It is hard believe that it has now been six years since I gave the keynote address at the National Sports Concussion Summit in Marina del Rey, California. Harder, yet to think we have been leading this charge since 2000.
In that speech (a full copy of which you can view by clicking here [1]), I offered some suggestions on how each of us — whether we be parent, coach, official, athletic trainer, clinician, current or former professional athlete, sports safety equipment manufacturer, whether we were there representing a local youth sports program, the national governing body of a sport, or a professional sports league, could work together as a team to protect our country's most precious human resource — our children — against catastrophic injury or death from sudden impact syndrome or the serious, life-altering consequences of multiple concussions.
Note that my focus was on second impact syndrome and the effect of multiple concussions. I wasn't talking then about total head trauma - a concept popularized by MomsTEAM's concussion expert emeritus, Dr. Robert Cantu - or discussing the effect of repetitive subconcussive hits, or what is now commonly being referred to repetitive head impacts, or RHI. It wasn't until two years later that researchers at Purdue [2]stumbled upon, literally, evidence that high school football players who had not been diagnosed with concussion neverless suffered similar short-term neurocognitive impairment from the cumulative effects of RHI. As anyone who has been following the subject of sports-related head injuries knows, the concern about RHI has continue to grow exponentially over the past four years, as researchers have used ever more sensitive and sophisticated imaging techniques such as diffusion tensor imaging (DTI) and fMRI to identify short-, medium, and long-term effects on the brain of RHI.
In assessing progress on such important health and safety matters as head injuries, childhood obesity, and physical activity, issuing report cards seems to be all the rage, so in assessing which of my suggestions have been adopted, to what extent, and how much more work we need to do, I'm going to assign grades as well, recognizing that they are just my personal opinion as to the degree of progress.
As I told the audience that day in April 2008, one which included such luminaries as super sports agent Leigh Steinberg and representatives of the National Football League, the story of how I became a sports safety activist, with a particular interest in concussions is one that is likely familiar to those of longtime readers of MomsTEAM.
As the mother of triplet sons, I had always taken a keen interest in their safety. I suspected then, and I suspect now, that all parents would say, if asked, that they put their kids' safety first — whether it is playing organized sports, at home, or riding their bike in the neighborhood. Some parents — particularly mothers, who have been the guardians of children at play since the dawn of day — not only talk that talk, but walk the walk, and are very protective.
I admit that, when it came to my sons' safety — and the safety of their teammates, I fell — and still fall — at that end of the spectrum, because I feel that, while life always involves some degree of risk, childhood should be a time when it is our responsibility as parents to minimize those risks and make it one of our highest priorities.
Not a whole lot has changed in six years.
While there were then, and are now, lots of very protective parents, at the other end of the spectrum, there are still some parents who are, sad to say, willing to sacrifice their child's safety and — in the case of concussions, their long term health — at the altar of a winning performance, a touchdown scored, a scholarship won, a pro contract inked, not just fathers, but mothers, too (for proof, one only has to watch the recent reality television show, "Friday Night Tykes.").
Many parents admit that they allow their children to play in such circumstances even though they know about the potential for adverse long-term health consequences, like major depression and permanent cognitive impairment.
Where I think we have started to make progress is with the large group of parents in the middle, who want to protect their children from long term injury but simply didn't know their role and what to expect of their "teammates" — the coach, the ATC, the team doctor, the athletic director. Fewer parents still think that concussions only occur with a loss of consciousness and/or that it isn't dangerous to play with a concussion. More parents are becoming educated about the risks head injuries - whether of the diagnosed concussion variety or the result of repetitive impacts - and the steps that can and are being taken to minimize those risks.
In part, of course, the increased public awareness of the issue is the result of relentless, saturation media coverage of the issue (I have a whole bookshelf of concussion books and DVDs). Studies are also showing that the enactment of Lystedt laws in 48 states and the District of Columbia (all since May 2009, a year after my speech), which require that parents receive at least some minimal head injury information as a prerequisite for their child's sports participation, is increasing awareness.
I would also like to think that MomsTEAM's continued efforts to educate parents about concussion risk management and our PBS documentary, "The Smartest Team: Making High School Football Safer," which aired on over 300 stations last fall and which will be broadcast on almost all 387 stations in the fall of 2014, has played a role in increasing awareness.
Yet we still have work to do.
