Growing concern about concussions in young football players

photoPhoto © AdobeStock

There is growing concern about concussions among football players, especially young ones. What once seemed like mild injuries are being recognized as something that can cause serious problems later in life. A study in December 2018 found that at least five percent of young football players — aged 5-14 — are suffering concussions each year. 

What can be done to reduce head injuries, short of eliminating football? The obvious answer is to reduce the number of head impacts, but just how that can be done isn’t clear. So researchers at the Wake Forest School of Medicine ran a study that compared head impact exposure (HIE) in practice drills among six youth football teams and evaluated the effect of individual team practice methods.

How to reduce head impacts?

They found that full-speed tackling and blocking drills resulted in the highest number of head impacts. Reducing time spent on contact drills may not reduce impacts. Instead, the researchers found that reducing speed, correcting tackling technique, and progressing to contact may reduce impacts more effectively.

“Solely reducing time spent on contact drills may not lower overall head impact exposure in practice,” said Jillian Urban, Ph.D., assistant professor of biomedical engineering at Wake Forest. “The severity and frequency of head impacts in practice may be more influenced by the individual athletes and how drills are taught and run rather than the amount of time spent on each type of drill.”

In the study, the researchers collected on-field head impact data from athletes age 10 to 13 on six North Carolina youth football teams during all practices in one season. Video was recorded and analyzed to determine impact severity using the Head Impact Telemetry System, a system of sensors embedded in football helmets to detect and record head impacts.

Among all six teams, full-speed tackling and blocking drills resulted in the highest head impact severity and frequency, according to the study’s lead author, Urban said.

About the Wake Forest study

Head impact exposure was measured in terms of impacts per player per minute and peak linear and rotational head acceleration. The Wake Forest Baptist research team analyzed the differences in head impact magnitude and frequency among drills, as well as differences among teams within the most common drills. A total of 14,718 impacts during contact practices were collected and evaluated in this study.

More study is needed to find the best ways of reducing head impacts, she said.

The findings are published in the Dec. 21 online edition of the Journal of Neurosurgery: Pediatrics.

More evidence of long-lasting effects

The concussion issue is a matter of growing concern, as researchers find more evidence of long-lasting effects from seemingly minor injuries . A study released in November 2018 found it may only take one season of high school football to cause microscopic changes in the structure of the teen-aged brain. The scientists at the University of California, Berkeley, said their study adds to evidence that repeated blows to the head may lead to cognitive disorders later in life, even when the injuries are not serious enough to cause a concussion.

This is the period when the brain is still developing, when it is not mature yet, so there are many critical biological processes going on, and it is unknown how these changes that we observe can affect how the brain matures and develops,” Prof. Chunlei Liu said in a news release.

Over the past decade, researchers have found that an alarming number of retired soldiers and college and professional football players show signs of a newly identified disease called chronic traumatic encephalopathy (CTE), believed to cause mood disorders, cognitive decline and eventually motor impairment as a patient ages.

“There is a lot of emerging evidence that just playing impact actually changes the brain, and you can see these changes at the molecular level in the accumulations of different pathogenic proteins associated with neurodegenerative diseases like Parkinson’s and dementia,” Berkeley’s Liu said. “We wanted to know when this actually happens — how early does this occur?”

UNH study finds persistent cognitive changes

Researchers at the University of New Hampshire have found that young adults who experienced repetitive mild traumatic brain injury (mTBI), or concussions, can experience persistent cognitive changes as well as altered brain activity.

“Multiple concussions, even after general symptoms have subsided, decrease an individual’s ability to flexibly shift their mode of thinking,” said Robert Ross, assistant professor of psychology. “We found that these decreases in performance are associated with changes in how the brain communicates information.”

In their study, recently published in the European Journal of Neuroscience, researchers looked at young adults ranging in age from 18 to 24 who had sustained at least two concussions with the most recent one being at least a month before the testing. The participants were asked to switch between two tasks which included telling the difference between colors and shapes, like red and green and circle or square. Cognitive changes, like working memory and processing speed, were noted and oscillatory activity, or brainwaves, were monitored with an electroencephalogram (EEG), which tests for changes in the brainwaves.

In both the concussion group and the control group, researchers looked for differences in three different types of brainwaves and their effects on executive function, which is the ability to control cognitive functions like attention, inhibition, performance, flexibility, stability, working memory, and planning. They found an overall lower performance rate from those in the concussion group during the task-switching exercise. They were less accurate and processing performance was low.

