Concussion Frequency and Dangerous Repercussions Rising in Youth Sports

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( — May 13, 2016) — Americans pour billions of dollars into sports and their related enterprises, affecting the economy, family habits, school life, and clothing styles. People from all classes, races, and ages participate in sports activities.

It is challenging to know what the first types of sports ever played might have been, and when they took place. Competitions involving hitting, kicking, throwing a ball-like object, along with hunting, would be expected to have taken place in practically all ancient civilizations.

Although historians believe methodized games were held much earlier than what has been documented, the first recorded Olympic game took place in Greece about 776 BC.  The first events were equestrian (introducing chariot racing) and pentathlon competitions.  Jumping, wrestling, javelin and discus (disc throwing) were later added. 

Thriving for about 1200 years before being banned by Roman Emperor Theodosius, who accused the event of having pagan origins, it was revived centuries later. Following a speech given by Frenchman Pierre de Coubertin in 1894, which led to a meeting attended by 79 delegates from nine different countries, the delegates unanimously voted for hosting Olympic tournaments.

According to historians Elliott Gorn and Warren Goldstein, the Civil War “engendered an ethos of sacrifice, of dedication to the heroic cause” in male soldiers who played a variety of organized sports on teams within military units. After the war’s end, educational institutions began to emphasize the importance of athletics.

Football was one of the most popular of these new collegiate activities, and it developed rapidly. The first intercollegiate American football game took place on November 6, 1869, when students from Princeton and Rutgers faced-off in an informal match. University football teams continued to grow in numbers after Princeton, Yale, Columbia, and Harvard established the Intercollegiate Football Association in 1876. 

As reported by historian Allen Guttmann, early American folk football and British rugby, appealed to young men hoping to “demonstrate the manly courage that their fathers and older brothers had recently proved on the bloody battlefields of the Civil War.”

Bravery was a prerequisite for players in an era preceding the widespread use of helmets. In 1905 alone, 18 players were killed, and 150 sustained severe wounds, causing some universities to eliminate the sport on their campuses. Football continued to thrive despite its rough nature.

By the late 19th and early 20th centuries, football had emerged with military significance. In 1908, The New York Tribune noted: “football as played in America t0day between school or colleges is not a mere game, but an intercollegiate contest that assumes in the minds of players, coaches, students, graduates, and the affiliated public, the importance of war.”

For many, football itself became training for war. In 1895, Yale’s coach Walter Camp expressed in his Book of College Sports, that players should exhibit the bravery of a soldier entering a difficult battle. Charles Daly, coach of the United States Military Academy in 1921, called football “a war game.”

In his manual American Football: How to Play It, he went on to advocate the application of military exercises to players, arguing, “No soldier ever benefited more by an intensive and carefully planned drill than does the football player.”   

Competitive events for college women increased in the early 1900s. The Women’s Suffrage Movement in the late 19th and early 20th centuries, resulted in the passage of the Nineteenth Amendment in 1920. The right to vote for women renewed emphasis on women’s freedoms.

Still, society’s erstwhile perception and expectation of the woman’s place was ‘in the home.’ This view remained largely unchanged until the events of the 1940s. After millions of men entered the military due to World War II (WWII), women either joined the military service, or left their positions as homemakers to fill employment opportunities not previously available.

The All-American Girls Baseball League was started in 1943 in an attempt to replace the Major League of Baseball. By the end of WWII, organizations for women in sports began to increase, and became more competitive as intercollegiate and interscholastic competition spread.

As the social consciousness of Americans changed in the 1950s and 1960s, along with the passage of the Civil Rights Act of 1964, opportunities expanded with respect to women, and groups and races of people who were routinely subject to inequality in sports, many occupational fields, and societal treatment in general.        

Today in sports, the discipline to do the right thing in the right way every day, builds the habits that players need to be competitive on the practice field, so that they will be automatically available in their designated capacity in the game, with winning value. This expectation is what drives male and female children, adolescents, and professional players.

In addition, young players makes friend, and learn how to be part of a team. However, sports should not rob a child of an opportunity to be a child, and to play freely. They should be inspired to explore sports, or other activities of interest that maybe they will come to love. 

But there are other, very serious dynamics that influence players, especially young athletes.  Sometimes children are encouraged to participate in sports by their parents or coach, even when they are not interested.

