Concussions in High School Sports: Are They Worth the Risk? Should School Football Be Banned?

Transcription

1 Concussions in High School Sports: Are They Worth the Risk? Should School Football Be Banned? by Bran L. Mahaffey, MD The risk of serious injury or accidental death to our youth is much higher than football participation while riding their bicycles, swimming in home pools, walking or riding to school or living in homes where alcohol, prescription drugs and household poisons and toxins are stored. Brian L. Mahaffey, MD, MSPH, MSMA member since 1999, is Director, St. John s Sports Medicine in Springfield, Head Team Physician, Missouri State University and Team Physician, Springfield Cardinals. Contact: Brian.Mahaffey@Mercy.Net Editor s Preface Following the suicide death of All- Pro National Football League (NFL) linebacker Junior Seau and the avalanche of lawsuits filed by more than 2,000 former NFL players, the subject of the inherent violence of the gridiron and noxious effects of cumulative head trauma, especially concussions, have been widely discussed. (American Medical News: Doctors Key Players in NFL Concussion Litigation Alicia Gallegos, 8/6/12 p1a) This is the second of two articles dealing with football-related injuries. In the September/October 2012 issue former University of Missouri Academic All- American Jake Stueve, MD, discussed his experience and opinions as an outstanding high school and college tight end. The following article by the Journal s Sports Medicine Editor and Mercy-Springfield Primary Care Sports Medicine Specialist Brian L. Mahaffey, MD, thoughtfully discusses diagnosis, treatment and prevention of conclusions, and whether football is inherently too dangerous and should be banned. Introduction In the past several years, the interest in sport-related concussions in the lay press has increased dramatically. Almost weekly there is a story on sport-related (usually football) concussions. This involves every level of sport from youth to professional. Sports medicineneurology-neurosurgery physicians began research on the diagnosis, treatment and rehabilitation of sports concussions many years ago. Consequently over the last fifteen to twenty years the recognition and care of these injuries has dramatically improved. A study by Gilchrist at the Center for Disease Control (CDC) found that the number of emergency room visits for patients diagnosed with concussions increased 62% from 2001 to The study did not address why this occurred. Did concussions really become much more frequent during the study? Or did the prevalence of concussions remain relatively constant but emergency room visits increase secondary to heightened awareness and better diagnosis? I believe that it is likely the latter than a true increase in the incidence of concussions. The publicity of sport-related concussions has facilitated a general understanding that concussions can be devastating injuries with long-term consequences. In the past as team or personal physician, I have had players, parents, and coaches argue with my treatment recommendations; now this rarely occurs. The overwhelming majority of people, including coaches, involved in high school and college sports are truly concerned for the short-and long-term health of their Missouri Medicine November/December :6 433

2 athletes. There are a few, usually highly publicized, exceptions. The most egregious being some NFL teams surreptitiously paying cash bounties for injuring opponent star players. There are increasingly strident calls from a variety of groups and individuals for the elimination of football from high school and college campuses. A school board member and teacher in Council Rock, Pennsylvania tried to ban high school football, which she compared to gladiator fights of ancient times. 2 Friday Night Lights author Buzz Bissinger argued in a Wall Street Journal editorial that college football should be banned. 3 One of his arguments was the risk of serious head injuries. Malcolm Gladwell, in a 2009 New Yorker article titled, Offensive Play: How Different are Dog Fighting and Football? discussed their similarities ultimately questioning whether football is worth it? 4 As usual it was just a matter of time before government became involved. The state of New York in 2009 banned dodge ball, tag, red rover, and wiffle ball at children s summer camps to make them safer. 5 This was later reversed because of widespread public outcry. Nevertheless, the efforts of those that believe that all risk can be legislated and regulated out of sports and children s play continues unabated. Many states, starting with Washington (2009), have passed concussion legislation. These laws restrict the return to competition of high school athletes diagnosed with concussion for at least 24 hours and only after evaluation by a medical professional. In Missouri, a similar law was passed in Even with these laws, head trauma deaths still occur. Concussions Concussions are potentially very serious injuries and youth between ages thirteen to eighteen years are the most vulnerable. 