Grade: B-
In 2008, I commented that "Too many young athletes — from 9-year old cheerleaders to star middies on high school Lacrosse teams — are still failing to self-report their symptoms to the coach, sideline medical staff, their friends or even their parents, forcing clinicians to try to manage concussions somewhat in the dark."
I noted that "Kids fail to self-report because, too often, they are told by their parents, but far more often by their coaches, and, more subtly, by the very culture of sports itself, that they should remain silent:
I noted that such silence can, as we all know, be deadly.
Progress in overcoming what a 2014 report by the Institute of Medicine and National Research Council termed the "culture of resistance" has been, unfortunately, painfully slow. A number of studies have shown that, despite increased awareness on the part of athletes, chronic under-reporting of concussion symptoms continues to plague sports, at every level, from Pee Wee to the pros.
Just as in 2008, there are still far too many coaches in this country, of youth gymnastics, football, field hockey, soccer, lacrosse, basketball, skiing, who berate and ostracize players complaining of concussion symptoms, who call them "wimps," who yell at doctors, and athletic trainers for refusing to let a player with concussion symptoms go back into the game, and have kicked kids off of the team for refusing to play for two weeks because of a concussion. Again, "Friday Night Tykes" and a recent incident during a high school football game in Oklahoma - caught on videtape - in which a player who was so disoriented after a blow to the head that he didn't know where he was or the score - was literally shamed back into the game when an assistant coach asked him rhetorically, "Are you still gay?"
Parents have a right to expect that, when they entrust their children to a sports program that it will take reasonable precautions to protect them against harm. In other words, parents have a right to expect that the entire team to whom they entrust their children's safety — including the national governing body for the child's sport, the state association, the athletic or club director, the athletic trainer (if there is one), and especially the coaches - are part of the concussion solution, not part of the problem.
That they will witness their child suffering a serious injury playing sports is one of a parent's worst nightmares. The possibility of injury was often in the back of my mind when I watched my children play sports. Two of my sons have received a total of seven concussions. Thank you Hunter--he is my golfer.
But because the signs and symptoms of concussions [3]are not as obvious as a broken leg or a sprained ankle and are often very subtle, because most don't involve a loss of consciousness [4], and because self-reporting by athletes is critical to the detection and treatment of concussions, the only way parents can sit in the stands without worrying sick about what might happen if their son or daughter suffers a concussion is if they know the program, and especially the coach, takes concussions very seriously and that every member of the team is using the same playbook. How are parents going to know?
Parents will know that the program and the coach take concussions seriously if the coach has met with parents and athletes before the start of every season to educate them about the dangers of concussions.
Parents will know the program and the coach take concussions seriously if the meeting includes a presentation by a medical physician familiar with the grading and evaluation of concussions [5] and return to play guidelines [6]; a doctor who can educate parents on the important role [7] they play in their child's recovery from a suspected concussion, especially in terms of checking for signs of deteriorating mental status [8] requiring immediate hospitalization, ensuring that their child gets the cognitive rest required, and monitoring for continuing concussion signs or symptoms that should absolutely rule out a return to play and may indicate the presence of post-concussion syndrome.
Parents will know that a program takes concussions seriously if it has brought in former athletes from the school to share personal stories about the consequences of continuing to play with concussion symptoms or after a series of concussions, to tell them about their reoccurring headaches, their depression, and their memory problems.
Parents will know that a program takes concussions seriously if it brings in members of their peer group — parents of concussed athletes like me — to emphasize how critical it is that, in making the all-important return-to-play decision, they consider not the here and now, but the entire life cycle of their child: if I let her play now, what will her life be like in ten, twenty, thirty years? Will she be suffering from chronic, major depression, or Alzheimer's?
Parents will know that a coach takes concussions seriously if they hear the coach at the preseason safety meeting actively encourage athletes not only to self-report post-concussion symptoms, but to inform the coaching staff or athletic trainer about teammates with symptoms if they fail to report them to the staff.
Parents will know that the coach takes concussions seriously if he tells them that if they self-report their symptoms, they will not jeopardize their place on the team, but also that, if they don't play by the rules, if they don't report symptoms — their own or a fellow player's — if they lie about them when asked, if they try to fudge their answers on baseline neuropsychological tests, if they say they are symptom-free so that they can be cleared to play in the next game, they will be suspended or kicked off the team entirely for violating team rules.