If interest is apparent on the part of the young player from the very beginning, once the child, adolescent, or teenager achieves skills that exceed his or her own expectations, and observes and experiences the words and actions of approval and reward from parents and coaches, when injuries such as a concussion occur, the symptoms are sometimes covered up, or downplayed. 

 “There’s a machismo to sports, whether you’re male or female,” said Dustin J. Fink, an athletic trainer who supervises a dozen sports at Mt. Zion High School in Illinois. “It’s most often seen in professional sports, where they are celebrated for being warriors and champions, for doing everything they can to stay on the field and play.”

“That message trickles down to parents and children, said Mr. Fink. My dad would say, ‘Play unless you can’t walk.’ And with some injuries, like broken fingers, you can play through the pain. But once your brain is hurt, it’s hurt. Yet what gets instilled in the child is, ‘You play no matter what.’ ”

As an athletic trainer at other junior high and high schools, “I’ve seen coaches who tried to be the decision-maker with injuries,” Mr. Fink said. They need that win, so they will try to override the athletic trainer or manipulate the athlete to get back in the game.” He added that Mt. Zion coaches did not behave in this manner.

Head impacts and concussions caused by contact sports are a quickly growing epidemic among young athletes. When left undetected, concussions can result in long-term brain damage, and may even prove fatal.

A concussion may be caused by a direct blow to the head, face, neck, or elsewhere on the body with an ‘impulsive’ force transmitted to the head. This fast movement can cause the brain to bounce around, or twist in the skull creating chemicals changes in the brain, sometimes stretching and damaging the brain cells, jeopardizing delicate neural pathways, or causing neurological disturbances.

More serious consequences that can arise include persistent post-concussion symptoms, chronic traumatic encephalopathy (CTE), and second-impact syndrome (SIS).

A concussion can: change the way your brain normally works; occur during practices or games in ‘any’ sport; happen even if you have not been knocked out (only 10 per cent of concussions result in unconsciousness); be serious even if you have just been ‘dinged’.  

The Centers for Disease Control and Prevention (CDC) reports show concussions have risen 200 per cent among teens ages 14 to 19 in the last decade.

Robert Cantu, medical physician and chairman for the Department of Surgery, and director of Sports Medicine at Boston University School of Medicine, explains why young children are more vulnerable to brain injury than adults for a given acceleration force.

He points out that children’s brains are largely not myelinated (coating of nerve fibers). This coating or myelination, helps transmission, and also gives the brain strength. It is an insulating layer that is essential for the proper functioning of the nervous system.

Since the extent to which the coating has developed in young children is incomplete, the nerve fibers are more easily torn apart, and lighter in weight. Consequently, it takes less acceleration to put that brain in motion than the brain of an adult.

Another factor is the prefrontal cortex, a part of the brain that does not finish developing until a person’s early 20s. The brain develops in a back to front pattern. The prefrontal cortex is the last portion of the brain to fully develop. It is associated with attention and cognition, as well as emotion.

Dr. Cantu added, the fact that children have smaller and weaker necks in relation to their skulls increases their risk. This can result in 80 or 90 Gs (gravitational force; type of acceleration that causes weight) of force on the brain, even when the speed at which the children collide is very slow. The metabolic cascade of concussion, and the excitotoxic shock issue, is more easily actuated in children than it is in adults.

Dr. Cantu also felt that children in sports often have access to older equipment, and their coaches are generally less experienced.

A 2015 publication by The Journal of Clinical Sports Psychology reported that roughly 33 per cent of all sports concussions happen at practice. The amount by which cumulative concussions (two or more) are shown to increase catastrophic head injury, leading to permanent neurologic disability, is about 39 per cent.

Motivations to not report a suspected concussion before the 2012–2013 athletic season were: (1) did not think it was serious enough—64 per cent; (2) did not want to be pulled out of the game or practice— 36 per cent; (3) did not know it was a concussion—50 per cent; (4) did not want to let down teammates—21 per cent; and (5) other—7 per cent.

An estimated 5.3 million Americans live with a traumatic brain injury (TBI) related disability, as reported by the CDC. About 21 per cent of all TBIs are associated with sports and recreational activities among children in the United States.

Approximately 33 per cent of high school athletes who have a sports concussion report two or more in the same year.

