3/2/2012 5:46:00 AM Concussion scrutiny sweeps the world of sports Growing movement pushes for rule changes, legislation and youth bans in multiple sports
Study: Youth football should eliminate high-impact practices
New research finds seven- and eight-year-old players take hits as severe as those in college
By Richard Moore
of The Lakeland Times
A just released paper - and one that is groundbreaking because of its study of football players below high school age levels - shows younger players take high-impact hits that can be as severe as those college football players receive, and the researchers are calling for an end to high-impact practice drills that do not replicate game situations.
What's more, the study's authors conclude, the hardest hits happen most often in practice, not in games, and the way younger players fall when being tackled and the lack of neck muscle strength may increase the susceptibility of younger players to hit their heads on the ground after being tackled.
The study, 'Head Impact Exposure in Youth Football,' was released Feb. 1 by the Center for Injury Biomechanics, Virginia Tech-Wake Forest University.
As the researchers indicated, the study of younger players was long overdue.
"Previous research has investigated head impacts in high school football, college football, and the NFL; however, this population only accounts for 30% of football players," the authors wrote. "To date, no work has been performed investigating head impact exposure in youth football, which accounts for 70% of all football players. Investigating head impact exposure at the youth level would allow researchers to understand when head impacts occur most frequently and which activities cause the most severe impacts."
Less frequent but still severe
The researchers used a version of the HITS (Head Impact Telemetry System), in which sensors are placed in players' helmets that measure the biomechanical head response to every head impact they receive. The youth head impact data was compared to that of high school and college levels of play.
The study measured impact data for seven instrumented players aged seven and eight during the football season. Surprisingly, most high-impact hits occurred during practices, not games.
"A total of 748 impacts were collected from the seven participating players during the season, with an average of 107 impacts per player," the authors wrote. "During games, 307 impacts (41% of total) were collected, while 441 impacts (59% of total) were collected during practices."
The researchers also found the force of some of the impacts to be impressive.
"The average instrumented player experienced at least one impact greater than 10 g in 14.1 sessions, consisting of 4.7 games and 9.4 practices," they wrote. " ... A total of 38 impacts above 40 g were collected, 29 of which occurred during practices. A total of 6 impacts were collected with linear accelerations above 80 g, with all six occurring in practices."
The authors labeled the latter category of hits severe, especially for players so young.
"This level of severity is similar to some of the more severe impacts that college players experience, even though the youth players have less body mass and play at slower speeds," they observed.
The relative high-impact frequency in practice ran counter to findings at higher age levels.
"More notably, impacts of higher magnitude were associated with practices rather than games, where 76% of impacts greater than 40 g and 100% of impacts greater than 80 g occurred during practices," the authors wrote. "This contrasts trends exhibited in high school and college football, where more severe impacts are associated with games."
In addition, impacts to the sides of the helmet were most common, accounting for 36 percent of all impacts, the study stated. The front of the helmet received approximately 31 percent of all impacts, with the top and rear of the helmet affected least.
What it means
The findings make an arguably valuable addition to the body of concussion and head impact research in sports because it focuses for the first time on younger players, and it suggests important differences between younger and older players.
The bottom line finding is, younger players don't hit their heads as much as older players do, but when head impacts occur, it's not all low-impact hitting that goes on.
"Valuable insight to the head impact exposure in youth football has been presented," the researchers wrote. "While youth football players impact their heads less frequently than high school and college players, and have impact distributions more heavily weighted toward low magnitude impacts, high magnitude impacts still occur."
The researchers also observed that the younger players experienced a substantially higher percentage of impacts to the side of the helmet and a substantially lower percentage of impacts to the rear of the helmet than in college or high school.
"This can likely be attributed to the differences in the style of play between the different age groups, as well as the youth players having a tendency to fall to the side while being tackled," the authors wrote. "Furthermore, the helmets that the youth players wear may influence some of these trends. Youth football helmets are very similar in size and mass to adult football helmets. With that said, the neck muscles of 7-8 year olds are undeveloped in comparison to high school and college football players. These two factors may result in a youth player being more susceptible to impacting his head on the ground while being tackled."
Because most high-impact hits occur during practices, the researchers concluded, restructuring youth football practices could be an effective method of reducing the head impact exposure in youth football.
"This can be achieved through teaching proper tackling techniques and minimizing drills that involve full contact; and instead, focusing on practicing fundamental skill sets needed in football at these young ages," they wrote.
Finally, the authors acknowledged the limitations of the study and the need for further research.
"First, it should be noted that a total of seven youth football players were included in this study," they wrote. "This is a small sample size in comparison to some of the studies investigating head impact exposure in high school (95 players) and college (>300 players) football."
