News from MomsTEAM/ SmartTeams

 

Earlier this year, the Centers for Disease Control and Prevention (CDC) released its Report to Congress: The Management of Traumatic Brain Injury in Children. The 90-page report describes the public health burden of TBI in children and adolescents, including the range of outcomes that may be experienced following a TBI, lays out the current systems involved in the management of children with TBI, identifies gaps that exist, and outlines some practices that hold promise in addressing those gaps. Finally, opportunities for action are offered that suggest ways to improve TBI care in children, and how we might advance our understanding of TBI care in the future.

CDC Report to Congress on TBI in Children

As the Executive Director of MomsTEAM Institute of Youth Sports Safety, I was honored to be among the select group of external reviewers the CDC asked to provide feedback on the proposed report content and review drafts. The final report is culmination of that collaborative, three-year effort for which the distinguished authors and my fellow reviewers can be justifiably proud and stands as a stellar example of what can be accomplished when the public and private sector work together.

Our understanding of TBI has come a long way since MomsTEAM launched its pioneering Concussion Safety Center in 2001. But the work of educating sports stakeholders about the management of TBI in children and adolescents, and ways to minimize the risk of brain injury in sports is, by its very nature, a never-ending and ongoing process.

I am immensely proud that, for the past eighteen years, grants from organizations such as the NCAA and DoD, and contributions from corporate underwriters and individuals, have allowed MomsTEAM to provide comprehensive head injury safety information to sports parents, coaches, athletic trainers, and athletes on our legacy website, MomsTEAM.com, and via our SmartTeams Head Injury Safety Center, completely free of charge.

And, now a request; a tax-deductible contribution to MomsTEAM in any amount will help us to continue to be a leader in head injury safety education. In return for a generous contribution corporate donors will receive a banner ad placement on an article of their choice on MomsTEAM and inclusion as an underwriter on SmartTeams. 

Won't you consider making a donation today? Thanks in advance for your help in keeping kids safe.

0

Lost in Translation: The Perils of Tweeting About Concussions

One of the things I try to do every day is carve out time to keep up with what people are saying on Twitter, and occasionally throwing in my two-cents worth. For those of you reading this blog who follow MomsTEAM on Twitter, it won't come as any big surprise that concussions in sports seems to be the topic that most often lights up the youth sports Twittersphere.

But as anyone active on Twitter also knows, condensing one's thoughts into 140 character "tweets" is often a challenge, and can sometimes leave a lot to be desired, especially when one is talking about a subject as complex as concussions.

Last night was one of those times.

I was following a conversation about benching kids in case of suspected concussion and the use of sideline assessment tools in making "remove from play" decisions, and decided to offer my thoughts.

The use of screening tools on the sports sideline in case of suspected concussion is a subject with which, with all due modesty, I have more than a passing familiarity, not just from writing blogs and articles on the subject and from reading all of excellent articles written by MomsTEAM's Team of Experts, but also from my first-hand experience in producing "The Smartest Team: Making High School Football Safer (PBS)" MomsTEAM's soon-to-be-released documentary about the implementation by one Oklahoma high school football program - with our help - of a concussion risk management program.

One of the most important elements of such a program we highlight in the documentary is to make sure, in case a concussion is suspected, that the team doctor and/or certified athletic trainer conducts an immediate assessment on the sideline utilizing one or more available sideline screening tools (e.g. Standardized Assessment of ConcussionSCAT2Balance Error Scoring System a/k/a BESS and King-Devick) and, based on such assessment, to either allow an athlete to return to play or hold the athlete out for the remainder of the game (as is now required by law in more than 40 states) and referred for further evaluation. The default rule, of course, is to follow the by now familiar mantra, "When in doubt, sit them out."

Last night, one of MomsTEAM's favorite Twitter followers, Andrew M. Blecher, M.D., the Medical Director of the Center for Rehabilitation Medicine and occasional guest blogger for MomsTEAM who goes by the handle, jocdoc, tweeted the following:

If concussion is suspected enough to give test then sit them out & send for eval.

I responded with the following post:

Some ATs and coaches are going overboard and the sideline tests help validate if kid is ok.

Some viewed my post as suggesting that athletic trainers and coaches were being too conservative by sitting out kids suspected of concussion, but that is not what I said, and certainly not what I meant to say in the slightest.

Lost in the post was the admittedly nuanced point I was trying to make: that athletic trainers and coaches who kept kids from returning to play simply because they saw a kid take a hard hit, or because a sensor went off alerting them to a blow that might cause concussion, without performing any sideline assessment, might be viewed as going overboard.

There are lots of times players take very hard hits and get right up and run back to the huddle. For any of number of reasons, as I wrote in my last blog post, the mere fact that the player got up and kept playing doesn't mean, of course, that they haven't sustained a concussion.

I am all in favor of a coach or AT pulling a player out of the game, based solely on the blow they witnessed or that triggered an alert on their iPad. But here is where it gets tricky: If they simply sit the player down for the rest of the game without doing any sideline assessment, I think that is going overboard.

Here's an example of what I am talking about. During one of the pre-season practices I attended last August during the filming of "The Smartest Team," one of the players sustained a hit which, from my untrained eye, appeared to be one that could have caused a concussion. Even though the athlete got right up, the athletic trainer had him come off the field so he could administer both the King-Devick (see screen grab from the movie at right) and BESS tests. When he passed both tests, he was allowed to return to practice.

Athletic trainer Damon Glass administering King-Devick test

What if the athletic trainer had decided, based solely on the magnitude of the hit, to hold the player out without using any of the assessment tools he had in his concussion toolbox? Could he have been accused of "going overboard"? I respectfully suggest that he might.

Again, I am not saying the opposite: that players should be allowed to return to play willy-nilly, without an evaluation, or that, when a sideline assessment is inconclusive, the athletic trainer shouldn't, in the exercise of caution, hold the player out.

All I am saying is that there has to be some  basis for holding the player out beyond the fact that he took a big hit. After all, every player's brain is different. Where he was hit (the top of the helmet, the side of the helmet etc.), whether the hit was direct (to the head) or indirect (a hit to the body with forces transmitted to the head), the direction and magnitude of both the linear and rotational forces involved, and a variety of other factors, both known and yet to be identified (such as the player's concussion history, possible genetic pre-disposition, and/or pre-existing neurological conditions, such as a history of migraines or ADD/ADHD), all affect how a player responds to concussive and sub-concussive blows. Concussion management is not one-size-fits-all. Concussion identification shouldn't be either.

The bottom line: it isn't just players on the field who need to play smart; sideline personnel need to play smart, too. 

0

National Youth Sports Safety Month: We've Come A Long Way

When the National Youth Sports Safety Foundation was formed in 1989, its mission was to provide information on the prevention of youth sports injuries. The non-profit 501(c)(3) foundation was founded in Massachusetts by Rita Glassman after her young daughter Michelle suffered a severe back injury that ended her tennis career. Rita was the first to designate April as National Youth Sports Safety Month, which MomsTeam has been celebrating every year since 2001.

I recall visiting Rita and her daughter in their Boston office shortly after I launched MomsTeam in 2000.  Rita and Michelle have worked tirelessly to make youth sports safer for many years.  Twelve years ago, NYSSF and MomsTeam were the only organizations  providing extensive and well-researched information on youth sports safety and injury prevention.   Since then, of course, we have been joined by many wonderful organizations who are working hard to educate parents, coaches and caregivers of young athletes about safety issues. Websites have been launched to support safety products and services.  Countless others have jumped on the concussion "bandwagon", many in just the past four years. Others have started their own youth sports injury prevention organizations.

While MomsTeam has been on the cutting edge of a number of youth sports safety issues, most notably on the issues of concussions, we believe in the old saying that imitation is the sincerest form of flattery, and thus are thrilled that so many other groups and people have joined us. We know that because of our efforts kids playing sports are safer than ever before. We hear from parents and coaches all the time how much they rely on MomsTeam as the trusted source of youth sports parenting information.

But MomsTeam is a TEAM effort. Just like any great team, our staff works with our experts, guest contributors, scientists, doctors, athletic trainers, physical therapists, nutritionists and countless others to create the mix of timely and timeless content that make MomsTeam what it  is today.

A word about the logo

Youth Sports Safety MonthWhen we started recognizing April as Youth Sports Safety Month, I worked with a Swiss graphic designer named Radek Zmitko to create a special logo.  The three carabiners have special meaning for me. When my triplet sons were young, I dressed them in red, green and blue. They loved to climb, and my son Taylor continues to climb at the elite level all around the world.  I think rock-climbers are among the most safety-aware athletes. The carabiners represent safety almost more than any other piece of equipment. Strong and durable, they are literally a climber's life line.  I will write more on the topic in my blog later this month. But, for now, I will leave it to the experts to teach and share with all of us.

How can you help advance MomsTeam's continuing mission of making youth sports safer?  By clicking on the Facebook and Twitter icons below each post to share them with your family and friends.  If even one young athlete is saved from serious injury through this project, if even one person is inspired to go into sports medicine by reading how one of our experts got into the field, we will have achieved our goal.  Together, I know we can all make a difference in the lives of our sports active children!

