NYTimes: The Right Response to Youth Concussions


The Right Response to Youth Concussions By Jane E. Brody August 31, 2015 6:00 am Jane Brody on health and aging. As the number of youngsters who participate in organized sports grows and reports of concussions rise, it’s vital for parents, athletes and coaches to know how these injuries are properly diagnosed and treated to avoid long lasting consequences. While preventing an injury is always best, limited progress has been made in keeping youngsters free of concussions in sports with a high risk of head injuries. The best available headgear doesn’t cut it. While helmets remain critically important protection in many sports, no helmet can prevent or reduce the risk of a concussion. Helmets are designed to prevent a skull fracture and brain bleed, not to keep the brain steady when a player is hit, the underlying cause of concussion. Research is underway to design helmets that can better absorb the shock of a hit that jostles the brain against an unyielding skull. Changing the rules in the most hazardous sports has been somewhat successful. Professional football, for example, has banned helmet­first tackling, and similar restrictions exist for amateur players. But for pros as well as young athletes, “some of these collisions are unavoidable,” said Steven P. Broglio, an expert on concussion management. Exercises to strengthen neck muscles — chin to chest and ear to shoulder against resistance — have also been suggested as helpful for some sports. The relatively high rate of concussions among girls who play soccer, for example, has been linked in part to their smaller neck muscles, which leaves them less able than boys to stabilize the head when hit. “These wouldn’t hurt, but I don’t think they will fully solve the concussion problem,” Dr. Broglio said. Dr. Broglio, the director of the Neurotrauma Research Laboratory at the University of Michigan and the lead author of the National Athletic Trainers’ Association position statement on concussions in young athletes, advocates stricter enforcement of the rules of play, with larger penalties and fines for flagrant violations. For younger players, he suggests encouraging “a less aggressive game, with kids playing for fun” rather than going all out to beat their opponents. He and others attribute the rise in reported concussions among young athletes primarily to an increase in awareness, not an increased risk. Before every state had laws to protect youngsters with suspected head injuries, there were fewer reported cases of concussions in states without these laws, he said. “The absolute number of concussions is really the same, but now we’re dealing with them,” Dr. Broglio said. “Coaches and athletes are better educated.” Injured players are more likely to report telltale symptoms of a concussion, and coaches are less likely to tell them to “get back in there,” he said. The most essential rule is that no player suspected of having sustained a concussion should go back in the game that day or at any time until a trained medical professional certifies that the athlete is free of any signs or symptoms of a concussion. Decisions about returning to play are best made by people other than a gung­ho coach in the heat of intense competition who may fear losing a top player. Nor should coaches rely on players determined to stay in the game or who think they have to “suck it up” to report their symptoms honestly. Ideally, an athletic trainer should attend every practice and game to properly evaluate a suspected injury. More concussions occur during practice than games because there are more hours of practice. However, many schools cannot afford such sideline expertise even for games. Properly diagnosing a concussion can depend on knowing an athlete’s cognitive and physical abilities before an injury. All athletes, especially those in sports with a high risk of concussion, should have a preseason baseline examination that includes “a clinical history (including any symptoms), physical and neurological evaluations, measures of motor control (e.g., balance), and neurocognitive function,” the athletic trainers’ statement urges. If a concussion is suspected, these or comparable tests should be administered and the results compared with the preseason findings. “Traditional questions” to assess an athlete’s mental status, like “What time is it?” “Where are we?” “When is your birthday?” are ineffective and should not be used in a sporting environment, the statement says. Nor should players simply be asked, “Are you O.K.?” A proper diagnosis of concussion takes time, and rarely is enough allowed during competitions. If there is any doubt about the extent of a player’s injury, a better­safe­than­sorry approach dictates taking the player out of the game. Dr. Broglio urged competitive sports to allot more time at a site of competition to assess an injury. He also recommends changing the rule, in some sports, that once a player is taken out of a game, he or she cannot go back in no matter what. Once a concussion is diagnosed, a low­stress environment and lots of extra sleep are essential to repair the brain. Recovery cannot be rushed. A safe and effective recovery demands that players avoid physical activity and limit cognitive activity. That means refraining from physical workouts and conditioning exercises and limiting academic work, video games, television watching, texting, computer use and listening to loud music. Teachers can make temporary accommodations, like using written instructions and giving shorter assignments and more time to complete them. The goal of cognitive rest is to protect the brain from mental challenges that can increase symptoms and delay recovery. Once all signs and symptoms of concussion are gone, which can take one to two weeks or longer, a gradual return to activity can begin. But activity should be stopped immediately if symptoms return. Athletic trainers suggest that injured players and their parents or roommates be given a list of signs and symptoms that “indicate a deteriorating condition and warrant immediate referral to the emergency department.” They include increasing confusion and irritability, a fluctuating level of consciousness, a worsening headache and repeated vomiting. While recovering from a concussion, a patient should avoid all medications that contain aspirin or nonsteroidal anti­inflammatory drugs (acetaminophen can be used sparingly), as well as alcohol, narcotics or any substance that affects the brain.