weight indicated that lighter players were not at increased risk for injury, and in fact heavier players had a slightly higher prevalence of injury."
Many interpret those findings to mean that young football players remain in their own age categories and not be moved to higher or lower age groups. For example, Dr. Bill Melms of the Marshfield Clinic-Minocqua Center, who is in charge of concussion management at Lakeland Union High School and Northland Pines, said his own experience as a coach reinforced the Mayo Clinic's findings.
"The Mayo Clinic study reminded me of when I coached Pop Warner," Melms said. "There were no injuries, and these kids played both ways and there were no injuries. I think I dealt with one dislocated finger in three years."
Still, Melms said, shuffling young players between age groups is not normally a good idea given the study's findings.
"I think to say that we shouldn't be moving kids from a seventh-grade to an eighth-grade team is probably a good general rule, from the standpoint of what was postulated in the results of the Mayo Clinic study," he said. "I think that's reasonable because mixing maturities of kids could potentially lead to problems."
The Mayo Clinic study analyzed all injuries in the league it studied, not just concussions, and Melms thought it interesting that the rate of compared to other injuries was so low.
"What I found in this study that I thought was interesting was that it was 915 players that they evaluated over the course of the year, . . . ., but in looking at the injuries that were seen during this study there were 55 injuries, I believe," Melms said. "Thirty-three of these were bruises, four were fractures. In this study of 915 players over the course of a year there was one concussion, which is phenomenal for a few reasons. That's a mighty low rate of concussions for any league, but it also does underscore that these kids don't tend to get concussed."
Of course, 1997 is an eternity ago when it comes to concussion research, as well as to the definition of a concussion itself, and so what might be deemed a concussion today might not have been in 1997. Even so, Melms said the Mayo Clinic study retained its relevance because it showed that speed and age are critical factors in injury risk.
"When you get to be eighth grade, maybe ninth grade, you're right about the theory being speed and age because age correlates with strength as they mature," he said. "It's not so much size. It's not body mass index. It is speed and strength. Force equals mass times acceleration, and so if you have a faster impact you are going to generate a whole lot more force."
As for the lack of concussions, Melms said "different standards in measuring concussions make it hard to analyze the data regarding concussions, but the study does point to more injuries with speed."
Don't ignore concussion research
Evidence since 1997 reveals many more concussions, of course, whether that is due to recognizing concussions today that were dismissed then, or whether they are increasing absolutely, and that has generated a lot of debate about the future of youth football.
Dr. Ken Reed, the United States Sports Academy sports policy director, took up the cause last September in Sports Digest, pointing to the growing body of evidence that subconcussive impacts cause damage over time and warning that, as the title of his article put it, "Concussion research can't be ignored."
"It's not just full-blown concussions that are a cause for concern," Reed wrote. "Perhaps the most important recent finding in the area of concussion research is that repetitive small hits to the head can cause as much damage as big blows."
Reed pointed to the University of North Carolina, which used helmet sensors to track the numbers of hits to the heads of players in the UNC football program taken during a season, including games and practices. Researchers found the average to be around 950 head impacts each season. That was important, Reed said, because it's not just the major blows that are dangerous: "They all count."
Reed cited University of North Carolina medical researcher Kevin Guzkiewicz and his belief that repetitive subconcussive hits were enough to cause cumulative damage to young brain tissue even if they did not cause immediate symptoms.
"There's what we call a dose response," Guzkiewicz was quoted as saying. "After a certain number of hits, the damage starts to show."
Reed said youth sports needed to be the focus when it comes to head trauma, because the still developing brain is more likely to suffer repetitive injury.
For his part, Guzkiewicz himself doesn't advocate minimizing hits. He is a Pop Warner football coach, and three of his four children have played football. Rather, Guzkiewicz focuses on better teaching and training methods. According to the University of North Carolina, Guzkiewicz has no desire to fundamentally change the nature of football or other contact sports.
"His research team, which includes faculty, staff and graduate students from several UNC departments, learned that the location and force of a hit did not necessarily relate to the clinical outcome following concussion," the university said of his work. "More importantly, however, they found that the head impact data can be valuable in changing a player's behavior, by educating them about poor techniques that predispose them to concussive injury."
In an interview this month with NewPublicHealth said his work was shifting toward prevention through teaching better techniques and conditioning.
"More recently we're trying to look at the biomechanics of concussion and the way in which youth athletes often lead with their head inappropriately," Guzkiewicz said. "So they might predispose themselves to a concussion because they're tackling incorrectly or hitting a soccer ball incorrectly or blocking incorrectly. I think we've done a good job of answering questions on what happens after they've had the injury. So now we want to try and focus on prevention."
Guzkiewicz said evidence pointed toward the neck in particular,
"We think a lot of it has to do with neck strength," he said in the interview. "We're beginning to look at prevention methods that might allow us to strengthen that neck muscular, to try to teach kids how to prepare to take a hit if they get one because we know that to take an ill-prepared hit, where they can't brace the head and tense the neck muscles, that the forces to the brain are worse than they are if they're prepared for it."
And all of that, he said, has to be taught at a young age and that means retraining coaches, both professional and volunteer, on how best to train a child to maximize performance while also preventing injury.
A hit count?
Dr. Robert Cantu, a clinical professor in the Department of Neurosurgery and co-director of the Center for the Study of Traumatic Encephalopathy at the Boston University School of Medicine, would go further. Cantu is also a senior advisor to the NFL's Head, Neck and Spine Committee and co-director of the Neurologic Sports Injury Center at Brigham and Women's Hospital and director of sports medicine at Emerson Hospital in Concord, Massachusetts.
Put simply, Cantu believes the growing evidence of damage caused by repetitive hits - the dose response, as Guzkiewicz said it - calls for more dramatic measures, including minimizing head impacts.
