Sports Parents Asking Tough Questions: Are They Troublemakers?

This past weekend,  the Hey Coach Tony show on a local Connecticut radio station devoted an entire hour to discussing one of MomsTeam's most popular  articles: the one listing questions to ask youth sports coaches at the pre-season meeting with parents. 

In case you don't know about Coach Tony, he is what I would call a "guy's guy": a tough-talking "shock jock"-type of radio host who tends to shoot from the hip, and with a reputation for disdaining political correctness and for using outdated terms for people he doesn't like (I cringed while listening to an earlier show when he used the word "retarded" and "retard' more than a dozen times to describe a person he did not care for). 

Listening to Tony discuss the article with his guest, a local high school coach, gave me the chance to hear how it was viewed from the perspective of two male coaches in Connecticut.  Youth baseball coach huddling with team

Based on that input, I have now updated and added to the original article listing the questions (expanding the list from twenty to twenty-one questions), and updated and substantially revised a second, companion article to include some additional background for, and the rationale behind, the list of topics that I believe should be discussed at a meeting between parents, coaches and players before every sports season.

All in all, Tony and I agree on many things, but on some I am left scratching my head. Saturday's show shed some light on Coach Tony's views on issues where we do not agree.  Particularly instructive was the way he chose to end his show: by reading an email he received from a listener saying that parents who ask questions such as the ones suggested in my article will be labeled as troublemakers.

That parents wanting to talk with the coach about what I believe to be essential questions about safety and coaching philosophy will be viewed by some, perhaps even the majority, as asking for trouble is itself extremely troubling. 

That Tony chose to end his show with what amounted to a warning shot across the bow to parents, suggesting to them that they might want to keep their head down and not make waves or risk having their kids suffer the consequences made it clear to me that Coach Tony and all the Coach Tonys like him around the country are more part of the problem than the solution to what I think is wrong with youth sports today: a lack of accountability on the part of coaches, a culture that is adult-centered, not child-centered, and that is more about winning at all costs - even if at the risk of injuring children, not just physically, but emotionally and sexually - than it is about safety, having fun, skill development and learning life lessons. 

While his attitude may well reflect that of many of his fellow coaches, as well as his listeners, it is definitely not the way I look at, and have been looking at, youth sports.  I started MomsTeam almost a dozen years ago with the mission that I still work towards every day: making youth sports safer, saner, less expensive and more inclusive.

My original articles have prompted quite a few emails over the years, thanking me for tackling the thorny subject of the parent-coach relationship and being willing to suggest that parents be brave enough to ask coaches some very tough questions. 

In updating my articles, in having to explain why it is important to ask questions, and in admitting that it takes courage for parents to ask them, that they risk being ostracized by the go-along-to-get-along crowd, that their child may end up suffering more emotional harm when they find themselves, through no fault of their own, riding the bench because their parent is considered pushy or a troublemaker, is not only extremely ironic but very sad, as is the fact that it is a reality which needs to be acknowledged. 

But it won't stop me from fighting for change, even if means calling out all the Tonys of the world.

 

Questions/Comments:  delench@momsteam.com

Brooke de Lench is the author of HOME TEAM ADVANTAGE: The Critical Role of Mothers in Youth Sports (Harper Collins) and the founder of MomsTeam.com 

UPDATE: In September 2012 "Hey Coach Tony" was dropped by ESPN Radio where he had an hour long show.

 


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Aspen Institute Football Roundtable Was Valuable, But Changed Few Minds

Last Friday, I participated in a roundtable discussion in Washington, D.C. conducted by the Aspen Institute's Sports & Society program called "Playing Safety: The Future of Youth Football?" It was moderated by ESPN's Tom Farrey and, in the phrase made famous by the movie Casablanca, rounded up all the usual suspects on concussion safety and football, including MomsTEAM concussion expert emeritus Dr. Bob Cantu, USA Football Executive Director Scott Hallenbeck, and NFL Player Association President DeMaurice Smith, among other luminaries from the world of football and journalism. I was indeed honored to be asked to join those debating the future of the sport.

Brooke de Lench at Aspen Institute football roundtable

Although the participants admittedly came to the table viewing football and concussion safety through the prism of their own experience and advancing the narrow interests of the organizations they represented, the roundtable was a valuable exercise, even though I'm pretty sure almost everyone left the meeting still hewing to the same views they had coming in.  But the goal wasn't to change minds (if it was, it didn't meet that almost impossible challenge.)  Instead, as the saying goes in diplomatic circles when a consensus can't be reached, what took place was, at its best, a "full and frank discussion" of the issues. 