Read all of our blogs for this special event:  http://www.momsteam.com/blogs/april-national-youth-sports-safety-month


Comments/Questions? delench@momsteam.com

Brooke de Lench is Executive Director of the non-profit MomsTEAM Institute, Inc., author of HOME TEAM ADAVANTAGE: The Critical Role of Mothers in Youth Sports (Harper Collins), Founder of MomsTeam.com, and the Producer/Director of the PBS documentary, "The Smartest Team: Making High School Football Safer."

0

Buyer Beware (Part Two): NFHS Has NOT Endorsed Use of Football Helmet Covers As Reducing Concussion Risk

In recent weeks I have written a number of blogs about claims by equipment manufacturers that their products prevent or reduce the risk of concussions.  

First, it was to call attention to a settlement between the Federal Trade Commission and Brain Pad, a mouth guard manufacturer, barring the company from claiming that its mouthguard reduced the risk of concussion.

Next, it was to deconstruct some carefully-worded claims in a press release by a company named Unequal Technologies touting supplemental helmet protective pads utilizing so-called CRT (concussion reduction technology).

Today, in the latest installment in my continuing series of blogs called "Buyer Beware," it's time to examine claims by three more companies, at least two of whom, like Unequal Technologies, manufacture football helmet pads, that their products prevent or reduce the risk of concussions.  

ProCap 

First up is a product called ProCap ($79.95) from Erie, Pennsylvania-based Protective Sports Equipment, Inc. (PSE).  In an August 6, 2012 press release on PR Newswire captioned "Concussion and Player Safety Take Center Stage in NFHS Ruling; Protective Sports Equipment Inc. Announces ProCap Is Approved for Football Game Day," PSE describes ProCap as a "safety accessory affording significant protection against concussion in football."  The press release goes on to claim that, "[a]fter an extensive examination" by the Football Rules Committee of the National Federation of State High School Associations, the governing body for high school football, the NFHS had decided to permit the use of Pro Cap on game day in high school football.  

To the casual reader, the headline implies an endorsement by the NFHS.  But it is clear from reading the actual NFHS press release that NFHS did no such thing. All it did was to say that, because the evidence on whether ProCap conflicted with NFHS football rules by causing helmets to be altered in such a way as to decrease protection was "inconclusive," the NFHS wasn't prepared to ban use of such equipment and was therefore leaving "the decision as to whether to use or not use helmet attachments ... at the high school level and all other levels, [to] the discretion of ... teams, coaches, athletes and parents."  

The NFHS was careful to note that it does not "perform scientific tests on any specific items of equipment to determine if the equipment poses undue risks to student-athletes or others." In fact, the NFHS said it was unable "to form a definitive conclusion as to whether" Pro Cap is "on balance, beneficial or detrimental."   On the one hand, the group noted that, from "a common sense standpoint, padding would seem to be helpful. On the other hand, however, the larger circumference of a padded helmet increases the likelihood of contact, and there may be a change with respect to the coefficient of friction."  The bottom line from the NFHS's standpoint: we just don't know.   

But it's a long way from "we just don't know" to touting the ruling, as ProCap was quick to do, as an endorsement which "will benefit thousands, perhaps hundreds of thousands, of football players at all levels of the game." 

ProCap's website doesn't do much to clear up the confusion.  It's tagline, "Keep your head in the game," is a very strange one, given the effort in recent years, especially by the National Football League and its youth football partner, USA Football,  to take the head out of the game of football, to eliminate the kind of helmet-to-helmet contact, such as contact with the helmet of defenseless receivers and intentional head-hunting, that we know not only results in concussion but can sometimes lead, tragically, to catastrophic brain and spinal cord injuries, paralysis or even death.   

It is just the kind of claim that Dr. Robert Cantu labeled "dangerous" in his new book, Concussions and Our Kids (look for my review of Bob's book next week) because players wearing such products may play more aggressively, believing they are somehow protected against injury. 

Shockstrip

Another product that the NFHS specifically mentioned in its August 2012 press release as not being a violation of its rules was ShockstripTM ($50.00). Shockstrip has been on my radar screen since June 2011, when I was introduced to the product by its inventor, Steven D. Novicky, D.C., a Canfield, Ohio chiropractor.

After the NFHS issued its ruling, Shockstrip sent out two press releases, which Dr. Novicky was only too happy to share with me in a series of recent emails. The first one bore the headline "First Time Ever NFHS Permits Use of External Helmet Device That Reduces Concussions On the Playing Field."  The second was captioned "NFHS Steps Up Player Safety & Concussion Prevention With Ruling to Allow Use of Shockstrip Helmet Padding on Game Day", and claimed in the first paragraph that the product "significantly reduces short-term brain injuries, concussions, hearing problems and headaches." 

But, as with ProCap, Shockstrip's claims simply don't withstand close scrutiny, and, at the very least, have the potential to be misleading. Nowhere in either the NFHS press release or its August 23, 2012 letter to Dr. Novicky advising him that use of the Shockstrip was not a violation of its rules, is there any language even remotely suggesting that the NFHS had in any way, shape or form bought into the company's claim that the Shockstrip product significantly reduces short-term brain injuries, hearing problems and headaches, much less that its ruling was intended to "step up" player safety and concussion prevention.  "The NFHS does not endorse or approve football equipment.  This ruling," the NFHS was quick to point out, "only means that permissive use of the Shockbox product is not illegal under NFHS Football Rules."  

In other words, confessed the NFHS, we don't know, one way or the other.  Facts are facts. Opinion and puffery - well, they are something else again. 

Guardian Cap 

Which, brings me, finally, to the third product the NFHS ruled could be attached to the outside of a high school football helmet without violating its football rules: the GuardianTM protective helmet cover ($69.95).  GuardianTM manufactured by Alpharetta, Georgia-based POC Ventures in partnership with the creators of ProCap, is a one-size fits all, lightweight, soft shell football helmet cover that the company claims "reduces impact up to 33%" and has been scientifically tested at Penn State University, Wayne State University and Oregon Ballistics labs with "great results" and was field tested by over 600 players in 2011. 

Unlike ProCap and Shockstrip, it doesn't appear that Guardian made a big deal out of the NFHS ruling.  To its credit, Guardian Cap is quick to point out on its website that "No helmet or practice apparatus can reduce or prevent concussions." It claims only that linear impact testing and drop testing showed that the helmets equipped with the Guardian Cap reduced forces transmitted to the head, that field testing had yielded "outstanding results and lower head traumas," and that their product "was being worn by 6,100 players this year with only 2 reported head injuries at this time."  

More specifically, the company admits that "Guardian Caps CANNOT prevent concussions but they CAN reduce impact and maybe, just maybe, reduce the possibility of injuries."

Voiding helmet warranty? 

Another thing that parents need to know about these products is that they may void the limited warranty extended by the football helmet manufacturer.  

According to Paul Jonff, Brand Manager at Rawlings Sporting Goods, "any alterations of, additions to, or component omissions or removals made to the [Rawlings] football helmet may affect the intended performance capabilities of th[e Rawlings] football helmet and void the football helmet warranty."

Glenn Beckmann, Director of Marketing Communications for Schutt Sports, told me in an email that, "Third party or after-market products, whether they are temporarily or permanently added to our helmets, will likely void the warranty on the helmets and transfer liability for the helmet to the owner of the helmet."

Beckmann went on to say that, "Until our helmets have been configured with these products, tested and certified under industry standards in these configurations and until the third-party or after-market products have been independently tested to show that they do not affect the performance of the helmet or the structural makeup of the helmet itself, we recommend that our helmets not be altered from their original configuration."

He also points out that the addition of permanent third-party or after-market products to a Schutt helmet "effectively prevents that helmet from being reconditioned and recertified to its original condition and configuration, which is a vital component of maintaining the safety standards and performance of the helmet.  Ultimately, customers can choose to whatever they wish to helmets they purchase from us. But they should be aware of the potential consequences."

Guardian alerts potential customers on its website that its product "is classified by helmet manufacturers as an 'external enhancement device' and the use of the GuardianTM might void the warranty of the shell of your helmet," but promises that, "if your shell cracks and the helmet manufacturer refuses to replace it, citing GuardianTM usage as the reason, GuardianTM will cover the warranty on your helmet for up to five (5) years, provided that the helmet meets all NOCSAE reconditioning requirements."

Shockstrip does likewise, stating that "Because application of this product MAY void the original helmet manufacturer warranty, ShockstripTM will warrant your helmet under normal use for a period of five (5) years from date of purchase by the original purchaser ("Warranty Period") provided [the] helmet is properly maintained by a Factory Authorized Reconditioner. Proper maintenance requires reconditioning of your helmet at least every two (2) years by a NOCSAE Licensed Reconditioner using only new factory replacement liners in the reconditioning process." 

As for ProCap, its website doesn't - as far as I can tell - alert customers to the potential voiding of the helmet manufacturer's warranty, nor does it promise, like Guardian and Shockstrip, to step in with its own warranty if that were to happen. 

