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Concussions and Our Kids

America's Leading Expert on How to Protect Young Athletes and Keep Sports Safe

Concussions and Our Kids by Robert Cantu
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1
What is a Concussion?

“We need to do something now, this minute. Too many kids are at risk.”
— Dr. Ann McKee (Time)

“We still have this culture where it’s hard to convince people that a concussion is a very serious brain injury.”
— Dawn Comstock, principal investigator, Center for Injury Research and Policy, The Research Institute, Nationwide Children’s Hospital, Ohio State University (Time)

IN THE LATE 1950S, I was a student at Cal-Berkeley and a member of Cal’s baseball team. We were playing Stanford one afternoon, and I came to bat. This was the dark ages before batters wore helmets with ear flaps. Our protection—if you can call it that—was a flimsy liner inside our felt caps.
   A pitch came inside and tight, and I didn’t react as quickly as I needed to. The ball caught me flush on the side of the head. The cap and the hard liner were just about worthless. The force of the blow stunned me, and I wobbled a bit as I made my way down the line to first base. This didn’t seem to bother anyone as much as the blood trickling from my ear. It wasn’t really coming from my ear—the force of the pitch had shattered the cap liner, which sliced into my scalp.
   The coaches didn’t know that, of course. They took one look at me and thought, “My God, Cantu has a skull fracture! Get him to the hospital!”
   In those days, it wouldn’t have occurred to anyone in either dugout that I might have had a concussion. Even at the hospital it wasn’t diagnosed. It’s only looking back with years of experience in this field that I can say—based on my symptoms, which included not knowing where I was for a while, lightheadedness, and a violent headache—that I certainly had a concussion.
   We’ve come a long way since those unenlightened times. Now head trauma in sports is a topic that leads nightly newscasts and is debated at every level of amateur and professional sports. I knew that concussions had become something of a national obsession when Jerry Seinfeld built an entire monologue around the question “Why did we invent the helmet?” Normally, there isn’t a lot of humor associated with head trauma of any kind, but Seinfeld’s take is amusing. First, he says, we invented sports, the main feature of which is slamming our heads into each other over and over. Then, “We chose not to avoid these activities but to make little plastic hats so we could continue our head-cracking lifestyles.”

A Concussion Is . . .

The word derives from the Latin concutere for “to shake violently.” Concussions are just that—a shaking of the brain inside the skull that changes the alertness of the injured person. That change can be relatively mild. (She is slightly dazed.) It can be profound. (She falls unconscious.) Both fall within the definition.
   According to the Centers for Disease Control and Prevention, almost four million sports- and recreation-related concussions are recognized every year, with many times that number occurring but going unrecognized. For young people ages fifteen to twenty-four years, sports are the second leading cause of traumatic brain injury behind only motor vehicle crashes. According to research by the New York Times, at least fifty youth football players (high school or younger) from twenty different states have died or sustained serious head injuries on the field since 1997. One study estimates that the likelihood of an athlete in a contact sport experiencing a recognized concussion is as high as 20 percent each season. In my office, there is a very discernible cycle in the number of concussion patients. In the fall (football season) and winter (ice hockey) the numbers go up, sometimes exceeding fifteen new young athletes with a concussion per week. In the spring and summer, they slide back down.

