Concussions and Our Kids: America's Leading Expert on How To Protect Young Athletes and Keep Sports Safe
About a month ago the folks at Houghton Mifflin Harcourt sent me a review copy of Dr. Bob Cantu's new book, Concussions and Our Kids: America's Leading Expert on How To Protect Young Athletes and Keep Sports Safe, which launched today and which he co-authored with sports journalist Mark Hyman. I took it to read on the short train ride from Boston to New York the very next day, and was able to finish it before the train pulled into Penn Station.
While it has much to recommend it, the book is marred by several pieces of advice it gives - or omits to give - that seem to ignore critical changes in the thinking of concussion experts over the past decade, including some from Dr. Cantu himself.
Concussions and Our Kids is just the latest in a slew of concussion books that I have read and reviewed over the past couple of years, and I was curious, for both personal and professional reasons, to see how they handled a subject that has grabbed so much of the media's spotlight over the last five or six years, much of which has featured the work Bob Cantu has done with his colleagues at the Sports (now Concussion) Legacy Institute. which he co-founded, and the Center for the Study of Traumatic Encephalopathy at Boston University, of which he is the Director.
As those who have read my past reviews of books about concussions, the fact that I have lived and breathed this subject for many years, not just as the founder and publisher of MomsTEAM, but in my own life, as the mother of a son forced by multiple concussions to give up playing high school football and lacrosse, gives me a perspective on the subject that few in the media enjoy. I take the subject very seriously, and expect that books on the subject of concussions provide information that is as well-researched and accurate as I believe is the concussion information on MomsTEAM.
In reviewing Bob's book, I also bring to the table a professional relationship with him that goes back more than a decade. In October 2001, a little over a year after the launch of MomsTEAM, I received an email from Deron Colby, the grieving uncle of 17-year old California high school football player Matthew Colby, who had died tragically from Second Impact Syndrome two weeks earlier. He told me that his Internet research had identified MomsTEAM as the only youth sports parenting website addressing the subject of concussions, but he wanted us to do more. He said that he had read in his research some excellent journal articles written by a Dr. Robert Cantu, who he said was practicing at Emerson Hospital in Concord, and wondered whether I knew Bob.
At the time, I had not heard of or read anything by Dr. Cantu, as he was only writing for his peers (and the impression I got was that not enough of them were listening) and not doing much of anything to educate sports parents. But the really exciting thing for me was that I lived less than 2 miles away from the hospital where he was working! How ironic that it took a grieving uncle a continent away to introduce me to a leading expert on sports concussions right in my own back yard! The ensuing collaboration between MomsTEAM and Dr. Cantu not only helped us educate sports parents about the dangers of concussion and second impact syndrome and the ways in which concussions were then managed, but helped Dr. Cantu reach, not just his peers in the medical community, but an entirely new audience of sports parents.
It was an extremely fruitful partnership which continued until 2007. I remember leaving my first meeting with Bob with a huge pile (17 or so) of journals and books containing his peer-reviewed articles, which, along with a MomsTEAM editor, Lindsey Barton Straus, I then fashioned into drafts of articles for a lay audience of sports parents, which were then sent back (in big orange folders, as I recall) to Bob for his review and approval.
Over the span of the next month, we were able to generate about thirty MomsTEAM articles on a wide range of concussion subjects, which were then either posted under Bob's byline, or under my byline or Lindsey's, but which he had reviewed and approved. Over the ensuing years, as the number of peer-reviewed studies on concussions exploded and the thinking about concussion management rapidly evolved, Bob worked with MomsTEAM to keep our audience abreast of all the new developments.
I have great admiration for Bob, for being the pioneer he was in concussion management back in the 1980's and 1990's, when concussions were largely unstudied and ignored, for the work he did in helping MomsTEAM educate sports parents about identifying and managing concussions for seven years, and for the work he has done in recent years, both as a reform advocate and in research, on ways to prevent concussions, reduce the risk traumatic brain injuries and repetitive head impacts pose to our kids, and the management of traumatic brain injury.
But, while I think there are many, many reasons to recommend Concussions and Our Kids as a worthy addition to the ever-growing body of literature on sports concussions, it is marred, ironically, by several pieces of inaccurate or confusing medical advice that, frankly, left me scratching my head.
