Head Games Concussions and Other Brain Traumas Can Pose Serious Risks to Athletes

For many parents, says Dr. Ellen Deibert, youth sports can be a headache.

“We deal with a lot of kids out there who are active in sports. A lot of them play soccer year-round. I feel bad for their parents,” she said with a wry smile.

As a neurologist who runs the Comprehensive Brain Injury Program at Berkshire Medical Center, however, Deibert knows that the real headaches occur on the field, when players’ heads collide with the ground, equipment, or other players.

“Right now we’re taking care of a soccer kid with a fractured temple bone. You can get seriously hurt out there,” she said.

According to the Journal of Sports Medicine, the medical community generally places the total number of sports-related traumatic brain injuries at about 300,000 per year nationally. However, the Centers for Disease Control and Prevention (CDC) estimated this year that the actual number is likely between 1.6 million and 3.6 million, and most of these injuries are concussions.

That speaks to the difficulty in diagnosing concussions, said Deibert; in fact, even if an athlete is taken to the hospital, there’s no way to scan for a concussion with any consistency.

“With concussions, the scans are always normal, but the kids are not normal,” she explained. “We do know that in youth sports, recovery takes longer than in college or professional sports. Why, we don’t understand yet, but the data looks pretty solid, and from my experience, that seems to be true.

“I have a snowboarder who got hurt early in 2008 who’s still coming around from a concussion,” she continued. “Sometimes, you can get somebody with a concussion better in seven days, and someone else takes months recovering. It really depends on the situation — the forces applied to the brain, and what the kid’s history is.”

Neurosurgeons as a group have really taken this seriously, both on the research side and the public-health side, in terms of campaigns to include helmets and head protection during athletic events,” said Dr. Kamal Kalia, a neurosurgeon with New England Neurosurgical Associates. “There are a lot of good papers out there regarding head injuries and athletes.”

Specifically, he referred to the work of Drs. Julian Bailes and Robert Cantu, who released a landmark study on the topic in 2001, determining that about 9{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of all injuries related to sports and recreational activities are head injuries. Actually, he explained, the preferred term in neurosurgical circles these days is MBTI, or mild traumatic brain injury, which spells out with more clarity what a concussion actually does.

A concussion, Kalia explained, is an immediate and temporary impairment in neural function, affecting vision, equilibrium, and other responses. But not every concussion is equal, and doctors grade them on a three-part scale.

Grade 1 concussions, the mildest type, involve no loss of consciousness, but some confusion or alteration in mental status that clears within 15 minutes, with no long-term effects. Typically, an athlete may safely return to play during the same event. Grade 2 also features no loss of consciousness, but the effects last longer, and the athlete should be pulled out for at least that day. Grade 3 involves loss of consciousness, and these athletes should be transported for further evaluation, Kalia said.

“These injuries can occur in football, soccer, skiing, equestrian sports, skateboarding, all sports,” Kalia said — and participants in many such activities don’t wear helmets. “Internationally, there are about 200 million soccer players. There is great risk for concussion related to that event.”

The challenge is teaching coaches to recognize when it’s time to sit an athlete, and Kalia says most seem to take that evaluation seriously. “I think there has been a big effort to make sure they are aware.”

Deep Impact

Some efforts specifically target coach and trainer education around head trauma, such as the ImPACT program that Deibert oversees in the Berkshires.

That acronym stands for Immediate Post-concussion Assessment and Cognitive Training, and it’s a tool to help coaches and trainers recognize when a player might have a brain injury, even when the outward signs aren’t obvious, and determine whether or not he or she may safely return to play.

The key is the establishment, before the sports season even begins, of a baseline cognitive level for each player. Athletes are tested in short-term memory, attention span, reaction time, and other tasks to demonstrate what cognitive abilities they have off the field. Deibert has brought ImPACT into area schools at the start of each season, administering the baseline test to athletes and training coaches in recognizing when to sit a player or seek further medical attention.

“One of the biggest concerns in coaching is being able to diagnose a concussion,” Deibert said, particularly in fast-moving, high-impact sports like football or ice hockey where violent collisions aren’t out of the ordinary.

“I get very worried about ice hockey; I know those kids are getting hit, but we didn’t see a lot of ice-hockey players in the clinic this year,” she told The Healthcare News. “Some kids have said the coach held up three fingers, and they went back out on the ice. But a repeat concussion during the symptomatic period can be very dangerous.”

