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New Concussion Study Highlights Need For More Education, Stricter Return To Play Guidelines

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A new study in the journal Pediatrics contains some good news and bad news.

First, the bad news: the study reports that less than 50% of high school athletes understand the possible long-term consequences of concussions.  More troubling was the study's finding that 69% of players who suffered a loss of consciousness and 81% of those who experienced signs and symptoms of concussion were allowed to return to play the same day, contrary to current guidelines for the management of concussions, which strongly recommend a more conservative approach to managing concussions in youth athletes, including a ban on allowing athletes with concussion signs or symptoms to return to play in the same game or practice.

The good news is that the study's authors at Children's Hospital in Boston come out strongly in favor of jettisoning the old concussion grading systems and instead following the approach taken under the Prague consensus statement in which concussions are classified as either simple or complex based on the child’s symptoms and how long they take to clear.  The authors also come out in favor of baseline and post-injury neuropsychological testing, wherever possible, and, finally, call for adoption of the Prague "step-wise" return to play guidelines which call for a child, once his or her symptoms have cleared - both at rest and with exertion - to only gradually return to sports play, during which time the athlete should continue to be closely monitored.

I have been speaking and writing about the need for more concussion education and the need for stricter return to play guidelines for years, but, as the Pediatrics article makes abundantly clear, far too many athletes, parents, coaches, athletic trainers and team physicians, despite all the attention concussions have been getting lately in the media, still don't seem to be getting the message.

There are still too many parents who are, sad to say, willing to sacrifice their child's safety and — in the case of concussions, their long term health — at the altar of a winning performance, a touchdown scored, a scholarship won, a pro contract inked.

It is not only fathers who fall into this unfortunate category. There are also many moms:

  • Who are over-invested in their child's athletic success;
  • Who enjoy too much basking in the reflected glory of their child's athletic achievements;
  • Who are content to let their child's very identity become wrapped up in sports; and
  • Who are unwilling — or unable — to make the decisions that I had to make: to end their child's dream of playing high school sports, to take away something their child cherished, and, in doing so, put their child's very future at risk by allowing him or her to return to contact sports while still experiencing post-concussion symptoms or despite a history of multiple concussions.

Some parents admit that they allow their children to play in such circumstances even though they know about the potential for adverse long-term health consequences, like major depression and permanent cognitive impairment.

Too many parents — and their children — still think that concussions only occur with a loss of consciousness and/or that it isn't dangerous to play with a concussion.

Too many young athletes — from 9-year old cheerleaders to star middies on high school lacrosse teams — are still failing to self-report their symptoms to the coach, sideline medical staff, their friends or even their parents, forcing clinicians to try to manage concussions without all the facts.

Kids fail to self-report because, too often, they are told by their parents, but far more often by their coaches, and, more subtly, by the very culture of sports itself, that they should remain silent:
  • to avoid jeopardizing their spot in the starting lineup
  • to avoid being labeled a "sissy" by their coach and/ or their parents
  • to demonstrate to the coach and their teammates that they can "take a hit like a man,"
  • to show that they can be as tough as their professional heroes
  • because they believe that the glory of individual and team success, the promise of a college scholarship, or the lure of a lucrative professional career, is somehow worth the risk of lifetime impairment.

Unfortunately, there are also still far too many coaches in this country - whether it be in youth gymnastics, football, field hockey, soccer, lacrosse, basketball, or skiing - who berate and ostracize players complaining of concussion symptoms, who call them "wimps," who yell at doctors and athletic trainers for refusing to let a player with concussion symptoms go back into the game, and have kicked kids off of the team for refusing to play for two weeks because of a concussion. I hear these stories all too often.

The bottom line, then, is that there are lot of myths about concussions and many reasons why youth athletes are still being unnecessarily put at risk when it comes to concussions, including the very culture of sports and of our competitive society.  I nevertheless continue to believe that the number of concussions, and particularly their long-term consequences, can be reduced if parents, in particular, demand of both themselves and of the sports program to whom they entrust their children that reasonable precautions be taken to protect them against harm. In other words, that parents demand that the entire team to whom they entrust their children's safety — including the national governing body for the child's sport, the state association, the athletic or club director, the athletic trainer (if there is one), and especially the coaches - be part of the concussion solution, not part of the concussion problem.

I have summarized what I feel should the the rights of parents in a Concussion Bill of Rights under which every parent has the right to expect that:

  1. A concussion education and safety meeting is held for parents and athletes before every season;
  2. The coach is a part of the concussion solution not part of the concussion problem;
  3. The program has adopted and enforces conservative guidelines for evaluating and managing concussion;
  4. The athletic department has a certified athletic trainer (ATC) on staff;
  5. Every child in a contact sport undergoes pre-season baseline and post-injury neuropsychological testing;
  6. Parents or guardians receive written notice of injuries and must give written consent before their child is allowed to return to play;
  7. Every child is provided with a safe helmet;
  8. An ambulance and paramedics are present at all high school football games, and, if they are not, procedures in place on how to properly contact EMS ;
  9. Coaches and officials are required by law to be trained and certified in basic safety and emergency procedures, including the recognition of concussion signs and symptoms;
  10. Sports officials are given the right to send any athlete who they reasonably suspect has suffered a concussion during play to the sideline for further evaluation;
  11. High school athletic programs require that each athlete undergo a comprehensive pre-participation physical examination (PPE); and
  12. The national governing body for their child's sport has taken steps to address concussions, both in terms of education and prevention.
Sadly, the Pediactrics article makes it clear that we have a long, long way to go in making these goals a reality for our children.  Adopting and following them all, while it won't make youth sports a concussion-free zone, will make it as safe as it can reasonably be.

I continue to believe that our children deserve no less.