Homework time

As I have been pointing out for quite some time, and as Bob Cantu writes in Concussions and Our Kids, "Parents and coaches are vulnerable, willing to spend freely to keep their kids safe in sports, yet wary of being taken advantage of."  Like Bob, I advise parents, before buying one of these products, to do you own research.  Check them out by visiting reputable sources on the Internet (like MomsTEAM) before you plunk down your hard-earned cash.  

Will sending your son or daughter out on the football field with a helmet equipped with one of these products provide, literally and figuratively, an extra layer of protection?  As Guardian Cap says, the most we can say at this point is, "Maybe, just maybe."

Until we know for sure, my advice has been and continues to be, "Buyer beware."  

Stay tuned for Part Three, and Four, and ...

For Part One, click here.

NOTE: Please read my Law review article that speaks to above: (March 2015)

Standard-Setting by Non-Governmental Agencies in the Field of Sports Safety Equipment: Promoting the Interests of Consumers or Manufacturers >>

http://digitalcommons.law.umaryland.edu/jbtl/vol10/iss1/4/  


Brooke de Lench is the Executive Director of MomsTeam Youth Sports Safety Institute, producer of THE SMARTEST TEAM: Making High School FootballSafer (PBS) and the author of Home Team Advantage: The Critical Role of Mothers in Youth Sports (HarperCollins). Contact her at delench@MomsTeam.com

 

Do you know about a product that you think MomsTEAM should check out? Send an email to delench@MomsTEAM.com.

0

Women's Hockey: Gold Medal Showdown At Vancouver Olympics Draws Closer

It has been lots of fun watching the U.S. Women's Hockey Team in action live this week, rink-side, in the first three games at the Vancouver Olympics. It has been especially enjoyable because I know so many of the players (and their moms) and have been following them for the past eight years.

Angela Ruggiero Four-Time Olympic Hockey PlayerIt was fitting that Angela Ruggiero, along with Jenny Potter the only four-time Olympians on the team, scored the first goal of the tournament (unassisted) for the U.S. in the opening game, a 12-1 rout of China. Angela also scored the first goal eight years ago in Salt Lake City, the last Olympics I attended. Before the game, she exchanged pins with the Chinese captain, who she had met while working with Project Hope, a non-profit founded by New York Islander owner, Charles Wong, which built 15 rinks in China.

It was also great to see three-time Olympian, Julie Chu, do so well. I met Julie, along with her mom, for the first time after a game against the Hockey East All-Stars at Northeastern's Matthews Arena in the run-up to the 2002 Games. She has always been a strong player but she really has become so much stronger. Her goal and two assists on Sunday were special for a number of reasons: first, they came on Chinese New Year, second, they came against China, the birthplace of her dad, and third, they were cheered by a large contingent of Asian-Canadians.

The second game, a 13-0 blowout of Russia, was more of the same. Another goal from Angela (shot from behind the goal line off the back of the goalie and into the net!), with Julie chipping in with an assist. I liked how, when the U.S. scored a goal early in the third period to go ahead by a baker's dozen, it took its foot off the accelerator and refused to run up the score, settling instead for cycling the puck around the Russian zone instead of putting more shots on goal. A sign of really good sportsmanship!  The final game in group play, a 6-0 win over a scrappy team from Finland, put the U.S. into the semi-finals against Sweden on Monday.

How good are the U.S. and Canada? Clearly, they are head and shoulders above the rest of the field. It should all come down to the gold medal game, although I am sure Angela, Julie and their teammates will make sure that they won't look past Sweden to a final against the Canadian so they won't suffer the same fate as four years ago, when Sweden beat them in a shocking upset to deprive them of the chance to play Canada for the gold.

If all goes according to plan, I will be in the stands with Angela Ruggiero's mom, Karen, and other friends and family of Team USA to see them battle Canada for the gold medal showdown on Thursday, February 25th.

I am hoping that a US v. Canada matchup will do for women's hockey what the 1999 Women's World Cup in soccer did for women's soccer. I was fortunate enough to be in the stands at Giants Stadium for the opening ceremonies that day. Until surpassed by the 100 thousand fans that packed the Rose Bowl for the Cup final between the US and China (highlighted by Brandi Chastain's famous celebration of the winning penalty kick), the crowd in the Meadowlands was the largest to ever see a women's sports event, and the Cup led to a women's soccer pro league the next year.

Women's hockey is a great spectator sport. It has all the speed, stick handling, great goaltending, and sharp passes of the men's game. The only real difference is that, while body contact is allowed, body checking isn't. As a result, women's hockey is actually more wide open and more fun to watch in many ways than the men's game, where all those crunching body checks tend to make the game a lot more choppy - and chippy.

The smooth-as-silk stick handling and goal-scoring moves of players like Canada's Haley Wickenhauser and America's Jenny Potter have been on full display at the Olympics. It would be hard to say that the goals they scored weren't just as pretty as those scored by the NHL's top scorers, like the Penguins' Sidney Crosby.

Not only are they great athletes, but the women who play hockey, as I have found out over the years, are really, really nice people, and work very hard to give back to people in need (more on this later). Because they aren't playing for money, they are playing for the love of the game. In this era of ultra-commercialism in all things sport, they are a breath of fresh air!

Here's hoping for a spine-tingling, edge-of-the-seat game for the gold next week. Stay tuned to this space for reports from Vancouver.

 

 

0

Letting Kids Play Football is Not Child Abuse


The last three weeks have witnessed an all-out assault on the game of football, not coincidentally timed with the beginning of NFL training camps. First came a study reporting CTE in 110 of 111 brains of former NFL players. Following closely on the heels of that media circus was the publication last week of a new book by Dr. Bennet Omalu, Truth Doesn't Have a Side, and interviews in which Dr. Omalu, as he has for several years, argues that letting kids play football is the "definition" of child abuse. The not-so-surprising result has been a tsunami of emails in my Inbox asking for my views on the subject.

On the abuse question, the short answer is that, in my view, parents are not engaging in child abuse simply by allowing their kids to play a collision sport like football before middle school.

Personally, I believe kids should probably delay the start of tackle football until middle or high school. One of my three sons began football at the age of 13 and by the age of 16 he was forced by concussions sustained while snowboarding to retire from both football and lacrosse. Knowing all that I know now about the risks of football (and other contact sports) it would be easy to simply tell parents who allow their children to play tackle football that they are committing child abuse by exposing them to the risk of ending up with CTE, and throw up my hands and walk away in disgust when they don't listen. But, I know better. Not all players who play contact sports have or will develop CTE.

That doesn't mean risk can't and shouldn't be minimized wherever possible. It should. One of my principal missions the past seventeen years has been to do what I can to help minimize the risk of injury in youth sports through training and education of sports parents, coaches and administrators, advocating for rule changes, and by urging the use of safer equipment. After working with youth and high school football programs, producing a PBS documentary, The Smartest Team: Making High School Football Safer, starting a comprehensive sports safety program (SmartTeams), and developing an educational intervention designed to increase honest self-reporting by athletes of concussion symptoms, I can say without hesitation that football is safer now than it has ever been. 

Nevertheless, it is a given that all sports, whether collision, contact, individual or team, involve a certain amount of inherent risk. Football can no more be made completely risk-free any more than riding a bike, skiing down a mountain, or running around on a playground can be made injury-proof. Kids can't live in a bubble, nor should they.

Having said that, there are circumstances in which I believe a parent, or for that matter, a coach or athletic trainer, could be deemed guilty of child abuse - as, for instance, if they allowed a child to return to the playing field knowingthey were experiencing concussion symptoms, thus recklessly exposing them to the risk of a longer concussion recovery, a more serious traumatic brain injury, or even, in very rare cases, death from second impact syndrome.

But unless such recklessness is really extreme, unless it rises to the level of a callous and wanton disregard for a child's safety (e.g. reckless endangerment), I believe the degree of risk a parent is willing to have their child take on is really up to them, such that exposing them to that risk does not rise to level of child abuse.

University of Missouri law professor Douglas Abrams, a juvenile law expert and a youth sports coach for more than 40 years, agrees. "There is no room for prosecuting parents merely for allowing their child to play youth-league or school football," says Abrams. "The Constitution guarantees parents broad discretion to raise their children, so the law requires a strong showing to defeat parental decision-making. Football safety concerns are real and safety advocates should continue to speak out to educate, but parents commit no crime when they decide to allow their child to play the nation's most popular professional and amateur sport." But, Abrams cautions, "A child endangerment prosecution might be appropriate if parents expose their football player to specific health or safety consequences during play, such as by coaxing him to play with a concussion or other serious injury."

In the ideal world, of course, a parent's decision about whether to allow a child to start playing or continue playing collision sports before high school under current rules of play (which are evolving in the direction of safety, fortunately, as seen, for instance, in USA Hockey's ban on body checking at the Pee Wee hockey level and below, limits on full-contact practices instituted at every level of football, from Pop Warner, to high school, college, and the NFL, and a ban on heading in soccer before age 12), will be a conscious and informed in which up-to-date information about the inherent risks of the sport, a consideration of risk factors unique to their child, such as pre-existing learning disabilities (e.g. ADHD ), a history of multiple concussions, seizures, or migraines ), or a reckless and overly aggressive style of play - are balanced against the benefits to the child of participating.