In addition, they stated, the instrumented players ranged in age from seven to eight years old, though youth football encompasses players ranging in age from six to 13 years old. A larger sample size of players ranging from six to 13 years old was thus needed to completely define head impact exposure in youth football.
The authors of the study are Ray W. Daniel, Steven Rowson, and Stefan M. Dum. The paper is published in The Annals of Biomedical Engineering.
Richard Moore may be reached at firstname.lastname@example.org
Former Indy racing star Danica Patrick made her official debut in NASCAR stock car racing this week at Daytona, and she was an immediate hit - not only with the crowd but with the wall.
Patrick took a hard hit on the last lap of her qualifying race - "it felt pretty big," she said of the wreck that propelled her car into the wall and then into the air - but walked away and could wisecrack about it later. NASCAR, though, isn't joking about such crashes, and hasn't been since the death of racing icon Dale Earnhardt, Sr., in 2001 because of blunt force trauma to the head.
The racing behemoth has already made a number of changes to minimize head injuries and is taking an even closer look now with the nation's sudden scrutiny of concussions.
For example, NASCAR now requires drivers to wear head and neck support devices, while in the cars foam braces on both sides of the seat keep helmets virtually immobile during a crash. So-called SAFER barriers have been installed on track walls to soak up impacts when cars smash into them at about 200 mph.
The Steel and Foam Energy Reduction, or soft, wall is a matrix of steel tubing behind which is placed crushable foam insulation. The idea is for the wall rather than the car to absorb and apportion the force of the impact along the wall, much as a fall onto a mattress.
And NASCAR might not be done making changes. While the organization says it is confident in its concussion policies - of 29 concussions confirmed since 2004, it says only 11 occurred in the last five years - officials said last week in various media reports they were heeding new research linking repetitive brain injury to chronic traumatic encephalopathy, a long-term degenerative brain disorder, and are closely monitoring changes other sports are making.
"It's something we pay attention to on any aspect of other sports, what they're doing," Steve O'Donnell, NASCAR's senior vice president of racing operations, told CBS News last week. "Can we learn from it? Can we implement some of these things? We're open to working with any other sport as well."
Like a gold rush
NASCAR will have plenty of opportunities to team up, if recent news stories are any indication. Sports officials across the athletic landscape are hustling like miners in a gold rush to fashion rule changes designed to minimize head impacts; in other cases, a wide array of medical researchers and policy experts are trying to pressure some sports to make hard adjustments now rather than be exposed to legal liability later.
In hockey, officials have picked up the pace and push for change in the last year. The New York Times reported Tuesday that both USA Hockey, the national governing body for ice hockey in the United States, and Hockey Canada are contemplating strict rules to stop fighting in nonprofessional leagues. As The Times reported, hockey has long glorified ritualistic fights as an integral part of its sports entertainment package. Now mixing it up is seen as a prelude to paying it out later.
It's not just fighting. The elimination of bodychecking, or using intentional body contact to block an opposing player, among younger players is another recent adaptation, though, as long ago as 2000, the American Academy of Pediatrics called for eliminating the practice for younger players.
"A high proportion of injuries in hockey appear to result from intentional body contact or the practice of checking," the AAP stated in 2000. "The American Academy of Pediatrics recommends limiting checking in hockey players to 15 years of age and younger as a means to reduce injuries."
The high risk of injury was associated with intentional contact at high rates of speed.
"In recent years, an increase in the number of serious head and neck injuries related to body checking has alarmed the hockey community and has led to a reassessment of the role of body checking in the various classifications of youth hockey as soon as next season," the AAP stated.
This past June, 11 years after that recommendation was published, USA Hockey took action as evidence of the long-term risk of head trauma surfaced, and as studies showed the rate of concussions among young hockey players to be much higher than previously thought, about three times higher, in fact. Beginning in the 2011-12 season, it announced, legal bodychecking in games would begin at the Bantam age level (ages 13 and 14). It had been allowed at the younger Peewee level.
"This program has taken several years of research and discussion to formulate," Ron DeGregorio, president of USA Hockey, said. "USA Hockey has the training and support elements in place for our coaches and referees. Parents should know that this program will better prepare their children for the physical part of the game. It should produce less risk since we will be training players in body contact at an earlier age in a progressive manner. We'll also be tightening up the standard of play for intimidation hits in the youth checking divisions."
Soccer is another sport where angst is on the rise, particularly over the practice known as "heading" the ball.
A 2011 study by researchers at Albert Einstein College of Medicine of Yeshiva University and Montefiore Medical Center, the University Hospital and academic medical center for Einstein revealed that repeatedly heading a soccer ball increased the risk for brain injury and cognitive impairment.