Parents will know that the coach and the program takes concussions seriously if they enforce strict penalties for any lacrosse, ice or field hockey player who strikes a blow to another players head in a game or practice.
Parents will know that the coach and the program takes concussions seriously if they know that the athletic director or administrator, the coach, the athletic trainer (if there is one), and the team doctor have, at the very least, agreed upon and adopted a philosophy for grading and managing concussions before the start of the season and use it consistently during the season, regardless of the athlete or circumstances surrounding the injury. In other words, that no double standard when it comes to concussions will be applied — one for regular players, another, more lenient, standard for the "stars."
The sad fact, and what makes it sometimes hard for parents to truly believe that programs are taking concussions seriously, is that many of the sports programs in which their children participate do not follow any set of return-to-play guidelines, and many clinicians believe that the current return-to-play guidelines are too conservative. When parents are kept in the dark like that, when they have no clue as to how a program treats concussions, their anxiety level naturally goes up. This happened to me when my son Taylor sustained a soccer concussion and his AT told him he only needed to sit out one day.
Some advocate against any rule that would flat out bar players who experience concussion signs or symptoms from returning to the same game or practice. They view such a rule as not only unworkable but counter-productive. Their fear is that such a strict, unyielding rule is likely to be evaded by the very players it is designed to protect, leading players to simply stop telling sideline medical personnel that they have any symptoms so as to avoid being benched for the remainder of the game. Many parents, either out of ignorance of the risks or out of a desire to see their child achieve athletic success, adhere to this view as well.
Others, myself included, believe that the rule that best protects our children, is the easiest to apply and the one best supported by the available science, is that reflected in the consensus statement of the 2nd International Conference on Concussion in Sport held in Prague in 2004: a rule that recommends no return to play for concussed athletes in the same game regardless of how quickly the symptoms appear — to clear. I strongly believe that, if, as I suggested earlier, the penalty for not reporting symptoms, for not playing by the rules, is to be suspended or get kicked off the team, then players will not, as some fear, try to evade this rule; that adoption of such a rule will not lead players to simply stop telling sideline medical personnel that they have any symptoms so as to avoid being sidelined for the remainder of the game.
All of the recent consensus statements recommend more conservative management of concussions in athletes under the age of 18.
In the face of such evidence, the only reason I can think of for allowing a youth athlete to return to play in the same game after concussion symptoms clear is because it increases the team's chances of winning. As I write about at length in my book and on the MomsTeam website, our youth sports culture has become so obsessed with winning that not only has fun taken a back seat, but, more dangerously, safety as well.
Winning, at any level simply isn't worth it, at least when it comes to concussions, which are simply in a league of their own apart from other types of injuries. To the extent our culture teaches that winning is more important for athletes who don't get paid to have their clocks cleaned for a living, needs to change.
If parents know about the rule in advance; if the reason for the rule is explained before the season begins, I think that, by and large, they will see it as putting their child's safety first, which is exactly as it should be in youth sports.
I submit that the alleged lack of scientific studies and the amount of clinical judgment involved in concussion management, and the lack of a consensus, either about grading the severity of concussions or in return to play guidelines, while it complicates our efforts to educate parents on concussions, should not be used as an excuse to do nothing.
Conservative management of youth concussions is also necessary, in my view, in order for a program to fulfill the fundamental duty of care — a duty embodied in the United Nations' Conventions on the Rights of the Child adopted by every country in the world with the notable exception of two (Somalia and the United States) — our sports programs, like the rest of adult society, owe every child a duty of care.
Adding to the challenges sports programs face in evaluating and managing concussions, and the anxiety level of parents of children playing contact sports, is the fact that many high school programs don't employ athletic trainers who have received training in recognizing the often subtle signs of a concussion. Only 42 percent of U.S. high schools, according to the National Athletic Trainers' Association, have access to an ATC. In some states, the number is much lower (Over three-quarters of Nebraska high schools, for instance, are without ATCs).
Because physicians are present at relatively few youth sports contests and never at practices, an ATC is essential for a number of reasons.
For many-many good reasons, we should work towards the goal of having a certified athletic trainer on staff at every high school in this country.
With several recent studies demonstrating the value of neuropsychological testing [9] in evaluating the cognitive effects of and recovery from sport-related concussions, such testing has become increasingly popular in recent years, so much so that it is now a recognized "cornerstone" of concussion evaluation, at least for "complex" concussions.