Ultimately, our kids have to rely on their parents to make sure they are doing everything they can to minimize injuries by knowing the risks, and by making sure that, if and when they do suffer a sports injury, such as concussion, they receive appropriate treatment. More than that, I think, we cannot expect.

I say all of this knowing that there is a growing body of research which has linked the playing contact or collision sports for a long period of time, at least for some unknown percentage of athletes, with serious adverse health consequences, not just from concussions but from the cumulative effect of sub-concussive blows to the body or head, impacts which athletes in youth football, lacrosse, rugby, and, until recently, Pee Wee hockey and soccer, suffer on an almost constant basis in both games and practices.

With all due respect to Dr. Omalu, who is a courageous fellow truth-teller and whom I greatly admire, the reality is that, as terrible, frightening, and real as CTE is, especially to those who once played or still play professional football and their families and friends, and as gut-wrenching as it is to see, read about, or hear the stories of athletes whose lives have been affected or cut short by CTE, it is by no means clear whether playing football, especially for the vast majority of those who end their careers in high school, inevitably leads to the development of such neurodegenerative diseases as CTE.

In the final analysis, what I tell parents who are deciding whether to let their child start playing tackle football is, if they do let them play - a decision that is theirs, and not mine, to make - that, before they do, they make sure the program puts their child's safety first: by, among other things, educating coaches, officials, parents, and players about concussions, supplying players properly reconditioned and fitted helmets, proving youth players with helmets designed for their heads that are less than 3.5 lbs., teaching players how to tackle without using those helmets, minimizing the amount of full-contract practice time, creating an environment in which players feel safe in honestly reporting concussion symptoms, ensuring that concussions, when they do occur, are managed properly, and prohibiting players from returning to practice and play until a doctor with concussion expertise decides in the exercise of good clinical judgment that their growing brains have been given all the time they need - and then some - to heal.

Admittedly, in an age in which more and more people tend to gravitate towards opposite ends of the spectrum in their opinions on just about anything (in the case of the great debate about football, either urging parents to find another sport for their child to play or extolling its many benefits while minimizing its risks), the challenge I face - that all those of us who love all sports and are dedicated to making them safer face - in occupying the reasonable, pragmatic, pro-safety middle, is being heard.

For the most part, the national media doesn't seem interested in reporting good news - that there are steps being taken to make football and contact and collision sports such as soccer, lacrosse, and hockey, safer - because it is bad news, scary news, sensational news, that sells, and that some in Concussion, Inc. depend for their very existence on promoting.

From my vantage point, having spent countless hours working with youth and football communities around the country, from talking with football parents, coaches, administrators, athletic trainers, clinicians and academicians, and from becoming educated about the actual facts about the safety of football, I believe that, not only is football a sport worth saving, and that it can be saved, but that those who call for it to simply be abolished, represent an extremely loud but vocal minority.

I simply refuse to be cowed into turning my back on the millions of kids who continue to play the game and their parents, and on the thousands of youth and high school football programs around the country which for the past seventeen years have looked, and continue to look, to me and MomsTeam/SmartTeams for advice on how to make the game as safe as it can be.

In the end, I don't believe it will be those who scream the loudest, the trolls on social media engaged in the politics of emotion, intimidation, and innuendo, who will prevail. It will be those who discuss the risks and benefits of sports calmly, rationally, calmly, and objectively, who work tirelessly to make sports safer, based on science, who will win out.

This blog was originally published on Medium.com on August 14, 2017 


Brooke de Lench is a child athlete safeguards and rights advocate and legal consultant. Founding Executive Director of MomsTeam Institute, Inc., Producer/Director/Creator of the documentary, "The Smartest Team: Making High School Football Safer" (PBS). Director of Smart Teams Play Safe, Publisher of MomsTEAM.com, and author of Home Team Advantage: The Critical Role of Mothers in Youth Sports (HarperCollins). Brooke is also a founding member of the UN International Safeguards of Children in Sports coalition and is an active adviser for the CDC Heads Up brain injury prevention program.

Follow me on Twitter @brookedelench and share your story with me at delench@MomsTeam.com

Note: In the interest of full disclosure, neither I nor MomsTeam Institute, the non-profit of which I am the Founding Executive Director, has ever accepted any donations from the NFL, USA Football, Pop Warner, or any equipment manufacturer. In order to remain fully independent and objective, this has always been our policy.

 

 

0

CTE: Is The Media Scaring Young Athletes To Death?

As someone who has been educating sports parents about head trauma in sports for the past seventeen years, and about the very real risk posed by chronic traumatic encephalopathy (CTE) for the last decade, it is not surprising that I receive emails from parents all the time expressing deep concern about stories in the media that have led them - wrongly - to fear that playing contact or collision sports, or suffering a sports-related concussion, especially one slow to heal, makes it inevitable that their child will develop CTE and is at greatly increased risk of committing suicide.

When a recent email prompted me to pick up the phone to talk to one concerned mother, she told me that her son - who had suffered a concussion playing indoor lacrosse, but, seven months later, and after seeing a number of concussion specialists, was still experiencing symptoms - was giving up hope of ever getting better. Most disturbingly, she said he had begun expressing the belief that he might be better off dead, because at least then he would no longer be a burden to his family and community and, if his brain ended up in a jar next to those of other athletes who also had CTE, perhaps he might find a place in medical history.

My reaction was one of sadness, frustration, and worry: sadness that a young athlete simply assumed that he had CTE as a result of a single concussion and considered it to be a death sentence; frustration that, despite concerted efforts by researchers and clinicians, along with some in the media, to set the record straight on CTE, the prevailing media narrative continues to be that concussions or repetitive subconcussive blows "cause" chronic traumatic encephalopathy (CTE), that CTE "causes" former athletes to commit suicide, and that such causal links are proven scientific fact (they're not); and, finally, worry: concern about the consequences of the football=CTE and CTE=suicide memes in the real world.

For the authors of a 2016 editorial in the British Journal of Sports Medicine the tragic case of a former NHL player, Todd Ewen, is Exhibit A of those real-world consequences. Suffering from bouts of depression - which he was convinced were the result of CTE - and terrified at the thought of a future living with an untreatable neurodegenerative disease, Ewen committed suicide at age 49. But before an autopsy could even be performed, the media's verdict was in: his depression and suicide were most likely the result of a career in the NHL, repetitive head trauma, and the inevitable onset of CTE. A subsequent autopsy, however, found no evidence of CTE.

How, asked the authors - three researchers at Vanderbilt and an epidemiologist at the University of North Carolina - Chapel Hill - did an athlete with treatable depression come to believe that he had an untreatable condition and commit suicide? Because, they asserted, the media, ably aided and abetted by Dr. Ann McKee of the Department of Veterans Affairs and Boston University's CTE Center, along with the PBS series, Frontline, had for years been using the results of autopsies of the brains of a small, self-selected group of former athletes to create a "sensationalized state of fear" about CTE.

To make matters worse, they argued that many in the media - most especially, in my personal experience, those active in social media - not only ignore and/or severely criticize research findings that don't fit the football=CTE and CTE=suicide narrative, but label anyone who dares to challenge that narrative or call for further study a ‘CTE denier' or a ‘shill' trying to advance their own vested interests,* confuse the public and conflate the issues, or all the above.

Are cases like Ewen outliers or do they represent an increasingly common and worrisome phenomenon? Unfortunately, it appears to be the latter. Every clinician who routinely treat athletes with post-concussion syndrome (i.e. patients whose symptoms after suffering a sports-related concussion persist for months or years), with whom I spoke for this article expressed variations of the same concern: that their patients, hearing media reports about athletes suffering symptoms associated with CTE (such as depression), were losing hope of a full recovery, to the point of considering suicide.

"As a clinician, I see patients that come to our clinic months and years after they've been diagnosed with a concussion," said Shannon Bauman, MD, director of the Concussion North Clinic in Barrie, Ontario, Canada. It is "very concerning," she said, "when my patients share their story and fears that they will not recover, and are being told by physicians and other health care providers that they trust that they will likely not get better and that living with lingering symptoms was likely to be their ‘new normal.' Without hope, patients begin to believe that they will not recover," Bauman said. "For young athletes, this can be devastating. Without hope, they begin to believe the messaging from media focusing on professional athletes who have died and been found to have CTE. This takes a great toll on the mental health of a patient recovering from a prolonged concussion leading to increased anxiety and depression, and even thoughts of suicide."

The problem, argues Bauman, is that too many media stories focus on professional athletes, CTE, and poor outcomes of prolonged concussion (or sports exposure to repetitive head trauma), and [there are] too few stories about athletes who make full recoveries and improve (even after years of concussion symptoms). This unbalanced media coverage further fuels the mindset of the public and patients who are now believing that they, too, may not recover. We need to restore hope and share positive stories of the many patients who do recover and the importance of having medical treatment and care provided by those who have an interest in managing cases of persistent symptoms."