How They Happen

Concussions happen to all types of athletes—young and old, boys and girls, and in every conceivable sport. In a typical year, I see hundreds of children and adolescents in my office. We see more than athletes, of course. Some patients have suffered concussions in traffic accidents, mishaps around the house (they walked into a door), or a slip and fall in the grocery store.
   In a chapter later in this book, I offer observations about concussions in “non-collision” sports such as volleyball and tennis that parents—for good reason—do not think of as posing a great risk of concussion. However, there is risk in every sport. I would have to think a long time before naming one that has not sent a single patient to our office at Emerson Hospital in Concord, Massachusetts.
   Many patients get well over two to three weeks, pretty much as expected. Other cases take unexpected turns. Mario was an eleven-year-old kid making one of those typical recoveries. After his concussion, he had a number of symptoms. We held him back from sports, gym, and physical activity. He was also under restrictions regarding his schoolwork. Just as he was about ready to resume normal activity, Mario hit his head on a bedpost and suffered another concussion. The process started all over again. I can’t count the number of stories like that. Unfortunately, they happen a lot.
   Concussions in sports occur when an athlete is slammed and makes sudden and forceful contact. That contact can be with the ground, court, or pool deck. It also can be with a batted ball, a thrown ball, a kicked ball, a goalpost (football), the boards (hockey), the scorer’s table (basketball), and of course another player. Dylan Mello, a high school soccer and ice hockey player from Rhode Island, suffered a severe concussion in a collision with a player who smashed him with the plaster cast on his arm.
   Concussions can and frequently do occur without any contact with the head. Rather, the player’s body receives a jolt that causes his shoulders and head to change speed or direction violently. It’s the whiplash effect. Inside the skull, the brain shifts in the cerebrospinal fluid and bangs against the inside of the skull. Even falling from five or six feet and landing upright, if it’s unexpected, and therefore jarring, can send a shock through the spine and shake the head with a force that may cause a concussion. Concussions that are the most damaging to the brain tend to be the ones that involve a direct blow to the head, however. When you’re struck in the head, the forces generated are about fifty times greater than being struck in another part of the body.
   With such a blow, the brain pushes forward until it crashes into the skull, reverses, and bumps against the back of the skull.

Two Forces

Concussions are caused by two types of accelerations. In this book we’ll refer to them not as accelerations but as forces. It’s a shorthand that might make an invisible and somewhat obtuse idea easier to think about. (There is a difference between the two, as noted in Newton’s law: force equals acceleration multiplied by mass.)
   The first of the two forces is linear. It’s akin to the straight-on force of a car smashing into a tree. At the moment of impact, the driver’s head snaps violently. The collisions cause injury, of course. That damage is worse than it would otherwise be because the inside of the skull is rough, not smooth. Contact between the brain tissue and the bony surface can be irritating, sometimes bruising or even tearing brain tissue.
   The second type of force is rotational. Think of a football player running from sideline to sideline and a head-hunting defensive player appearing out of nowhere to make a crunching tackle from the side. The force of the collision violently whips the ball carrier’s head to one side. If it’s jolting enough, the brain comes into contact with the skull. The cerebrospinal fluid in which the brain floats protects the brain and dampens the impact. However, if the force is large enough, an injury occurs. Driven into the skull by rotational forces, the brain can stretch and shear. Blood vessels and brain tissue are exposed to trauma and may tear.
   The effects of rotational forces can be much worse than those from linear forces. Concern about them caused the NFL to outlaw blind-side or “defenseless player” helmet-to-helmet hits. On virtually every hit to the head, both the linear and rotational accelerations are present. Among researchers and other experts, it’s believed that rotational forces are more injurious.
   Changes to the brain’s structure—tears and other injuries—are difficult to see. They’re often invisible on head CT scans and routine magnetic resonance imaging (MRI), the imaging tests most relied on. For that reason, there are misconceptions about the damage that occurs to the brain from a concussion. Through the years, even medical professionals have questioned whether the structure of the brain was different after a concussion than before.
   We know now that in some cases, the answer is yes. At the Center for the Study of Traumatic Encephalopathy at Boston University, the brains of more than one hundred deceased professional and amateur athletes have been studied. Several of these athletes died within days of a concussion. Several of their deaths were suicides. As one of the cofounders of CSTE, I’m familiar with these cases. The brains I am referring to were examined by my colleague, Dr. Ann McKee, a world-renowned neuropathologist.
   The patients had widespread diffuse axonal swelling and other abnormalities that would have been missed if they had been tested when they were living. Some of the changes were limited to one region of the brain. In other cases, changes happened over several areas from the cortex and brain stem down to the spinal cord. All the injuries were microscopic. But they were and are real.