But while baseline pre-injury and post-injury testing is now ubiquitous at the professional and collegiate level and is becoming more common at the high school level as well, the cost of either conventional pen-and-paper or computerized testing, and the fact that most states require advance training and licensing to purchase and use them, have thus far restricted how widely testing has been implemented at the youth level and in rural areas where access to neuropsychologists for consultation is limited.
Funding and ways need to be found to allow for Web-based testing on a wide scale. I trust, in the coming months and years, that MomsTeam.com can become a place where every parent, can come to get the kind of testing that is currently out of the reach of the vast majority of athletes in contact sports.
A child's parent or guardian should be informed in writing if he suffers a serious injury and provide written consent before he is allowed to return to play.
In the case of concussions, parents should be provided information on post-concussion signs and symptoms, signs of deteriorating mental status to watch out for in the first 24 to 48 hours after concussion, follow-up care and return-to-play guidelines. Implementing such a rule will, by itself, prompt all of the stakeholders to take every injury to an athlete with the appropriate degree of seriousness. Most sports helmets (lacrosse, football, skiing, biking ) currently in use do little if anything to protect brains from the forces that cause concussions, a fact that most parents and athletes don't know. Fortunately, technological advances in helmet design while they are not going to make concussions in football a thing of the past, hold out at least the promise of being able to significantly reduce the and possibly detect the number of concussions.
Parents need to know about these new helmets [10]. They need to know that their child's football program thinks enough about their safety that it will find the money to buy them; that if it can't find the money, they will have the option of buying them on their own at the least possible cost or getting together with other parents to raise the money necessary to buy every player a safe helmet.
They also need to know about the importance of proper mouth guards [11], where to buy them how to judge the correct fit.
An ambulance and paramedics should be present at all contact high velocity sports, and, if they are not, procedures need to be in place on how to contact 911. For a reason, we need look no further than the tragic story of Will Benson, a 17-year old football player from Austin, Texas, who paramedics were unable to reach for nearly 30 minutes because the person who called 911 didn't tell the dispatcher exactly where he was, causing paramedics to waste valuable time trying to find the trainer's room where Will lay unconscious after collapsing during a game in September 2002.
Laws should be enacted in every state modeled on "Will's Bill," the 2007 Texas law named after Will Benson, which requires that every high school coach and official to be trained in basic safety and emergency procedures. Every coach needs to be certified in CPR, the use of an AED (which should be available at all games and practices), and first aid, with special attention paid to hydration, cardiac and concussion awareness.
Sports officials should be given the right to send any athlete who they reasonably suspect has suffered a concussion during play to the sideline for further evaluation.
High school athletic programs should require that each athlete undergo a pre-participation physical examination that includes the taking of a structured concussion history, including specific questions about previous symptoms of concussion (not just the perceived number of concussions) and previous head, face or neck injuries, as well as questions about symptoms currently being experienced, if any. If a school can't afford to foot the bill for such exams, parents need to get them on their own or, better yet, alternative ways should be explored to provide such exams to all athletes, either through parent fundraising or by asking local medical groups to donate the exams as a community service. While parents with kids in some sports can take some comfort in knowing that the national governing body for that sport is taking steps to address the concussion issue, too many have yet to follow its lead.
And, even though only a tiny fraction of athletes playing sports at the youth and high school level will go on to play college ball and then to the pros, this country's professional leagues could and should be doing more when it comes to concussions, not just for their own athletes, but because children follow and take their cue from the examples set by their heroes in the pros.
From where I sit, as a parent and editor of a site for parents with children in sports, I believe that the NFL has thus far been a little too slow to get on the concussion bandwagon and to set the right example for the parents and children of this country. The NHL recently became the first professional league to offer baseline testing of players, and has made the glass and the boards more forgiving, but hasn't done nearly enough to penalize players for illegal hits, like the one by the Flyers' Randy Jones on the Boston Bruins' Patrice Bergeron last fall that left him sitting on the sidelines with a Grade 3 concussion for the rest of the season.
Unless and until professional sports send a clear message that concussions are dangerous and need to be treated as the serious, potentially life-altering or -ending injuries they can often be, parents are going to be fighting an uphill battle in convincing their young warriors to likewise take concussions seriously.