As I knew would be the case going in, a number of the participants came out strongly against the playing of tackle football before the age of 14, or said they would personally never let their child play football, period. As was also to be expected, the no-football-before-14 group, led by Bob Cantu, encountered push-back from USA Football's Hallenbeck, Pop Warner's Jon Butler, NFLPA President Smith, and NFL Senior Vice President Jeff Miller, among others.   

When I finally had a chance to speak, we were already running over the 2 1/2 hours allotted for the roundtable, so I was only able to briefly touch on two of my many message points: one, that the game can be and is being made safer, and two, that, based on my experience following a high school football team in Oklahoma this past season  - which will be the subject of a MomsTEAM documentary to be released in early 2013 called The Smartest Team -  I saw the use of hit sensors in football helmets as offering an exciting technological "end around" the problem of chronic under-reporting of concussions that continues to plague the sport and remains a major impediment, in my view, to keeping kids safe (the reasons: if an athlete is allowed to keep playing with a concussion, studies show that their recovery is likely to take longer, and they are at increased risk of long-term problems (e.g. early dementia, depression, more rapid aging of the brain, and in rare cases, chronic traumatic encephalopathy, and in extremely rare instances, catastrophic injury or death. )

Some expressed the view that a decline in participation in youth, junior high and high school football is inevitable.  I am not one of those who is in that camp, either.

Some also said it was inevitable that research would eventually lead us to one ineluctable conclusion: that football poses an unacceptable level of risk of long-term injury. Again, while I am not a scientist or medical doctor, I don't necessarily agree, especially if the amount of what Bob Cantu calls "total brain trauma" can be significantly reduced through a combination of limits on full-contact practices and/or hit counts, rule changes, and if we do a better job of identifying concussive injury to get concussed players off the field (or ice, or field, or court, or pitch), and and hold kids out longer before they are allowed to return to play so the risk of reinjury is reduced as much as reasonably possible.   

Instead, I predict that we will ultimately learn that football and other contact and collision sports with high concussion rates do not pose an unreasonable risk of harm to the vast majority of athletes (especially those whose football careers end after high school), and that, while it may take a while, we will eventually learn to identify those athletes who, because of genetic predisposition or environmental factors, are at greatest risk, so that they and their parents can intelligently assess the level of risk and decide whether football is right for their family.  

No need to panic

What continues to be lost, in my view, in much of what the media has reported over the last six years about the results of autopsies conducted by researchers at the Sports Legacy Institute in Boston on the brains of athletes - autopsies which show the presence of the dark splotches of tau protein which are the tell-tale sign of CTE - which is that they provide, at most, anecdotal evidence suggesting a possible connection.  There are no studies that show a statistically significant increase in the likelihood of CTE simply from playing football or other contact or collision sport, and none, as far as I know, are even in the research pipeline, but those who say it is too early to connect the dots, well, their voices are being drowned out by those who suggest exactly that.

Could it be that the athletes found by SLI to have CTE were genetically predisposed to developing Alzheimer's and aren't representative in any way shape or form of the general population but, instead, of the small percentage of vulnerable ones? In other words, that not everyone who plays sports is destined to develop CTE.  How many millions of men in their twenties, thirties, forties, and beyond, have played football without enduring cognitive damage? 

While a 2012 study by researchers at the University of Michigan suggests that concussions may speed up the brain natural aging process, the long-term effect of a concussion, even two or three, remains unclear.  

"The last thing we want is for people to panic. Just because you've had a concussion does not mean your brain will age more quickly or you'll get Alzheimer's," said lead author of the study, Steven Broglio, Assistant Professor of Kinesiology and Director of the Neurotrauma Research Laboratory at Michigan.  "The influence of various lifestyle and environmental factors, such as smoking, alcohol consumption, physical exercise, family history (genetics), whether or not a concussed athlete 'exercises' their brain, and even how dense the gray matter in a person's brain is, which gives them greater 'cognitive reserve' to draw upon may also impact the brain's aging process," he said, such that "concussion may only be one small factor."  

