ARTICLE IN BRIEF
A new report from the Institute of Medicine on youth concussion calls for a national surveillance program that should include demographic data, pre-existing conditions, concussion history, the use of protective equipment, and the impact of monitoring devices, as well as the qualifications of individuals making concussion diagnoses. Neurologists who are involved in the AAN Sports Neurology Section expressed disappointment that the report did not offer anything new and that neurologists did not participate on the committee.
Visits to emergency departments for concussions and other non-fatal, sports- and recreation-related traumatic brain injury (TBI) among players ages 19 and under jumped from 150,000 in 2001 to 250,000 in 2009. This statistic — as well as the severe dearth of research on concussions and subconcussive injuries in younger athletes, and a “culture of resistance” pervading youth sports — make a strong case for a nationwide surveillance program on the incidence of such injuries in youths between the ages of 5 to 21 years, an Institute of Medicine (IOM) panel has concluded.
In its 306-page report, the Committee of Sports-Related Concussions in Youth, which is affiliated with the IOM, called on the Centers for Disease Control and Prevention (CDC) to undertake such a surveillance program.
“Concussion is an injury that needs to be taken seriously,” IOM Committee Chairman Robert Graham, MD, who directs the Aligning Forces for Quality national program office at George Washington University, told reporters at a news briefing on the report on Oct. 30. “If an athlete has a torn ACL on the field, you don't expect him to tape it up and play.”
In reviewing the existing research on concussion in young players, the committee found some data on youth concussions in high school sports injuries, but “very little” on younger children, said panelist Tracey M. Covassin, PhD, associate professor of kinesiology at Michigan State University in East Lansing.
“Constantly, we came to this place where there's just nothing about kids,” she said. “We have to start doing better studies.”
Susan Margulies, PhD, professor of bioengineering at the University of Pennsylvania, said the most critical research needs include data on vulnerability timelines for younger children and the potential differences in the biomechanics of concussions at younger ages. Equally important is the need to educate players, parents, coaches, and others on the risks of head impacts, including those that do not result in a concussion, she said.
“We need an objective surveillance system,” she said. “We have no data on timelines for vulnerability, but we know that [injury] thresholds vary with age.”
A national surveillance program should include demographic data, pre-existing conditions, concussion history, the use of protective equipment, and the impact of monitoring devices, as well as the qualifications of individuals making concussion diagnoses, she noted.
At a time when many school districts face budget cuts, the purchase of better and more protective helmets may be less of a priority.
While media attention on concussions in professional and collegiate sports, notably football, have raised awareness of the problem, and rules and protocols been widely implemented for these older players, these changes have yet to trickle down to youth sport leagues, for the most part, where there remains a “culture of resistance” among younger athletes, coaches, and even parents, she told reporters. This is due, to some extent, to peer pressure and reticence among young players to let their teammates down.
But the main problem is the overall lack of data, the report emphasized.
“Until we have that information, we urge parents, schools, athletic departments, and the public to examine carefully what we do know...so they can make more informed decisions about young athletes playing sports,” said Dr. Graham.
The report recommended more research on changes in the brain following concussions in young players, including long-term consequences of concussions and repetitive head impacts, as well as a review of the effectiveness of current rules and playing practices.
Young athletes usually recover from a concussion within two weeks, according to the report, but symptoms can persist for a number of weeks, months, or even years in 10 percent to 20 percent of individuals, and each injury requires an individualized treatment plan that includes physical and mental rest, although current research does not support any universal level or duration of rest needed, it said.
Among the report's other key findings:
* Despite growing awareness of sports-related concussions and campaigns to educate athletes, coaches, physicians, and parents of young athletes about concussion recognition and management, confusion and controversy persist in many areas.
* Current sports helmet designs may reduce the risk of concussions, but they only address linear impact and do not prevent rotational injuries that may cause head injuries.
* The interval between concussions may be an important factor in the risk and severity of subsequent concussions; however, it remains unclear whether repetitive head impacts and multiple concussions in youth lead to long-term neurodegenerative disease, such as chronic traumatic encephalopathy.