Information shared by the Sports Concussion Institute reveal:

– Football is the most common sport with a 75 per cent concussion risk for males, putting high school players at greater risk than college football players
– Soccer is the most common sport with a 50 per cent concussion risk for females
– One in five high school athletes will sustain a sports concussion during the season
– 50 percent of second impact syndrome (brain injury that occurs when an athlete is prematurely put back into play after suffering an earlier unhealed brain injury, resulting in cumulative tissue damage, and sometimes bleeding and swelling inside the brain) result in death
– Nearly all cases of SIS happen to athletes 18 years of age and under
– The impact speed of a football player tackling a stationary player: 25 miles per hour (mph)
– The impact speed of a soccer ball being headed by a player: 70 mph
– Over time, amateur and professional boxers can suffer permanent brain damage. The force of a professional boxer’s fist is equivalent to being hit with a 13 pound bowling ball traveling 20 mph, or about 52 times the force of gravity.  

The numbers below indicate the amount of sports concussions taking place per 100,000 athletic exposures. An athletic exposure is defined as one athlete participating in one organized high school athletic practice or competition, regardless of the amount of time played.

Football – 64 – 76.8 per cent

Boy’s ice hockey – 54

Girl’s soccer – 33

Boy’s lacrosse – 40 – 46.6

Girl’s lacrosse – 31 – 35

Boy’s soccer – 19 – 19.2

Boy’s wrestling – 22 – 23.9

Girl’s basketball – 18.6 – 21

Girl’s softball – 16 – 16.3

Boy’s basketball – 16 – 21.2

Girl’s field hockey – 22 – 24.9

Cheerleading – 11.5 – 14

Girl’s volleyball – 6 – 8.6

Boy’s baseball – 4.6 – 5

Girl’s gymnastics – 7

Golf – 0.5        

The National Athletic Trainers’ Association (NATA) released the following statement in the March, 2014, Youth Sports Safety Summit in Washington, D.C.:

– An estimated 3.8 million concussions occur each year as a result of sport and physical activity.
– Sport-related concussions account for 58 per cent of all emergency department visits in children 8 – 13 years old, and 46 per cent of all concussions in adolescents 14 – 19 years old.
– Athletes who have had one concussion are 1.5 times more likely to have a second. Those who have sustained two concussions have a nearly three times greater risk of SIS or TBI, and those with three or more have a 3.5 times higher risk of SIS or TBI.

Traumatic brain injury (TBI) is the leading cause of disability and death in children and adolescents in the U.S., as reported by the CDC. The two age groups at greatest risk for TBI are 0 to 4 years of age, and 15 to 19. These brain injuries were sustained from motor vehicle accidents, falls, sports injuries, physical abuse and other causes.

Cheerleading has changed drastically in the last 20 years, with increasingly difficult acrobatic stunts being performed. According to cheerleading data from the American Association of Neurological Surgeons, in 2010, head and neck injuries accounted for 19.3 percent of total cheerleading injuries. Additionally, in the 2010-2011 school year, head injuries were associated with 1579 concussions, 361 contusions, and 2,292 internal injuries.

Female athletes are more likely to report concussions as a proportion of all injuries than boys in sports that both girls and boys play.

It should be noted, about 1,300 U.S. children experience severe or fatal brain trauma from child abuse every year.  

The 2012 study conducted by researchers at Vanderbilt University Medical Center and Vanderbilt Sports Concussion Center evaluated tightly matched, homogenous groups of 40 male, and 40 female concussed soccer players.  

The only significant gender-related difference identified, was that female high school soccer players reported a greater number of post-concussion symptoms.

“Generally speaking, states Dr. Robert Cantu, the medical profession does not do a very good job in recognizing that female athletes sustain concussions at an equal or even higher rate as males. It’s flying under the radar. And, as a result, looking for concussions in women is not pursued with the same diligence, and it’s setting girls up for a worse result.”  

Typical symptoms for a concussion are: difficulty thinking clearly, concentrating, or remembering new information; shortened attention span; headaches; changes in the ability to hear, taste, or see/blurry vision; queasiness or vomiting; dizziness or balance problems; feeling disoriented or confused; sensitivity to noise or light; irritability; moodiness; sadness or nervousness; excessive sleepiness or difficulty falling asleep or remaining asleep; numbness or tingling; and feeling slowed down or hazy.   

Some symptoms associated with TBI can, in fact, be misinterpreted as ADHD, social anxiety, or a number of other disorders.