Likewise, in her practice, Elizabeth Pieroth, Ph.D., Associate Director of North Shore University Health System's Sports Concussion Program, says she has seen a number of youth patients (athletes and non-athletes) who have sustained a concussion and believe they now have or are going to develop CTE. "On too many occasions, I have had young people crying in my office that they were going to ‘die of CTE,' even after just one concussion."

As heartbreaking as such encounters are, said Dr. Pieroth, she saw a silver lining: at least they afforded her the opportunity to educate them on the current state of the science on concussions and CTE. "What worries me," said Dr. Pieroth, "are the countless people who have the same fear but are not being seen by healthcare professionals with the appropriate training and experience to adequately address this issue."

The experience of Rosemarie Scolaro Moser, Ph.D, Director of the Concussion Center of New Jersey, was much the same. "In the past year, we've seen more young athletes at our Center who are overly anxious and worried about CTE," she said. "This worry has become irrational to the point that they are afraid to engage in normal activities for fear of further brain damage, even when it is clear to us that they have recovered. It's as if they have equated the diagnosis of concussion with doom and a sentence of irrevocable brain damage." She pointed to one patient, a high school athlete, who had clearly recovered from his concussion - to the point that he was performing in the superior range on neuropsychological testing and getting As in school - who was nevertheless so worried, anxious, and paranoid about hurting his head again that he thought he'd suffered another concussion when he happened to turn his head quickly from side to side! She wondered whether the media frenzy over CTE was creating a new medical condition she dubbed "Concussion Anxiety Syndrome."

Like Dr. Pieroth, she said that it was the responsibility of concussion specialists to directly address the emotional component of concussions and undo the myths to which athletes and their parents have been exposed as result of the "media hype" about CTE. "It's not always easy undoing the misinformation out there. Now, it is my job not only to help manage the concussion and facilitate recovery, but to challenge the myths and educate athletes and parents about the facts. We still do not have clear, medical, scientific data that indicates that concussion leads to CTE. We still don't know enough about it. We do know that most concussions resolve, that we should expect concussions to resolve, and that there are plenty of athletes who have had multiple concussions who do not have the emotional disturbance, brain damage, and suicidality that may be portrayed in the media

Media reports on the finding by Dr. McKee and her colleagues in a new study reported in the Journal of the American Medical Association that 110 of 111 deceased NFL players her group had autopsied had CTE will undoubtedly take the level of fear among sports parents and present and former athletes in all contact and collision sports alike to even more frenzied heights.

While I was encouraged by the amount of push-back from scientists, clinicians, and researchers objecting to the way in which the media has covered the story, and cautioning that the facts about CTE are far more nuanced and uncertain that many in the media would have us believe, I am concerned that their voices aren't being heard. For every article by a scientist calling for an "end to the media and public hysteria," and for both sides to "stop campaigning for their agenda and to let science take the lead," there are one hundred, or even one thousand, which will do nothing more than repeat the scariest of the study's findings: that 99% of those who played in the NFL whose brains were autopsied had CTE.

I worry that lost amidst the hoopla about the new CTE study is the fact that not every football player whose brain was donated to the CTE Center for pathological scrutiny was found to have the disease, and, that it was not detected in either the brains donated by the families of football players who died before they got to high school, and in only three of fourteen of high school players (and, in those, the disease had not progressed beyond the "mild" stage).

What I found most surprising was, that as far as The New York Times and Dr. McKee were concerned, her study didn't add to the debate about the football=dementia narrative; it ended it. According to the Times - which is widely acknowledged to have originated the football=CTE and CTE=suicide narrative in a January 18, 2007 article - all that was left for scientists to figure out was "how many blows to the head, and at what levels, must occur for C.T.E. to take hold."

Not only was that assertion completely at odds with the uncertain state of the existing science, but it was contradicted by the study itself, in which Dr. McKee and her colleagues acknowledged that several other factors, besides prior participation in football, may influence CTE risk and disease severity, including factors other than cumulative hits to the head, and admitted that it was even "unclear" what roles concussions and repetitive subconcussive hits play in CTE risk, disease severity, and progression.

That the Times didn't report these findings, much less bother to interview anyone for the article other than Dr. McKee, wasn't at all surprising to me (and, I'm sure, to many scientists) for one simple reason: such uncertainty didn't fit the Times' 10-year football=CTE meme.

Educating sports parents and athletes about head injury safety is tough enough without the media's sensationalist reporting, but it does come with its rewards. Recently, I received an email from a mother asking for help for her son, an ice hockey player, who was struggling with post-concussion syndrome to the point he was suicidal. I reached out to the clinicians on our organization's Head Injury Advisory Board to see if anyone could help. One of our members responded immediately, and, working with the athlete and his family, has developed and implemented a treatment plan that is putting him on the road to recovery. I would like to think that I played a part, however small, in that positive outcome.

Now, if only the media could focus its energies on educating the public instead of sensationalizing head injuries in sports, perhaps we could stop creating such a climate of fear that athletes end up literally being scared to death.

Share your story with me at delench@MomsTEAM.com

* In the interest of full disclosure, neither I nor MomsTeam Institute, the non-profit of which I am the Founding Executive Director, has ever accepted any donations from the NFL, USA Football, Pop Warner, or any equipment manufacturer. In order to remain fully independent and objective, this has always been our policy.

This blog was originally published on Huffington Post on August 9, 2017 


Brooke de Lench is a pioneer in child athlete safeguards and rights, a risk reduction in sports and legal consultant. Founding Executive Director of MomsTeam Institute, Inc., Producer/Director/Creator of the documentary, "The Smartest Team: Making High School Football Safer" (PBS). Director of Smart Teams Play Safe, Publisher of MomsTEAM.com, and author of Home Team Advantage: The Critical Role of Mothers in Youth Sports (HarperCollins), Brooke is also a founding member of the UN International Safeguards of Children in Sports global coalition.

She can be reached by email delench@MomsTeam.com, and you can follow her on Twitter @BrookedeLench.

 

 

 

0

Creating A Culture Of Concussion Safety Requires Teamwork All Season Long, Not Just One Day

 

If your child plays a contact or collision sport, whether at the youth, middle school or high school level, chances are they will suffer a concussion at some point in their athletic career. How quickly they recover may depend on how soon after injury - if at all - their concussion is identified so they can be removed from practice or game action. The problem is that concussion signs - still the best way to identify a concussion - are difficult to spot, and athletes often hide their symptoms. The consequences of such unreported and undiagnosed concussions range from a longer recovery up to and including, in rare cases, catastrophic injury and death.Newcastle OK football players

One way to improve the chances that an athlete's brain injury is identified is for teams to employ a "buddy" system in which team members are assigned to watch for signs of concussion in designated teammates and, if they spot signs, or if their teammates tell them they are experiencing symptoms, are encouraged or required to immediately report the possible injury to the athletic trainer or the coach.

While I had been advocating the use of a buddy system for many years in every sport, it was not until five years ago, during the taping of our PBS documentary, "The Smartest Team: Making Football Safer," in Newcastle, Oklahoma that I began to truly appreciate not just how culturally entrenched was an athlete's reluctance to self-report concussion symptoms but also the part a buddy system could play in changing that culture.

At a players-only meeting at the beginning of pre-season, and in interviewing athletes in small group and one-on-one, nearly every football player I spoke to freely admitted that they would not self-report concussion symptoms.

"If I can get up and walk away from it, yeah, I'll probably keep playing," one said.

"You see some dots and they go away ... so you just keep playing through it. It's my senior year," said another.

"As long as I can still see and keep my balance, as long as I'm not feeling dizzy, head injuries are all right," acknowledged a third.

Typical was what one player told me: "There was a time that I've gotten a concussion. I didn't think much of it, you know, just a headache, move on with it, keep playing. ... Got hit pretty hard, helmet to helmet, couldn't see, saw stars everywhere, just went back on the field, started playing again. Didn't need to tell anyone. I mean it's not like I was laying down, couldn't get up or anything. But I thought I was fine."

(He wasn't, of course, and should have told someone and removed himself, or been removed, from the game)

My anecdotal experience in Newcastle was that instituting a buddy system - not just players watching teammates but cheerleaders keeping an eye out for players showing signs of concussion - helped, although it's hard to say how much. One of the players recounted how he had noticed a teammate who seemed really "out of it" at practice one day. When he told the coach, his teammate "got really mad." But he said he was undeterred, because he "knew it was going to help [his teammate] in the long run."

Another player told me that, "As far as the buddy system goes, I know that we need to keep each other's backs, like me and Justin have each other's backs as far as like, if I get a concussion or he had gotten a concussion, then you know, make sure he's OK. If he's out of it, you know, can't answer simple questions, go alert the coaches. He got mad at me, but I learned it was the right thing to do."

One of the players recounted how he had noticed a teammate who seemed really "out of it" at practice one day. When he told the coach, his teammate "got really mad." But he said he was undeterred, because he "knew it was going to help [his teammate] in the long run."

Given my experience in Newcastle, I was not surprised when, three years later, a 2015 study suggested that a buddy system, while it does not remove the need for honest self-reporting by athletes themselves or place final responsibility on teammates for each other's health behaviors, may be an important step towards creating a culture of concussion safety on sports teams.

