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Concussion Safety: Past, Present and Future

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The other day I was asked in a radio interview what I thought were the biggest recent developments in concussion safety, and what I saw happening in the near future to protect our kids from the dangers of brain injury in contact and collision sports.  Here are the five developments that I view as the most significant, and a seven-point "wish list" for what I hope to see in the not too distant future to make such sports even safer:

Recent developments 

1.  Concussion safety laws.  This one, pardon the pun, is a no-brainer.  The passage of strong youth sports concussion safety laws by 40 states and the District of Columbia over the past two years promises to do more than anything that has ever been done to improve the safety of contact and collision sports.  Each law contains three components that MomsTeam and I have long been advocating:  First, that the education of parents and athletes about concussion safety before every season be made mandatory if the child is to play.  Second, that athletes suspected of concussion be immediately removed from the game or practice (as all current expert guidelines provide), and, third, that they not be allowed to return to the game or practice field until a health care professional with concussion training and expertise gives the okay.

Such laws will go a long way to protecting against athletes, not only from death from second impact syndrome (uncontrolled bleeding in the brain from a blow to the head before the brain has fully healed from an earlier injury) such as in the well-publicized cases of Ryan Dougherty of New Jersey, Jake Snellenberg in Colorado and Matthew Gfeller in North Carolina, but permanent disability, like that suffered by Zack Lystedt, which inspired the first of such laws in Washington State two years ago.

To parents, coaches, administrators, legislators, and governors in the other states, some which have weak concussion safety laws (Idaho, Vermont, and Wyoming), and some where legislation is pending or about to be reintroduced, but especially in the six states where no concussion safety bills whatsoever have even been introduced (Arkansas, Georgia, Kentucky, Mississippi, Montana and West Virginia), I ask, what are you waiting for? Help enact a law in your state now!  We owe to it the kids.

2. Exciting new technology:  Athough we are a long way off from seeing helmets or other equipment that can prevent all concussions, and, frankly, that day may never come, there is a lot of exciting new technology coming on the market. 

Helmet sensors

The latest product to hit the market is the ShockboxTM wireless impact sensors from Impakt Protective.*  Once attached to a player's helmet (a hockey version is available now, versions for football, lacrosse, and ski and snowboard helmets will be introduced in 2012) a sensor measures the G-Force of a hit to the helmet from any direction, and then sends the data wirelessly via Bluetooth to the athletic trainer, coach or parent's smart phone to alert them when the athlete suffers a traumatic head impact that may be concussive so they can be removed from the game or practice for evaluation on the sideline using standard concussion assessment tools, such as the Standardized Assessment of Concussion, Sports Concussion Assessment Tool (SCAT2) or King-Devick test.

 

It essentially gives parents, trainers, coaches and team doctors a set of electronic of eyes with which to watch out for concussions that might otherwise go undetected, either because the signs were too subtle to be seen by officials, coaches, athletic trainers,  team doctors or parents on the sports sideline, or because the player, out of a desire to stay in the game, failed to self-report experiencing concussion symptoms such as headache or dizziness that warrant, at the very least, further evaluation.

Another is Battle Sports Science's Impact Indicator,* a football chinstrap that flashes red when a force is transmitted to the head that may be enough to cause a concussion, alerting game officials and sideline personnel to check an athlete for signs or symptoms of concussion (even if they haven't observed any signs and/or the athlete hasn't self-reported experiencing any symptoms). Chinstraps are now available for football helmets, and versions for hockey and lacrosse - two sports with high concussion rates - will be in stores soon. 

Smart phone apps

In addition, there are now five concussion apps for smart phones on the market for parents and coaches:

  1. the CRR (Concussion Recognition and Response) app developed by concussion experts at the National Children's Hospital in Washington, D.C., and at the University of North Carolina;
  2. The Concussion App from Sports Safety Labs LLC
  3. An app called Play It Safe developed at the University of Texas;
  4. An app based on the SCAT2 sideline assessment test;  and
  5. The ImPACT concussion awareness tool (ImCAT) from the same folks at the University of Pittsburgh who developed the ImPACTTM computerized neurocognitive test in widespread use at the professional and college level and, increasingly, at the high school level as well.

For a review by the MomsTeam staff of the new concussion apps, click here.   

3. Exciting old technology with a new use: another tool that is being added to the concussion toolbox to help in the sideline assessment of concussion is the King-Devick test, a 25-year old test of rapid eye movements that two studies at the University of Pennsylvania, one of kick boxers and mixed martial arts athletes and a second more recent one of college athletes at Penn, show can be used to help identify athletes that may have suffered a concussion and warrant further evaluation away from the sports sideline. As with the Impact Indicator, the King-Devick won't prevent concussions, but, used in conjunction with other assessment tools in use on the sports sideline (e.g. SCAT2, Balance Error Scoring System), Post-Concussion Symptom Scale), identify athletes who should be referred for further evaluation.  And, speaking of old technology with a new use, a new campaign called BeUnstoppable, a collaboration between  Chicago-based Healthy-TXT and the STOP Sports Injuries Campaign (of which MomsTeam is a proud member), is using text mesages - which studies show are the best way to reach kids these days - to educate parents and kids.  Subscribers are sent free text messages on simple text messages about concussions, sports performance, injury prevention, and motivational tips from leading sports medicine experts and professional athletes.