“This is important because in the United States more than one and a half million people suffer traumatic brain injuries each year,” said Daniel Seichepine, assistant professor of psychology and neuropsychology and a co-author on the study. “Most concussion-related studies focus on older adults or professional athletes, but these findings offer insight into the cognitive changes many young adults may suffer even years after their injury.”

The researchers hope these findings may help develop better targeted treatment strategies for this population as they age.

Five percent of young football players suffering concussions

At least five percent of young football players — aged 5-14 — are suffering concussions each year, more than had previously been estimated, according to a December 2018 study by Seattle Children’s Research Institute and UW Medicine’s Sports Health and Safety Institute.

Published in the Journal of Pediatrics, the study summarizes the research team’s key findings from data collected during two, 10-week fall seasons in partnership with the Northwest Junior Football League (NJFL). Licensed athletic trainers from Seattle Children’s treated and recorded concussion from the sidelines at NJFL games to allow researchers to characterize concussions in this age group — from how often players sustained a head injury to factors that influenced their risk of injury.

The study adds to evidence released last month that found it may only take one season of high school football cause microscopic changes in the structure of the teen-aged brain. The scientists at the University of California, Berkeley, said their study adds to evidence that repeated blows to the head may lead to cognitive disorders later in life, even when the injuries are not serious enough to cause a concussion.

“This is the period when the brain is still developing, when it is not mature yet, so there are many critical biological processes going on, and it is unknown how these changes that we observe can affect how the brain matures and develops,” Prof. Chunlei Liu said in a news release.

The studies add to growing concerns about the safety of football for young players.

“Measuring the incidence of concussion in grade-school and middle-school football players is essential to improving the safety of the game,” said Dr. Sara Chrisman, an investigator in the research institute’s Center for Child Health, Behavior and Development and lead author on the Seattle study. “It’s hard to determine the impact of prevention efforts if we don’t know how often these injuries occur at baseline.”

Effects later in life

While mild concussions may not present many symptoms right away, researchers fear that they may cause serious problems later in life.

Over the past decade, researchers have found that an alarming number of retired soldiers and college and professional football players show signs of a newly identified disease called chronic traumatic encephalopathy (CTE), believed to cause mood disorders, cognitive decline and eventually motor impairment as a patient ages.

These findings have raised concern over whether repeated hits to the head can cause brain damage in youth or high school players, and whether it is possible to detect these changes at an early age.

“There is a lot of emerging evidence that just playing impact sports actually changes the brain, and you can see these changes at the molecular level in the accumulations of different pathogenic proteins associated with neurodegenerative diseases like Parkinson’s and dementia,” Berkeley’s Liu said. “We wanted to know when this actually happens — how early does this occur?”

Accurate data scarce

It’s not easy to get accurate data on how many football players suffer concussions. Previous studies may have underestimated the figure by as much as 4% simply because many injuries are not recognized or reported. The American Academy of Pediatrics recommends that athletic trainers provide medical coverage for youth football but that advice is often not followed.

To provide a more accurate snapshot of concussion incidence, the current study provided licensed athletic trainers for medical surveillance at all NJFL league games and practices during the 2016 and 2017 seasons. The athletic trainers helped researchers identify 51 football-related concussions among the 863 youth they followed as part of the study, with 133 of those players participating in the study for two seasons.

In addition to reporting on concussion incidence, researchers found two-thirds of concussions occurred during games, almost half from head-to-head contact. Follow-up surveys found a history of prior concussion was associated with a two-fold greater risk of concussion, and a history of depression was associated with a five-fold greater risk of concussion.

“We’re just starting to piece together how factors such as prior injury or depression may contribute to a child’s risk of concussion. Our study revealed patterns about who was most at risk for concussion, and these are areas we hope to explore in future studies,” said Chrisman, who is also an assistant professor of pediatrics at the University of Washington School of Medicine.

Researchers found most youth returned to school within a few days, but half took longer than 13 days to return to sport and longer than three weeks to return to baseline symptoms.

More research needed

No one seriously expects kids to stop playing football but researchers say more information is needed to find ways to make the game safer.

“This study lays the groundwork for new efforts to prevent head injuries in youth football,” said Chrisman, who also leads research using pre-game safety huddles to promote safe play. “Making sports safer for youth is at the core of our research.”

