Sports-Related Concussions in Youth

Sports-Related Concussions in Youth

In the past decade, few issues at the intersection of medicine and sports have had
as high a profile or have generated as much public interest as sports-related concussions.
In recent years there has been a growing awareness and understanding that all
concussions involve some level of injury to the brain and that athletes suspected of
having a concussion should be removed from play for further evaluation (CDC, 2013;
Halstead et al., 2010). Despite the increased attention, however, confusion and
controversy persist in many areas, from how to define a concussion and how multiple
concussions affect the vulnerability of athletes to future injury, to when it is safe for a
player to return to sports and the effectiveness of protective devices and other
interventions in reducing the incidence and severity of concussive injuries (Wilde et al.,
2012). Parents worry about choosing sports that are safe for their children to play, about
finding the equipment that can best protect their children, and about when, if a child does
receive a concussion, it will be safe for him or her to return to play or if it might be time
to quit a much-loved sport entirely.
It is within this context that the Institute of Medicine (IOM) and National
Research Council (NRC), in October 2012, convened the Committee on Sports-Related
Concussions in Youth to review the science of sports-related concussions in youth from
elementary school through young adulthood, including military personnel and their
dependents, and to prepare a report on that topic based on that review. The committee
was charged with reviewing the available literature on concussions within the context of
developmental neurobiology, specifically relating to the causes of concussions, their
relationship to impacts to the head or body during sports, the effectiveness of protective
devices and equipment, screening for and diagnosis of concussions, their treatment and
management, and their long-term consequences. Specific topics of interest included

  • the acute, subacute, and chronic effects of single and repetitive concussive and
    non-concussive head impacts on the brain;
  • risk factors for sports concussions, post-concussion syndrome, and chronic
    traumatic encephalopathy;
  • the spectrum of cognitive, affective, and behavioral alterations that can occur
    during acute, subacute, and chronic posttraumatic phases;
  • physical and biological triggers and thresholds for injury;
  • the effectiveness of equipment and sports regulations in preventing injury;
  • hospital- and non-hospital-based diagnostic tools; and
  • treatments for sports concussions.

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Anecdotal Evidence Provides Clues to Youth Concussions

Anecdotal Evidence Provides Clues to Youth Concussions

Published: May 5, 2013

Youth sports concussion clinics operate at the center of America’s heightened awareness and increasing worry about concussions among young athletes. Listening to the hundreds of stories of how concussions have occurred, examining patients and monitoring their recoveries, the doctors and staff members are a repository of anecdotal and medical concussion information.Here are some of their observations after watching the concussion phenomenon from the inside. Although it is not clinical data arrived at scientifically, it is meant to capture a picture of general findings.

Female patients are making up a larger percentage of the clinics’ overall concussion patient population, a percentage that continues to rise year to year.

“People used to say this was happening because female athletes are more likely than male athletes to report their concussion symptoms, but not many of us believe that is the reason any longer,” said Dr. Cynthia Stein of Boston Children’s Hospital. “Female athletes are just as aggressive about wanting to stay on the playing field, but maybe their sports are getting rougher.

“Forty-one percent of our new patients are now female, which is a huge amount when you consider that the No. 1 sport causing concussions is football, and that’s nearly all male.”

There are numerous theories about why the female percentage of the concussion cohort is climbing. The one most frequently mentioned by doctors focuses on the anatomy of the female neck. Because a whiplash effect is often blamed for a concussion — a brain injury can occur just by having the head violently snap back without a blow to the head — the generally thinner, less muscular female neck is thought to be a factor in the rise in head injuries.

The sports that doctors cited as leading to the most concussions for females were soccer, ice hockey, field hockey, gymnastics, cheerleading and basketball.

“Lots of girls getting elbowed in the head in basketball,” said Dr. Walter Panis ofMassachusetts General Hospital.

Dr. Susan Kirelik, the clinical director of the Center for Concussion at the Rocky Mountain Hospital in Denver, added: “In soccer, it is heads hitting the goal posts, heads hitting the ground and head-to-head contact. Very common in women’s soccer.”

Many concussions seem to result from a hit the young athlete does not see coming. It is not just blindside hits in football; it is collisions in which only one party is braced for the collision, as seen in sports with checking, like lacrosse and hockey. Many soccer players are injured when they are hit in the head by a kicked ball at close range that they did not see coming, especially blows from the side or behind them.

Doctors again have theorized that girding the neck for a collision or a blow to the head could be the body’s way of protecting the brain. If the blow comes without warning, that layer of fortification is not engaged.

“As coaches always say, ‘Keep your head on a swivel so you know what’s going on around you,’ ” said Dr. Michael O’Brien at Boston Children’s Hospital. “It might be good advice for a lot of reasons.”