6 The prevention and care of concussions is controversial but most sports medicine providers follow the 2008 Zurich Concussion Consensus Statement. 7 There remains many challenges in concussion recognition, care, and return to play criteria. Therefore caution and conservative treatment, especially in teenage athletes, is appropriate. Figure 1 Concussion Symptoms There are over 20 symptoms, including headache, which may occur in concussions. These can range from minor, such as a mild change in sleep patterns or emotions, to severe personality changes and disabling vestibular symptoms. Concussion Diagnosis Concussion is an easy diagnosis to make, as long as it s considered in the differential diagnosis of sports trauma. It is defined by a graded set of clinical symptoms that may or may not involved loss of consciousness. Its resolution will typically follow a sequential course. A small percentage of concussions may have prolonged symptoms leading to a diagnosis of post-concussive syndrome. Concussions are a clinical diagnosis, with standard radiology studies being negative. If any abnormality is noted on a CT scan or MRI, concussion is ruled out and a neurosurgeon should assume care. A common mistake in diagnosing concussions is to assume that no headache means no concussion. There are over 20 symptoms, including headache, which may occur in concussions. These can range from minor, such as a mild change in sleep patterns or emotions, to severe personality changes and disabling vestibular symptoms. See Figure 1. Due to the wide variability and severity of concussion symptoms, researchers have long looked for ways to improve diagnosis and treatment. Sport Concussion Assessment Tool 2 (SCAT2) is a standardized, sophisticated, widely-used diagnostic :6 November/December 2012 Missouri Medicine

3 test for concussion that can be performed in any setting. It uses cognitive and physical testing including balance assessment. It is useful in determining if an athlete may return to play. SCAT2 has not been validated. 8 A baseline test ideally is completed before the athletic season begins. We perform SCAT2 baselines on high school athletes in contact sports; in diagnosing concussion after an injury; in following and clearing athletes to return to play. Recently, we held a high school athlete recovering from a concussion because his balance testing was below his baseline score, even though he was asymptomatic for 48 hours. There are numerous computer-based concussion tests, with Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) being the most widely used including by the NFL. A baseline ImPACT score should be obtained on every athlete; subsequent testing can help with conclusion diagnosis, recovery and return to play. Population-based ImPACT baseline scores are published if an individual baseline test is not available. The ImPACT takes minutes to complete and costs $10-20 per test. Some problems exist with computer-based testing. One of the confounding factors is gaming the results. All NFL Pro quarterback Peyton Manning, in 2011, purposefully scored low on NFL baseline concussion testing stating, They have these new tests we have to take before the season, then after a concussion, you take the same test and if you do worse than you did on the first test, you can t play. So I just try to do badly on the first test. 9 Allegedly some NFL players use Ritalin to mask concussion symptoms during return to play evaluation. Some experts question the validity of computerized testing. 10 Randolph, a neuropsychologist, reviewed 11 the risks associated with sport-related concussion and the validity and reliability of the ImPACT program. He concluded there is no evidence that the use of baseline testing alters risk from sport-related concussion and questioned the rationale of using the test. Given the poor sensitivity and low reliability of these measures, they have an associated high false negative rate (i.e. classifying a player s neurocognitive status Dr. Mahaffey is Head Team Physician for Missouri State University. as normal, when it is not). The use of baseline neuropsychological testing, therefore, is not likely to diminish risk, and to the extent that there is a risk associated with premature return-to-play, the use of these measures even may increase that risk in some cases. A more forceful argument against computerized testing is made by Robert Sallis, MD, past president of the American College of Sports Medicine, It s a huge scam. They ve done incredible marketing, and they ve managed to establish this test as the standard of care with no evidence that it has any benefit. 12 I do not use any computerized testing preferring the SCAT2. Concussion Treatment Treatment is generally straightforward. Concussed athletes are placed under complete physical and cognitive rest until their symptoms improve. I always withhold television, computers, phones, and video games and may keep them home-bound if their symptoms warrant. There is no pharmacological treatment that has been shown to improve outcomes. Acetaminophen and NSAID s may help some bothersome symptoms. An athlete should not be cleared Missouri Medicine November/December :6 435

