At Their Own Risk

By Alexander Gelfand

“You’re making me nervous.”

Those are words you don’t expect to hear coming from the mouth of NHL bruiser-turned-broadcaster Matthew Barnaby. Drafted by the Buffalo Sabres in 1992, the Canadian-born right-winger was known as much for his pugilistic style as for his stickhandling skills.

But that was a lifetime ago. It’s now March of 2013, six years after a career-ending concussion forced Barnaby off the ice. He’s hosting his podcast, “Gloves OFF!,” and his guest is Elad Levy—professor of neurosurgery and radiology at the University at Buffalo, founder of the Program for Understanding Childhood Concussion and Stroke (PUCCS) and the man who advised Barnaby to retire in 2007. Levy is describing the effects of multiple concussions, like the 15 or so that Barnaby estimates he suffered over the years.

“You can think of concussions as mini-blast injuries,” Levy says, comparing them to the wounds caused by battlefield explosions. He goes on to emphasize the danger of receiving a second concussion before having fully recovered from the first, a circumstance that can greatly amplify the damage incurred and, in some cases, lead to permanent disability or even death.

“So,” Barnaby asks with grim humor, “when I returned to play after being knocked out cold during a game in 1994, that probably wasn’t a good thing?”

“I think that probably explains a lot, Matt,” Levy replies. You can tell he’s joking. Sort of.

Sports-related brain injuries are a hot topic these days. There are the headline-grabbing reports of professional athletes like Barnaby whose careers were sidelined by concussion. There is the ever-growing list of retired football and hockey players who have been diagnosed post-mortem (often post-suicide) with the degenerative brain disease known as chronic traumatic encephalopathy (CTE), allegedly brought on by repetitive head trauma. And then there are the parents’-worst-nightmare stories, like that of Damon Janes, the 16-year-old high school running back from Brocton, N.Y., who lost consciousness after an apparent helmet-to-helmet collision during a game this past September and died in the hospital soon afterward.

Add to all that a constant stream of new information that seems to widen the scope of concussion risk and consequences by the day, and it’s no wonder people are in a bit of a panic about concussions—particularly the parents of the millions of children and adolescents who play contact sports. In years past, many of those concerned parents funneled their children away from football and hockey, and into supposedly safer games like soccer and basketball. But according to the latest statistics, those sports are high on the list for concussion risk too. And while tragedies like the one that befell Damon Janes are exceedingly rare—according to a recent study in the American Journal of Sports Medicine, an average of 12 high school and college football players die annually, with cardiac failure the most common cause—concussions among children are not.

The Centers for Disease Control and Prevention (CDC) has estimated that during the period from 2001 to 2009, emergency rooms in this country treated more than 170,000 individuals under the age of 19 for sports- and recreation-related traumatic brain injuries—including concussions—with the overall rate rising 60 percent during that period. And several studies show that football, ice hockey, lacrosse, wrestling, soccer and basketball lead the league in concussions for high school athletes—concussions that can cause kids to miss school, suffer mood swings and experience difficulty focusing and learning new information for days, weeks or even months.

On a positive note, the rising youth concussion rate is at least partially due to greater public awareness. In addition to more kids getting the medical help they need, there are now organized efforts to prevent and deal with sports-related youth concussions, including laws in most states stipulating how concussions should be managed, and rules in organizations (such as the Pac-12 collegiate athletic conference and the Pop Warner youth football league) limiting contact during practice. There are also several outreach and education initiatives, like the CDC’s Heads Up program (see “Learn More”), where there used to be none.

On the negative side, greater awareness—much of it the result of alarming reports of depression and suicide among professional athletes, and stories of kids “just like ours” never returning home from a game—has come accompanied by a heavy dose of anxiety on the part of both sports-playing children and their parents.

Is it warranted? Yes and no. It’s worth noting that several of the concussion experts cited in this article have allowed their children to participate in sports that have relatively high rates of concussion (including Levy, whose 14-year-old son plays ice hockey—the very sport Levy advised Barnaby to quit). All attest to the benefits, physical and otherwise, of participating in youth athletics, and none advocates banning contact sports outright or indiscriminately prohibiting kids from playing them.

On the other hand, experts also agree that the still-developing brains of children and teens may be more vulnerable to concussion than those of adults; that young brains recover more slowly from concussion than do more mature ones; and that the estimates regarding the occurrence of concussions among our youth are still probably too low, with many student-athletes failing to report (or even recognize) their injuries.

Which leads to the most anxiety-provoking factor of all: the fact that there are so many more questions than answers. The onslaught of media reports notwithstanding, parents are still finding their most basic questions unanswered—questions like, How do I recognize a concussion? How should it be treated? How might one or more concussions affect my child down the road? And what, exactly, is a concussion anyway?

Surprisingly, there is no single answer to that last question. John Leddy (MD ’85), clinical associate professor of orthopaedics at UB and director of the UB Sports Medicine Concussion Management Clinic, says there is no objective, gold-standard definition of the injury. According to Leddy’s research partner, Barry Willer, UB professor of psychiatry and director of research for the Concussion Clinic, the classic description of concussion involves an altered state of consciousness brought about by some external force, whether that be a blow to the head or a blast from a bomb.