In addition, Broglio said, this line of research is still in its infancy.  "'It's not entirely clear," he recently told the Kalamazoo News, "if and how the brains of young athletes are affected by the sports they play.  'We are realizing it's probably not how many concussions you have that makes a difference, but the total exposure' to concussive and sub-concussive blows." 

EEGSo does Broglio think that if an athlete sustains a single concussion in high school, it means they will get dementia at age 50? "Clinically, we don't see that. What we think is it will be a dose response,"  Broglio said.

"So, if you played soccer and sustained some head impacts and maybe one concussion, then you may have a little risk. If you went on and played in college and took more head balls and sustained two more concussions, you're probably at a little bigger risk. Then if you play professionally for a few years, and take more hits to the head, you increase the risk even more. We believe it's a cumulative effect."

So what's Broglio's answer to my earlier question: Does the average high school athlete face risks similar to those of former professional football players - such as those whose brains, upon examination after death, show signs of chronic traumatic encepholapathy (CTE), or who, even if still alive, exhibit signs of serious depression or early-onset dementia, which researchers have linked to their years on the playing field?

Broglio says that there is little to no evidence that they do.  "We're not seeing an epidemic of men in their early 50s with early Alzheimer's because they played high school football," 

Play smart, not scared

When all is said and done, I continue to believe that, instead of sensationalizing and scaring parents, the media, not to mention the scientific and football communities, should take a much more balanced approach, one which recognizes that (a) the research is a long way from establishing that football or any contact or collision sport leads to a statistically greater risk of chronic traumatic encephalopathy, early dementia or Alzheimer's; (b) helmet-to-helmet contact can be dramatically reduced through the teaching of proper tackling and rules against such contact; and (c) long-term adverse health effects can be limited through better identification of concussive injury, immediate removal from play of those with suspected concussion, cognitive rest after injury, and more conservative return-to-play guidelines.

Specifically, I believe the following five steps, among others, can help make the game safer:

1. Make safety training and the teaching of proper tackling mandatory for coaches: In order to coach youth or high school football a coach should be required to be certified in concussion safety and safe tackling training.  The reasons are clear:

  • 76% of coaches in a 2012 Safe Kids Worldwide survey said they wanted more concussion training, but fully 40% admitted that they have no safety training at all;
  • An alarming half (52%) of all coaches mistakenly believe that there is an acceptable amount of head contact (ie. getting their "bell rung", seeing stars) young athletes can sustain without potentially causing a serious brain injury, with the percentages of those who felt this way highest among coaches under age 35, male coaches, and paid coaches; and
  • Nearly half (47%) agreed with the statement that they had so many other responsibilities as coaches and so little time that they could not focus on injury prevention.

2. Make sure helmets fit.  Making sure that football helmets fit properly, and that those with air bladder linings are properly inflated, may be two of the simplest but most effective ways to minimize the risk of concussion and catastrophic brain injury.  A recent study shows that, while properly fitting helmets don't necessarily reduce the risk of concussion, the risk goes way up if the helmet doesn't fit properly. This is the reason behind the new NFHS rule this fall requiring a player whose helmet comes off to sit out a play.  Kids need to wear lighter helmets specifically designed for their smaller heads and weaker necks.   There are new youth-specific helmets coming on the market, and more are sure to follow.  Also, football programs should not put all their helmets eggs in one basket: because one size does not fit all, they should offer at least two different types of helmets to ensure proper fit.

3. Use "hit sensors." Widespread use of accelerometers - whether they be inside the helmet, in a sweatband, or in the chinstrap, and transmitting data wirelessly to the football sideline on hits that might result in concussion, will help combat the chronic under-reporting of concussions resulting from the reluctance of players to self-report symptoms and the inability of sideline personnel and game officials to spot a concussed player. Hit sensors are needed at every level (including the NFL, where I know the players' union is currently against them), but especially at youth and high school level. There are lots of companies which have already brought or will be bringing hit sensors to the market, and I am excited about their potential in revolutionizing the identification of concussive injury, which could go a long way to making the sport safer, in my view. The athletic trainer of the Oklahoma high school team we are featuring in The Smartest 

Brooke de Lench

Team documentary told us he was glad sensors were in the helmets to alert him to a hit of sufficient g force that it that might cause concussion.  Likewise, the players said the presence of a hit sensor relieved them of the responsibility to report concussion symptoms themselves, something that they, like most players, candidly admit they are reluctant to do.  Widespread use on the sports sideline of the King-Devick test, which studies are showing can quickly identify on the sports sideline those athletes who should not be allowed to return to play and instead referred for further evaluation, and which can be administered in about two minutes by just about anyone, whether they be parent, coach, or athletic trainer), could also go a long way in solving the concussion identification riddle.