4 for any activity until they have stopped all medications. A graded activity progression back to full clearance should start only after the athlete is asymptomatic and only proceed if they stay asymptomatic. The SCAT2 assists with clearance. Based on the Zurich Consensus, below age 18, athletes should not return until they are asymptomatic for seven days and have passed a graded activity progression. This is longer than Missouri law mandates. Always lean toward the side of being conservative in return of athletes from concussion is paramount. Treatment is directed towards preventing long term post-concussive syndrome. This can be related to a single or multiple concussions. There are also concerns with long term histological changes to brain tissue, called chronic traumatic encephalopathy, a progressive degenerative disease that may be caused by multiple concussions. 13 It has been noted on autopsies of former athletes with known recurrent concussions. Other new unique research was performed by placing force transducers within football helmets to measure impact levels over the gridiron season. Steven Broglio, PhD has shown that the average high school football player sustains about 650 hits (major impacts) per season. A concussion usually occurs with a 90 to 100 g-force; this is equal to an unprotected head smashing against a wall at 20 mph. 14 A common misconception is that the harder the hit, the worse the outcome. Broglio s studies show that the magnitude of an impact doesn t predict the severity of injury. 15 Hit impact of varying magnitudes may, or may not, cause a concussion. Injury levels vary among individual athletes and may vary in the same athlete at different times. His research found that there is no cumulative effect of sub-concussion forces that summate in an acute concussions. There is concern that repetitive sub-concussive impacts may lead to long-term cerebral pathology. 14 Second Impact Syndrome is an infrequent concussion associated severe brain edema often leading to death. There is controversy whether this syndrome can be treated or actually exists. 16 Prevention of Concussions Prevention of sport-related concussions is the ultimate goal of physicians, coaches and sporting equipment manufacturers. Although there are many devices that are advertised to prevent concussions, there is a paucity of evidence-based research. These devices range from expensive mouth guards to padded soccer headbands. Most concussions occur with rotational force that is difficult to prevent unless the head is completely immobilized. Two companies, Riddell and Xenith, have developed new football helmets but there are no studies that demonstrate reduced concussions over older models. Education of football players and coaches on proper tackling stressing a heads up technique and rigid officiating by game officials is the best approach to prevent concussions from occurring. Is Football Worth the Risk? From 2001 until 2009, an estimated 2,651,581 children 19 years were treated annually for sports and recreation related injuries. Approximately 6.5%, or 173,285 of these injuries, were concussions. An estimated 6.6% of these concussions were hospitalized. 1 Fatalities among youth athletes involved in organized sports remains rare according to a study published in Pediatrics in Analysis of the U.S. National Registry of Sudden Death in Young Athletes over a period of 30 years showed the highest number of deaths, 16 of them, due to blunt trauma usually to the head/neck occurred in The average number of head/neck injury fatalities over the entire time period was nine per year. Seventeen high school athletes died from head trauma after sustaining concussions in the days or weeks prior to their death. 17 In North Carolina in 2008, two football-related fatalities from concussions were reported related to a release from untrained health providers. This lead North Carolina to pass a law requiring high schools to employ athletic trainers. How Risky Is Football Compared To Other Youth Activities? Figure 2 lists the causes of accidental death in young people. Summating organized and informal sports participation deaths in young people would not remotely approach these numbers. The Centers for Disease Control reported in 2009 that approximately 3,000 teens in the United States, aged fifteen to nineteen, were killed, and more than 350,000 were treated in emergency departments for injuries suffered in motor vehicle crashes. 18 In an Arizona study reviewing drowning deaths (aged eighteen or less) from 1995 to 1999, most children/youths died in the home swimming pools. One hundred thirty :6 November/December 2012 Missouri Medicine