There is no documented evidence that America’s intensifying youth sports culture is leading to more concussions. But several doctors said they thought the year-round schedules that millions of young athletes on travel and elite teams keep as they specialize in one sport was a contributing factor.

“They certainly play more games than ever and more games at a higher level of competition,” said Dr. Kevin Walter of the concussion clinic at the Children’s Hospital of Wisconsin. “They extend themselves more than ever. And with all the specialized training, they are bigger, faster and stronger. It adds up.”

Helmets, specialized mouth guards and headbands do not prevent concussions.“There is no known way to prevent concussions,” Stein said. “We love helmets and mouth guards; they protect your skull and your teeth. But they won’t stop a concussion from happening.”

While there is continuing research being conducted across the nation aimed at proving whether multiple concussions in a short period of time — or a lifetime — can lead to long-term or even permanent brain damage, doctors at Boston Children’s Hospital have recognized a pattern while studying lab mice subjected to repeated head trauma. The mice are analyzed as they perform various functions in a maze.

“We have seen there is a vulnerable time period, a certain distance between injuries that make things better or worse,” said Dr. Rebekah Mannix, one of the researchers. “We might be able to get to the truth — when it’s been a long enough time that even another concussion will not set me back in a permanent way.

“But we’ve also seen the other side with the mice. I hope they’re not predictive, but once they lose their cognitive abilities, it’s a lifetime thing. They don’t get it back.”

New Study Links Athletes’ Repetitive Head Injuries to Degenerative Brain Disease

New Study Links Athletes’ Repetitive Head Injuries to Degenerative Brain Disease

Audio available by clicking the source “PBS” below


JEFFREY BROWN: How tough is too tough when it comes to sports and brain injuries? It’s an issue we have followed over a number of years. Today, there was new data to chew on.

Week after week, the big hits keep attracting big TV audiences to professional and college football. But concerns over head injuries in football and other sports have also continued about a connection between repeated blows and a degenerative brain disease known as chronic traumatic encephalopathy, or CTE.

The latest evidence comes from a new report from BostonUniversity that’s been published in the scientific journal “Brain.” The four-year study examined brain autopsies of 85 male donors ranging from age 17 to 98. It included football players at various levels, boxers, hockey players and a group of veterans.

They have found evidence of CTE in 68 cases, almost all of them athletes. The football players included linemen, running backs and tight ends who had received repeated hits throughout their careers. One was the late John Mackey, profiled with his wife, Sylvia, in 2009 by Ray Suarez.

RAY SUAREZ: In the good days, how is it different from what we’re seeing now for Mr. Mackey?

SYLVIA MACKEY, wife of John Mackey: He will get up and walk up and down. He can — he will throw and catch the ball. Actually, today would be a good day if it weren’t for the myoclonic twitching, they call it, or myoclonic jerks.

Related: Pint-Sized Football Players Take Big-League Hits

RAY SUAREZ: And speech?

SYLVIA MACKEY: He doesn’t talk anymore, very rarely.

JEFFREY BROWN: Mackey passed away in July of last year.

Others in the study who show signs of CTE were Derek Boogaard, a former hockey enforcer who died of an accidental overdose in May of last year, and former NFL safety Dave Duerson, who took his own life in February of 2011 after complaining of headaches and a deteriorating memory.

The NFL faces a class-action lawsuit filed last July by thousands of former NFL players and their families, citing lack of disclosure about potential dangers.

For more, we’re joined by one of the lead researchers, Dr. Ann McKee, a neurologist and co-director of the center for the Study of Traumatic Encephalopathy at BostonUniversity, and Mark Fainaru-Wada, an investigative reporter with ESPN who is working on a documentary about this subject for “Frontline.”

Well, Ann McKee, let me start with you.

What do you see as the key finding from this study that perhaps we didn’t know before?

DR. ANN MCKEE, BostonUniversity: Well, this study, this disease, chronic traumatic encephalopathy, has been around since the 1920s.

But there have really only been a smattering of reports.

In this paper, we more than doubled the world’s experience with this disorder and take it from the very beginning, where it first affects the nervous system, where it affects the nervous system, and then we see it expand progressively in older and older individuals, until it really is a destructive disease that affects most of the brain.

JEFFREY BROWN: And just to be clear here, the focus is less on the — I guess, the major hits or major concussions, and more on sort of repetition over time?


This is exposure to what we call mild traumatic brain injury usually considered almost insignificant hits, not — they don’t even have to rise to the level of concussion. They can be sub-concussion. But when you’re exposed to these hits over a very long period of time, usually many years, you can set yourself up for some long-term consequences.

JEFFREY BROWN: All right, Mark Fainaru-Wada, you have been reporting on some of the — well, there was pushback from some of the experts to these findings.