4. Reduce the number of full-contact practices at the high school level. The NFL only allows one contact practice a week; the Ivy League, two. Steps have been taken by Pop Warner and USA Football to limit contact practice time at the youth level. Yet there is no limit on the number of full-contact practices at the high school level. Mandating such a limit would dramatically reduce total head trauma, including the accumulation of sub-concussive hits that researchers at Purdue in a 2010 study found can lead to subtle cognitive deficits that evade detection via the usual signs or symptoms method.

5. Better strength and conditioning, particularly of neck muscles. Younger players, as Bob Cantu points out, have weaker neck muscles.  MomsTEAM's concussion expert, Dr. Bill Meehan, Director of the Sports Concussion Clinic at Children's Hospital Boston, and author of Kids, Sports, and Concussion,  thinks one way that may reduce the risk of head injury is to strengthen the neck muscles so they better cushion against impact.

At a tipping point?

The differences of opinion at the Aspen conference were stark and sharply drawn. There were many in the room, of course, who don't share my views in the slightest.  But "sooner or later," predicted Bill Mayer, owner of the UFL's Virginia Destroyers, we will reach what Malcom Gladwell calls the tipping point.  "Tipping points," said Mayer, "are usually reached because there is some person that has an abnormal amount of influence in the opinion of others. Who it is, that person is probably in this room."

Who will it turn out to be?

Stay tuned. 

Note: For the video of the roundtable which appeared on C-SPAN2, click here.    


Brooke de Lench is the Founder and Publisher of MomsTEAM.com, author of Home Team Advantage: The Critical Role of Mothers in Youth Sports, and Executive Producer of the forthcoming football documentary, The Smartest Team, slated for release in early 2013.

 

 

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Micheli Center for Sports Injury Prevention: An Honor To Attend Groundbreaking Ceremony

Lyle Micheli, William Meehan, and Joe Andruzi

Yesterday, I had the honor of being a guest at the groundbreaking ceremony for the Micheli Center For Sports Injury Prevention, which is being built next to Children's Hospital Boston's Waltham, Massachusetts facility.

Lyle Micheli, MD at groundbreaking for Micheli Center

There isn't a person working in the field of youth sports injuries who does not immediately recognize the name Lyle Micheli, MD.  He founded the first youth sports injury clinic at Children's Hospital in 1974.  Dr. Micheli was also one of the first, if not the first, doctor to sound the alarm bells about overuse injuries.  He has seen first hand how year-round sports and early specialization have taken their toll on the bodies of our kids, and has worked tirelessly over the years to make youth sports safer.  It is not a stretch to say that Lyle is one of the truly great sports medicine doctors of this or any generation.

Kicking off the event was MomsTEAM expert William Meehan, MD, Director of the Sports Concussion Clinic in the Division of Sports Medicine at Children's Hospital Boston, and the Director of the new Micheli Center. Bill spoke about the need to prevent injuries in kids sports and the role of the Micheli Center will play in that mission, one which MomsTEAM has shared from its inception. 

Speaking of sharing, Dr. Micheli told us a wonderful story about his mother, who used to collect coal on the train tracks as a young woman and carry them in a large basket on top of her head. She was a soccer player, but managed to avoid the ACL injury problems that have reached epidemic levels among the young female soccer players of today.

Lyle believes that the reason the number of sports injuries is so high today is that our children do not have the opportunity to build up their muscles the correct way as kids once did while working on family farms, doing chores around the home, walking or riding their bikes to school, and in unstructured play in the neighborhood.

He also believes that, to avoid crippling ACL injuries, our sports-active daughters need to begin strength and conditioning training earlier (at the ages of 8, 9 or 10), even earlier than recently recommended by the authors of a new study on the benefits of neurmuscular training (NMT) for female athletes, who suggest that the best time to begin NMT may be in their mid-teens.