What I learned from working with the Newcastle team, and with youth football programs across the country over the years is that traditional concussion education in which athletes, coaches, and parents are taught the signs and symptoms of concussion, and the health risks of concussion and repetitive head trauma, isn't working to change the concussion reporting behavior of athletes. Between 40 and 60 percent of all concussions - and a much higher percentage of so-called "bell-ringer" events - still go unreported; indeed, a recent study found that four out of 10 athletes with concussion signs or symptoms return to play that same day. It has become increasingly clear that the problem isn't a lack of knowledge. Rather, it is the attitudes and beliefs of athletes about concussion reporting, what they think might happen to them if they report, and what they think are negative attitudes of coaches, teammates, parents, and fans about concussion reporting which combine to create a climate which discourages reporting.

In the age of social media, such negative attitudes by teammates about honest self-reporting can take the form of cyber-bullying and shaming. "As health care providers dealing with concussions, we need to be aware that many concussed patients may be bullied or shamed on social media by friends or teammates who may not believe that they are experiencing concussion symptoms, or that those symptoms are lingering," notes Mark Halstead, M.D., a sports medicine physician and Director of the Washington University Sports Concussion Clinic & Young Athlete Center.

The answer, then, is to work to change attitudes about concussion symptom reporting so that honest reporting is viewed as a valued team behavior and a hallmark of a good teammate. Like the Centers for Disease Control and an increasing number of concussion experts, I believe that the best way to increase the rate at which athletes report concussion symptoms, either their own or their teammates, is for coaches, parents, medical staff to work as a team to change reporting behavior - to reshape the culture around concussion reporting - by changing individual and team reporting attitudes and norms and by creating a climate in which athletes feel comfortable reporting their symptoms.

Available free of charge on MomsTEAM's new SmartTeams concussion website, the #TeamUp4ConcussionSafetyTM program, developed by MomsTEAM Institute as part of its SmartTeams Play SafeTM initiative with a Mind Matters Educational Challenge Grant from the National Collegiate Athletic Association and Department of Defense, is designed to do just that: to increase reporting by athletes of concussion symptoms by engaging coaches, athletes, parents, and health care providers in a season-long, indeed career-long program which emphasizes that immediate reporting of concussion symptoms - not just by athletes themselves but by their teammate "buddies" - not only reduces the risk the athlete will suffer a more serious brain injury - or, in rare cases, even death - but is actually helps the team's chances of winning, not just in that game, but, by giving athletes the best chance to return as quickly as possible from concussion, the rest of the season, and by teaching that honest reporting is a valued team behavior and a hallmark of a good teammate.

The rate at which student-athletes immediately and honestly report experiencing concussion symptoms, both their own and their teammates, will only begin to increase if all stakeholders first understand how much they know about concussions, and about their own attitudes towards and beliefs about symptom reporting. Our five-part program begins by asking coaches, athletes, athletic trainers, and parents to take a series of quizzes designed to test their concussion knowledge, and, more importantly, whether they view concussion symptom reporting in a positive or negative light.

While knowledge and awareness of concussion has increased substantially over the seventeen years that MomsTEAM/SmartTeamsTM has been engaged in concussion education, research shows that there are still important gaps that need to be filled. To fill them, coaches, parents, and athletes will be encouraged in Step Two in the #TeamUp4ConcussionSafety program to continue learning about concussions by taking our online concussion education course.

Because studies show that one-off concussion education isn't enough to change concussion symptom reporting behavior, Step Three in the SmartTeams Play SafeTM #TeamUp4 ConcussionSafetyTM game plan calls for coaches, athletes, athletic trainers, team doctors (and, at the youth and high school level, parents) to attend a mandatoryconcussion safety meeting before every sports season to learn in detail about the importance of immediate concussion symptom reporting, not just in minimizing the risks concussions pose to an athlete's short- and long-term health, but in increasing the chances for individual and team success. (As I have learned from long experience with youth and high school sports programs, making attendance at a concussion safety meeting voluntary virtually guarantees a lot of no-shows.)

Anecdotal evidence from NCAA Division I football programs suggests that the signing by athletes of pledges acknowledging their responsibility to report concussion symptoms increases the rate of reporting by athletes, both of their own symptoms and those of teammates. Because improving concussion safety requires a team effort, we believe that all those with a stake in concussion safety should sign pledges, not just athletes. Step Four of our concussion safety game plan thus calls for athletes, coaches, parents, and medical staff to demonstrate in a tangible way their commitment to creating a culture in which immediate reporting of concussion symptoms by athletes is a valued team behavior and the sign of a good teammate by signing a concussion safety pledge at or shortly after the pre-season concussion safety meeting,

And, finally, because prevailing attitudes towards concussion symptom reporting and reporting behavior are deeply entrenched in our sports culture, we encourage, as Step Five, that coaches, athletes, athletic trainers, team doctors, and parents continue working over the course of the sports season to create and maintain an environment in which athletes feel safe in immediately reporting concussion symptoms (both their own and their teammates) by sharing and reinforcing positive messages about the importance of immediate concussion symptom reporting via social media, by maintaining open lines of communication and an ongoing dialog about concussion safety among and between and among coaches, athletes, medical staff and parents.

With consistent messaging and constant reinforcement of the value of immediate concussion reporting in achieving your team's performance goals, and by making athletes feel comfortable in reporting, we believe that, not only will attitudes and beliefs about concussion reporting begin to change, but the concussion reporting behavior of your athletes will start to change as well, and that, over time, the culture of resistance to concussion symptom reporting will be replaced by a sports culture of concussion safety.

First published on Huffington Post on September 11, 2017 


Brooke de Lench is a pioneer in child athlete safeguards and rights, a risk reduction in sports and legal consultant.  She is Founding Executive Director of MomsTeam Institute, Inc., Producer/Director/Creator of the documentary, "The Smartest Team: Making High School Football Safer" (PBS). Director of Smart Teams Play Safe, Publisher of MomsTEAM.com, and author of Home Team Advantage: The Critical Role of Mothers in Youth Sports (HarperCollins), and Brooke is also a founding member of the UN International Safeguards of Children in Sports global coalition.

She can be reached by email delench@MomsTeam.com, and you can follow her on Twitter @BrookedeLench.

0

Are Parents Who Allow Young Athletes To Play Contact or Collision Sports Guilty of Child Abuse?

As long-time visitors to MomsTeam or readers of my blog and 2006 book, Home Team Advantage, know, I have always taken a somewhat expansive view of what constitutes child abuse in the context of sports. 

Among other things, I have long advocated for adoption by the United States of the protections against abuse contained in the U.N. Convention on the Rights of the Child [Update: as of December 11, 2015, the U.S. was the only country in the world that has not signed the convention] and believe that a parent or coach who knowingly allows a child to continue to play while injured, or recklessly exposes a child to an unreasonable risk of sports injury, is engaging in child abuse.

So, when I was asked in a recent radio interview, whether I viewed parents who allow their children - particularly elementary school age-children  - to participate in collision sports as committing child abuse, I had to stop for a moment to think.  

On the one hand, there appears to be a growing body of research suggesting that playing contact or collision sports for a long period of time likely has, at least for some unknown percentage of athletes, serious adverse health consequences, not just from concussions but from the cumulative effect of sub-concussive blows to the head, blows which athletes in youth football, lacrosse, and, until recently, hockey, suffer on an almost constant basis in both games and practices.  Such evidence. while far from conclusive, has raised alarm bells among some in the youth sports community and prompted at least one leading concussion expert, Dr. Robert Cantu, MomsTeam's concussion expert emeritus, to recently recommend that kids not play such sports until middle or high school, at least under current rules.

On the other hand, while I personally think Dr. Cantu's recommendation is worthy of serious consideration, I don't believe parents who allow their kids to start or continue to play collision sports before middle school are engaging in child abuse.

Here's why:

  • All sports, whether collision, contact, individual or team, involves a certain amount of risk. Risk of injury is inherent to sport, and sport cannot be made completely risk free any more than riding around on a bike or running around on a playground can be made injury-proof.1  Kids can't live in a bubble, nor should they.
  • That doesn't mean risk can't and shouldn't be minimized wherever possible.  It should.  One of my principal missions, from even before MomsTeam was launched in 2000, has been to minimize the risk of injury in youth sports through training and education of sports parents, coaches and administrators, advocating for rule changes, and by urging the use of safer equipment.
  • While there is a level of risk at which a parent could be deemed guilty of child abuse - say, for instance, by allowing their child to return to the playing field knowing that they are still experiencing concussion symptoms, and thus recklessly exposing them to the risk of a further delay in concussion recovery, long-term brain injury, or even death from second impact syndrome - unless their recklessness is really that extreme, I believe the degree of risk they are willing to have their child take on is really up to them, such that exposing them to that risk is not, in my view, child abuse.