First, the good news.
To begin with, the book does a very good job of suggesting ways in which contact and collision sports can be made safer, some of which I endorse, and about which I will highlight further in upcoming blogs and articles, including: no body checking in youth hockey before age 14; eliminating heading in youth soccer until kids are old enough (around age 14) to have strong enough neck muscles and mature enough brains to better handle the pounding of a soccer ball [Update: On November 9, 2015, a settlement was reached in a class action against US Soccer and a number of youth soccer organizations recommending no heading for players in U11 programs and younger, either in practice or games; that heading be limited in practice at the U12 and U13 level]; holding sports officials to a higher standard in enforcing existing rules designed to protect player safety; and requiring chin straps for baseball helmets and restricting the head first slide (While the book advocates in favor of rules requiring helmets in field hockey and girls' lacrosse, as a former field hockey and lacrosse player, I don't favor those proposed reforms for reasons I will also save for a later blog.)
Bob's recommendation that kids not play tackle football until age 14, which generated such intense media interest when he first proposed it about a year ago, has, I believe correctly, been softened somewhat in the face of the reality that the sport is, in his words, "too entrenched" to make shutting the "spigot of youth football" a practical objective. [Update: In October 2015, the American Academy of Pediatrics issued a Policy Statement on Tackling in Football which refused to go so far as endorse Bob's initial recommendation, for much the same reason (e.g. because it would require a fundamental change in the way the game is played), but did suggest that, if programs did delay the teaching of tackling in football, that special attention be paid to teaching proper, "heads up" tackling when it was introduced.]
His "Plan B" advocates a two-pronged approach emphasizing education and a significant reduction in contact, both during preseason and in-season workouts, that I also feel is the most appropriate way of tackling the problem. He is especially passionate about the need for a "profound rethinking of practice" at the high school level, which, by cutting back on full-contact practices, could dramatically reduce the total brain trauma sustained by players. I also advocate such a multi-pronged strategy and am glad to see that he has backed away from calling for an outright ban on kids playing tackle football before high school. [Update: The last several years have seen a growing movement at all levels of football, from the NFL to high school to Pop Warner, to reduce the number of full-contact practices, with some early studies showing that such limits do not, as some feared, increase concussion rates but, indeed, lead to reduced risk of concussion]
I found interesting and valuable the explanation in the book as to the reason why kids' brains take longer to recover from concussion than adults, centering on how the child's brain responds to trauma because they have less myelin, the fat that covers the fiber tracts in the brain to protect them from injury. The book's chapter on baseline testing is also solid, including a good explanation of what baseline (e.g. pre-season) computerized neurocognitive testing does and doesn't do, with a focus on the development and refinement of the ImPACT test, the most widely used test.
Dr. Cantu also, I believe appropriately, calls for expansion of baseline testing to not only include neurocognitive testing but balance (e.g. BESS) and vision testing (e.g. King-Devick). The chapter concludes with a helpful discussion of the ways in which technology is changing youth sports and making it safer, especially through the use of helmet sensors or accelerometers designed to measure forces generated by blows to the head, a discussion of SLI's innovative "Hit Count" proposal to reduce the number of hits players, especially young players, sustain in practice and games as a way of reducing the risk of adverse long-term health consequences, and a brief "Buyer beware" section, which I have already referenced in some of my recent blogs, where I have called out companies for making unsupported claims that their products reduce the risk of or actually prevent concussions.
Reducing total head trauma
Concussions and Our Kids is strongest when it focuses on the steps that are, or in some cases, are not being taken by organizations at the professional, college, high school and youth sports level to reduce the risk of traumatic brain injury, both from a single hit and from, what Dr. Cantu calls, "total head trauma" (lifetime exposure to concussive and repetitive sub-concussive hits)
An apocryphal story about a Boston-area high school football coach who, after listening to Dr. Cantu describe the dangers of concussion to his team, informs him that he won't be invited back because he didn't want to scare his players, illustrates perfectly the challenge MomsTEAM and everyone involved in concussion education continue to face in trying to change the culture of collision sports to make safety a priority instead of taking a back seat to winning in the minds of too many coaches, players, and, frankly, parents.