Micheli declared that the new center named in his honor will be, as the name states, all about preventing injuries, and he told us that it will do in three important ways:

  1. By providing access to young athletes so they can train correctly to prevent injuries (look for three new gymnasiums and training rooms when construction is complete in 2013);
  2. By developing a customized, individual profile for each young athlete to determine what they need to strengthen in order to avoid sports injuries; and
  3. Through cutting-edge injury prevention research, an area in which we do not have enough good data.
Joe Andruzi at groundbreaking for Micheli Center

In addition to Drs. Micheli and Meehan, we also heard from special guest speaker, former New England Patriot, three-time Super Bowl winner and cancer survivor, Joe Andruzzi.  He spoke about the importance of taking the rehabilitation process after injury slowly under the guidance of experts who are able to help determine the best way to structure rehab so that an injured athlete ramps up weight training gradually in order to rebuild muscles to stabilize joints. Joe's story about how he used a positive attitude and a sense of humor to beat cancer is truly inspirational.

Inspiring, too, is the work of people like Lyle Micheli and Bill Meehan in making youth sports safer.  It was such an honor to be invited to the event.

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Head Games Movie Review: Most Appreciated My Candor


As I expected, my review of Head Games: The Movie has generated a lot of mail in the last two days, many from respected health care professionals and experts around the country.  Most wrote to congratulate, thank, and/or applaud me for having the courage to post such a thorough, candid, and critical review, one which was informed by my years covering the concussion issue, not by all the media hype surrounding the film. Just as predictably, some of the mail I received was not quite so flattering.

Teen football player sitting at locker

One I liked in particular was from Brenda, a mom of five in Nebraska with three sons playing football. She was one of MomsTEAM's very first followers when we launched twelve years ago. At the time, her twins were just starting sports. Now, twelve years later, the twins are seniors in high school, a son playing football, and a daughter playing soccer. She wrote to say:

We were thinking of renting Head Games until I read your review. Thank you. Your reviews are brutally straightforward and your concern for keeping all children active and safe speaks volumes. I would expect nothing less from you or MomsTEAM. I have come to trust that staff reporters skim the issue and report what others are too lazy to report on accurately. I'll donate the money saved to our boosters.

Another wrote to remind me that the movie "was not really meant to be educational and helpful to parents. It was meant to shock and grab attention."

Along those same lines was another e-mail observing that "sensationalism sells, not safety and common sense."  

A leading concussion researcher wrote in support of my view of the movie as scaring parents: "Parents and kids should not be scared away from sports. Quite to the contrary, we do this research to find ways to make the sports a safer place and teach the athletes to become wiser players. 

A well-known sports medicine doctor wrote this: "It is only over the last month that I have come to realize how difficult your job can be," and how much he appreciated what he called my "direct, honest, apolitical, and heartfelt review" of Head Games and the flood of concussion books that have been published in the last couple of years.

For me, Head Games simplifies, sensationalizes, and speculates, and gets in the way of reasonable solutions to the concussion challenge. 

Having said that, I am not so naive that I don't also appreciate that it is money, as the song from Cabaret goes, that "makes the world go around," and that it is the sensational which sells movie tickets.

Do some parents, coaches, athletes, game officials, and administrators need to get their heads out of the sand and face up to the fact that head trauma - any head trauma - in sports needs to be taken seriously? Absolutely. Might Head Games be the wake-up call they need? I hope it is.

But from my perspective, I continue to believe that there is a better way to get the message across.

My mission, and MomsTEAM's, has always been and will continue to be to provide the objective, well-researched concussion information sports parents need to decide what is best for their family and for their child, to make a decision rationally based on facts, not emotion, motivated out of concern, not driven by fear.

If it means I continue to take flak from those who think that, by saying that Head Games was not the movie I hoped it would be, I am in any way minimizing the challenges concussions pose, or being unfair, it is a price I will gladly pay. 


Brooke de Lench is the Founder and Publisher of MomsTEAM.com, and the author of Home Team Advantage: The Critical Role of Mothers in Youth Sports. Her e-mail is delench@MomsTEAM.com.

 

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Concussion Safety: Past, Present and Future

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

 

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Baseline Neurocognitive Testing Before Winter Sports Activities: An Idea Whose Time Has Come?

I remember one time, when my kids were six, going ice skating at a new rink with my sister Drew, her daughter Courtney, and my triplet sons. The excitement of a new rink and lots of kids zipping around provided for a lot of great fun and laughs, but ended, unfortunately, in an accident and a terrifying trip to the hospital, the memory of which is still vivid.Girl lacing up figure skates

As we laughed and talked in the stands, Drew and I kept our eyes glued to our kids as they skated in a little pack.  I can play over and over in slow motion Courtney's accident: how her skates seemed to fly out in front of her, sending her falling back hard, hitting her head on the ice. My sister and I gasped and look at each other as we made our way to the ice. Courtney was still down and holding her head. "Oh, my God, Courtney are you ok?", my sister asked over and over. Courtney was not okay.

