If your child plays a contact or collision sport, whether at be 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  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  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). 
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 study  but probably much higher) they won't self-report symptoms to sideline personnel, much less voluntarily remove themselves from the game.
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; 
- to avoid being seen as weak or cowardly by their coach or teammates, or even their parents; 
- 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; 
- because they want to win the game at all costs; or
- 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 forthcoming 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  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 last fall 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. A brand new study [reported after this blog originally appeared] [13,14] by researchers at Cincinnati Children's Hospital  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.
Are impact sensors the solution?
Fortunately, I think there may be a 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 widespread 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,  but "permit early intervention, potentially in advance of an injury, rather than simply as a management tool postinjury."
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 concusson 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 acceleromter 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.
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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.
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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.