The researchers used diffusion tensor imaging (DTI), an advanced MRI-based imaging technique, on 38 amateur soccer players with an average age of 30.8 years, all of whom had played soccer since childhood, according to the study. They were asked to estimate the number of times they headed the ball in the previous year, and, researchers found, frequent headers showed brain injury similar to that seen in concussive patients.
Additional analysis indicated a threshold level of approximately 1,000 to 1,500 heads per year, the study stated. Once players topped that number, the researchers observed significant injury.
In a related study, lead author Dr. Michael Lipton and his colleague Molly Zimmerman, an assistant professor of neurology at Einstein, gave the same 38 players tests designed to assess neuropsychological function, they reported. Players with the highest annual heading frequency performed worse on tests of verbal memory and psychomotor speed compared to the others.
"These two studies present compelling evidence that brain injury and cognitive impairment can result from heading a soccer ball with high frequency," Lipton said. " ... Heading a soccer ball is not an impact of a magnitude that will lacerate nerve fibers in the brain, but repetitive heading may set off a cascade of responses that can lead to degeneration of brain cells."
The findings were especially troublesome given soccer's reputation as the world's most popular sport, and its continued growth among young people, the researchers said. Of the 18 million Americans who play soccer, 78 percent are under the age of 18.
"While heading a ball 1,000 or 1,500 times a year may seem high to those who don't participate in the sport, it only amounts to a few times a day for a regular player," Lipton said.
The findings aside, heading is an essential aspect of soccer and is unlikely to be eliminated from practice or play, the researchers acknowledged. They hoped the evidence could help shape guidelines for heading frequency, however.
Because a safe range for heading frequency appeared to exist, they suggested, as additional research helps refine that number, the frequency of potentially harmful actions in practice and games could be monitored and regulated based on confirmed unsafe exposure thresholds.
"These are findings that should be taken into consideration in planning future research to develop approaches to protect soccer players," Lipton said.
An ethical sucker punch?
Beyond soccer, there's boxing, obviously, and, when it comes to concussions, there's a real fight going on, with both sides landing punches.
In one corner is the American Academy of Pediatrics and the Canadian Paediatric Society, which want the sport banned for children and adolescents. About 18,000 young people aged 18 or younger in the United States are estimated to participate in the sport.
"Although boxing provides beneﬁts for participants, including exercise, self-discipline, and self-conﬁdence, the sport of boxing encourages and rewards deliberate blows to the head and face," their policy statement asserted last year. "Participants in boxing are at risk of head, face, and neck injuries, including chronic and even fatal neurologic injuries," they reported. "Because of the risk of head and facial injuries, the American Academy of Pediatrics and the Canadian Paediatric Society oppose boxing as a sport for children and adolescents. These organizations recommend that physicians vigorously oppose boxing in youth and encourage patients to participate in alternative sports in which intentional head blows are not central to the sport."
Some surprising experts demur. In the other corner is 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. Cantu is a vocal proponent of hit counts in football and of prohibiting collision sports for youth under the age of 14 (or changing the rules to avoid head impacts).
But Cantu is also a spokesman for USA Boxing's Medical Commission, and he thinks the medical community should work toward improving safety in boxing because of its unique socioeconomic context.
"I think it's a well-intended statement (the AAP and CPS statement on banning boxing for children), but I don't think that it takes into consideration the realities of who mostly gets involved with boxing," Cantu told Serena Gordon of HealthDay last year. "These are people that don't have, for the most part, your local golf course, tennis or basketball court as an option. These are youngsters, often from deprived backgrounds, that flourish with direction and flourish with having individuals take an interest in them. They are far, far safer in the boxing ring than they are out on the street. I'm not advocating boxing for anybody and I'm not advocating anybody take head trauma from any sport. Everything in life is risk and reward. The reality is, it's far safer for these individuals to be in the ring at all levels of their life than it is to be out where they come from."
Could, then, the rules of boxing be revamped to protect younger athletes who continue to participate, and would that be ethically acceptable to sports physicians who abhor the sport as it is?
The latter proposition would smack of an ethical sucker punch to some. Dr. Suzanne Leclerc of the McGill Sport Medicine Clinic and Christopher D. Herrera of McGill University addressed the question in an article, "Sport medicine and the ethics of boxing."
"The obvious and more practical solution would be along the lines of rule changes that may penalize punches to the head," they wrote. "This would no doubt reduce some health risks. The rule changes would at the same time create a substantially different sport and leave open the question of whether the new boxing would be an athletic activity that sport physicians should welcome as 'reformed.' Would it be ethically improved, for example, if some other body part were the target area for scoring in boxing?"
To Leclerc and Herrera, athletes, sports physicians and society itself should reevaluate the idea that sports should involve people "battering each other" until one can no longer go on or the body is damaged.