Thank goodness Drew is a nurse and realized immediately that Courtney needed to go to the emergency room. In fact, I realized as soon as Courtney began asking the same questions over and over that she was seriously hurt. An hour later, the doctors at the hospital in Boston told us that she had suffered a very serious concussion. It took many months for the symptoms to disappear.

Years later, my son Spencer suffered a concussion when he, his brothers, and cousins were snowboarding in New Hampshire. All the kids came down the mountain, found us and in unison declared that "something is wrong with Spence."  He had fallen on the ice and hit the back of the head. A trip to the ER confirmed that he, too, had sustained a concussion.

Could anything in the concussion "tool bag" have prevented these accidents? No.  While kids who snowboard or ski should always wear helmets  to protect against skull fractures and serious traumatic, life-threatening bleeding in the brain (the kind that led to the death of actress Natasha Richardson, for example), they don't prevent concussions.  Could one of the new iPhone concussion apps have helped? No.  In these emergencies no one has time to take out an app, and they are for helping to diagnose a concussion, not preventing them. How about baseline neurocognitive testing?

Again, neuropsychological baseline testing wouldn't have prevented the concussions Courtney and Spencer suffered, but they undoubtedly would have helped in post-concussion management, especially in determining when it was safe for them to be back on the slopes or skating on the rink.  While the use of computerized neurocognitive testing has increased dramatically in recent years among high school athletes playing team sports, like football, soccer, and lacrosse (use of the Immediate Post-Concussion Assessment and Cognitive Test has become so widespread that many think of it as being an "ImPACT test"), perhaps kids, like Spencer and Courtney, who weren't playing team sports but are participating in winter sports such as curling,skating, skiing, snowboarding or sledding, in which head injuries are common, should have baseline tests too, prior to hitting the slopes or the rink.

My advice to parents, then, is to consider getting a baseline test done on your child before they strap on skates, buckle up their ski boots, or hop on their Flexible Flyer this winter. You never know when those results might come in handy.  

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Computerized Neurocognitive Baseline Concussion Testing At Home: Why I'm Against It

A couple of weeks ago a team and league management technology provider and a neurocognitive testing company announced a partnership to provide online testing for athletes. The announcement prompted emails to MomsTEAM from parents asking for my opinion on how and where to have their children's baseline neurocognitive tests done, and whether they could do them at home.  While I have been fielding similar e-mails for years, the uptick in emails prompted me to do some digging to come up with an answer.

In formulating a response, as with so many other aspects of youth sports, I was able to draw on my own personal experience as a sports parent and the past 12 years of covering the concussion beati. Back before they were computerized, one of my sons (the one who played football) took the old "paper and pencil" neurological exam. The test was administered by a neuropsychologist who had been trained to give the tests, and who had given them to hundreds, if not thousands, of children before she switched over to using a computerized exam.  I also asked MomsTeam's concussion experts for their opinions. iConcussion icon

I recalled a conversation I had with my son's pediatrician when he explained why he was referring him for testing in Boston by a neuropsychologist.  He told me that, when it comes to matters involving the brain - the most delicate and important of all organs - one needed to "work with those who are highly trained in the field of neuropsychology; that even we [pediatricians] defer to their results."

The more things change ...

Yes, a lot of time has past since then, and a lot has happened over the past decade in terms of what science knows about concussions, and in technological advances. We know so much more than we ever did. 

But, in some ways, things haven't changed all that much.  Yes, paper and pencil tests have largely given way to computerized tests (you may have heard of the Immediate Post-Concussion Assessment and Cognitive Testing, or ImPACT tests, for short), which are now being administered in stand-alone concussion treatment centers all across the country or in a hospital setting.