While Dr. Cantu applauds the leadership of USA Hockey and Hockey Canada as "progressive and unafraid" in confronting the concussion crisis by outlawing hits to the head and eliminating checking at the Pee Wee level, he is appropriately critical of the National Hockey League, calling its current policy regarding hits to the head "disappointing", and singling out commissioner Gary Bettman for much of the blame for what he terms "the league's inadequate response" to the concussion crisis in the sport.
A lot has been written in the media in recent years criticizing the response of the National Football League to the issue of concussion safety. But like Dr. Cantu, I agree that the league has become, under current commissioner Roger Goodell, what Bob calls a "force for change," especially compared to five years ago when, under former commissioner Paul Tagliabue, the NFL was in what Bob appropriately calls a "state of denial." Bob applauds, as I have, new rules put in place by the NFL and the Ivy League reducing the number of full-contact practices, and hopes, as I do, that such rule changes will, sooner rather than later, be implemented by all of college football, and at the high school and youth level. [Update: as noted above, limits have since been enacted by the NFL, a few college football conferences, by a growing number of state high school athletic associations, and by Pop Warner at the youth level]
I also found the discussion of Pop Warner's mixed grades on its concussion safety report card informative and enlightening. Like MomsTEAM, Cantu and Hyman applaud the organization for new rules announced this year limiting contact drills to one-third of practice time and banning some especially violent head-on blocking and tackling drills, but appropriately criticize Pop Warner for what they see as its narrow focus on winning, and for promoting tackle football for kids as young as five, an idea of which Bob "disapprove[s] in the strongest terms."
Dr. Cantu also calls out Pop Warner for what he views as efforts by the organization to obscure its safety record, including turning down a research study he and his colleague at the Concussion Legacy Institute, Chris Nowinski, had proposed which was designed to get a handle on just how big a problem concussion is at the youth level (there are some, including Kevin Guskiewicz, PhD, ATC., Kenan Distinguished Professor and Director of the Matthew Gfeller Sport-Related Traumatic Brain Injury Research Center at The University of North Carolina at Chapel Hill, who think the benefits of contact sports, properly taught, far outweigh the risks). I do agree, though, with Bob's conclusion that, "The fact of the matter is, Pop Warner's data about its safety record is incomplete, and until the organization opens the door to scientific study, there is still no truth."
I also agree with many, if not all, of the recommendations listed in Concussions and Our Kids regarding ways in which youth sports can be made safer, and the long-term effect of repetitive trauma on the developing brain of young athletes - the true effects of which, at this point, he correctly admits, are still unknown - can be mitigated simply by reducing the number of hits.
I am already on record as supporting the "Hit Count" initiative begun by the Sports Legacy Institute of which Bob is co-founder, and, in particular, his call for a significant reduction in the number of hits players sustain in high school football by reducing the number of full-contact practices, where most of the head trauma in football occurs. Like Bob, I continue to find it very puzzling that the National Football League and the Ivy League have moved to reduce the number of full-contact practices, as has Pop Warner at the youth level, but, so far at least, similar restrictions have not been adopted at the high school level. [Update: again, as noted above, a growing number of state high school athletic associations have now adopted limits on full-contact practices; change has come more slowly at the college level, however, with only the Ivy League and Pac-12 formally adopting limits]
Dr. Cantu also calls for every high school in America to have a full-time athletic trainer, and that having one "would seem to be a given, a no-brainer." I, too, have long been in favor of a full-time AT on staff at every high school. [For my article explaining why, which includes a powerful video, click here].
The chapter on the treatment of patients with post-concussion syndrome (PCS) who comprise, he says, 20 percent of those who suffer sports concussions (a number that seems high to me based on what I have read in other studies) and 50 percent of his practice, is solid and Dr. Cantu and Hyman use the case histories of several of patients with PCS to good effect in educating parents and athletes on how the condition is treated.
But now for some criticisms of the book.