Neck-strengthening exercises may help prevent injury

Rutgers researchers have proposed a solution for athletes at higher risk for sports-related concussions, such as football and soccer: Protect your head with neck-strengthening exercises in the pre-season.

A paper by researchers at the Rutgers School of Health Professions, published in the Journal of Orthopaedic and Sports Physical Therapy, examines previous studies on the role that the neck’s strength, size and posture play in reducing concussion risk. They also looked into the greater risk of head injury to female and young male athletes who play contact or impact sports, such as when heading a soccer ball.

Based on their findings and the clinical judgment of the research team, the Rutgers researchers developed recommendations that physical therapists and athletic trainers can use to protect athletes.

These include performing a thorough cervical spine assessment as part of the pre-athletic participation exam; screening for pain because baseline reports of neck pain have been associated with increased concussion risk in young athletes; and providing interventions such as exercises to strengthen neck muscles.

May reduce energy transferred to brain

“Our ability to detect sports-related concussions has greatly improved, but our ability to prevent concussions and decrease post-injury outcomes remains limited,” said lead author Allison Brown, an assistant professor at the Rutgers School of Health Professions. “We have identified neck strength, size and posture as potential factors that reduce risk by lessening the magnitude of force upon impact. Thus, increasing neck strength and possibly size could substantially reduce risk or severity of injury or outcomes.”

Concussions are caused by an impact that makes the brain move within the skull. A neck that is stronger, thicker or aligned in a forward posture – with the ears ahead of rather than aligned with the shoulders – may reduce the amount of energy transferred to the brain during an impact, thus reducing the risk and severity of injury, said Carrie Esopenko, an assistant professor at the School of Health Professions and the report’s senior author.

Women typically have less neck strength and experience a greater risk of concussion as well as greater severity of symptoms and longer duration of recovery compared with their male peers, Esopenko said.

Concussions may lead to epilepsy

Researchers at the Fralin Biomedical Research Institute at Virginia Tech have identified a cellular response in mice to mild traumatic brain injuries that may lead to seizures.

Traumatic brain injury is a leading cause of epilepsy, which is characterized as the repeated occurrence of seizures. No treatments currently interrupt the process that the brain undergoes after injury that can eventually lead to the chronic condition of epilepsy.

The study, published in JNeurosci, suggests that the development of epilepsy triggered by mild traumatic brain injury may be related to an atypical response from brain cells known as astrocytes, which change to form scars after a severe brain injury. This process is important to protect uninjured brain areas but comes at a price, because these scars have been associated with epilepsy.

The scientists found that astrocytes do not form scars after mild traumatic brain injury, but some astrocytes are altered in a different way almost immediately by these less severe types of injuries. Then, weeks later, the scientists observed spontaneous, recurrent seizures in some mice.

“Our experiments show a strong relationship between changes in astrocytes and the eventual occurrence of a seizure,” said Stefanie Robel, the corresponding author of the study, who is an assistant professor with the Fralin Biomedical Research Institute and at the School of Neuroscience in Virginia Tech’s College of Science. “The findings point to a unique population of astrocytes that respond within 30 minutes of an injury being at the root of a problem where seizures may occur after a latency period of weeks or months, suggesting a therapeutic window to prevent seizure disorders after concussive injuries.”

Normal brain housekeeping interrupted

Robel, research associate Oleksii Shandra, and colleagues at the Fralin Biomedical Research Institute discovered areas of the brain where astrocytes no longer performed their usual housekeeping work to support normal nerve cell function after mild traumatic brain injury.

They first assumed these pockets of nonfunctioning astrocytes were dead, because they no longer made the proteins that normally identify them as astrocytes. Later, Alex Winemiller, a research assistant at the Robel lab and one of the first authors of the study, discovered the cells were alive, but not reacting to injury in their typical manner.

Researchers compared data from mice that eventually developed epilepsy with mice that never developed seizures and found a correlation between the loss of function in patches of astrocytes and the development of epilepsy.

“Each of these astrocytes is connected to multiple neurons, which make hundreds of thousands of connections, which means the loss of function of even a few astrocytes can be devastating to other cells in the brain,” said Shandra, the first author of the study. “Not only have these astrocytes lost their function, but due to these altered connections, the effects can be widespread to brain cells far away. The degree of this astrocyte dysfunction might be something that defines whether epilepsy develops.”

