Sidelined
Posted: June 21, 2013
Kids and sports go together like a ball and glove. Kids are competitive, energetic, active. Sports are fun, fast, lively. If only sports and safety were as synonymous. Consider the nearly four million sport-related concussions that occur annually in the United States. The large number of athletes sustaining this injury, their young age, and the potential for cumulative effects of repeated injuries make this one of today’s most important public health issues.
According to the American Academy of Pediatrics, the number of young children treated in hospital emergency departments for concussions received while playing school sports has doubled in the last decade. Sport-related concussions account for nearly four million injuries annually and approximately nine percent of all high school athletic injuries, according to the Center for Disease Control and Prevention.
Keeping score
1.6-3.8 million sport-related concussions occur annually in the United States
8.9% of all high school athletic injuries suffered were concussions
67.6% of high school football concussions were caused by tackling or being tackled
173,000 No. of brain injuries treated yearly by U.S. ERs, including concussions, related to sports/recreation among people less than 19 years old
Center for Disease Control and Prevention
Recent media headlines raised concerns that sport-related concussions may have contributed to the suicides of professional football players, prompting the U.S. government to launch a study of the rising incidence of injuries among youth athletes. The Institute of Medicine found a shortage of data on sportrelated concussions among young people. With no current data on concussions or musculoskeletal injury in this population, the scope of the problem in the youth athlete is relatively unknown. Of particular concern is what repeat injuries over time will do to a young individual both cognitively and emotionally.
Closing the research gap is the ATSU Concussion Program. Led by ASHS Athletic Training Professor Tamara Valovich McLeod, PhD, ATC, FNATA, the program studies how concussions affect pediatric athletes using a variety of measures, including some not traditionally used in concussion research.
Dr. McLeod’s research focuses primarily on high school and youth athletes, evaluating children as young as age 5. Sport-related concussion is a significant concern at all levels of athletic participation; however, the pediatric population is of special concern in respect to maturity and how their body responds to traumatic events. A child’s maturity rate (physical growth, motor development, cognitive, visual-motor, auditory, and perceptual motor) greatly affects how they will respond to a sport-related concussion. In addition, their brains are continuing to develop and it is unclear how a concussion may affect long-term function.
According to Dr. McLeod, clinicians have several tools for assessing concussion impairment, such as symptomology, neurocognitive testing, and balance testing. But, it is unclear how concussions affect a student athlete’s health-related quality of life, which is important, says Dr. McLeod, because it assesses functional loss or disability—thought to be more important to a person’s subjective experience of health.
Also unique to Dr. McLeod’s research is its whole person approach, investigating how concussions affect young people as students and in their relationships with friends, teammates, and families.
Dr. McLeod looks at the computer screen as balance is assessed using the Sensory Organization Test in the ATSU Neuromuscular Research Laboratory.
“[Our research] puts a different spin on concussions,” Dr. McLeod explains. “There is more going on than just whether or not an athlete should return to play. We look at the potential for long-term issues and how to mitigate these issues. We are now starting to determine whether there are certain interventions we can do to improve their outcomes and success in the classroom as well as in the sports arena.”
Dr. McLeod works primarily in Arizona, where concussion research is a priority. Arizona is the leading state in the education and management of concussions among young athletes. In 2012, the internationally known Barrow Neurological Institute, based in Phoenix, launched the Barrow Concussion Network in partnership with ATSU, Arizona Interscholastic Association (AIA) schools, and the Arizona Cardinals. The network is the most comprehensive concussion prevention, treatment, and education program in the nation and raises awareness of the dangers of playing through a brain injury. It includes mandatory concussion education, voluntary pre-injury testing, post-injury medical resources to all AIA schools, and research on injured Arizona students.
In addition to the network, Barrow debuted Brainbook in 2011, the nation’s first mandated online concussion education and test for high school athletes. Brainbook is modeled after social networking sites to make it more approachable to its young audience. Since its inception, more than 100,000 Arizona athletes have been educated.
ATSU’s collaboration with Barrow gives Dr. McLeod front row access to the latest data on youth sport-related concussions. She is also a referral source for athletic trainers and athletic directors at participating secondary schools for questions and evaluation. She found schools are often not equipped to handle a concussed student-athlete in the classroom. According to Dr. McLeod, there is a disconnect between academic and athletic sides of schools. However, the obvious lack of communication tends to improve when the school’s athletic trainer can facilitate the process.