The press blurb from the publisher described the book as "part manifesto, part how-to guide." The manifesto part is strong, but the how-to guide, not so much. For someone who holds himself out as America's "leading expert" on youth sports concussion, I was disappointed and surprised by some of the how-to part, which in some instances I found confusing, and in others, especially the discussion of how the severity of a concussion is assessed and return to play decisions are made, is at odds with the current thinking of most concussion experts, including Dr. Cantu himself.
Perhaps because, by his own admission, half of his practice is devoted to treating concussed athletes long after their initial injury (e.g. athletes who come to his office experiencing post-concussion syndrome), the advice in the book regarding cognitive rest is somewhat confusing. While he advocates for cognitive rest as the "hallmark of concussion therapy" his approach seems to be at odds with the approach taken by other leading clinicians, including MomsTEAM's current concussion experts, William Meehan, M.D., and Rosemarie Scolaro Moser, Ph.D., about the need for cognitive and physical rest in the first several days after a suspected concussion.
Dr. Cantu's approach seems to be to reduce the thinking and reasoning in a patient's life as much as needed "so that the symptoms are not provoked", beginning with restrictions at school (modifying or reducing class schedule, no exams if exacerbates symptoms) and eliminating intellectually stimulating activities only outside of school. This suggests that he would allow an athlete to return immediately to school after a concussion. The approach of other clinicians, including Drs. Meehan and Moser, is for a concussed student-athlete to stay home from school and for complete cognitive rest, with a return to school with academic accommodations only when symptoms subside or disappear. [Update: a growing number of concussion experts, including Drs. Cantu and Meehan, meeting at the University of Pittsburgh Medical Center in October 2015 at a conference closed to the press and sponsored by the National Football League, endorse the view that more than a few days cognitive rest after concussion is not recommended. As a result, my criticism in the initial review of Bob's book appears to have been unwarranted. Mea culpa, mea culpa.]
It could be that Dr. Cantu's advice is for concussed students whose symptoms don't go away in the first week to ten days after injury, but that point isn't made clear. Later in the book, Dr. Cantu states that "patients need cognitive and physical rest after concussion, and when they don't get it, symptoms last a lot longer" and that "without proper care, the average person is set up for a few more weeks of misery dealing with symptoms and the inconvenience of missing valuable time at work or in school." Which is it? Back to school and respond to continuing symptoms by cutting back on school after the fact, or stay out of school for the first few days after concussion to get the cognitive and physical rest they need? It's hard to tell, and the reader is left to parse the distinction, if it was intended, which isn't made clear.
I also was puzzled as to the basis for the statement made at page 117 of the book that if a concussed student-athlete is "seen by a physician in the first few days [after concussion], chances are there will be fewer symptoms to deal with and they will be milder." Simply put, I don't know what that statement is based on; seeing a physician bears, as far as I know, no relationship to the number and severity of symptoms an athlete experiences after concussion.
Not making the grade
But most inexplicable, and, frankly, astounding is the discussion in the book about the "grading" of concussions and Dr. Cantu's continued advocacy for the use of a return to play matrix he developed in the late 1980's, revised in 2001, and again in 2011, which determines how long an athlete is sidelined by a concussion depending on the "grade" and the number of concussion suffered that sports season, return-to-play guidelines that he includes as the last appendix in the book.
The problem I - and many others- are likely to have with suggesting that concussions be given a "grade" and that using a cookie-cutter approach to return to play is acceptable is that they completely fail to account for a number of critical changes in concussion management over the last decade, as well as some of Dr. Cantu's own advice:
- As reflected in international consensus statements on the management of sports concussions issued in 2004 (Prague) and 2009 (Zurich), concussion grading scales have been completely abandoned in favor of a symptom-based approach to individually guide return to play decisions. The reason is that experts concluded that it is simply impossible to determine, based solely on whether an athlete suffers a loss of consciousness (and, if so, whether the LOC is less than or longer than 60 seconds), experiences post-traumatic amnesia (and, if so, whether it lasts for more 30 minutes), the length of time it takes for an athlete to become asymptomatic at both rest and with exertion, and whether the concussion is the player's first, second or third that sports season, when it is safe for him or her to return to play;
- Indeed, in issuing the 2011 revision to his return to play guidelines, Dr. Cantu himself notes that a number of "modifying" factors" may influence concussion management considerations beyond simple return to play advice, some of which include the number of, duration, and severity of symptoms, multiple concussion history, and history of migraines or depression. Yet there is no mention in the book of such other complicating factors; and
- Dr. Cantu has previously rejected exactly the sort of cookie-cutter concussion management he now suggests by inclusion of his return-to-play matrix, saying, for instance, in one MomsTEAM video, that every concussion is different and hence requires individualized management, although to be fair, the book does note on page 13 that his return to play protocol is "intended to augment, not replace, clinical judgments."