While it has been known that traumatic brain injury is a leading cause of acquired epilepsy, the precise relationship between such injuries and seizures has been elusive.

This new study shows that after a latency period, some of the mice developed spontaneous recurrent seizures reminiscent of post-traumatic epilepsy in human patients with traumatic brain injuries, providing a new experimental model that could contribute to understanding of post-traumatic epilepsy.

Younger players also at risk

Elementary school-aged children who participate in recreational sports are at greater risk of concussion than most other sports-related injuries. A new study published in PLOS ONE in June 2019 focused on children 5-11 years old who play recreational football, soccer and baseball/softball.

Karen Liller, PhD, professor of community and family health at the University of South Florida College of Public Health followed more than 1,500 athletes each year for two years in Hillsborough County, Florida. She and her colleagues collected baseline neurocognitive data using ImPACT Pediatric, the only FDA-approved concussion assessment tool for ages 5-11. The digital program asks athletes a number of questions pertaining to word memory, sequencing/attention, visual memory and reaction time. It was administered prior to practice and games to help prevent fatigue from impacting test performance.

“To date, research on sports injuries has largely been focused on high school and collegiate athletes. For child athletes, many sports/recreational activities are not organized for reporting injuries, so almost no data for this group have been collected,” said Liller. “No effective prevention strategies can be properly developed without the knowledge of the mechanisms related to these injuries including concussions.”

Certified Athletic Trainers (ATCs) were hired to collect injury data using High School Reporting Information Online (RIO), an internet-based injury surveillance system. During the two-year study, 26 athletes were injured, 12 were diagnosed with a concussion. Of those concussions, ten occurred during boys’ and girls’ soccer, the remainder happened during recreational softball games.

In addition to noting specific injuries, the RIO records how frequent each athlete participates in their sport, where they were located and what they were doing when they got hurt, and exactly how it happened. Researchers found the leading mechanisms of injury were caused by colliding with another athlete, contact with a playing apparatus and contact with playing surfaces. While none of the injuries required surgery, they did result in lost playing time.

Recovery like snakes and ladders

New guidelines that reduce the amount of rest required for children recovering from a concussion have been developed by CanChild, a McMaster University research institute.

“For children, recovering from a concussion is like a snakes and ladders game, as there are times where they may have rapid improvement and climb through the steps more quickly, and other times where returning symptoms mean they have to take a slide back,” said author Carol DeMatteo, professor of rehabilitation science and a CanChild researcher in March 2019.

“Our new research, along with our review of studies from all over the world, has led us to update the guidelines for recovery, and we have different but compatible guidelines for returning to school and for returning to activity including sport.

“Families have always felt the recovery instructions were too restrictive and difficult to follow. We now know that too much rest after concussion is not a good thing, and children can begin some activity sooner as long as they don’t overdo it and make their symptoms worse.”

She said the updates suggest that during the first 24 hours, home and leisure activities may be undertaken as long as they are only for five minutes at a time, and stopped if symptoms increase.

3 categories of concussions

The guidelines give pathways for three categories of concussions: For those who are symptom free within 48 hours of the injury, those who are symptom free or much decreased within one to four weeks, and those who have the symptoms for more than four weeks.

DeMatteo said the recovery has been broken into stages, and each stage outlines the goal, activities allowed and what to look for before moving to the next stage. For example, at stage two in getting back to school, children are allowed to walk, have 15 minutes of screen time or school work twice a day, and socialize with one or two friends for no more than 30 minutes.

DeMatteo said the most important thing to remember is that every child is different and will progress at their own pace based on the severity of their symptoms.

“In addition, we’ve shown, based on our research, the average time to move through each stage towards return to school and return to full activity or sport,” said DeMatteo. The return can take from 48 hours to six weeks or longer.

DeMatteo said that among children in Canada, the average age for a sport-related concussion is 13.5 years old, and that in Hamilton and Canada, the most common sports resulting in concussive injuries for boys is hockey, and for girls is soccer.

The guidelines may be found at https://www.canchild.ca/en/diagnoses/brain-injury-concussion/brain-injury-resources

Concussion recovery recommendations for kids

The American Academy of Pediatrics (AAP) has updated its concussion recommendations to support children and teens engaging in light physical activity and returning to school as they recover. The report, revised for the first time in eight years, also advises against complete removal of electronic devices, such as television, computers and smartphones, following a concussion.

