ARTICLE IN BRIEF
The Centers for Disease Control and Prevention reports an increase in traumatic brain-injury related emergency department visits for young athletes (younger than 19), but attributes the rising number to heightened awareness among parents, coaches, and schools about the importance of diagnosing and managing these injuries.
In 2010, 17-year-old Nathan Stiles collapsed and died during a high school football game in Spring Hill, KS. He had suffered a concussion three weeks before and had been treated and sidelined by physicians until his symptoms were resolved. However all it took was one hard tackle to cause the fatal subdural hematoma.
Stiles was just 1 of 32 young football players who died from brain injuries between 2000 and 2010, according to the University of North Carolina's National Catastrophic Sports Injury Research Center in Chapel Hill.
His death, as well as several others among high school football players in recent years who had been sidelined for a previous concussion, cleared to play, and then fatally reinjured by a subsequent head impact, demonstrates the difficulty in determining when a player is, in fact, still at risk. It also underscores the need for improved outreach and training in concussion detection and management at the high school level and in younger youth league players, according to Anthony G. Alessi, MD, chair of the AAN Sports Neurology Section.
“Our biggest issue is the focus on college and professional players while so many of these injuries continue to occur in youth sports,” he said in a telephone interview with Neurology Today.
“College and professional teams have sideline physicians or athletic trainers experienced in recognizing potential concussions; we just do not have that yet below the high school levels.”
The American Conference of State Legislatures reports, as of July, that all 50 states either now have laws on the books to increase concussion detection and management of high school players, or have pending legislation addressing the issue.
NUMBER OF INJURIES UNKNOWN
What makes matters difficult is that the actual number of young athletes who suffer football-related head injuries is difficult to determine.
According to the Centers for Disease Control and Prevention (CDC) in Atlanta, more than 170,000 individuals under age 19 are seen at their local emergency department for a suspected sports- or recreation-related traumatic brain injury. But, this figure is based on data that also include injuries incurred while engaged in a wide variety of other activities, including bicycling, according to Julie Gilchrist, MD, a medical epidemiologist at the CDC's Injury Center.
Between 2001 and 2009, the last year for which data are available, emergency department visits for sports- and recreation-related TBIs, including concussions, increased by 60 percent, according to a CDC Grand Rounds report in the July 12 Morbidity and Mortality Weekly Report.
The report cited data first published by the CDC in a 2011 report that was based on a review of data from the National Electronic Injury Surveillance System—All Injury Program. In its discussion of the report, the agency cautioned that it was unclear if the increase reflected actual brain injuries, increased participation in sports and recreational activities, and/or an increased awareness of the importance of early diagnosis of TBI.
Dr. Gilchrist, one of the authors of the 2011 study, confirmed this in a telephone interview with Neurology Today.
“We saw a strong upward trend in injuries in the data in the 2011 paper, but we looked at all sports and recreational injuries among children from birth through age 19, not just traumatic brain injuries or concussions,” she said.
“If more injuries are occurring because children have become bigger, stronger, and faster, then there would likely have been an increase in all sports and recreation-related injuries as well as an increase in more severe injuries requiring hospitalization, but this was not borne out by the data,” she told Neurology Today.
“Instead, the rise in TBI-related ED visits is probably due to more awareness of the importance of diagnosis and management of these injuries among parents, coaches, and schools,” she noted. “At some point awareness will reach its peak and the numbers will stabilize.”
Other data suggest that the rate of serious head injuries in high school players is actually falling, especially fatalities.
In its annual report on injuries during the 2012 football season, the University of North Carolina's National Catastrophic Sports Injury Research Center reported a “dramatic reduction” in brain injuries that resulted in incomplete recovery from the year before, four of which involved high school players. This was nine fewer injuries than during 2011.
The center has also found that the number of deaths from football-related head injuries in high school and college players has fallen steadily over the decades, from 128 deaths between 1961 and 1970 to 77 between 1971 and 1980. Between 1981 and 1990 there were 42 deaths, 37 during the next decade, and 32 during the 2001–2010 playing seasons.
This downward trend in fatalities seems at odds with public perception that youth football deaths from TBIs are increasing, but it illustrates both the difficulty in gathering and interpreting injury data and the age-old adage that the devil's in the details.
Dr. Gilchrist noted that the CDC is working with the American Academy of Pediatrics and others to develop “a more uniform pathway” for playing field injuries. The CDC Foundation, in partnership with the CDC, recently launched the latest materials in the Heads Up Initiative: Heads Up to Parents, a website and smart phone app. The site includes expert advice on concussion, and information on the proper way to choose and fit helmets for sports and recreation.
In addition, the AAN launched a new app last March called “Concussion Quickcheck,” to help coaches, athletic trainers, parents, and athletes quickly evaluate if someone may have a concussion and needs to see a licensed health care provider, such as a neurologist. The app, which is available for the iPad, IOS (Apple), Android, and mobile phone, incorporates the Academy's updated guideline for diagnosing and evaluating sports concussion. The AAN also offers a sports concussion tool kit for physicians, parents, coaches, and athletes.
TARGETING EVEN YOUNGER PLAYERS
More needs to be done to address the risk, detection, and management of head injuries in youth sports from high school athletes down to children playing in youth leagues, according to Dr. Alessi, associate clinical professor of neurology at the University of Connecticut in Norwich.
While considerable progress has been made in raising awareness and initiating (or mandating) better sideline protection at the collegiate and professional levels, the same protections have yet to be make sufficient gains to protect younger players in most areas, he told Neurology Today.
The AAN sports concussion guidelines, which were updated earlier this year, allow that licensed health care providers, including athletic trainers, coaches, and others who have received concussion training, can fairly quickly determine if a player has suffered a head injury and take appropriate action, including seeking immediate medical attention where warranted, he said, but this really only comes down to the high school level, he noted.
“Below that, many if not most younger football players who experience head impacts are being evaluated by untrained individuals, usually a parent who played football when they were younger and has volunteered to coach,” he said. “This is now the biggest thing we need to push for — requiring someone on the sidelines of these youth league games to be trained in concussion recognition and emergency management.”
For scholastic football coaches, part of their licensing is a course in recognizing concussion, he said. This is not true for youth sports, although some states now require or are considering requiring the same training for coaches of younger players.
There are many concussion recognition programs available for non-health care professionals, some for as little as $10 that can be done online at home, he said.
“But sideline recognition is only one piece of the puzzle. You really have to make sure than an injured player is seen by a health care provider who is trained in concussion and can make a judgment call based on their experience. And not just physicians, these can be athletic trainers, physical therapists, and nurses.”
Dr. Alessi has an eight-minute online video outlining concussion recognition in young athletes at www.backushospital.org/concussion.