Not only do the return to play guidelines printed as Appendix D in the book still classify concussions as Grade 1 (mild), Grade 2 (moderate) and Grade 3 (severe)(categories that are not fully explained anywhere in the book), but the most recent RTP guidelines issued by Dr. Cantu don't themselves use the grading terminology. The book mentions only that, in 2001, his return to play protocol was "updated and sharpened" so that "[n]ow a player who reports a single concussion symptom is not permitted to return to that game." But no mention is made of his 2011 revisions, nor does Dr. Cantu explain to his readers, that the grading of concussions is a thing of the past, no longer considered the standard of care by concussion specialists. Strangely, the chart also defines being "asymptomatic" in a footnote as having "no headache, dizziness, or impaired orientation, concentration, or memory during rest or exertion," where the 2011 guidelines on the SLI website specifically refer in the body of the chart to being asymptomatic at rest "and during progressive exercise protocol." This key requirement for return to play is completely glossed over and left unexplained by Dr. Cantu. These are serious shortcomings, in my view, that, unfortunately, suggest a sloppiness and lack of rigorous fact-checking that detract from my otherwise positive view of the book.
Finally, while I agree with Bob that the "avalanche of publicity of concussions in recent years has distorted the connection - the public's perception of the connection - between concussions and CTE," I think the statement ignores the leading role that he himself, along with the Sports Legacy Institute, and the Center for the Study of Traumatic Encephalopathy, have played in creating that very perception.
It may be that his work colors his thinking about concussions because he spends so much of his time treating the complicated cases, and talking about athletes whose autopsies reveal them to have been suffering from CTE. But we just don't know whether they reflect a representative piece of a much larger puzzle. Viewed in isolation, they may not present a statistically valid or true picture of what is going on in the larger world of youth sports. Indeed, if only 1 in 7 concussions is reported and treated, as the book states in reliance on a 2010 Canadian study of junior hockey players, that means there are a whole lot more athletes out there who suffer concussions than we know about who seem to recover from concussion without seeing a doctor, and the vast majority of them end up doing just fine.
Unless and until we have data quantifying the risk, I agree that the most appropriate approach is to minimize hits in a reasonable way, as Dr. Cantu recommends, but, at the same time, I do not think we should overstate the risk of long-term injury to the youth sports population as a whole, a message which Cantu tries to espouse but has a hard time doing with a straight face when SLI and the new movie "Head Games" (which, not coincidentally, has its official premiere on September 20, 2012, a day after the release of Concussions and Our Kids) could be viewed as taking a "sky is falling" approach to concussions, which has whipped the country into a frenzy with reports on the autopsies of athletes who drink antifreeze or shoot themselves in the chest so their brains can be sliced and diced by his colleague, Dr. Ann McKee.
After all, the autopsy results are no more than anecdotal; they are no substitute for controlled, longitudinal studies from which statistically-valid conclusions about risk of CTE and other long-term consequences, and factors that increase or reduce that risk, can be drawn. The publicity given to the autopsies and other horror stories leaves in the public's mind the impression that concussions are a problem that is out of control and getting worse.
Could it just be that, the problem only looks like it is out of control and getting worse?
Brooke de Lench is Executive Director of MomsTEAM Institute of Youth Sports Safety, a 501(c)(3) non-profit, Founder and Publisher of MomsTEAM, author of Home Team Advantage: The Critical Role of Mothers in Youth Sports (HarperCollins), and Producer of the PBS documentary, The Smartest Team: Making High School Football Safer.
For a complete list of Brooke's reviews of concussion books, click here.
Updated November 10, 2015