The more serious concern and condition that can develop out of TBI is chronic traumatic encephalopathy (CTE). First discovered in 1928 by Dr. Harrison Martland as ‘punch drunk syndrome’ after evaluating boxers, the condition was found to be present in football players decades later.  

In 2005, Pittsburg pathologist Bennet Omalu published the first evidence of CTE in Pittsburg Steeler Mike Webster. The diagnosis of CTE in a football player caught the attention of Concussion Legacy Foundation co-founders Chris Nowinski and Dr. Robert Cantu.  

To better understand CTE we must consider the significance of tau protein in the brain. Tau is a critical brain protein that helps stabilize and support certain structures within brain cells, including the cell’s transportation system.  

Repeated brain injury (repeated concussions) can cause the tau to become distorted or ‘misfold’ and change its shape. The misfolded tau releases into the cell, triggering a chain reaction that causes it to clump together. The clumps slowly kill neurons and spread to nearby cells.

Unlike any other disease, CTE tangles first appear around the blood vessels. As the disease progresses, the tau proliferates to other areas of the brain. In late stages of CTE, the entire brain is overcome with tangles.

“While CTE is a separate diagnosis, the symptoms are often similar to those found in Alzheimer’s, Parkinson’s and ALS (Lou Gehrig’s disease), and can occur as the result of multiple concussions,” said Everett J. Lehman, author of the study published in the September, 2015, National Institute for Occupational Safety and Health’s (NIOSH) Neurology report.

Dr. Ann McKee, director of neuropathology at Boston College, also serves as a member of the Mackey White Traumatic Brain Injury Committee for the National Football League. She is an expert on brain injuries, especially those involving CTE. She stated at a sports medicine symposium at Texas A & M University, November, 2014:     

“We have known about CTE since the 1920s, when it was first associated with boxing,” McKee said. We are just now learning its devastating effects on football players, from youth league to the NFL. It is totally different from Alzheimer’s because CTE is caused specifically by trauma.”

That CTE is directly associated with football and blows to the head are obvious, McKee noted. She said she had studied the brains of 80 former football players and 77 of them showed definitive signs of CTE.

“CTE results in memory loss, mood swings, change of behavior, and sometimes suicide,” McKee stated.  We have found it in the brains of healthy 18-year-old high school players, and it simply should not be there. It results in shrinkage of the brain, and we examined the brain of one former NFL player whose brain at the time of his death was the size of a 1-year-old child.”

McKee said one of the most disturbing aspects of CTE is that the disease continues even when an athlete is no longer playing.

“There is no doubt that the disease progresses even after a player has retired,” she explained. A player may retire in his early 30s, and by the time he is approaching 40 or so, he begins to have memory loss, and dementia. The disease is still spreading in his brain.”

“We have no treatments for CTE,” she added. Plus, the only sure way to determine if a player has it, is through an autopsy and not while the person is still living.”

However, Ann McKee, her colleagues, and other researchers have found a link between repetitive head trauma and a ‘new’ form of motor neuron disease similar to amyotrophic lateral sclerosis (ALS), or Lou Gehrig’s disease.  ALS attacks motor nerve cells in the brain and spinal cord without warning, leading to muscle weakness, atrophy, and often paralysis.

“ALS or CTE may be the most difficult diseases in existence to watch,” McKee says. They are slow, agonizing deteriorations that are witnessed helplessly by loved ones.” ALS is fatal in nearly all cases.  

This new form (after evaluating three deceased athletes—two former football players and one boxer) shows the finding of an abnormal protein TDP-3 in the brain and spinal cord in a unique pattern and distribution, along with tau protein—creating tangles that strangle and destroy brain cells.

These findings suggest that the motor neuron disease that affected the three athletes, while similar to ALS, represents a distinct disease never before described in the medical literature.   

The risk of ALS has been reported to be higher among collision athletes and military veterans. A study of professional soccer players in Italy found that the incidence rate of ALS was 6.5 times higher than in the general population. 

Boston University’s Center for the Study of Traumatic Encephalopathy (CSTE) raised the question of whether Lou Gehrig, a deceased former baseball player, suffered from CTE, rather than the disease that bears his name.

“If repetitive head trauma can spark this kind of neurodegeneration,” McKee says, then by studying the effects of repetitive mild brain trauma, we can learn about the initial, early triggers of neurodegenerative disease, and how to slow, reverse, and lessen them.”