In the end, at least in the United States, the dialogue about concussions and sports always wends its way back to football, and no entity has been more assertive on the issue in recent years than the National Football League, which has been furiously revising rules to protect athletes from injury and the league from lawsuits.
Consider it a NFL Hail Mary, and it's too early to tell whether its pass will be completed, not least because litigation is already underway en masse. At least four lawsuits blaming the NFL for concussion-related brain disease will be consolidated in Philadelphia, the Associated Press reported this week.
The players allege NFL negligence and intentional misconduct in responding to their various symptoms, diseases, and disorders, including dementia, the AP stated. One former player has even been diagnosed with chronic traumatic encephalopathy, the only living player to have been so diagnosed. In total, the lawsuits represent more than 300 retired players or spouses, the AP reported, with as many as a dozen similar cases filed in New York, New Jersey, Georgia, Florida and Philadelphia.
While the NFL is not conceding negligence or misconduct, it has been aggressively revising rules since 2009 to give players and referees added protection. In 2010, for instance, the league added six new tough safety provisions.
First, as explained on the NFL website, during a field-goal attempt, punt, or try-kick, a defensive team player who is within one yard of the line of scrimmage at snap must have his entire body outside the snapper's shoulder pads. Second, after a half has expired, dead ball personal fouls by either team are enforced on the succeeding kickoff.
Third, a player who has just completed a catch is protected from blows to the head or neck by an opponent who launches himself off the ground, while, fourth, all "defenseless players" are protected from blows to the head delivered by an opponent's helmet, forearm, or shoulder.
Fifth, kickers and punters during the kick and return, and quarterbacks after a change of possession, are protected from blows to the head delivered by an opponent's helmet, forearm, or shoulder, instead of just helmet-to-helmet contact.
Finally, the ball is declared dead at the spot if a runner's helmet comes completely off.
In 2011, the league expanded the list of "defenseless players" to include a kicker/punter during the kick or during the return, a quarterback at any time after a change of possession, and a player who receives a 'blindside' block when the blocker is moving toward his own endline and approaches the opponent from behind or from the side. In addition, the website continues, a receiver who has completed a catch is a "defenseless player" until he has had time to protect himself or has clearly become a runner.
Perhaps the biggest adjustment this past season was the shift of kickoffs from the 30-yard line to the 35-yard line in an explicit effort to increase touchback frequency. The NFL says concussions dropped 12.5 percent this past year, while data for the 2011 and 2010 seasons shows less than one reported concussion a game.
NFL commissioner Roger Goodell says the league has not seen the end of the rule changes, even though they are not wildly popular among many players. Goodell said recently the league would even consider abandoning the traditional three-point stance that allows player to get a swift and aggressive start once the ball is snapped.
Speaking of Goodell, the commissioner is an ardent supporter of state legislation to compel changes in the way the game is played at younger levels, especially in the area of concussion management.
In particular, Goodell wants all 50 states to pass a measure called the Zackery Lysted law, requiring the removal of a young athlete from play or practice who appears to have suffered a concussion at the time of the suspected concussion, and requiring the athlete to be cleared by a licensed health care professional trained in the evaluation and management of concussions before returning to play or practice.
As of February, 31 states plus the District of Columbia and the city of Chicago had adopted youth concussion laws.
In Wisconsin, the state Assembly passed such a bill last November. However, a companion Senate version authored by Sen. Alberta Darling (R-River Hills) has been stalled for months as of this writing.
In mid-February, opponents circulated a draft amendment that would have removed the state-mandated education and information protocols in Darling's bill and would instead require school districts to create their own concussion and head injury policies to educate coaches, players and parents.
The amendment would have deleted any requirements for club sports such as Pop Warner, as well as language in Darling's bill obligating coaches to immediately remove players who suffer a head injury from the activity.
While that amendment has so far never officially surfaced, last week state Sen. Pam Galloway (R-Wausau) said she planned to introduce a compromise amendment that would provide for more local control.
Galloway's amendment would still direct DPI to form concussion guidelines and education information, but local school districts could either adopt the DPI brand or create their own program, she said.
"To reiterate my earlier comments on this issue, I am supportive of school districts implementing a concussion plan to suit the needs of their communities," she said. "As a physician, I myself have treated a number of head injuries, and I am well aware of the damage that they cause. In both my capacity as a legislator and a medical professional, I believe strongly in evaluating this legislation from a balanced perspective."
Galloway said she did not believe anything was wrong with the Darling bill's intent but she believed modifications were necessary.
"I will continue working with the author of this bill to find a solution that is not a one-size-fits-all approach, but instead can fit the needs of the coaches, parents and student athletes in communities that may have limited resources," she said. "That also being said, there is nothing preventing a school board or school district from implementing a plan now that deals with concussions on their own volition."
Richard Moore may be reached at email@example.com