Metabolic Changes

Concussions also trigger a complicated chain of chemical and metabolic reactions, which are known as the neurometabolic cascade of concussion. This process confuses the brain, throwing off its ability to regulate, to transmit signals, and to send messages that control how we think and what we remember.
   From being pushed and pulled violently, the brain goes into an overactive state, a state of hyperalertness, releasing chemicals called neurotransmitters. These are the chemicals needed for one cell to communicate with the next and the next. In this situation, the cells begin communicating in a disorderly way, blasting out impulses to all cells at the same time so that the system becomes overloaded. At this point the brain loses its ability to regulate certain chemical balances. Potassium ions, which are typically contained within brain cells, flood out. Calcium ions, which are on the outside, rush inside the cells. The brain’s chemical batting order is turned upside down, and returning things to normal is a very difficult process. To pump the ions back to the right places, the brain needs energy. But the chemical imbalances resulting from the concussion hinder that process, slowing or preventing the metabolic processes. At a time when the brain needs energy to set itself straight, its ability to make energy is greatly impaired.
   David Hovda, a well-regarded research scientist at UCLA, has studied these chemical imbalances in laboratory rats. Dr. Hovda’s research points out that while cell chemistry in rats is disrupted for a short time after a concussion, it takes longer to return to normal. That reversal may occur over weeks, even months. Assuming that our brains function exactly as the brains of rats is quite a leap—and likely inaccurate. Still, it is worth thinking about these findings and what they reveal about concussed athletes.

Symptoms

All concussions are accompanied by symptoms. They fall into four major categories:

Somatic: Headaches, nausea, vomiting, balance and/or visual problems, dizzy spells, and issues such as sensitivity to light and noise.
Emotional: Sadness to the point of depression (even suicide), nervousness, and irritability.
Sleep disturbance: Sleeping more or less than usual and trouble falling asleep.
Cognitive: Difficulty concentrating, troubles with memory, feeling mentally slow or as if in a fog that will not lift.

   The first time I see patients, I ask them to complete a symptom checklist, a three-page form on which twenty-six symptoms associated with concussions are listed (see Appendix A, page 163). The symptoms are listed in alphabetical order starting with “balance issues” all the way to “trouble falling asleep” and “visual problems.” In between are a range of symptoms, some commonly associated with concussions—fatigue, feeling in a fog, headache, problems with memory and concentration, sensitivity to light and noise—and others less common, such as ringing in the ears and vomiting. We ask our patients to tell us which of the symptoms they have experienced and to rank them by severity. In addition, patients complete a similar form that records symptoms they suffered with any past concussions (see Appendix B, page 165) and, thirdly, a medical history form (see Appendix C, page 167). This is how it might work on the form noting past concussions. If a young person had previous head trauma, the instruction would be, for concussion number one, put a “1” here noting that the symptoms affected balance issues only and “2” beside it to show that the symptoms were moderate. For the second concussion, the only symptom was confusion and it was relatively mild. The patient puts a “2-1” in the appropriate box for the second concussion. For each of the previous concussions, I’m able to calculate what is called a symptom load—the total number of concussion symptoms he’s had for each concussion, and a symptom score based on the severity of the symptoms. Most important, when they come in, patients go through a similar process letting me know about their symptoms that day. I have a symptom load and scale for that visit and every future visit. In addition, I ask the patient to tell me how many times he’s had the symptoms without a concussion being diagnosed. For many, the number may exceed recognized concussions by more than fivefold.
   Under past medical history, I also record conditions that can negatively affect concussion recovery and prevent one from being asymptomatic after full recovery from the concussion. Such conditions include attention deficit disorder (ADD), attention deficit hyperactivity disorder (ADHD), other learning disorders, depression, anxiety disorders or panic attacks, and migraine headaches.
   Symptoms are clues. They reveal many things—the severity of the injury and the pace of recovery, for example. The number and combination also can pinpoint areas of the brain affected by a concussion. Those that are focal—the insult is to one area—tend to result in fewer symptoms of shorter duration. When trauma is diffuse—spread across several regions—the patient has more symptoms that persist longer. Take the case of a hockey player who falls on the ice and cracks his head. If the blow affected the medial temporal lobe (controlling thought, attention, memory, and so on) and the calcarine cortex (affecting vision) located in the medial back of the brain, there would be multiple symptoms.

When will my child be over her concussion? When will I be better? These are questions that every patient and every parent of every patient wants answered. There is no “normal” recovery for a child with a concussion—no timeline or timetable to predict when symptoms will lift. In approximately 80 percent of concussion patients, symptoms clear within seven to ten days. In 20 percent of cases, the patient feels the effects for a longer period, sometimes much longer. Symptoms can last for weeks or months or, in a few cases, years. In a chapter on post-concussion syndrome we will learn about these cases in detail. We’ll review the reasons that mild concussions become more serious ones and the consequences when they do. Some kids have to leave school for a year. Others have to give up one collision sport that they really enjoy or, even worse, all competitive sports.