Previously, the academy had recommended that kids recovering from concussions not be active or use electronics, due to concerns that either were too simulating and might hinder the brain from recovering. These recommendations are included in a new clinical report published online Nov. 12 in Pediatrics, the journal of the AAP.

“We’ve learned that keeping kids in dark rooms and eliminating all cognitive and physical activity actually worsened a lot of kids’ symptoms rather than improving them,” said Mark Halstead, MD, an associate professor of pediatrics and of orthopedic surgery and lead author of the AAP report offering updated recommendations on sports-related concussions in children and adolescents.

The basis for the AAP’s original recommendations stems from the notion that the brain needed time to recuperate after a concussion. However, researchers found that recovering children who were prohibited from activities and electronics can develop feelings of social isolation, anxiety or depression.

“Shutting down an active child entirely doesn’t make them feel good and, frankly, can make them feel like they are being punished for getting hurt,” said Halstead, director of the St Louis Children’s Hospital Young Athlete Center Sports Concussion Program. “Kids can develop anxiety by missing school, and the fear of getting behind can overwhelm them.”

Light exercise OK while recovering

Young athletes should stop playing immediately after a concussion is suspected, Halstead said. But light physical activity, such as brisk walking, can be incorporated as they are recovering. Similarly, academic workloads may need to be lessened after brain injury; however, such students shouldn’t need to miss prolonged periods of school or disengage in learning.

“A cookie-cutter treatment approach does not work, because no two concussions are alike,” Halstead said. “Although we have these recommendations, physicians and families need to evaluate each child or teen with a concussion on an individual basis.”

For boys, the report attributed most concussions to playing ice hockey, football and lacrosse. For girls, head injuries most often resulted from playing soccer, lacrosse and field hockey.

The AAP estimates 1.1 million to 1.9 million children and teens are treated for a recreational or sports-related concussion each year.

Additionally, the report concluded that each concussion is unique, with symptoms varying in type and severity; most child and teen athletes will recover from a sports-related concussion within the first four weeks after injury; and the long-term effects of one or more concussions have not been determined.

Don’t use unapproved devices, FDA warns

The U.S. Food and Drug Administration is warning the public not to use medical devices marketed to consumers that claim to help assess, diagnose or manage head injury, including concussion, traumatic brain injury (TBI) or mild TBI. In a new safety communication, the FDA warned that such tools — such as apps on a smartphone marketed to coaches or parents for use during sporting events — have not been reviewed by the FDA for safety and efficacy and could result in an incorrect diagnosis, potentially leading to a person with a serious head injury returning to their normal activities instead of getting medical care.

To date, there are a limited number of medical devices that have been cleared or approved by the FDA to aid in the diagnosis, treatment, or management of concussion, and all of them require an evaluation by a health care professional.

“I want to be clear, there are currently no devices to aid in assessing concussion that should be used by consumers on their own. Using such devices can result in an incorrect diagnosis after a head injury that could lead a person with a serious injury to return to their normal activities instead of seeking critical medical care, putting them at greater danger,” said Jeffrey Shuren, M.D., J.D., director of the FDA’s Center for Devices and Radiological Health.

“Products being marketed for the assessment, diagnosis, or management of a head injury, including concussion, that have not been approved or cleared by the FDA are in violation of the law. The FDA routinely monitors the medical device market and became aware of violative products being marketed to consumers. The FDA has alerted companies to our concerns and asked them to remove such claims. We will continue to monitor the marketplace for devices making these unsubstantiated claims and are prepared to take further action if necessary.”

Avoid smartphone or tablet apps

In the safety communication, the FDA explains that the products of concern include those that claim to assess and diagnose any changes in brain function by having an injured person perform tests on a smartphone or tablet-based app to determine a change in physical or mental (cognitive) status including vision, concentration, memory, balance and speech.

The FDA’s recommendations for consumers, parents, caregivers and athletic coaches note that individuals should seek treatment right away from a health care professional if any head injury, including concussion, is suspected.

 

About the Author

Truman Lewis
Truman has been a bureau chief and correspondent in D.C., Los Angeles, Phoenix and elsewhere, reporting for radio, television, print and news services, for more than 30 years. Most recently, he has reported extensively on health and consumer issues for ConsumerAffairs.com and FairfaxNews.com.