Deibert is sympathetic to the challenges faced by coaches, who, after all, are not medical professionals. “Coaches have a lot to do; I get that,” she said. “They’re watching not just one kid, but a number of kids. But they need to take the time to evaluate kids. It’s not their job to diagnose how sick someone is, but whether they’re sick enough to be pulled out and seen by a professional. That way, the coach can’t get blamed for further injury.”

Referring to the baseline results from ImPACT testing is important, she said, because many young athletes seem to ‘shake off’ symptoms easily — or simply desperately want to get back to the action — when a closer comparison with the baseline behaviors would belie that enthusiasm. “We know some kids can take a bad hit and clear, but in many cases, they shouldn’t be put back in until they’re seen by a professional.”

Kalia cited the long-term damage incurred by many athletes who sustain repeated concussions. One condition common to boxers, characterized by Parkinson’s-like symptoms, even has an appropriate name: dementia pugilista.

Other athletes have also served as living — and sometimes not — warnings to others. Andre Waters, a former defensive back with the Philadelphia Eagles, took his own life at age 44 a few years ago; doctors attributed his depression to head trauma that caused his brain to resemble that of an 85-year-old man.

Former Patriots defensive lineman Ted Washington, whose brain shows dementia-like symptoms, has accused the team of having him run full-contact drills while in a concussed state. And many former football players, from quarterback Steve Young to running back Merril Hoge, have decided to leave the sport early after repeated concussions rather than risk further damage.

Deibert ticked off a wide range of sports and recreational activities that could be considered high-risk for head injuries, from obvious choices like football and hockey to lacrosse, skiing and snowboarding, motocross, snowmobiling, even cheerleading.

“Common sense says that any high-speed sport where kids are at risk of hitting another kid — or a pole, or the ski slope — that would be considered high risk for head trauma,” she explained.

Although not every risky activity merits a helmet — some might imagine the gear out of place on cheerleaders, for example — Deibert leans toward extra caution in most cases, supporting helmets in sports such as soccer and lacrosse.

“The thing about lacrosse is, girls do not wear helmets, and boys do,” she noted. “They tell me it has to do with the rules — girls are not supposed to carry their sticks as high — but that depends on how well-coached the team is and how well-refereed the game is. We get some serious lacrosse injuries in the clinic, as well as soccer.”

Soccer brings a wide range of injury possibilities, she said, with the head prone to collide with the goalpost, another player’s head, or the ground. “When the ground is frozen, even natural grass can turn into hard turf when the cold weather arrives,” she said. “Soccer has developed headbands that some kids are wearing, but they haven’t been mandated by the U.S. Soccer Federation yet. The data shows it protects in some high-intensity injuries, but I’m not sure what it does in other cases. I do think these kids need good training, good coaching, and good refereeing.”

And that goes back the baseline tests and why they are so important, Deibert explained. “A lot of people think that, because their scans are OK, they’re OK,” she said. “We do scans not to look for concussions, but for things like fractures. Kids who have delayed functional outcomes, memory problems, things like that are picked up with ImPACT and other neuropsychological tests. That’s how you find out how sick a kid really is. People need to understand that they shouldn’t ignore their symptoms, but seek help.”

Sudden Death

In terms of sheer numbers of concussions, Kalia said, football leads the way among all sports, and the average number of deaths in the sport related to head injuries — roughly four per year — hasn’t changed in three decades. The danger used to be worse; not only has helmet design improved over the years, but starting in the 1970s, the NFL and NCAA instituted rules penalizing the use of the helmet in tackling, which has doubtless prevented many serious head and spinal injuries.

Sometimes, the story is not one of long-term, sustained damage, but of a life snuffed out instantly, as in the case of actress Natasha Richardson, who recently suffered a head injury and died while skiing — without a helmet. But Kalia was quick to note that just wearing any helmet isn’t enough.

“You have to choose the right helmet and make sure it fits properly,” Kalia said. “If you’re out on the slopes and 80{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of your forehead is exposed, with your helmet resting like a beanie on your head, that’s not a properly fitting helmet.”

Kalia recalled when he was a child, and kids rode bicycles helmet-free and wriggled freely across the back seat of the family automobile without a carseat — and that was considered normal. He prefers the caution of today’s world.

“Maybe there’s some loss of freedom with all these things,” he said, “but then you see how devastating these injuries can be.”

After all, freedom means little when you’re battling a severe head injury — or when you’re no longer alive to fight it.