The technology behind ImPACT
As part of the Barrow Concussion Network, all Arizona athletes may undergo ImPACT testing, a neurocognitive evaluation tool that helps determine when cognitive function has improved enough to return to play following a concussion. Athletes voluntarily take a baseline test before the start of the season to measure their cognitive level when they are healthy. When an athlete suffers a concussion, they repeat the test and athletic trainers and physicians compare the scores to help gauge whether the athlete is ready to return to play. The computerized test uses words, shapes, colors, and patterns to measure symptoms, reaction times, and processing speeds.
“In general, most concussions recover in two weeks. Athletes with prior history of concussion take longer; some are out of play for six months, and we have had a few out of school for a month. Some can stay home for a few days; some need temporary accommodations at school, such as rest breaks,” says Dr. McLeod, who is a John P. Wood, DO, Endowed Chair for Sports Medicine.
But for researchers everywhere, the million dollar question is how many is too many? What is the impact to youth on having successive concussions, especially when there is no prevention?
“There’s really no way to prevent concussion, but we can reduce the risk,” Dr. McLeod says. “Coaches know their players better than anyone. If they don’t seem right, start asking questions and get them evaluated by a medical professional with experience in this area.”
Most concussion diagnoses are selfreported or someone sees a hit and brings it to someone’s attention.
“There is no blood test, litmus test, or imaging to diagnose a concussion,” says Dr. McLeod. “We use a lot of tools to help in the assessment, but none of them are diagnostic.”
One important tool used in Dr. McLeod’s research is qualitative one-on-one interviews with athletes and parents, an area of collaboration with Program Director and Associate Professor of Athletic Training John Parsons, PhD, AT/L. These interviews allow researchers to look at how concussion affects changes in personality and behavior. Patient narratives allow them to describe their unique experience without biases imposed by the researcher.
“Narratives can provide meaning, context, and perspective regarding the patient’s health-related quality of life,” explains Dr. McLeod, who found three themes characterizing the experience of patients with sportrelated concussions: isolation, minimization and masking, and emotional slippage.
“Concussed student-athletes often feel isolated from their team when they are held out of play or school because of their injury,” says Dr. McLeod. “They often then try to minimize their injury, as a means to prevent further isolation. However, the emotional changes resulting from the injury are eventually revealed and noticed by parents. Collectively, these issues place some strain on the family relationship until the concussion resolves.”
Sport-related concussion has also been linked to depression, mood disturbances, sleep disturbances, and attention/concentration issues, all of which may affect one’s perception of health-related quality of life. A recent concussion consensus statement by the Concussion Sport Group identifies psychological management as an area that should be addressed, as mental health issues and depression may persist following concussion.
And, as with any research, there is still much to discover.
Richelle Mayfield, AT, ’14, works as a research assistant with Dr. McLeod. Soon she will begin doctoral studies in kinesiology at the University of Michigan where she will continue investigating the biomechanics and physiological effects of concussion in football athletes in the Neurotrauma Research Laboratory.
“This research will use accelerometers in football helmets that measure acceleration forces and the number of impacts to the head that an athlete sustains,” Mayfield explains. “Additionally, EEGs are collected to determine brain wave activity. The different technologies used with concussion are intended to help better identify what type of force may result in a concussion, as well as the detrimental short- and long-term effects following a concussion.”
According to KCOM alumnus P. Gunnar Brolinson, DO, ’83, FAOASM, FAAFP, FACOFP, the 3.5 million youth football players in this country are the most poorly studied of athletes participating in helmeted sports activities. Dr. Brolinson, sports medicine chair and associate dean for clinical research at Edward Via College of Osteopathic Medicine and head team physician for Virginia Tech Hokies football and team physician for the U.S. Olympic Ski Team, has been studying traumatic brain injury since 2003. Dr. Brolinson and his research team were the first to use in-helmet accelerometers to characterize head accelerations in collegiate football.
Did you know?
Sports equipment like helmets and mouth guards cannot prevent a child from suffering a concussion.
His previous research collected biomechanical data to characterize brain injury in collegiate athletes, and his team recently instrumented the helmets of youth football players with a sensor array capable of measuring the linear and angular acceleration the head experiences with every impact.
“This research allows for better characterization of head impacts, which has led to improved helmet testing and design, as well as rule changes to protect young athletes,” says Dr. Brolinson. “Based in part on our research, significant rule changes have been implemented in Pop Warner Football.”
A concussion is as individual as the person sustaining it, and the patient’s care must too be individualized. The common denominator is the serious long-term cognitive deficits a concussion presents, making continued research critical to determining proper management and timing for safe return to play and classroom participation.
This gets kids, sports, and safety together on a more level playing field.