Rest

Rest is the hallmark of concussion therapy. The best we can do for patients is to shut things down physically and cognitively. That doesn’t mean going into a dark room and staying in bed. That would ruin the rest of your body. Generally speaking, it means reducing the thinking and reasoning in a patient’s life as much as needed so that symptoms are not provoked. We start with restrictions at school. If paying attention in class makes symptoms worse, the student shouldn’t be in class or should be on a modified schedule of classes. If taking a one-hour exam exacerbates symptoms, the child needs to refrain from such tests. Outside school, patients should virtually eliminate anything that’s intellectually stimulating. This includes any activity that involves staring at a screen or a page: text messaging, Facebook-ing, TV, movies, and outside recreational reading.

When a patient isn’t doing well, we continue to reduce cognitive load. We turn the dial a half crank until the patient has reached a point at which she is functioning without symptoms being provoked. It can take several attempts to find this level. In some patients, it can mean recommending that the young person withdraw from virtually all that had defined her life before the injury.
   School attendance can be a highly emotional issue because of all it encompasses in a child’s life.
   Taking away the young person’s sport is bad enough. Coping with the common twenty-six post-concussion symptoms making him feel absolutely miserable is bad enough. Taking him out of school for an extended period, perhaps an entire school year, is another blow. For many, it is sober confirmation that their lives are on indefinite hold. Their classmates are graduating at a certain time and they’re not. It adds a hurdle to their recovery at a time when they do not need one.
   These situations are complicated for the patients and the doctors. We are asking these young athletes to walk the thinnest of tightropes. On one hand, we do not want them to lose a school year. On the other, the cognitive activity inherent in attending school is hurting their recovery. There is a balance, and we try to find it.

Why Children Are Vulnerable

There’s considerable research to support the proposition that a child’s brain takes longer to recover from concussion than an adult’s brain. Most of these studies deal with high school athletes; that limits the conclusions we can draw about younger kids. Yet what is known points to children being at risk.
   Not surprisingly, the comparison centers on key developmental differences between adults and children. There are several worth emphasizing, all bearing directly on the brain’s response to trauma. Myelin is the fat that covers the fiber tracts in the brain. Think of a copper wire inside the wall of your house and of the plastic or rubber coating around the wire. The coating insulates, protects, and strengthens that wire. The fiber tracks of adults have a coating of myelin that acts in the same way, protecting the fibers from injury or insult. Brain trauma still can occur, of course. But myelination is an excellent defense. Children’s brains have less myelin, so structures in their brains are more easily damaged.
   A child’s brain and head are disproportionately large for the rest of the body, especially through the first five to eight years of life. It’s true up through about the age of fourteen, by which time a child’s skull has grown to be about 90 percent as large as an adult-size one. That may sound like trivia, but it’s important to a discussion of concussions and concussion risk. The extra size and weight, coupled with a child’s weaker neck, mean that the child can’t brace for a hit the way an adult does. Rotational forces will be greater for a child, proportional to the severity of the hit. The hit itself may not generate the same force because of the speed of the collision and the weights of the (junior) players involved, but what is transferred to the head may be as great or greater. It’s all about neck strength.
   Total brain trauma is the worry regarding child athletes. If you start accumulating injuries early in life, chances are that you will have a greater number of them during your life. It’s unclear what the effects of that long-term repetitive trauma might be. The philosophy I preach to my patients is as follows: No head trauma is good head trauma. If knocking around the brain can be avoided, then avoid it. This is my mantra even though there are many blanks to fill in regarding our knowledge of head trauma and its true effects. One concern is that kids who are playing in a tackle football league at age five (yes, such leagues exist) or engaged in another rough-and-tumble sport are at risk of a degenerative brain disease, chronic traumatic encephalopathy. CTE has been detected in the brains of many adult football and hockey players and in the brains of several teenagers. We know that total brain trauma (concussions and subconcussive blows) is a risk factor for CTE. Beyond brain trauma, what allows one person to have CTE and another person not to is for now unknown.