We also know that, increasingly, baseline tests (which can include, not only computerized neurocognitive tests, but balance tests, and of vision) are being administered by trained personnel at the nation's high schools, especially those that have an athletic trainer on staff.  And now, a child can even log on to a website of a youth sports organization, testing company, or a sporting goods store to take a baseline test, and he and his parents can get the results with a click of a mouse.  It is these tests, taken online without any supervision, which seem to be the ones parents are asking me if they are "safe" and "ok" for their children to take. Hand on computer mouse

It is not up to me, of course, to tell parents what they can or cannot do. The "dash board" types of tests are an option.  But based on the research I have studied, the opinions of experts I have consulted, and, frankly, my own personal experience, I come down strongly on the side of those who feel the taking of an online baseline test is not the way to go.

Looking back on the time and care that my own sons' neuropsychologist took in administering the test, interpreting the results, and then going over them with me and my son in detail, and how much I counted on the reliability of the test results, which I needed not only in working with his school on an individualized education plan (IEP) but to compare against the results obtained after he suffered concussions, I cannot square in my mind how a "dash board" take at home test can achieve the necessary degree of reliability to be of much use, beyond perhaps giving parents a sense that the blow to the head their child suffered in yesterday's soccer game wasn't so bad because, comparing his baseline to post-injury test results doesn't show much of a difference.

... the more they stay the same.

My recommendation to parents is to leave the concussion testing where it has always been: in the hands of concussion professionals.  While it may be tempting for parents to think that the technology has advanced so far as to eliminate the need for trained professionals in administering and interpreting neurocognitive test results, and while home concussion testing may be all the rage, I don't think we have reached that point.  We may someday, but, in my view, we aren't there yet.  Not by a mile. I just don't think parents of athletes in contact and collision sports can afford to take a chance.  We're talking about our kids' brains, here, after all.

Should every child playing sports or engaging in activities in which concussion is a possibility, such as winter sledding or even riding their bike, have access to affordable, reliable neurocognitive testing? You bet. I hope to see a day in the not too distant future when periodic baseline computerized neurocognitive testing will become a routine part of a child's pre-participation or sports physical.  But neurocognitive tests need to be administered by professionals with appropriate training and experience (e.g. Credentialed ImPACT Consultant). Period.  End of story.

Don't have to take my word for it. If you aren't inclined to believe me (after all, while MomsTeam and I have been at the forefront of concussion prevention and education for more than a decade, I don't have any initials after my name), I invite you to read what Rosemarie Scolaro Moser, Ph.D., a leading sports concussion neuropsychologist, MomsTeam expert, has to say about the challenge, even for trained experts, of obtaining valid baseline test results, and why parents should exercise caution in buying baseline tests on line for their child to take at home. *

Look before you leap, so the saying goes.  In the case of neurocognitive testing, it couldn't be more true.

Questions/Comments? Reach me at delench@momsteam.com 

*Important April 18, 2012 update: The Centers for Disease Control and Prevention's recently issued "FAQs about Baseline Testing among Young Athletes1 supports my position stating that: (1) Baseline tests should only be conducted by a trained health care professional; and (2) "[o]nly a trained health care professional with experience in concussion management should interpret the results of [a] baseline exam.  When possible, ideally, a neuropsychologist should interpret the computerized or paper-pencil neuropsychological test components of a baseline exam."

1. http://www.cdc.gov/concussion/pdf/baseline_testing_FAQs-a.pdf)(accessed April 16, 2012) 

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Another Concussion Book Review

Because I didn't blog about it, some of you may have missed my lengthy review last week 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 he co-authored with sports journalist Mark Hyman, the latest in a slew of concussion books that I have read and reviewed over the past couple of years (that will teach me; if I really want people to read what I write, I better at least mention it in a blog!). 

While it has much to recommend it, I ultimately came away from reading the book disappointed at several pieces of advice it gives that seem to ignore critical changes in the thinking of concussion experts over the past decade, including some from Dr. Cantu himself, that detracted from what is otherwise an excellent book.

Instead of posting it again as a blog entry, I invite anyone who is interested to click here for the full review.

And speaking of Bob Cantu, a heads up for those of you who may be wondering what I thought of the new movie, Head Games: The Movie, a concussion documentary which, like Bob's book, premiered last week, and in which he features prominently.

Look for my blog post tomorrow, which will link to a lengthy review.  

 

 

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Education, Not Testing Key To Winning Steroid Battle

If you saw the recent stories  about the preliminary results of the two-year, $6 million dollar high school steroid testing program in Texas, you might be confused.