Picture your brain: a gelatinous mass suspended in fluid within a hard, bony shell. When a sudden impact causes this delicate organ to accelerate and decelerate rapidly inside its solid casing, there are, understandably, consequences: Chemical imbalances occur, the autonomic nervous system goes out of whack, even the filaments that allow brain cells to communicate with one another may become twisted. The precise mechanisms that underlie concussion have yet to be completely understood, but Leddy and Willer have demonstrated that patients who continue to experience concussion symptoms beyond the standard seven- to 10-day recovery period—a condition known as post-concussion syndrome, or PCS—have difficulty regulating their cerebral blood flow, causing blood pressure in the brain to rise abnormally during physical or mental exertion.

There is no simple physiological test for concussion; even brain scans do not reveal the injury. Rather, diagnosis is based on the kind of trauma sustained—that is, you got hit on the head—and on the presence of signs and symptoms, such as headache and dizziness (see “How to Recognize a Concussion”). Complicating matters is the fact that symptoms can appear in different combinations and at different times during the hours or even days following the initial injury, which underlines the need to continue monitoring someone who has been dinged (asking how they feel not just after they’ve been hit but also later that day and the following few mornings) and to seek help from a health care professional if there’s any sign of trouble. “Keep asking, keep assessing,” advises Maegan Sady, a pediatric neuropsychologist at National Children’s Hospital in Washington, D.C., who works with young concussion patients.

It’s also important to keep up with the latest findings, as concussion management has changed significantly over the past several years. For example, parents were once advised to keep concussed children from falling asleep for fear that they would never wake up again. But Keith Yeates, director of pediatric psychology and neuropsychology at Nationwide Children’s Hospital in Columbus, Ohio, says that studies have shown that the risk of sudden and severe deterioration while snoozing is so slim, “it’s not worth having a kid totally befuddled the next day because they didn’t get any sleep.”

It also was once common practice to send a kid who’d had his or her bell rung during a game right back onto the field. Today, however, researchers agree that returning to play before having fully recovered from a concussion is a very bad idea. The data suggest that an athlete who has already had one concussion is more likely to have another, while an athlete who has had multiple concussions in relatively quick succession is more likely to experience prolonged effects. As a result, children should not go back into play the same day they have suffered a concussion, nor should they return to play until their symptoms have disappeared. “When in doubt,” Sady says, “sit it out.”

Therapy has changed somewhat too. Physical and cognitive rest has long been the bedrock of concussion treatment, and doctors still recommend that patients refrain from strenuous physical and mental activity while they heal. But that emphasis is now coupled with an understanding that cutting kids off completely from school and sports for an extended period can leave them feeling isolated and depressed, and may even delay recovery. “There is growing evidence that if they continue to do nothing,” says Sady, “they aren’t going to get better.”

Experts now advocate for graded return-to-play protocols that ensure athletes are neither overtaxed nor kept unnecessarily inactive. Willer and Leddy have even developed an aerobic rehabilitation method that uses a treadmill to gradually increase patients’ heart rates until they can comfortably reach their maximum level of exertion. Experts also recommend using return-to-learn guidelines to help children and adolescents gradually resume their studies after an initial period of rest—for example, first trying homework, then returning to school for a few periods or a half-day—rather than shutting them in a dark, quiet room for a couple of weeks, as was once common, and then expecting them to pick right back up where they left off.

As for those terrifying long-term consequences, Willer and Yeates are careful to point out that, though studies are currently underway, there is as yet no definitive scientific proof linking concussion to CTE. According to Yeates (who suspects that one of his own daughters suffered a soccer-related concussion), there is nothing in the scientific literature that persuades him that youngsters ought not to be allowed to play contact sports, including football and hockey. Most kids do not in fact get concussed, and there’s little evidence to suggest that those who do receive one or two knocks to the head will be at substantial risk in the long term.

Similarly, Sady and her colleagues at National Children’s Hospital very rarely counsel student-athletes to retire from a sport—“maybe one or two per year, out of hundreds,” she says. Instead, they impress upon parents, coaches, teachers and athletes the importance of learning to recognize the signs and symptoms of concussion, seeking professional help if they appear, and making sure that patients avoid reinjury during the recovery period. “Parents must of course make their own choices,” says Yeates. “But there’s a limit to how much we can protect kids and still let them grow up.”

Alexander Gelfand is a freelance writer based in New York. His work has appeared in The New York Times, the Chicago Tribune and The Economist.

Symptoms are what a patient experiences and reports; signs are what an observer sees. Below are some of the key signs and symptoms of concussion. If a young athlete—or anyone, for that matter—experiences a bump or blow to the head and any of the below signs or symptoms appear, consult a health care professional. (More comprehensive lists are available from the sources listed in “Learn More”)

Heads Up

The CDC’s clearinghouse on sports-related youth concussion provides educational materials (fact sheets, podcasts, online training videos) for parents, coaches, school personnel and health care professionals, as well as student-athletes themselves.

SCORE

The Safe Concussion Outcome Recovery and Education Program at Children’s National Medical Center provides information and services for parents, coaches and others. The program even offers a smartphone app that helps parents and youth coaches recognize the signs and symptoms of concussion.

Concussion Toolkit

Nationwide Children’s Hospital offers custom-tailored information packets for different audiences (parents, coaches, student-athletes), along with a concussion symptom log.