"We believe that the fastest and most effective path to safer youth sports is to regulate the amount of brain trauma that a child is allowed to incur in a season and a year," Cantu and Chris Nowinski wrote in a Sports Legacy Institute white paper in February. "Like youth baseball has widely adopted a 'Pitch Count' to protect the ulnar collateral ligament of the elbow from wear and tear, we urgently call for the development and adoption of a Hit Count to limit the frequency of repetitive brain trauma."
Theoretically, they wrote, a lower hit count would reduce the risk of concussion, risk of brain damage from subconcussive blows, and would theoretically reduce the risk of CTE, a degenerative brain disease linked to repetitive brain trauma.
Indeed, Cantu states, minimizing impacts among younger players is important in the long term because the young brain is more vulnerable to trauma than the mature brain and because brain trauma victims are infinitely more likely to develop CTE - indeed, he states, no one has ever been diagnosed with CTE who was not exposed to repetitive brain trauma.
More alarming, research is showing MRI changes in the region of the brain associated with CTE even after so-called nonconcussive hits.
Not surprisingly, then, Cantu and Nowinski reject the advice of those experts who believe the research related to the long-term damage of subconcussive repetitive hits is too inconclusive at this stage.
"Some experts have stated that we should not act until we know the incidence and prevalence of CTE to ensure we do not overreact," they wrote. "We believe the true incidence and prevalence of CTE in the population to be irrelevant to this policy decision. What percentage of youth football players with greater than four years of experience, e.g. high school seniors, developing CTE is acceptable in our culture? I challenge anyone to propose a non-zero number."
While a hit count might not be as easy to implement as a pitch count, it can be done, the authors stated.
"A Hit Count is not as simple as a pitch count, where coaches only need a pencil and paper," they wrote. "However, hits to the head can be accurately estimated, and methods can be developed to approximate the brain trauma exposure during games and during practice based on known variables, like position. With these estimations, rule changes and practice guidelines can be provided to ensure few, if any, athletes exceed a proposed limit."
A Hit Count could establish guidelines establishing a minimum threshold to be considered a hit, maximum hits per day, with all counts stratified by age, maximum hits per week, maximum hits per season, and maximum hits per year, they wrote.
"In football, a Hit Count might lead to fewer practices that involve helmets and pads or the limits on the use of high impact drills," Cantu and Nowinski wrote. "In soccer practice, it may mean tracking headers in practice and games. This policy is probably most critical to the youngest athletes, who may be at the greatest risk, and should receive less brain trauma than older athletes."
Cantu and Nowinski said their goal was to have a hit count adopted by major youth sports organizations by 2013, and the next step would be to convene a meeting of experts, sports organizations, thought leaders, and industry to explore the current state of knowledge and the steps that would need to be taken to establish, adopt, and measure a hit count.
To start the conversation, they proposed, no athlete under 18 years old should be exposed to more than 1,000 hits to the head exceeding 10 g-forces in a season, and no more than 2,000 times in a year.
"Many youth athletes already exceed this high threshold, and would not be allowed to finish a season," they concluded. " . . . we are asking youth sports organizations to change the ways games are played and practiced, with the goal of significantly reducing the number of head hits children incur during sports participation."
As Cantu and Nowinski acknowledged, the proposal is being greeted with skepticism among those who embrace concussion management more so than prevention and who think the research is too premature. Put Melms in that camp.
"I don't know why Dr. Cantu is pushing that to the degree he is," Melms said. "I'm sure he's basing it on his research. I really think that over the next few years a lot of these questions will be answered. And I don't know where this is going, if we're going to talk about pitch counts versus hit counts."
Melms says a pitch count makes more sense to him because it seems reasonable that if a person is 15 years old and throwing a curve ball, the elbow is going to take a beating, and much more so with 100 pitches than with one.
"Maybe the same thing goes for concussions," he said. "I'm not sure how you implement it, and I'm not sure just what science it is based on yet. The hit count thing seems to be pretty theoretical at this point. If we get to the point where we have good science about a hit count and starting at hit number 1, and then the second hit sort of doubles your risk for CTE, and then the third hit adds a little bit more, then what we're going to be looking at is probably banning the sport, I would think. At some point, if we have such tremendously good data that kids should not get hit on the head - because it is not going to be some bright line where it's, say, 500 hits in a season and at the 501st, now they have a risk for CTE and at 499 they don't. It's going to be some gradual slope. So at what point on that slope is an acceptable risk? No one is going to be able to answer that question so I'm not sure how we're going to be able to come up with an absolute count."
Melms was going in exactly Cantu's direction when he mentioned banning the sport, or at least the contact version of it. In other venues, that's exactly what Cantu has proposed for players younger than 14.
"We're going to be recommending that nobody under the age of 14 be involved in collision sports," Cantu told a Boston television station last September. "The young brains are more vulnerable, they're less myelinated, the necks are weaker, the heads are bigger proportionately so the forces that accelerate the brain need not be as high to produce higher accelerations."
That means concussions can happen even with minor hits and cause more damage than the same injury to an older player, and equipment does not offer adequate protection, he said in the interview.
"If one is ultimately going to be superior in a sport, it's their genes that are going to determine that, plus their work ethic," he said. "It's not going to be that they started the sport earlier."
To be absolutely accurate, Cantu emphasizes that he is not calling for a complete ban.
"I'm not asking for the sport to be banned," he told newsy.com. "I'm asking that the head contact part of the sports be banned so the rules need to be changed. I think below the age of 14, it's just too dangerous to allow our youth to be banging heads."
Next: Other sports look at curtailing head impacts, and even NASCAR recognizes the danger.
Richard Moore may be reached at firstname.lastname@example.org