On the one hand, the program didn't catch many users: of the 10,117 students tested in 2008 under a state-mandated program in Texas, only four tested positive for steroids (resulting, for the first offense, in a 30-day suspension of the student from playing his or her sport), although another 22 cases were classified as "positive" because students either refused to provide urine samples, were absent from school without excuse on the day they were supposed to be tested, or left the testing area without approval.

On the other hand, proponents of the testing program called it "an incredible success" because the point was to deter drug use, not catch offenders; as Texas Republican state representative, Dan Flynn, who sponsored the testing bill in 2007, told reporters, "We don't have a bunch of pelts hanging on the wall. The success is that we haven't had a lot of positive tests."

Testing programs in a handful of other states have yielded similar results: A one-year, $100,000 program in Florida tested 600 student-athletes in 2007 was discontinued after only one student tested positive for steroids. Random testing in 2006 in New Jersey produced one positive result from 500 athletes screened. Results from Illinois, which is testing athletes at its state championship events, are not yet available.

The testing programs undoubtedly act as a deterrent to some, but few athletes are tested, the tests only detect certain steroids, and the Internet is full of tips on how to avoid detection.

My position, as it is with respect to so many safety issues in youth sports, has always been that education is the key; that the best way to reduce steroid use among teen athletes is through straight, honest talk in a setting that allows for give-and-take with student-athletes.

While I like the award-winning public service campaign called "Don't Be An Asterisk" about the dangers of steroid use, I think the best way is for high schools themselves to do the education. After all, they are in the education business

Fortunately, high schools don't have to reinvent the wheel when it comes to steroid education: there are already programs on the shelf, including a multimedia educational initiative called "Make the Right Choice" from the National Federation of State Athletic Associations (NFHS) , and, most notably, the award-winning ATLAS (Athletes Training & Learning to Avoid Steroids) and ATHENA (Athletes Targeting Healthy Exercise & Nutrition Alternatives) programs from Oregon Health & Science University they can use.

More and more schools seem to agree with me.

At the very least, parents have, in my view, a responsibility to be proactive when it comes to the use of performance-enhancing drugs.

  • Talk to your kids about the risk of permanent injury and criminal consequences (including up to a year in jail and a minimum $1,000 dollar fine).

  • Scare them with a horror story or two

  • Become educated about the visible signs of steroid use and be on the lookout! 

  • And, finally, don't ignore the problem. If you suspect your child is using steroids, seek help immediately before it's too late.

 

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Exertional Heat Stroke: A Must-See Video

Since our launch in August 2000, MomsTEAM has been educating parents, coaches, athletic trainers and players on the dangers of heat illness, how to prevent exertional heat stroke - particularly among football players who are most at risk during pre-season practice - and how heat stroke should be treated if and when it occurs.  

Football player drinking from water jug

Our sports hydration and heat illness expert, Susan Yeargin, Ph.D., ATC,  has been working alongside Doug Casa, head of the Korey Stringer Institute at the University of Connecticut, to get states to pass laws modeled on the 2009 heat acclimatization guidelines developed by a joint task force on which she and Doug served, and to educate the youth sports community about heat illness.

Most recently, Susan worked with KSI on a handout on heat acclimatization, and reported that, despite strong lobbying efforts by KSI, only a handful of states had thus far acted to pass heat acclimatization laws. 

Heat-related deaths tripled 

Sadly, the fact is that, while they are one of the most - if not, the most - preventable of all catastrophic sports injuries, heat-related deaths among high school and college football players in the United States nearly tripled between 1994 and 2009, according to a new study by researchers at the University of Georgia, with an average of nearly three players dying each year during that time period versus about one death per year during the previous 15 years.  Six deaths occurred in Georgia alone, the most of any state.  (No wonder that in 2012 Georgia became the sixth state to enact strong heat safety legislation).

So, when I learned that KSI had come out with a great new video about heat stroke, I was thrilled to be able to post it on our site.  It features Doug Casa and includes some video from a fantastic PBS Frontline documentary that aired a while back which focused on the fate of four high school football players in Arkansas who suffered heat stroke during pre-season practice in the summer of 2010. 

I encourage every parent of an athlete in any sport, but especially football and endurance sports like marathon, cross-country, triathlons, and road cycling, to watch the video and then go to MomsTEAM's hydration safety center on our Health and Safety Channel for comprehensive information about heat illness prevention and treatment.

I know Doug Casa, Susan Yeargin, and I won't rest until we can report that a summer has gone by without any athlete dying from exertional heat stroke. 

 

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