Scientific Advisory Services, Ltd.
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SportingKid Magazine
Fall 2007


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An estimated 135,000 youngsters between the ages of 5-18 visit hospital emergency rooms each year due to concussions - and that's just the tip of the iceberg. Countless others suffer concussions that aren't recognized by volunteer coaches and parents and continue playing, opening the door to even more serious problems.
By Greg Bach

Millions of young athletes participating in organized sports programs across the country skin their knees, sprain their ankles and strain their muscles, while thousands of others suffer much more serious concussions, many of which - alarmingly - go unidentified by volunteer coaches and parents. As youngsters nationwide fasten on football helmets and strap on soccer shin guards - to step on fields for two of fall's most popular and contact-laden youth sports - the alarm on concussions is being sounded by not only medical experts but everyone from researchers to professionals in the sports industry.

"The 10- to 18-year-old range is really that window when a child's brain is most vulnerable to injury," says Dr. Kevin Guskiewicz, a certified athletic trainer and professor and director of the Sports Medicine Research Laboratory at the University of North Carolina.

While the high-speed collisions in the NFL - the ones that raise fans out of their seats in excitement on Sunday afternoons - are well documented for the concussions they produce and the careers they chop short, young heads bumping together on community soccer fields or smashing into one another on local football fields are beginning to draw much more attention, too. While the bodies aren't as big and the force of the impacts aren't nearly as great as what is seen in the professional and collegiate ranks, jostling a child's still-developing brain is still major cause for concern.

"Parents and coaches need to be aware that children are at risk," says Dr. Julie Gilchrist, a medical epidemiologist with the Centers for Disease Control and Prevention' (CDC) Injury Center. "You can't tell kids to shake it off, to play through the pain or that they'll be fine. Those mantras we heard growing up are not appropriate. Concussions need to be taken seriously and parents and coaches need to know what to do."

The numbers are startling: The CDC estimates that approximately 135,000 youngsters between the ages of 5-18 visit hospital emergency rooms for brain injuries every year.

"It seems like a lot, but this is only the tip of the iceberg," Gilchrist says. "What's more concerning is that there are many children who don't receive any type of medical care anywhere. They may have a headache for a few days but they don't know they have suffered a concussion."

Gilchrist was one of the lead authors on the study analyzing head injuries in sports and recreational activities from 2001 to 2005. The results were published last month in the CDC's Morbidity and Mortality Weekly Report. The study also reported that 5 percent of all sports-related injuries for youngsters in the 5 to 18 age bracket that require emergency room visits involve the brain.

The American College of Sports Medicine reports that approximately 85 percent of all concussions are never diagnosed, and according to the Ontario Brain Injury Association, approximately one third of all children will have suffered a concussion by the time they finish high school. Furthermore, once a child suffers a concussion he is four to six times more likely to sustain another one.

"The real number of concussions that occur may not have increased much in the past 10 years, it's just that we're learning how to recognize many of the ones that were missed in the past," says Dennis Piper, second vice-chair of the Headgear Subcommittee for the American Society for Testing and Materials, an international standards development organization.

PLAYING THROUGH THE PAIN

A child doesn't have to be knocked out to suffer a concussion, and the vast majority of concussions do not include a loss of consciousness. Therein lies a big part of the problem, as kids scramble to their feet to get ready for the next play when they should be escorted to the sidelines and observed for the remainder of the game.

The most typical concussion symptoms include a feeling of having been dinged, amnesia about the injury event, nausea, headache, dizziness and sensitivity to light or sound.

"These symptoms occur surprisingly often in youth sports, but most players play through the injuries because they've been taught to be strong and resist pain," Piper says.

That is particularly true in sports like football and hockey, where coaches preach toughness and bouncing back up after taking, or delivering, a hit.

"Football is a very macho sport," says Dr. Barry Boden, of the Orthopaedic Center in Rockville, Mary. "Athletes are taught to play through pain. But concussions need to be taken seriously. The single most important piece of advice that I can give is to never let an athlete play football if he has any neurological symptoms (amnesia, dizziness, headache, irritability and personality change) whatsoever."

The American Academy of Neurology classifies concussions into three different types. Grade one is the most common, and accounts for approximately 90 percent of all concussions suffered. The athlete is only momentarily confused and does not lose consciousness, though he may have difficulty remembering the event for up to 30 minutes after the injury.

"Kids are more apt to experience dizziness, nausea and sensitivity to light," says Guskiewicz. "These are the red flags. When an adult takes a blow to the head and isn't thinking clearly it's more easily identified because they can communicate back that they're having concentration problems. With kids it's a little more challenging to determine if the youngster is just being silly or if he's really injured."