4. New rules and stricter enforcement of existing rules: Not only is the NFL more strictly enforcing the ban on intentional helmet-to-helmet tackling of defenseless wide receivers, but the NHL is finally tightening substantially its rules against head shots, although it is too bad implementation came only after a concussion sidelined its biggest star, Sydney Crosby from January to November 2011.  Two recent rule changes are particularly noteworthy: first, the Ivy League's reduction of the number of full-contact practices in football, which came in response to recent studies by researchers at Purdue and Boston University showing that the cumulative effect of blows that aren't enough to result in concussion may be doing short-term and, unfortunately, long-term damage, including CTE, and, second, the adoption by USA Hockey in June 2011 of what it calls its Progressive Checking Skill Development Policy, which tightens the standard of play for intimidation hits in the legal body checking age categories, and only allows, beginning in the 2011-12 season, legal body checking in games at the Bantam age level (ages 13-14).

What next?

I don't have a crystal ball, but, based on where we have come, I believe, or at least hope, the future will bring the following improvements in concussion safety:

  1. Limits on contact practices. Look for adoption of the Ivy League rule limiting the number of contact practices to spread across all of college sports and, sooner rather than later, down to the high school level and below.
  2. Stricter enforcement of existing safety rules, and adoption of new rules in contact and collision sports.  We are never going to eliminate all the risk, but we need to do even more to reduce the risks.  Chances are, hopefully sooner than later, strict youth sports concussion safety laws will be put in place in all 50 states. Rules governing contact and collision sports at the youth level will also be modified to make the sports safer and reduce the risk of concussion.
  3. More and better education of coaches, parents, and athletes.  Education has been a cause to which MomsTeam has been totally committed for over a decade.  Increased awareness by parents, coaches, and athletes of the critical importance of physical and cognitive rest after concussion will help speed the recovery process.  A better understanding not only of the signs and symptoms of concussion, and of the risks from returning to play before symptoms have not only cleared, but the need for athlete's cognitive functioning (memory, concentration, reaction time, reasoning processing) to return to baseline before return to play is permitted, will put fewer athletes at risk of delayed recovery and long-term injury.
  4. More baseline and post-concussion neurocognitive testing. Even if the tests, (e.g. ImPACTTM) in current use aren't perfect, when properly administered and evaluated by a health care professional with the appropriate training and expertise (e.g. neuropsychologists), studies are showing that they clearly help make sports safer, both by identifying athletes who have suffered concussion but, because they have either failed to self-report their symptoms or escaped detection in the initial instance because the signs of injury were so subtle as to avoid detection through other means, have fallen between the cracks, and by keeping athletes on the sidelines until their cognitive function has returned to their individualized normal, even if they themselves believe they have sufficiently recovered to return or, out of a misguided belief that it is safe to play while still experiencing symptoms, simply lie.  A 2011 study reports that, in the 42% of U.S. high schools that have at least one athletic trainer on staff, the use of computerized neuropsychological tests continues to rise rapidly, increasing to 41.2% of all concussions recorded from 25.7% just a year earlier.1 
  5. More athletic trainers. Less than half of all high schools in this country have access to or a certified athletic trainer on staff. Legislation at the federal and state level to require and/or fund more ATCs hasn't gone anywhere so far, but we need to get to the point where communities and school boards see devoting resources to hiring ATCs, instead of building fancy stadiums and hiring more assistant coaches for a football program, as the best way to use the limited funds available and to protect our kids, who, after all, are our future.
  6. Continued research. There have been lots of studies of concussed athletes at the pro and college level, and even of high school athletes, but we still don't know much about the effects of concussion on the developing brain of younger athletes, and what we do know is prompting at least some concussion experts to suggest that kids delay playing contact or collision sports until middle school or later, or that, at the very least, the rules be modified for the younger athlete to reduce the risk. We still don't know whether mouth guards do anything to reduce the risk of concussion, and research on the cumulative effect of concussions and sub-concussive blows is still in its infancy.
  7. Culture change: Ultimately, I hope to see a change in the very culture of sports itself, including elimination of the "code of silence," leading to more honest self-reporting by athletes about symptoms.  One of the major, ongoing problems in the concussion area is the chronic under-reporting of concussions by athletes.  As the risks of not reporting concussion symptoms are more widely known, I think we will see more parents, coaches, and athletes come to their senses, literally, about the dangers of concussions.
For the most comprehensive concussion information on the web, please visit MomsTeam's concussion center.

* MomsTeam sponsor.

1.  Meehan WP, d'Hemecourt P, Collins C, Comstock RD, Assessment and Management of Sport-Related Concussions in United States High Schools. Am. J. Sports Med. 2011;20(10)(published online on October 3, 2011 ahead of print) as dol:10.1177/0363546511423503 (accessed October 3, 2011).

Updated and revised October 2, 2012