I think it is time for the NFL, as the professional league in the sport which experiences the largest number of concussions by far, to demonstrate in a tangible way its commitment to concussion safety and education, both for its players, for the players at the youth level who emulate them, and the parents whose job it is to keep them safe. To that end, I would love for the NFL to join with MomsTeam in sponsoring a public service campaign about the dangers of concussions in sports. This need not be a campaign about the danger of football but the importance of concussion management.
There is no doubt that the key to keeping our young athletes safe when it comes to concussions is education. I know this from long personal experience. When I started MomsTeam in 2000, I included some information — not a great deal — about concussions based on my own experiences with my sons. After five families contacted us requesting more information we rolled up our sleeves and started looking for more answers. I knew that, working less than two miles away at Emerson Hospital in Concord, Massachusetts was Dr. Robert Cantu, who we are all fortunate to be in the company of today — is widely acknowledged as one of the world's foremost experts on concussions in sports.
Dr. Cantu was concerned that many athletes and their parents did not understand the risk of playing while still symptomatic from an initial head injury. For their part, coaches, especially in sports with the highest risk of head and neck injury, may not fully understand the risk, he said, because most of them have not received training in managing sport concussions.
While Dr. Cantu was traveling the world speaking to his peers in the sports medicine community about concussion management, he felt that those presentations were simply "preaching to the choir." In his view, the most effective way to reduce the number of cases of SIS and protect athletes from suffering long-term effects from concussions was for MomsTeam.com to reach all of the parents, aunts and uncles of youth sports athletes to educate and inform them about Second Impact Syndrome and concussions.
In 2001, working closely with Dr. Cantu, who joined MomsTeam as an expert, the MomsTeam health & safety editor spent two months researching and writing articles for the Head Injury Awareness channel to provide comprehensive information on concussions to coaches, parents, players and trainers.
In the seven-plus years since, we have been continually updating our concussion section to reflect the enormous advances that have occurred in the last seven years in concussion management, and have, I believe, become one of, if not the leading, sources of concussion information for parents on the Internet.
We are proud of what we have accomplished and the impact we have had in concussion education, and we are proud to partner with the Sports Concussion Institute and others in this important and critical educational effort.
Yet we know there is much more that we can do. In the coming months and years, we at MomsTeam will be doing everything we can to provide a forum where everyone with a stake in concussion education and management — parents, including parents of children who have died from second impact syndrome or suffered lifetime impairment from repeated concussions, athletes, coaches, officials, administrators, clinicians, and sports safety equipment manufacturers — can meet in our community to exchange ideas and information and share concerns.
To that end, I am pleased and excited to announce that, in three weeks, MomsTeam will re-launch providing the kind of tools that I believe will allow us to harness the incredible power of the Internet to build the largest social networking community of sports parents in the world and make it possible for the message to get out, not only about concussions but about other safety topics, nutrition, hydration, the need to balance fun with winning and to involve more woman and mothers as coaches and administrators, to the largest possible audience.
I invite each of you to become active members of the MomsTeam community, to post on our forums, to start your own MomsTeam blog, to submit your journal articles to our editors, to see MomsTeam as a place to inform everyone in the youth sports community about your technological and product innovations, and as a place to share your expertise with parents around the country and the world.
When there is total accountability and transparency and every stakeholder is talking with each other we will begin to see the code of silence broken. Sports programs will begin to value safety before winning. If we all work together towards our common goal, I am confident that we can make youth sports safer and more enjoyable for everyone, and parents, in particular, will be able to sit in the stands comfortable in the knowledge that all of us are playing our part, that we are all part of the same team, that everything that can reasonably be done to reduce or prevent injuries is being done.
It has been a pleasure speaking with to you today——thank you.
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Links:
[1] https://momsteam.com/team-of-experts/brooke-de-lench/sports-safety/momsteams-de-lench-gives-keynote-address-on-concussion
[2] https://momsteam.com/sub-concussive/sub-concussive-hits-growing-concern-in-youth-sports
[3] https://momsteam.com/node/149
[4] https://momsteam.com/node/145
[5] https://momsteam.com/node/132
[6] https://momsteam.com/node/137
[7] https://momsteam.com/node/115
[8] https://momsteam.com/node/146
[9] https://momsteam.com/node/801
[10] http://www.xenith.com/
[11] https://momsteam.com/node/228
[12] http://www.momsteaminstitute.org/donate