Grade one concussions, oftentimes referred to as "dings," pose all sorts of potential problems for youngsters, primarily because they're difficult for coaches and parents to recognize. Consequently, many kids - without them or their coaches being aware that a concussion has been suffered - continue right on playing.

"When a child breaks his arm he knows it's broke and he knows when it's healed," says Dave Rossi, the chief marketing officer for Schutt Sports. "It's not as easy to detect with a brain injury. If the child is not fully recovered, and his brain's chemical function is not back to normal and he sustains a second injury, then that is where the risk goes up dramatically."

Known as Second Impact Syndrome (SIS), youngsters suffer permanent brain damage or die after a head injury occurs while the brain cells are still recovering from a previous head injury. Although rare - approximately four to six youngsters die due to SIS each year - it is devastating. It is believed that it occurs almost exclusively in athletes under 18-years-old.

Grade two concussions are typically associated with a loss of consciousness for less than five minutes, followed by difficulty remembering events lasting anywhere from 15 minutes to 24 hours.

A grade three concussion - the most severe - results in a loss of consciousness for more than five minutes and includes more than 24 hours of post-injury amnesia. Grade two and three concussions are the most easily recognizable, due to the loss of consciousness, and require immediate medical attention.

SAFETY ADVANCEMENTS

In the late '70s Dr. Carl Abraham was busy interviewing former middle school and high school football players who were paraplegics and quadriplegics to determine, in part, the causes of their horrific injuries. After speaking with roughly 20 athletes he became emotionally invested in their heart-breaking stories, which led to him patenting the flexible face-mask that was licensed and manufactured by Riddell in the early '80s.

"The face-mask I invented for use with the football helmet was related to a need to reduce the risk of paralyzing injuries to young children," Abraham says. "The steel face-mask the children were using weighed over a pound, did not absorb and dissipate forces and was much too heavy for young children. As a result, their heads and necks sagged and were prone to flexing extensively during a tackle, resulting in fractures of their spines. By cutting the weight in half and allowing the facemask to absorb and dissipate some of the impact forces, we were able to eliminate the paralyzing injuries that were caused by impact to the facemask during a tackle. Since the players started to use the facemask there have been no reported spinal injuries."

These days Abraham, well-known for his expertise in the area of head injuries and concussions, serves as the technical director for Forcefield, makers of the popular headbands touted to reduce the risk of head injuries and concussions for children participating in soccer.

"I feel that as a parent and grandparent, that we have a responsibility to offer our children as much protection as possible and reduce the risk of foreseeable injuries when they participate in a contact sport," Abraham says. He points to the results of independent tests performed in the United States and Canada that the headbands reduce the risk of head injuries to children and that the impact forces to the head are significantly reduced when a child wears these headbands.

"I commend the people who have the passion for developing these and I hope they stay the course and push their products, because in the end it may make a difference," Guskiewicz says. "But until it's proven to make a difference I'm real cautious about promoting their use to prevent concussions and prevent that second concussion. The jury is still out."

These days, leaders in the sports industry are well aware of the seriousness of the issue when it comes to protecting kids' heads, and are doing their part to continually upgrade the quality of equipment that kids wear.

"We take this issue very seriously," says Thad Ide, vice president of research and product development at Riddell, Inc. "We're in the business of protecting kids. That's what we do. The march toward providing improved protection keeps going on."

UPGRADING THE SIDELINES

Every year millions of dads and moms step forward to volunteer to coach youth sports. Though well-meaning and good-intentioned, many don't know how to teach kids some of the sport's skills, which increases the risk of injury. That's of particular concern in contact sports, where the proper way to tackle in football, head in soccer and check in hockey and lacrosse is crucial to helping youngsters sidestep concussions and other equally serious injuries.

"It's wonderful that parents are jumping out on the field and that they want to be involved in their son or daughter's activity," says Guskiewicz, a father of three young boys involved in a variety of sports. "But probably a lot of them are ill prepared as coaches. I've been studying concussions for 15 years but I never played soccer, so I'd be the last person you'd want teaching a child how to head a soccer ball. We need to be better at developing clinics and putting money into training parents how to coach kids."

He is also a proponent of having more certified athletic trainers at the youth level - at YMCAs, parks and recreation departments, Little League and Pop Warner - to get advanced medical training on the sidelines to better manage injuries.

"The largest number of participants is at the youth level, yet they have the least amount of expertise on the sidelines with knowledge of how to recognize and handle head injuries," says Rossi, whose company will soon release its Schutt Concussion Awareness Program, an initiative aimed at educating volunteer coaches. "Every coach at the youth level should know the signs of recognizing symptoms that a player may have sustained a concussion and then knowing what to do about it."

