Young athletes in the United States face a "culture of resistance" to telling a coach or parent they might have a concussion, according to a new report from the Institute of Medicine and National Research Council.
The 306-page report, "Sports-Related Concussions in Youth: Improving the Science, Changing the Culture," was released during a briefing today at the National Academy of Sciences in Washington, DC.
"Even though there is an increased willingness to report a concussion, there is still the desire on the part of the athlete not to report it because they feel they are letting their teammates down; on the part of the coaches because it upsets the team they have on the field, or their own belief that, 'I had these, I'm okay, it's just part of the sport'; and on the part of the parents who want to see their children excel and be accepted," said Robert Graham, MD, chair of the committee that wrote the report.
Attitude Adjustment
Efforts are needed to "change the culture," said Dr. Graham, who is director of the National Program Office for Aligning Forces for Quality at George Washington University in Washington, DC.
Over 9 months, the committee did a comprehensive review of the literature on concussions in youth sports with athletes aged 5 to 21 years.
"The findings of our report justify the concerns about sports concussions in young people," said Dr. Graham. "However, there are numerous areas in which we need more and better data. Until we have that information, we urge parents, schools, athletic departments, and the public to examine carefully what we do know, as with any decision regarding risk, so they can make more informed decisions about young athletes playing sports," he added.
The reported number of individuals aged 19 and under treated in US emergency departments for concussions and other nonfatal sports- and recreation-related traumatic brain injuries (TBIs) increased from 150,000 in 2001 to 250,000 in 2009.
"This could possibly be due to an increase in awareness or reporting of concussions," committee member Tracey Covassin, PhD, director of the undergraduate athletic training program at Michigan State University in East Lansing. "However, we do not know the true incidence of concussions as several concussions go unreported, as well as a lack of consistency in terminology with different studies that have reported different definitions of concussions."
The committee found that the majority of research into concussions is at the high school and collegiate levels, with very few to no data reported below the high school level.
The committee also found a "shift" in the incidence of concussions, with more reported at the high school level than the collegiate level, Dr. Covassin said.
Football, ice hockey, lacrosse, wrestling, and soccer are associated with the highest rates of reported concussions for male athletes at the high school and college levels, while soccer, lacrosse, and basketball are associated with the highest rates of reported concussions for female athletes at these levels of play.
Limited Evidence Helmets Cut Risk
The committee found little evidence that current sports helmet designs cut the risk for concussions.
"What the literature tells us is that diffuse brain injuries like concussion are caused by a combination of linear and rotational forces," explained committee member Kristy Arbogast, PhD, engineering core director, Center for Injury Research and Prevention, Children's Hospital of Philadelphia in Pennsylvania. "What we do know is that helmets reduce that linear portion. There is limited evidence that they can manage the rotational components of the impact. This is in part due to standards."
The committee stressed, however, that properly fitted helmets, face masks, and mouth guards should still be used because they reduce the risk for other injuries.
The committee also examined the scientific literature on concussion recognition, diagnosis, and management. They found that the signs and symptoms of concussion are usually placed into 4 categories — physical, cognitive, emotional, and sleep — with patients having 1 or more symptoms from 1 or more categories.
Most youth athletes with concussion will recover within 2 weeks of the injury, but in 10% to 20% of cases concussion symptoms persist for several weeks, months, or even years.
Return to Play
The committee advises that a concussed athlete return to play only when he or she has recovered demonstrably and is no longer having any symptoms. An individualized treatment plan that includes physical and mental rest may be beneficial for recovery from a concussion, but current research does not suggest a standard or universal level and duration of rest needed, the committee notes.
Athletes who return to play before complete recovery are at increased risk for prolonged recovery or more serious consequences if they sustain a second concussion. "The evidence is pretty clear" on this, said committee member Arthur Maerlender, PhD, director of pediatric neuropsychological services at Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire.
The literature also suggests that single and multiple concussions can lead to impairments in the areas of memory and processing speed. However, it remains unclear whether repetitive head impacts and multiple concussions sustained in youth lead to long-term neurodegenerative disease, such as chronic traumatic encephalopathy, the committee said.
It notes, however, that surveys of retired professional athletes provide some evidence that a history of multiple concussions increases risk for depression. In a survey of more than 2500 retired professional football players, approximately 11% reported having clinical depression. "Very little" research has evaluated the relationship between concussions and suicidal thoughts and behaviors, the committee notes.
In youth sports, several organizations have called for a "hit count" to limit the amount of head contact a player receives over a given amount of time. Although this concept is "fundamentally sound," the committee found that implementing a specific threshold for the number of impacts or the magnitude of impacts per week or per season is without scientific basis.
The committee calls for establishing a national surveillance system to accurately determine the number of sports-related concussions, identify changes in the brain following concussions in youth, conduct studies to assess the consequences and effects of concussions over a life span, and evaluate the effectiveness of sports rules and playing practices in reducing concussions.
The report was sponsored by Centers for Disease Control and Prevention (CDC), US Department of Defense, U.S Department of Education, Health Resources and Services Administration, National Athletic Trainers' Association Research and Education Foundation, the National Institutes of Health, and the CDC Foundation with support from the National Football League.
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