* Football, ice hockey, lacrosse, wrestling, and soccer have the highest rates of reported concussions for US male athletes at the high school and college levels.
* Soccer, lacrosse, and basketball are associated with the highest rates of reported concussions for US female athletes at the high school and college levels.
* Women's ice hockey at the collegiate level has the highest rate of reported concussions.
* Youths with a history of prior concussion have higher rates of reported sports-related concussions.
Members of the AAN Sports Neurology Section were looking forward to reading the IOM report, but they expressed some disappointment that the committee panel — which included pediatricians and adolescent psychiatrists, orthopedists, kinesiologists, neuropathologists, pediatric neuropsychologists, sports medicine experts, and professors of bioengineering — did not include neurologists.
“I think this is odd, especially since they asked us who should be on the committee,” Jeffrey Kutcher, MD, associate professor of neurology at the University of Michigan Health System and director of the school's Neurosport Program in Ann Arbor, told Neurology Today.
Anthony G. Alessi, MD, associate clinical professor of neurology at the University of Connecticut, added: “I believe this is telling of how we as neurologists need to make up lost ground in the field of sports medicine.” The report, he noted, fails to add anything to the findings of the American Academy of Neurology guidelines issued a few months ago.
“We are now just scratching the surface on this issue,” Dr. Alessi said, and it is questionable if a national surveillance program will provide any useful data. “I think we are all anxiously awaiting more concrete information regarding the predictive value of the neurologic evaluation after concussion in children — what information obtained in the history and neurologic exam can help us know who is more susceptible to catastrophic injury.
“Our problem remains the issue of athletes not reporting head injuries, so we need better education of youth athletes, coaches, and parents about these risks.”
Christopher Giza, MD, assistant professor of pediatric neurology and neurosurgery at the University of California, Los Angeles, Brain Injury Research Center, said that any efforts to establish a nationwide surveillance program will depend on the CDC having adequate funding to undertake such an initiative.
“Right now we lack a good tool for evaluating younger players, but the major problem is overcoming resistance to players wanting to stay in a game even though they might have such injuries. As it is, between one-third and one-half of them will continue playing, from what I have seen.”
Dr. Kutcher, who has worked for years treating college athletes with concussions, agreed that while the IOM's recommendation for a national surveillance program is well-intended, it will not provide much useful information for better understanding the risks in younger players.
“Using diagnosis of a concussion may establish incidence, but misses the point,” he said. “Symptoms are widely independent of this diagnosis, so surveillance will only give us a general view. It would be better have some way of recording the number and force of head impacts as well.”
In general, he said, the report adds little to what is already known. “For one thing, teens are being better educated about concussion risk today, despite the underreporting, and it is not as big a problem as it used to be. In fact, now we get over-reporting, maybe because more kids are aware of the system and just want to get out of school or practice.”
There is also significant variability in concussion education and training of physicians, he said, noting that many of them are primary care doctors and there is no standard for concussion training in most medical schools.
“This is very important because these are the physicians who will be making return-to-play decisions for these young athletes now and in the future.”
Dr. Giza identified several areas that need more research, including the development of age-appropriate equipment standards and rules based on evidence, as well as age- and gender-based biomechanical thresholds for injury and the relevance of timing and number of injuries.
“We need a more formal definition of concussion and age-specific tools to assess and diagnose it, and it will be important to have a longitudinal natural history study of concussion across the age-range,” he said. He noted that he and Dr. Kutcher are involved in a study along with colleagues — from the fields of neuropsychology, athletic training, and physical and medical rehabilitation — to collect that data as part of the National Sports Concussion Outcomes Study, a pilot program funded by the National Collegiate Athletic Association.
“We have just concluded our first full year data collection and are partway into year two,” Dr. Giza said. “These types of studies will help determine whether the duration of contact sports participation and other factors contribute to the long-term cumulative cognitive effect of concussions.”
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