Recognizing Concussions

If you played competitive sports as a child, you know that concussions were thought to be not that serious. Few leagues educated coaches. There literally were no rules regarding concussions. It basically was up to the youth player to decide whether he was injured and should come out of the game. In many cases, a coach would ask a player, “Are you all right?” If the answer was yes, the player went back in.
   Thirty years ago, even medical personnel received little guidance. Basic protocols were left up to individual schools, teams, athletic trainers, and physicians. If a player had a concussion, what were the restrictions? Was it safe for that player to play in the next game? To return to that game? There were lots of opinions and methods of treatment.
   In 1986, I published the first “Return to Play” guidelines in a peer-reviewed journal, Physician and Sports Medicine, with the intention of moving toward a universal standard (see Appendix D, page 169). Over the years, these guidelines became an integral part of the care received by athletes. They classified concussions by grades one, two, and three, three being the most severe. At each grade, there were recommendations as to how the player should be handled. A player with a grade two concussion, for instance, was held out a minimum of two weeks if he was symptom-free for seven days. A player with a grade three concussion whose trauma caused him to lose consciousness for minutes was out for at least a month. The “Return to Play” protocol was intended to augment, not replace, clinical judgments. Decisions about how to care for an injured player remain with medical personnel on the scene, and always should. In the decades since the first guidelines, more than thirty alternatives have been published. In 2001, the “Return to Play” protocol was updated and sharpened. Now a player who reports a single concussion symptom is not permitted to return to that game.
   More than thirty states now have laws that incorporate a similar principle, known as “When in Doubt, Sit Them Out.” Under “When in Doubt,” if a player shows signs of being drowsy or confused, or has another concussion symptom, that player is out for the rest of that game, end of discussion. In addition, the player cannot be left alone (out of concern that her condition could deteriorate). Before being allowed to return to the game, the athlete must be cleared by a doctor or other medical personnel trained in concussion recognition and management.
   Some of the most ardent supporters of “When in Doubt, Sit Them Out” are athletes—often young athletes. When the Minnesota state legislature was debating a bill that embraced this standard, Kayla Meyer was one of the first to testify. Kayla had been playing ice hockey since she was three years old. At age fifteen, she’d suffered two concussions that had kept her out of school for more than two months. She also suffered from persistent headaches.
   “Players today have their mind-set that ‘I’m tough and strong’ whether they’re a girl or a guy . . . Coaches, teammates, players, parents, team trainers, and doctors need more information about concussions and brain injuries, to help people not go through what I’m going through,” Kayla told the legislators. It’s hard to imagine a better endorsement of “When in Doubt, Sit Them Out.”

Underreporting of Concussions

Despite our progress, challenges remain. Underreporting of concussions exists in all sports and is a special challenge in a few sports such as football and ice hockey. Football’s rules and rhythms camouflage the problem. In a football game, there is more “stop time” than “go time”—thirty seconds between plays, four or five seconds for the average play. A player who gets knocked silly has a few seconds to recover, remember where he is, and get back to the huddle. Unless he’s the quarterback, he isn’t speaking in the huddle. He’s wearing a huge helmet. No one can look into his eyes if they’re trying, which they probably aren’t. Line up these factors and a running back might be able to play a series or even a half before it is discovered he was playing impaired.