Tell us what you have been hearing from them and from the NFL, for example.

MARK FAINARU-WADA, ESPN/”Frontline”: Right. Well, my brother and colleague Steve Fainaru and I have been reporting on this for a while for a book and a documentary and for ESPN.

And, as Dr. McKee stated, the findings on this are substantial in terms of the numbers. They’re the largest number ever reported.

And what we did find, though, was there’s a lot of pushback in the scientific community. Dr. McKee told us about her recent experience at a conference in Zurich where there were various folks who criticized the work. We talked to some of those people, including some of NFL doctors who were there.

One NFL member of their brain committee said, you know, relating these cases, creating a causal link based on these case studies to football is akin to saying basically all the ankle injuries suffered by football players wearing Nike shoes were because of the shoes.

The argument there is that — and, as Dr. McKee has acknowledged — the data set they’re working from is skewed because it’s based on a series of brains from athletes and players who were showing signs before death in large cases of having mental issues.

And so the question that everybody is trying to figure out is, what is the actual incidence of this disease in looking at brains that were healthy vs. players who actually were exposed to football?

JEFFREY BROWN: Well, let me ask you, Dr. McKee, to comment on that. How definitive is this? What else do you need to look at to know especially things like how to treat people?

DR. ANN MCKEE: Well, this study is definitive in describing and defining what the disease is and how it affects the nervous system.

But a key question remains, what’s the incidence and prevalence? How common is this disorder? And that, we will never establish from an autopsy study.

For that, we really need to be able to identify this disease in living individuals. And that’s a huge focus of our more recent research. How can we identify this in people that are living?

And that might be through MRI scans or PET scans and especially the ones that might peg the TAL protein that develops. It might be seen through blood tests or tests of your urine or CSF.

But we are really going to need those tests to be able to determine if a living person has this disease and then be able to measure that person’s exposure to head trauma. And that will be the defining moment. And that will probably take a longitudinal prospective study involving probably thousands of subjects.

JEFFREY BROWN: Well, so, Mark Fainaru-Wada, how are professional leagues, people who work with students, student athletes, how are they taking this? How should parents take this in terms of the stakes here, the implications for when people should be in contact sports?

MARK FAINARU-WADA: Well, I think the numbers what are strike most people.

And I think those are the questions that raise issues for some of the leagues and how they deal with it and how significant this is.

The study talks about, out of 34 NFL players studied, 33 of them ended up having CTE. And so I think that obviously creates questions. Some people have suggested that the numbers raise more alarming questions than are real.

But the league for its part, the NFL, which faces the most scrutiny on this issue, with, as your piece noted, 4,000 former players suing the league right now, the league has looked at the changed rules to address the issue of these sort of larger hits that we have seen, these sort of defining hits.

I think the larger question, though, as Dr. McKee touched on earlier, is the subconcussive blows, there’s increasing research around that; 40 percent of the cases of CTE they identified in NFL players were lineman.

And so that raises questions about, is just the definitive — the nature of repetitive hits in the game something that exposes a player?

And I think that’s what the leagues and parents are trying to figure out as they try to find out how significant an issue is this and what the risk is for their kids.

JEFFREY BROWN: Well, Dr. McKee, how far would you go at this point in terms of what you say to parents or athletic directors or professional teams about taking the findings and using them somehow?

DR. ANN MCKEE: Well, I think the major caution I would have is that all parents, coaches should take every head injury seriously and try to eliminate the minor hits or the hits to the head as much as possible in any sport.

We have already seen in the last four or five years a tremendous focus on concussions. It used to be considered a fairly trivial injury that no one needed to sit out for.

And now we’re taking it seriously and we’re resting those athletes and making sure they’re completely asymptomatic until they return to play.

And I think this has been a tremendous development. And it will probably go a long way in terms of preventing the development of these long-term consequences in these individuals.

At this point, we don’t have any evidence, there’s no available evidence that a single isolated or a few isolated concussions that are well-managed — that means well-rested, the individual is asymptomatic before he goes back to play — there’s no evidence that those injuries lead to this disease.

The injuries that seem to lead to this disease are years and years of exposure to many hits. And those hits may be relatively mild.

JEFFREY BROWN: And, Mark, let me just ask you very briefly. You mentioned that lawsuit. Just tell us briefly where do things stand? That goes on, right?

MARK FAINARU-WADA: Yes, it’s ongoing.

And the current state is that both sides are arguing. The NFL has argued for dismissal of the case. It’s before a federal judge in Philadelphia.

I think both sides expect some ruling on whether the case will get tossed out or not in the spring. And, surely, there will be an appeal, one would expect, either way. So I think one expects the lawsuits are going to drag on well into next year at least.

JEFFREY BROWN: Mark Fainaru-Wada and Dr. Ann McKee, thank you both very much.