 

Knowledge is power

In the end, it all comes back to education: In the ideal world, a parent's decision about whether to allow a child to start playing or continue playing collision sports before high school under current rules of play (which are evolving in the direction of safety, fortunately, as seen, for instance, in USA Hockey's ban on body checking at the Pee Wee hockey level and below, and limits on full-contact practices instituted at every level of football, from Pop Warner, to high school, college, and the NFL), will be a conscious one; a decision in which the risks of participating in a particular sport - provided it is based on the most up-to-date information about those risks and a consideration of other risk factors that might come into play for their child, such as pre-existing learning disabilities (e.g. ADHD), chronic health conditions (e.g., a history of history of multiple concussions or seizures, history of migraines), or a reckless and overly aggressive style of play - are balanced against the  benefits to the child of participating.

Ultimately, our kids have to rely on their parents to make sure they are doing everything they can to minimize injuries by knowing the risks, and by making sure that, if and when they do suffer a sports injury, such as concussion, they receive appropriate treatment. More than that, I think, we cannot expect.  


Brooke de Lench is Executive Director of MomsTEAM Youth Sports Safety Institute, Founder and Publisher of MomsTEAM.com, producer/director of the PBS documentary, The Smartest Team: Making High School Football Safer, and author of Home Team Advantage: The Critical Role of Mothers in Youth Sports (HarperCollins)  

1. The Centers for Disease Control's study on traumatic brain injuries in youth and high school sports and recreational activities agrees.  "Risk for TBI," it says, "is inherent to physical activity and can occur during any activity at any age."   Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report (MMWR). Nonfatal Traumatic Brain Injuries Related to Sports and Recreation Activities Among Persons Aged ≤ 19 Years -- United States, 2001-2009; 2011; 60(39):1337-1342 (http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6039a1.htm?s_cid=mm6039a1_e&s...)(accessed October 7, 2011).  Interestingly, riding a bike and playground were number one and number three on the list of activities resulting in emergency room visits for traumatic brain injury overall (8.1% and 7.9% respectively), second and third among males under age 19 (16.5%, 7.8%), second and first among girls (11.8%, 14.2%), and number one and two for boys and girls aged 9 or younger.   

MomsTEAM Institute of Youth Sports Safety, Inc. is a registered 501(c)(3) tax-exempt organization which relies on donations from readers like you. Help us continue to provide the best in youth sports safety and parenting information by making a donation today.  

 

0

Chronic Under-Reporting Of Concussion: Is Changing The Culture A Realistic Solution?

 

If your child plays a contact or collision sport, whether at the youth, middle school or high school level, odds are that at some point in their athletic career they will suffer a concussion. How well they recover depends a lot on how quickly their concussion is identified so they can be removed from practice or game action. 

A lot of student-athletes - a declining percentage, fortunately - don't appreciate precisely when they have suffered a concussion. There are a lot of reasons:

  • the symptoms may not appear right away (as one recent study of college athletes  (1) found, 23% of diagnosed concussions were delayed, on average, 17 hours, and another 27% had unspecified onset (1,2), or  
  • they don't know the symptoms, or
  • they are not functioning at their cognitive baselines and do not recognize they have suffered an injury (2) or 
  • because they don't appreciate that concussions, however mild, are traumatic brain injuries (3,4,5), or 
  • because they still believe that a  loss of consciousness (LOC) is required for a concussion (again, the message that a concussion doesn't require LOC, and that, in fact, the vast majority of concussions - 90-95% of all concussions in high school sports - do not involve LOC, seems to be sinking in). (6)

Code of silence

Unfortunately, the problem is that, even for athletes who realize that they have suffered a concussion, there is still a very good chance (more than 50% in one oft-cited 2004 study (4) but probably much higher) they won't self-report symptoms to sideline personnel, much less voluntarily remove themselves from the game.  

Why?

For a variety of reasons, it seems, but mostly, I think, because the very culture of the contact or collision sport they are playing, and their own self-concept as invincible, strong adolescents, encourages them to remain silent:

  • to avoid jeopardizing their spot in the starting lineup or letting their teammates down; (3)
  • to avoid being seen as weak or cowardly by their coach or teammates, or even their parents; (3)
  • to demonstrate to the coach and their teammates that they can "take a hit like a man,"
  • to show that they can be as tough as their professional heroes;
  • because they fear they will be held out of play; (7
  • because they want to win the game at all costs; orThe Smartest Team
  • because they believe that the glory of individual and team success, the promise of a college scholarship, or the lure of a lucrative professional career, is somehow worth the risk of lifetime impairment from continuing to play with concussion symptoms.

That all of these forces conspire to prompt kids to be reluctant, indeed, unwilling to self-report concussion symptoms was driven home to me during the filming of MomsTEAM's PBS documentary, The Smartest Team.  Nearly every football player I interviewed for the film freely admitted that they would not self-report concussion symptoms.  Here is just a sampling of what they told me:

  • "If I can get up and walk away from it, yeah, I'll probably keep playing."
  • "You see some dots and they go away ... so you just keep playing through it. It's my senior year."
  • "As long as I can still see and keep my balance, as long as I'm not feelin dizzy, head injuries are all right."

I have been hearing and reading a lot lately about how we need to "change the culture" of football and encourage honest self-reporting by athletes of concussion.  It is seems clear from the research that if players don't tell anyone that they or a teammate are experiencing concussion symptoms and continue to play, they are increasing the chances their recovery will take longer, and, worse, expose them to increased risk of an even more serious brain injury, or, in very rare circumstances, catastrophic injury or even death from second impact syndrome.

Several years ago, HBO's Real Sports did a segment on high school sports concussions featuring the tragic story of Ryne Dougherty, a Montclair, New Jersey football player who died in 2008, likely from second impact syndrome, when he suffered a blow to the head when he returned to play, despite having confided to teammates that he was still experiencing headaches from an earlier concussion.

As needless as Ryan's death was, even more shocking was that his teammates, when asked if, knowing what they knew now about the dangers of playing with concussion symptoms, they would still hide their concussion symptoms in order to play, they still all answered without equivocation, "Yes."

Indeed, an ESPN poll of players, coaches, parents and athletic trainers in 23 states (8) found that players  - the ones whose brains are being rattled and who are putting themselves at risk of adverse long-term health consequences from concussions - are still the group least concerned about concussions. (Again, it's not surprising: teenagers all think they are invincible, which leads them to engage in a lot of risky behaviors)

When asked whether, if a star player got a concussion, they would rather lose the state title game as he sat out than win it because he chose to play with a concussion, more than half (54.1%) of the 300 players in the ESPN survey said they would play the star compared to 9% of athletic trainers, 6.1% of parents, and 2.1% of coaches. A majority of players (55.4%) also felt that a headache - far and away the the number one reported symptom of concussion - shouldn't disqualify them from returning to the same game.

The survey results were consistent with my anecdotal experience in talking to players for The Smartest Team.  Typical was what one player told me: "There was a time that I've gotten a concussion. I didn't think much of it, you know, just a headache, move on with it, keep playing. ... Got hit pretty hard, helmet to helmet, couldn't see, saw stars everywhere, just went back on the field, started playing again. Didn't, didn't need to tell anyone. I mean it's not like I was laying down, couldn't get up or anything. But I thought I was fine."   (He wasn't, of course, and should have told someone and removed himself, or been removed, from the game)

Yes, it is critically important that all athletes playing a contact or collision sport (including not only football, hockey and lacrosse, but soccer, basketball, cheer, and baseball), understand the symptoms of a concussion (things they feel) and appreciate the range of damaging health consequences they can suffer if they don't report them and keep playing, from making another concussion much more likely to long-term cognitive (concentration, memory, reasoning) and emotional difficulties (e.g. depression) to, in rare instances, catastrophic injury or death (e.g. second impact syndrome).  We should do everything we can to encourage honest self-reporting.  

We also need to encourage reporting by players about concussion symptoms being experienced by their teammates (One of the things I stressed at the players meeting back in June 2012 before the season began was the need for a "buddy system.")  My experience in Oklahoma gave me some reason to be cautiously optimistic that, by educating players and parents, and by enlisting the help of coaches, we can increase the number of athletes who are willing to self-report and use the buddy system.  

One of the players on the Oklahoma team we followed in the fall of 2012 appears in the documentary telling me that he had a friend on the line who seemed really "out of it" at practice one day.  When he told the coach, his teammate "got really mad."  But he was undeterred, because he "knew it was going to help [his teammate] in the long run." Another player told me that, "As far as the buddy system goes, I know that we need to keep each other's backs, like me and Matt have each other's backs as far as like, if I get a concussion or he had gotten a concussion, then you know, make sure he's OK. If he's out of it, you know, can't answer simple questions, go alert the coaches."

But while I saw some progress in terms of self-reporting and use of the buddy system during my time in Oklahoma, I don't think we can count on changing overnight a deeply entrenched culture as a panacea in solving the chronic problem of under-reporting.