Studies on concussions abound, and there is enough information on the topic to fill a library. The most recent tragedy - the suicide of former NFL defensive back Andre Waters, who had multiple concussions during his career and later suffered from depression - has further commanded the public's attention. Research on more than 2,500 former NFL players by the University of North Carolina's Center for the Study of Retired Athletes showed that players who had at least three concussions had triple the risk of clinical depression compared with those who had no concussions.

The Florida Institute of Technology has completed two years of an ongoing five-year study it's doing on concussions and heading in youth soccer players ages 9-13. "We have used direct observation of competitive games to gather our data so we are not relying on self reports," says Dr. Frank Webbe, professor of psychology. "We have had only two concussions occur, which is good news for all concerned. We have noted, however, that children report headache and dizziness from heading the ball about 50 percent of the time, which is much greater than reported in studies of adolescents and adults."


"The largest number of participants is at the youth level, yet they have the least amount of expertise on the sidelines with knowledge of how to recognize and handle head injuries."
Dave Rossi, chief marketing officer Schutt Sports

CREATING AWARENESS

The bottom line is that, as millions of children participate in assorted sports this fall, the risk of concussions is ever present. But then again, so are broken limbs and strained muscles, too.

"Parents need to remember that active sports always carry some risk of injury," Webbe says. "This does not mean that parents should withhold their children from contact sports, just that they need to exercise good judgment when it comes to participation. There is no substitute for having qualified coaches in structured leagues that are governed by well-developed rules and guidelines. Parents also should take the time to observe their child's practice sessions, as well as games. Good coaching not only transmits proper technical skill, but also smart playing tactics."

By making sure coaches teach only proper and safe techniques, that appropriate safety equipment is utilized and that adults understand the signs of concussions, the risk to young athletes can be minimized.

"We are a sport-crazed society and that's wonderful," Guskiewicz says. "We teach kids how to kick a soccer ball and throw a football before we teach them how to hold a fork or write their name. I'm a proponent of physical activity, and there comes a responsibility with every one of us in society to do our part."




CDC releases comprehensive Heads Up: Concussion in Youth Sports tool kit

In 2006 the Centers for Disease Control and Prevention (CDC) gathered leading experts to discuss the issue of concussions in youth sports. The result of that meeting is the recently released Heads Up: Concussion in Youth Sportstool kit, which features fact sheets for coaches, parents and athletes, as well as a variety of other materials to help everyone involved in youth sports get a handle on recognizing and responding to these injuries.

The following information is reprinted with permission from CDC. For more information, or to obtain the tool kit, visit www.cdc.gov/ConcussionInYouthSports.

SIGNS OBSERVED BY COACHING STAFF

  • Appears dazed or stunned
  • Is confused about assignment or position
  • Forgets sports plays
  • Is unsure of game, score, or opponent
  • Moves clumsily
  • Answers questions slowly
  • Loses consciousness (even briefly)
  • Shows behavior or personality changes
  • Can't recall events prior to hit or fall
  • Can't recall events after hit or fall
SYMPTOMS REPORTED BY ATHLETE
  • Headache or "pressure" in head
  • Nausea or vomiting
  • Balance problems or dizziness
  • Double or blurry vision
  • Sensitivity to light
  • Sensitivity to noise
  • Feeling sluggish, hazy, foggy, or groggy
  • Concentration or memory problems
  • Confusion
  • Does not "feel right"
WHAT SHOULD A COACH DO WHEN A CONCUSSION IS SUSPECTED?
  1. Remove the athlete from play. Look for the signs and symptoms of a concussion if your athlete has experienced a bump or blow to the head. Athletes who experience signs or symptoms of concussion should not be allowed to return to play. When in doubt, keep the athlete out of play.
  2. Ensure that the athlete is evaluated right away by an appropriate health care professional. Do not try to judge the severity of the injury yourself. Health care professionals have a number of methods that they can use to assess the severity of concussions. As a coach, recording the following information can help health care professionals in assessing the athlete after the injury:
    • Cause of the injury and force of the hit or blow to the head
    • Any loss of consciousness (passed out/knocked out) and if so, for how long
    • Any memory loss immediately following the injury
    • Any seizures immediately following the injury
    • Number of previous concussions (if any)
  3. Inform the athlete's parents or guardians about the possible concussion and give them the fact sheet on concussion. Make sure they know that the athlete should be seen by a health care professional experienced in evaluating for concussion.
  4. Allow the athlete to return to play only with permission from a health care professional with experience in evaluating for concussion. A repeat concussion that occurs before the brain recovers from the first can slow recovery or increase the likelihood of having longterm problems. Prevent common longterm problems and the rare second impact syndrome by delaying the athlete's return to the activity until the player receives appropriate medical evaluation and approval for return to play.