5 one of the 187 (70%) drowning victims were under five-years-old, and eighty-one of 131 (62%) died in a private swimming pool. The second highest drowning rate was in males, aged fifteen to eighteen. 19 According to recent data published by the CDC, the rate of poisoning deaths increased among teens aged fifteen to nineteen, by 91% from 2000 to 2009, largely due to prescription drug overdose. The death rate was 3.3 per 100,000 in Figure 2 Why Not Ban Bicycles, Home Swimming Pools and Teenage Driving? The risk of serious injury or accidental death to our youth is much higher than football participation while riding their bicycles, swimming in home pools, walking or riding to school or living in homes where alcohol, prescription drugs and household poisons/toxins are stored. Yet there is no serious effort to ban or prohibit these activities. The effort to ban football from schools and universities is unwarranted. Personally, if I had a son, I would not be concerned with him playing football. I would, however, make sure that his coaches understand the proper football techniques that decrease the risk of concussions. I would also ascertain that a Certified Athletic Trainer, working under a protocol from a physician who understands the care of concussions, works at their school. References 1. Gilchrist, K. Nonfatal Traumatic Brain Injuries Related to Sports and Recreational Activities Among Persons Aged 19 Years United States, MMWR 2011; 60(39): English, C 2012, CR Board Member Calls for Banning HS football, Phillyburbs.com. 11 June < times_news/cr-board-member-calls-for-banning-hs-football/article_4dbb a-589f-bf html>. 3. Bissinger, B 2012, Why College Football Should Be Banned, The Wall Street Journal Online. 8 May < html>. 4. Gladwell, M 2009, Offensive Play How Different are Dogfighting and Football, The New Yorker Online. 19 October < com/reporting/2009/10/19/091019fa_fact_ gladwell?currentpage=all>. 5. Curkin, S 2011, Regulators Try to Ban Games at Summer Camps, WABC-TV/ DT. 19 April < go.com/wabc/story?section=news/local/ new_york&id= >. 6. Cassidy J, Carroll L, Peloso P, Borg J, von Holst H, Holm L, Kraus J, Coronado V. Incidence, Risk Factors and Prevention of Mild Traumatic Brain Injury: Results of the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury. J Rehabil Med 2004; Suppl. 43: McCrory P, Meeuwisse W, Johnston K, Dvorak J, Aubry M, Molloy M, Cantu R. Consensus Statement on Concussion in Sport The 3rd International Conference on Concussion in Sport Held in Zurich, November SAJSM 2009; 21(2): Scorza K, Raleigh M, O Connor F. Current Concepts in Concussion: Evaluation and Management. Am Fam Physician 15 January 2012 ;85(2): Sportqa.com. (2011). Indianapolis Colts Peyton Manning Admits to Cheating on Initial Baseline Concussion Test < Indianapolis-Colts-Peyton-Manning-admits-to-cheating-on-initial-baselineconcussion-test-a16616>. 10. Kirkwood M, Randolph C, Yeates K. Returning Pediatric Athletes to Play After Concussion: the Evidence (or Lack Thereof) Behind Baseline Neuropsychological Testing. Acta Paediatr. 2009;98: Randolph C. Baseline Neuropsychological Testing in Managing Sport-Related Concussion: Does it Modify Risk? Curr Sports Med Rep. 2011;10: Aschwanden C 2012, Check your Head: Does Testing Athletes for Concussion with Fancy Software Do Any Good?, Slate.com. 20 January < examiner/2012/01/impact_and_other_concussion_tests_for_athletes_may_ not_work_.html>. 13. McKee A, Cantu R, Nowinski C, Hedley-Whyte E, Gavett B, Budson A, Santini V, Lee H, Kubilus C, Stern R. Chronic Traumatic Encephalopathy in Athletes: Progressive Tauopathy Following Repetitive Head Injury. J Neuropathol Exp Neurol July; 68(7): Broglio S, Eckner J, Martini D, Sosnoff J, Kutcher J, Randolph C. Cumulative Head Impact Burden in High School Football. J Neurotrauma Oct;28(10): Broglio S, Eckner J, Surma T, Kutcher J. Post-Concussive Cognitive Declines and Symptomatology are not Related to Concussion Biomechanics in High School Football Players. J Neurotrauma Oct;28(10): Epub 2011 Aug 29.16) McCrory P. Does Second Impact Syndrome Exist? Clinical Journal of Sports Medicine. 2001;11(3): Thomas M, Haas T, Doerer J, Hodges J, Aicher B, Garberich R, Mueller F, Cantu R, Maron B. Epidemiology of Sudden Death in Young, Competitive Athletes Due to Blunt Trauma. Pediatrics July; 128(1):e CDC.gov (2010). Teen Drivers: Fact Sheet < Motorvehiclesafety/Teen_Drivers/teendrivers_factsheet.html>. 19. Rimsza M, Schackner R, Bowen K, Marshall W. Can Child Deaths Be Prevented? The Arizona Child Fatality Review Program Experience. Pediatrics 2002:110;e Gilchrist J, Ballesteros M. Vital Signs: Unintentional Injury Deaths Among Persons Aged 0-19 Years United States, MMWR 2012;61(15): MM Missouri Medicine November/December :6 437