In fact, the evidence continues to be that athletes are resistant to such culture change, despite increased education.  Two studies [reported after this blog originally appeared] (13,14)  by researchers at Cincinnati Children's Hospital (2) of 120 high school football players, 30 of whom had suffered a concussion,  found that, while three-quarters had received concussion education, and 9 out of 10 recognized the risk of serious injury if they returned to play too quickly:

  • an astounding 91 percent felt that it was okay for an athlete to play with a concussion
  • 75 percent said they would play through any injury to win a game
  • 53 percent said they would "always or sometimes continue to play with a headache sustained from an injury,"
  • Only 54 percent would "always or sometimes report symptoms of a concussion to their coach," and
  • Only 4 in 10 would tell their coach immediately if they had concussion symptoms. 
Were the athletes with more concussion education more likely to self-report? Sadly, no. Researchers found that athletes with higher concussion knowledge scores were not significantly more likely to have a better attitude about self-reporting than those with lower concussion knowledge scores.

Are impact sensors the solution? 

One possible way around the problem: to avoid relying on athletes themselves, game officials and/or sideline observers to call for a concussion assessment, but to instead employ real-time monitoring of head impact exposure (e.g. number, severity, location, and cumulative impact) at all levels of football, and other helmeted and non-helmeted contact and collision sports where practical, to allow for early recognition and management of brain injury. (9,11,12)  

"The identification of a potentially injurious impact or series of impacts via real-time monitoring of head impact exposure in athletes may [not only] facilitate the early recognition and management of brain injury in helmeted sports," argues Richard M. Greenwald, PhD of the Thayer School of Engineering at Dartmouth College, lead author of an editorial in the March 2012 Clinical Journal of Sports Medicine (9) but "permit early intervention, potentially in advance of an injury, rather than simply as a management tool post injury."

Benefits of real-time hit monitoring  

While monitoring will not eliminate brain injuries altogether, the benefits of early identification and prevention of further injury are numerous:

  • Sideline personnel will benefit from objective data that might inform their medical decisions; [9,11,12]
  • Parents will benefit from reduced reliance on honest self-reporting of concussion symptoms by athletes and of the observational skills of sideline management in spotting signs of concussion;
  • Teams will benefit by having healthy, unimpaired athletes on the field more often; and
  • The student-athlete and professional athlete will benefit the most from reduced exposure to potentially injurious blows and from the "conundrum of having to self-report an injury that they may not recognize as being potentially injurious or dangerous in the moment of competition."  

As co-founder of Simbex, LLC, the Lebanon, New Hampshire company that makes the HITS (Head Impact Telemetry System) - a peer-reviewed, scientifically-validated technology used by researchers in biomechanical studies to measure head impacts on the playing field - Greenwald knows a thing or two about the technology of head impact exposure monitoring.  That his company might benefit from the widespread monitoring he and his colleagues at Simbex propose in the editorial, however, does not make their recommendation any less important. 

Writing about head impact sensors in the March 2013 issue of the British Journal of Sports Medicine (11) Jeffrey S. Kutcher, MD, of the Department of Neurology and Michigan Neurosport at the University of Michigan, observes that the "development of easily deployable sport equipment-based accelerometer systems ... provide[s] two unique and potentially useful, clinical opportunities:

The first is the ability to monitor impacts during the course of an athletic event for the purpose of screening for potential injury. Although many researchers have analyzed impact counts and characteristics across a variety of settings in the hopes of establishing force 'thresholds' for injury, no such threshold has been discovered.  As efforts to improve impact-monitoring accuracy continue, however, so will the search for the 'concussion threshold.'  At the same time, there may be a separate, but similar role for the real-time tracking of impact forces.  Although an on-board accelerometer system may not be able to accurately predict injury, it may have utility as a screening device by alerting sideline personnel of an impact that has occurred above a predetermined magnitude that triggers either observation or clinical evaluation of an athlete.  Although there are currently no published studies to support the use of impact sensor systems in this manner, and a 'concussion threshold' is unknown, the potential clinical utility should be carefully considered.

The second potential clinical benefit of impact monitoring systems stems not from the idea of monitoring impacts for the presence of an acute injury-generating hit, but from the potential advantage of acruately cataloguing the number of hits and post-impact head acceleration being experienced by an athlete over time.  Some have suggested that the idea of a 'hit count' that is kept for athletes over the course of a game, practice, week, month, season or career.  This concept is fairly new and, as yet does not have published data to suggest that any particular level or number of hits has significant clinical meaning for any particular sport or position.  Nonetheless, individual athletes may feel there is a benefit to having an estimate of forces their brain experiences over time. 

Head impact monitoring systems 

The day when monitoring of head impact exposure in football and other helmeted sports becomes commonplace may be closer at hand than one might think, as a number of helmet sensor products are already on, or about to come on, the market designed to capture the kind of data that not only Greenwald and his colleagues, but other concussion experts say is needed as a way around the underreporting/under-identification problem.

Watch this space. 

October 24, 2015 update: While the number of impact sensor products on the market or in development has grown exponentially since I wrote this blog back in February 2013, my direct, first-hand experience working with a host of sensor manufacturers and teams at both the high school, and for the past two years, at the youth football level, leads me to believe that, cost, reliability, specificity and sensitivity hurdles have pushed the day when widespread use of impact sensors as what one sensor company CEO called another "tool" in the concussion toolbox, or "another set of eyes" for an athletic trainer on the sports sideline to help him or her spot athletes who should be checked out for possible concussion, can be realistically achieved.  

While MomsTEAM and I continue to see sensors as holding out the promise of a technological solution to chronic under-reporting (which preliminary data collected during the 2014 season and presented to the American Academy of Pediatrics' 2015 Annual Meeting in Washington, D.C. suggests has not gotten better over the past ten years), our primary focus in the coming months and years to develop, under a NCAA-Department of Defense "Mind Matters Challenge" grant, a multi-media program designed to change the culture of sports from one of resistance to one of safety, and fight chronic under-reporting by working with coaches, athletic trainers, parents, and players to create an environment in which athletes feel safe in honestly self-reporting concussion symptoms.


1.  Duhaime A, Beckwith J, Maerlender A, McAllister T, Crisco J, Duma S, et. al. Spectrum of acute clinical characteristics of diagnosed concussions in college athletes wearing instrumented helmets. J Neurosurg. 2012; 117(6):1092-1099 (epub ahead of print October 2, 2012. DOI: 10.3171/2012.8.JNS112298).

2.  Ellenborgen R. Sports and Concussion. J. Neurosurg. 2012;117:1089-191.

3. McGrath N. Supporting the Student-Athlete's Return to the Classroom After a Sport-Related Concussion. J Ath. Tr. 2010:45(5):492-498.

4. McCrea M, Hammeke T, Olsen G, Leo P, Guskiewicz K. Unreported concussion in high school football players - Implications for prevention. Clin J Sport Med 2004;14:13-17.

5. Tomei KL, Doe C, Prestigiacomo CJ, Gandhi CD. Comparative analysis of state-level concussion legislation and review of current practices in concussion. Neurosurg Focus 2012; 33 (6):E11 (published online ahead of print)(accessed December 10, 2012).

6. Meehan W, d'Hemecourt P, Comstock D, High School Concussions in the 2008-2009 Academic Year: Mechanism, Symptoms, and Management. Am. J. Sports. Med. 2010; 38(12): 2405-2409 (accessed December 2, 2010 at http://ajs.sagepub.com/content/38/12/2405.abstract?etoc)

7. Echlin PS, Skopelja EN, Worsley R et al. A prospective study of physician-observed concussion during a varsity university ice hockey season: incidence and neuropsychological changes. Part 2 of 4. Neurosurg Focus 2012;33(6):E2. 

8. "Concussion Confidential"ESPN The Magazine (http://sports.espn.go.com/espn/news/story?id=5925876)(accessed December 21, 2010).

9. Greenwald R, Chu J, Beckwith J, Crisco J.  A Proposed Method to Reduce Underreporting of Brain Injury in Sports.  Clin J Sport Med2012; 22(2):83-85.

10. Kaut KP, DePompei R, Kerr J. Congeni J. Reports of head injury and symptom knowledge among college athletes: implications for assessment and educational intervention.  Clin J Sport Med 2003;13:213-221. 

11. Kutcher J, McCrory, Davis G, et al.  What evidence exists for new strategies or technologies in the diagnosis of sports concussion and assessment of recovery?  Br J Sports Med 2013;47:299-303. 

12. Broglio SP, Eckner JT, Surma T, Kutcher JS. Post-Concussion Cognitive Declines and Symptomatology Are Not Related To Concussion Biomechanics in High School Football Players.  J Neurotrauma 2011;28:1-8. 

13. Anderson B, Pomerantz W, Mann J, Gittelman M. "I Can't Miss the Big Game": High School (HS) Football Players' Knowledge and Attitudes about Concussions. Paper presented at the Annual meeting of the Pediatric Academic Societies, Washington, D.C. May 6, 2013.

14. Wall Street Journal (2013). Study Raises Concerns That Teen Athletes Continue to Play with Concussion Symptoms (http://online.wsj.com/article/PR-CO-20130506-904595.html)(accessed May 7, 2013)  

Note: this blog was updated on May 9, 2013 to reflect the new Cincinnati Children's Hospital study and to include information about impact sensors as a technological end-around the problem of chronic under-reporting.

0