Pop Warner, the nation’s largest youth football program, saw participation drop 9.5 percent between 2010 and 2012. Dr. Julian Bailes, a former Pittsburg Steeler neurosurgeon, cited concerns about head injuries as the number one cause.  “Unless we deal with these truths, we’re not going to get past the dropping popularity of the sport and people dropping out of the sport,” said Bailes.

Mark Hyman, a Sports Management Professor at George Washington University stated in October, 2015, that soccer, softball, baseball, basketball and touch football are especially affected, showing a significant drop off in participation.     

Dr. Hyman explains that now, approximately 70 per cent of children by the age of 13 walk away from sports because they recognize they are not talented enough, or they are burned out. He feels youth sports is part of a larger systemic problem. These issues are due to a system that was created to serve adults, not the interest of youth.    

All 50 states and the District of Columbia have now enacted laws addressing student athlete concussions. Most of the laws provide the following: (1) immediate removal from play is required when a student-athlete exhibits indications of having sustained a concussion; (2) same-day return to action is prohibited; and (3) return to action is permitted only after the athlete has been cleared by a licensed medical professional (the definition of which varies considerably between state laws).

Most of the laws also stipulate that coaches complete an education program, and require administering concussion information materials to student athletes and parents. While these laws appear to protect student athletes, new studies highlighting extended periods of impaired brain function post-concussion may establish that these laws are ineffective.

The state laws also almost universally fail to require baseline testing for student athletes. The decision to conduct baseline testing is left to schools and other youth organizations. When baseline testing does occur, a third-party vendor is often retained to conduct it. 

Researchers from Orlando Health and Dr. Linda Papa, the lead author of their study and an emergency medicine physician at Orlando Health, focused their attention on a biomarker known as glial fibrillary acidic protein.

After an injury, the glial cells that surround neurons in the brain release the protein, which has the unique ability to pass through the blood-brain barrier and enter the bloodstream.

The research team gave blood tests to nearly 600 patients 18 years and older, who sustained a head injury up to seven days prior. They cross-checked the results with their CT scans. The researchers had previously tested this technique on children; this was the first time they recruited adults.

This blood test detected mild to moderate traumatic brain lesions with up to 97 percent accuracy. Seven of the patients also found out that they were in need of life-saving neurosurgery. 

“This test could take the guesswork out of making a diagnosis by allowing doctors to simply look for a specific biomarker in the blood,” explained Dr. Papa.

Besides diagnosing concussions, this blood test will also reduce the need for CT scans, the current standard for identifying brain lesions, which are fairly expensive, and expose patients to harmful radiation.

Dr. Alexander Powers, pediatric neurosurgeon at Brenner Children’s Hospital in Winston-Salem, NC, shares the following:

“When I was a resident in training no one wanted to take care of concussions. They are too subtle, too hard to diagnose. You can’t see a concussion on an MRI and there’s no neurosurgery for it. The only treatment is rest, until all the symptoms clear up.

When I say rest, I mean no reading, no watching TV, no video games. Then you ease the child back into a normal routine after the symptoms have cleared—even if that means missing the championship game, or the practice that will give him a shot at starting next season.”

Before your child starts the season, consider getting your child a concussion baseline test. The results will provide information about what a child’s cognitive function is normally, an important benchmark against which a neurologist can evaluate the results of similar tests conducted after an injury.

Before sports play begins, find out what procedures the athletic organization overseeing your child’s sport has for handling concussions. Make sure the coach and league have thought about this, and have established rules. If there is any chance of a head injury, your child should cease participating until he or she can be evaluated.

Talk to your youngsters. Teach them about concussions. Instruct them to tell you right away if they hit their head. Often a child does not want to talk about being injured, and some might be dishonest and say they are fine because they want to play.

Pay attention to practices. These can actually be more dangerous than games. Practice, after all, involves repetition. Consider setting limits. If your child plays soccer, you might ban or discourage heading the ball, particularly in practice. 

Whatever sport your young one plays, it will be safer (and probably more fun) if practiced in moderation. After all, the more time on a court or field, the greater the risk of injury. At really high levels of play, children can also just burn out.

Have a good attitude. Of course, your children play to win. All good athletes do. But winning should not be your top priority when you sign your child up to play. If your child is the star of the team, but has to be taken out because he or she sustained any injury or collision, honor and appreciate that decision.

Observe, and periodically check in on your children even when they are indoors or outside playing.