Recent news reports about a Pop Warner football game in which five children suffered concussions have brought attention to a longstanding and under-appreciated problem in youth contact sports. In a game played on September 5, 2012, five boys aged 10 to 12 years old were so severely injured that they missed various amounts of school, despite substantial rule changes designed to prevent such injuries instituted only months before by the Pop Warner Football League. The league officers in attendance and the referees did not enforce the new protective rules; therefore, they received sanctions which included suspensions.
Football has attracted the most notoriety as a sport involving traumatic head injuries. Sixty-one concussion-related lawsuits have been filed by more than 1,260 players against the NFL. However, brain injuries can occur in a wide spectrum of sports. Sports-related incidents are the second leading cause of traumatic brain injuries in 15 to 24 year olds, only trailing behind motor vehicle accidents. Based on research by the Catastrophic Injury Research Center at the University of North Carolina, the most dangerous sports played in the United States are men's ice hockey, men's football, women's gymnastics, men's lacrosse, men's wrestling, men's track and field, men's baseball, men's swimming, men's soccer, women's soccer, men's basketball, and women's lacrosse. A strong argument can be made that the most dangerous "sport" is cheerleading; however, data tracking injuries in that activity is not as readily available as for organized sports. Concussions can occur in any sports, however, including "non-collision" sports such as tennis, volleyball, and field hockey.
One of the leading experts on the effect of concussions on children, Robert C. Cantu, M.D., recently published the definitive book on the topic: "Concussions and Our Kids." In his book, Dr. Cantu explains the physiology behind impact sports and brain injuries.
[Concussion] 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.
Dr. Cantu observes that concussions in sports occur when an athlete is slammed and makes sudden and forceful contact with just about anything such as the ground, court, a ball, a pool deck, and most typically, another player. A concussion can and frequently does 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."
There are two types of forces that cause concussions: linear acceleration and rotational acceleration. Linear acceleration is movement in a straight line when the brain moves back and forth or side to side in one direction. Rotational acceleration occurs when the brain takes an off center or tangential hit that causes the brain to rotate. Blows to the head involve both types of forces, but rotational forces are believed to be the most damaging.
Dr. Cantu notes that 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." Symptoms resulting from a concussion may include headaches, nausea, vomiting, dizziness, sensitivity to light and noise, sadness, depression, nervousness, irritability, sleep disturbance and cognitive issues such as lack of concentration, forgetfulness, and feeling like in a fog.
However, severe and repeated concussions over time can result in the condition known as chronic traumatic encephalopathy (CTE). CTE is a progressive degenerative disease of the brain found in individuals with a history of multiple concussions, head injuries or jolts to the brain. The repeated head trauma results in degeneration of brain tissue and an accumulation of an abnormal protein similar to patients with Alzheimer's. Symptoms may include loss of functions such as memory and impulse control, tremors, confusion, panic attacks, violent behavior and a general decline in thinking and reasoning. Dr. Cantu describes the process as "the patients' brains turn to Swiss cheese and their lives unravel."
Children are more susceptible to concussions for several reasons. First, their brains have less myelin, a fatty substance that acts like a shock absorber. Second, their heads and brains are disproportionately large for their bodies. The extra size and weight, coupled with a weaker neck, mean that a child can't brace for impact in the same way as an adult. Thirdly, the effect of multiple concussions is cumulative. If a young athlete begins having concussions in childhood, they will probably have more concussions during their lifetime.
Based on these findings, Dr. Cantu makes some very radical recommendations: No tackle football for players under the age of fourteen. No heading in soccer for players under the age of fourteen. The current ban on body checking in ice hockey should be raised from thirteen to fourteen years old. Mandatory chin straps for batting helmets and a ban on head first slides for all youth and high school baseball. Mandatory full coverage helmets for girls' field hockey and lacrosse.
Clearly parents, coaches, referees, league officials and the medical community must work together to prevent children from sustaining sports related injuries, especially concussions. Parents must not look the other way, but become part of the growing force for change in youth sports. While the effect of most concussions is not serious and can be treated with rest and reduced stimulation, the danger of a life-altering injury requires that all of those responsible for the health of young people advocate for and adopt stricter rules to improve sports safety.