DR. ANN MCKEE: Thank you.

Does Playing Soccer Change the Brain?

Does Playing Soccer Change the Brain?

White-matter integrity alterations seen in 12 soccer pros, even in the absence of symptomatic concussion
November 26, 2012
Soccer is one of the world’s most popular sports. It is also the only sport where the head, unprotected, is a primary point of contact for the ball when playing. In other contact sports, the negative effects of repetitive traumatic brain injury are well recognized; however, the effects of frequent blows to the head below the threshold of concussion, as seen in soccer players, remains controversial.
In the first study to show alterations in white matter in professional soccer players, HMS researchers and colleagues at Ludwig-Maximilians-University in Munich investigated the brains of 12 soccer players using high-resolution diffusion tensor imaging to investigate structural changes in the brain, specifically white-matter architecture. White matter is the communication network responsible for communicating messages between neurons (gray matter) in the brain.
This research was published in a letter in the Journal of the American Medical Association on Nov. 14.
“Our study found differences in integrity of the white matter of the brains of soccer players compared with swimmers,” said Inga Katharina Koerte, lead author and a visiting research fellow in thePsychiatry Neuroimaging Laboratory at Brigham and Women’s Hospital. “Although only participants without previous symptomatic self-reported concussion or physician-diagnosed concussion were included, we found changes in the brain that are consistent with findings observed in patients with mild traumatic brain injury.”
Researchers evaluated 12 right-handed male soccer players from elite soccer clubs in Germany and compared them to eight swimmers, a sport with low exposure to repetitive brain trauma, from competitive clubs. Aside from their professional sport, the groups were otherwise similar in age, handedness and gender.
In this study, conventional magnetic resonance images used routinely in clinical settings showed no abnormalities when read by a neuroradiologist, suggesting the importance of using more sensitive measures to detect subtle changes in the brain. Researchers then employed high-resolution diffusion tensor imaging, and observed widespread differences between the 12 soccer players and the eight swimmers.
High-resolution diffusion tensor imaging non-invasively provides information about the diffusion of water molecules in biological tissue and can therefore reveal microscopic details about tissue architecture. In the brain’s white matter, diffusion of water molecules reflects the coherence, organization and density of fibers, which makes this imaging technique highly sensitive to changes in white matter architecture.
The alterations were observed in the white matter of the frontal, temporal and occipital lobes in the soccer players when compared to the swimmers. These regions of the brain are known to be responsible for attention, visual processing, higher order thinking and memory.
“The origin of these results is not clear. One explanation may be the effect of frequent subconcussive brain trauma, although differences in head injury rates, sudden accelerations, or even lifestyle could contribute,” said Martha Shenton, senior author and professor of psychology and radiology at Brigham and Women’s and a researcher at the VA Boston Healthcare System. “Additional research is needed to confirm these results we observed in this small sample of soccer players and to help clarify the effects that alterations of white matter have on behavior and health.”
Co-authors, including Ross Zafonte, vice president of medical affairs at Spaulding Rehabilitation Network, echo the importance of following up on this finding as key to understanding the meaning of the changes observed in this group of athletes.
This research was funded by the Else Kröner-Fresenius-Stiftung, Germany (IKK) and the Deutsche Akademischer Austauschdienst (IKK). This work was also supported in part by the INTRuST Posttraumatic Stress Disorder and Traumatic Brain Injury Clinical Consortium funded by the Department of Defense Psychological Health/Traumatic Brain Injury Research Program (X81XWH-07-CC-CS-DoD; RZ, MES), and by an NIH NINDS funded R01 (R01 NS 078337 MES
This story was adapted from a Spaulding Rehabilitation Hospital news release.

Persistent differences in patterns of brain activation after sports-related concussion: A longitudinal fMRI study

A. Dettwiler, M. Murugavel, M. Putukian, R. Echemendia, V. Cubon, J. Furtado, D. Osherson
Princeton Neuroscience Institute, Princeton University
Department of Psychology, Princeton University, NJ

Avoiding recurrent injury in sports related concussion (SRC) requires understanding the neural mechanisms involved in recovery.Prior studies have reported functional differences of brain activation in athletes with SRC. fMRI studies using working memory tasks suggest altered patterns of activation in the dorsolateral prefrontal cortex. Chen et al. (2004) reported fewer task-related activations and significantly decreased BOLD signal changes in the DLPFC in athletes with persistent symptoms compared to normal controls. Differences in brain activation in response to varying degrees of working memory processing load (N-back: 0, 1, 2 and 3 back) were identified by McAllister et al. (1999) in subjects with mTBI (Glasgow score 13-15) within one month after injury. The primary purpose of this study was to define neural correlates of SRC during the 2 month following injury, using a working memory task and fMRI.

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