ARTICLE IN BRIEF
A pediatric neurologist's Op-Ed in the New York Times, claiming that concerns about concussion in children are overblown, draws discussion and debate from other neurologists.
Is concussion involving young athletes a public health crisis? Or is the scope of the problem in non-professional athletes overblown?
A provocative New York Times commentary piece by a pediatric neurologist said that America's obsession over concussions may be keeping some kids from leading active, healthy lives.
“Obviously, concussions are a real concern,” wrote Steven M. Rothman, MD, a Missouri neurologist, in the December 22 opinion piece. “But what's also worrisome is that excessive fear of concussion may discourage parents and medical professionals from letting kids play healthy team sports.”
Dr. Rothman told Neurology Today that he was moved to write the piece after seeing kids in his office who were no longer playing contact sports after a history of mild concussions. The “tipping point” came, he said, when he evaluated a high school senior volleyball player who had been advised by her pediatric nurse practitioner to give up the sport after a third very mild concussion in three years.
Dr. Rothman, who previously directed pediatric neurology at the University of Minnesota and Washington University in St. Louis, told Neurology Today that he agreed that young athletes who experience head trauma and show any possible neurological symptoms after impact should sit out the remainder of the game. He said they then can gradually return to play over the next two weeks if they remain symptom free.
“I do take concussion seriously,” Dr. Rothman said in the interview with Neurology Today. “My concern is that kids are being permanently pulled out of relatively nonthreatening activities that are beneficial to them.”
“Concussion has acquired a looser definition over the years,” Dr. Rothman wrote, adding that “mild head trauma that produces only headaches” should be redefined as “noncussion.”
His New York Times piece, which appeared online under the headline “Parents, Stop Obsessing Over Concussions,” and in print with the headline “America's Concussion Obsession” drew mixed reactions from fellow neurologists interviewed by Neurology Today.
“I had to go back and read it twice because it was so shocking,” said Francis X. Conidi, DO, an assistant professor of neurology at Florida State University and director of the Florida Center for Headaches and Sports Neurology. He is also the team neurologist for the Florida Panthers.
Dr. Conidi said that some of the ideas put forth in the opinion piece could set back the public's understanding of concussion “by 10, 20 years.”
“I think people can have their opinion, but I think it was irresponsible to publish something like this without looking at the facts and the literature. Some of the things he says are not consistent with current medical evidence,” said Dr. Conidi.
On the other hand, Kevin E. Crutchfield, MD, director of the sports neurology program at Sinai Hospital of Baltimore, told Neurology Today that the op-ed by Dr. Rothman is “not that far off the mark.”
“I think people truly are obsessing about this word ‘concussion,’” Dr. Crutchfield said, noting that he believed concussion is over-diagnosed. He said concussion should be a “diagnosis of exclusion,” and that some doctors may be so quick to buy into the possibility of concussion that they overlook other potential causes of headache, such as sleep problems, depression, or a neck injury.
He said frenzy over concussion has fueled an industry of concussion clinics and testing programs, including widespread use of computer-based neurocognitive testing to evaluate athletes pre-season and in the event of injury.
Dr. Crutchfield said he fully agreed that “young developing brains should not get hit again and again,” but said “the vast majority of concussions resolve on their own in a very short period of time.”
While Dr. Rothman steered clear in his opinion piece of advocating for or against any particular sport, he noted that fear of sports-related concussion comes at a time when the Centers for Disease Control and Prevention “reports that a third of American children are overweight, in part because of physical inactivity.”
“We have a disconnect,” he wrote. “At the elite level, men and women who suffer obvious brain injury are being left on the field. Meanwhile, too many teenagers who face little chance of long-term brain injury are being kept from playing in healthy organized sports out of an excessive sense of caution.”
Andrew Russman, DO, co-medical director of the Concussion Center at the Cleveland Clinic, said he thought Dr. Rothman made a leap, however, when he connected worries about concussion with childhood obesity.
“We should be concerned about the health impact of being overweight and physically unfit,” he said. “But the piece makes an assumption that people who are not participating in contact sports are not physically active.”
Dr. Russman said more attention, not less, needs to be paid to understanding concussion in children and teens, including “more sophisticated and scientifically-based testing of baseline function and a determination of what is meaningful in post-injury evaluation.”
He also disagreed with what Dr. Rothman said was his usual advice to the young athletes he evaluates — that they can return to non-contact practice if they remain symptom-free for a week and to games after two weeks if there are no symptoms. Dr. Russman noted that “prevailing evidence shows that up to a third of young athletes who say they are OK — and their symptoms are back to normal — may not be back to normal when we evaluate their neurocognitive function or symptoms during physical exertion recovery.” (In the case of two concussions, Dr. Rothman wrote that he advises sitting out the remainder of the season.)
Anthony G. Alessi, MD, FAAN, who is director of the University of Connecticut Neurosport Program, said Dr. Rothman's commentary made some valid points, “but I think he overreached in some regards.”
“There is no one-size-fits-all formula for concussions,” he said, “because people recover at varying rates. I like to make the point when I'm teaching that if you've seen one concussion, you've seen one concussion.”
Dr. Alessi said that while he believed that not every youth athlete who gets a head hit needs to see a neurologist, “what neurologists bring to the table is that we spend a lot of time with patients.” Part of a concussion evaluation needs to involve ruling out other potential causes of headache or difficulty focusing, such as migraine, depression, attention deficit hyperactivity disorder, or eating disorders.
COLLEGE ATHLETES STUDIED
Brian W. Hainline, MD, FAAN, a neurologist and chief medical officer for the National Collegiate Athletic Association (NCAA), said a research initiative cosponsored by the NCAA and the US Department of Defense (DOD) will provide important information about the impact of concussions in non-professional players. Preliminary findings from a study that is tracking more than 16,000 collegiate athletes and more than 400 cases of concussion will be reported at the upcoming annual meeting of the American Academy of Neurology, he said. Another aspect of the NCAA-DOD research involves analyzing data collected from sensors placed in the helmets of college football players and from head sensors on collegiate athletes who compete in men's and women's ice hockey, soccer and lacrosse.
Dr. Hainline, who co-chairs the AAN Sports Neurology Section, said more research needs to be focused on youth sports, including why some young athletes recover more quickly from concussion than others.
“The one thing we really do believe is that there may be some individuals predisposed to long-term sequelae of head injury,” he said.