Underreporting of concussions in youth ice hockey has been documented in several studies; a recently published one suggests the problem is significant. The study’s primary author is Dr. Paul Echlin, a physician from London, Ontario, who worked with researchers from an organization called the Hockey Concussion Education Program. Dr. Echlin and his colleagues followed two junior hockey teams in Ontario throughout the 2009–10 season. These were highly competitive teams—a number of players hoped to graduate to college hockey programs. The players’ ages ranged from sixteen to twenty-one.
   The purpose of the study was simple enough: to track the number of concussions reported among the players on the two teams. Just as important, Dr. Echlin was looking for evidence of possible concussions that were missed by either coaches, medical personnel, or the players themselves. Or simply ignored.
   When it was released in 2010, the study garnered a great deal of attention; the findings were that alarming. Foremost was that ice hockey is a much more dangerous game than was previously thought, at least more dangerous the way it was being played by the two teams in Dr. Echlin’s study.
   An earlier study looking at NCAA Division I programs had reported a rate of 3.1 concussions per 1,000 man-games. The Echlin study, observing athletes of roughly the same age playing exactly the same sport, found a rate nearly seven times greater than that—21.5 concussions per 1,000 man-games.
   It was more troubling than just the greater number. The Echlin study described a culture in which concussions were not treated as a serious health issue or, it seemed, an issue at all. Players described being under pressure from their coaches to continue playing even when they’d been told by medical professionals that they’d suffered concussions and should take time off. The attitudes of some parents were even more puzzling. One told the research team that it should leave the team and let his child go back to thinking about hockey instead of the potential for injury: “He needs to play on instincts and can’t be worried about getting a concussion every time he goes into a corner.” The researchers might have heard more comments like that had they been allowed to complete the season with both teams—they weren’t. The general manager of one pulled his team out of the study midway through the season, telling the researchers that he didn’t want his players submitting to in-game examinations anymore.
   An interesting angle of the study is the way in which the researchers collected information. At the hockey games, physician observers were placed in the stands. When one saw somebody get up slowly or noticed that a player seemed stunned from a blow, the observer would note it and between periods go to the locker room to examine the player involved. The examinations often turned up concussions that coaches, players, and on-the-bench medical personnel themselves had overlooked. For every concussion picked up by coaches and players, the physician observers picked up seven. Seven.

On the Sidelines

On the sidelines, the job of the physician or athletic trainer is to decide whether there is any doubt. The coach shares responsibility. If he or she has any concerns about a particular player, the kid should be pulled. For the doctor, the evaluation is a matter of looking into the eyes of the player and asking a series of questions. In this situation, I’m looking for clues that the individual knows what’s going on around her. If she’s not responding appropriately to simple questions, there are issues.
   Questions I would use are these: What was the play you were injured on? What was the color of the jerseys of the opposing team? (I don’t let them turn around to look.) What quarter is it? What’s the score? These things reveal whether the athlete is alert to what was going on at the time of the injury. Of course, there’s always the simplest question of all: Do you remember what happened?, followed by Tell me what you recall.
   If they’re getting through the simple stuff, I’ll move on to other cognitive tests. I give them six digits and ask them to repeat them, then to repeat them backwards. Then a simple balance test: Can the player stand firm with their feet together, in heel-to-toe tandem position, and on one foot, eyes open and then closed; with hands on hips, eyes open and then closed?
   The age of the athlete is important to take into account. There’s not a huge difference between evaluating an adult and evaluating a young athlete, say nine or ten years old. Yet there is a difference with very young kids. It’s necessary to explain more, and perhaps use more care about the language used. You have to be clear—and they have to be clear—about the meaning of words. For example, a young child probably won’t know about being “dinged” and would be confused by a term such as “feeling in a fog”—both are slang for being conked on the head. Some will know “dazed” and some won’t. The key is to communicate on a level that is understood by the athlete, whatever the age.
   Sideline evaluations aren’t foolproof. Occasionally, a player who has a concussion is tested and cleared to return to the game. It quickly becomes clear that there’s a problem. A colleague at the University of Florida shared one of the more dramatic examples I’ve heard.
   The story concerned a player on the University of Florida football team and a game in Gainesville, where conditions can be rough, especially the heat and humidity. As a result, dehydration, heat illness, and heat stroke are always issues of concern. This is important to note because early symptoms of dehydration and heat illness, before they progress to heat stroke, can be quite similar to symptoms of a concussion—headache, confusion, and feeling lightheaded.
   During the game, my colleague was asked to assess an athlete who’d just come off the field. He sat down with the player and gave him a thorough evaluation. The athlete appeared fine. After ten minutes, he was cleared to go back in.
   The player got in the game as a punt returner. He fielded the ball and returned it a few yards. As he came off the field again, the team doctor asked him about the punt he’d just caught. The player replied, “What punt?” He had no recall whatsoever.
   These situations are rare, fortunately. Our ability to recognize concussions and protect players who’ve had them has improved markedly. There’s lots of room for improvement, though, as we will see over the following pages.

Houghton Mifflin Harcourt; September 2012
256 pages; ISBN 9780547774039
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Title: Concussions and Our Kids
Author: Robert Cantu; Mark Hyman
 
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9780547774039