Concussion Rates Rising in Younger Athletes
Return-to-play guidelines issued.
By Heidi Splete
Elsevier Global Medical News
Approximately 40% of emergency department visits for sports-related concussions in young athletes occurred in children aged 8-13 years, based on data from concussion-related ED visits in the United States between 2001 and 2005.
There are two main concerns about sports-related concussion in younger children, compared with college athletes and adults, lead author Dr. Lisa L. Bakhos said in an interview. Dr. Bakhos conducted the study while she was a teaching fellow at Brown University in Providence, R.I. (Pediatrics 2010 Aug. 30 [doi:10.1542/peds.2009-3101]).
"First, many parents, coaches, teachers, and other adults feel that because these athletes are so young, they could not possibly get seriously hurt. As we have seen time and time again, this is, of course, not the case," said Dr. Bakhos, who is currently an emergency physician at the Jersey Shore University Medical Center in Neptune, N.J.
"Also, a few good studies have shown that head injury in younger children can have more long-term effects, as you are essentially damaging a developing brain," she explained. In addition, more data have surfaced about cognitive deficits in older children after concussion, she said, "which leads to conjecture that younger children would suffer the same - if not more - deficits long term." However, the link between sports-related concussion and cognitive deficits needs further study.
The American Academy of Pediatrics has just released a new clinical report, "Sport-Related Concussion in Children and Adolescents" (Pediatrics 2010 Aug. 30 [doi:10.1542/peds.2010-2005]).
To get a better picture of the scope of sports-related concussion in young athletes, Dr. Bakhos and her colleagues reviewed data from the NEISS (National Electronic Injury Surveillance System) from 1997 through 2007, and from the NEISS-AIP (All-Injury Program) from 2001 through 2005. The NEISS system allows researchers to investigate injury- and product-related ED visits.
In 2001-2005, approximately half of all ED visits for concussion across older and younger age groups were related to sports, including 58% of visits in children aged 8-13 years and 46% of visits in those aged 14-19 years. Put another way, approximately 4 in 1,000 children aged 8-13 years and 6 in 1,000 of those aged 14-19 years went to the ED for a sports-related concussion.
During the 10-year period of 1997-2007, ED visits for the most popular organized team sports (football, ice hockey, soccer, basketball, and baseball) doubled in 8- to 13-year-olds and increased by more than 200% in 14- to 19-year-olds.
"Because not every kid with a concussion goes to the emergency department, there are even more injuries occurring that are not being reported," Michael Collins, Ph.D., assistant director of the sports medicine concussion program at the University of Pittsburgh Medical Center, said in an interview.
"Children with concussion should be followed just as closely as a child with a sprained ankle or a broken bone. Return-to-play guidelines should be followed closely and stressed to parents," Dr. Bakhos said. Physicians "should also stress to parents the importance of concussion prevention in sports as well, mostly [by] the use of helmets at all times," she emphasized.
The study was limited by the exclusion of sports-related concussions that were treated in non-ED settings, and by the underreporting of sports-related concussions by young athletes, their parents, and their coaches, the researchers noted.
But the rise in sports-related concussions in younger and older children suggests the need for more research and guidance in preventing and treating these injuries, they added.
"Changes in the way we define the injury are driving the rise in reported concussions in young athletes," Dr. Collins said. "Until 10 years ago, the medical literature focused only on concussions that involved loss of consciousness. But what we have learned in the past decade is that the subtleties of this injury are absolutely critical for diagnosis." He is a coauthor of the Centers for Disease Control and Prevention's "Heads Up: Brain Injury in Your Practice" tool kit for physicians.
To help clinicians manage sports-related concussions in young athletes, the AAP published a new clinical report that "outlines the current state of knowledge on pediatric and adolescent sport-related concussions," wrote lead authors Dr. Mark E. Halstead and Dr. Kevin D. Walter, on behalf of the AAP's Council on Sports Medicine and Fitness. It includes the SCAT 2 (Sport Concussion Assessment Tool 2), a standardized method of evaluating concussion in athletes aged 10 and older.
The report outlines recommendations regarding sports-related concussion, including the following:
- Stay off the field. Even if symptoms subside, young athletes should never return to play on the same day they have a concussion. Younger athletes need more recovery time and a more conservative approach than do college or professional athletes.
- See a doctor. Any children or adolescents who suffer concussions during sports should be medically cleared by a physician before they return to activity.
- Rest mind and body. All young athletes should refrain from physical activity until they are asymptomatic at rest and when active. Rest includes mental as well as physical rest. Some evidence suggests that cognitive exertion - including doing homework, watching TV, and playing video games - can exacerbate symptoms post concussion.
In the last few years, several states have passed laws requiring educational materials about sports-related concussion for school-aged athletes, coaches, and parents. The state laws were a consideration, but the AAP began working on the report before the first law was passed, said Dr. Halstead, director of the sports concussion program in the department of orthopedics at Washington University in St. Louis.
"We felt there was a need to address specifically the [pediatric] athlete and address all the recent research that has been published on this topic," he said in an interview.
"The recommendations presented aren't significantly different from other recent documents published" in sports medicine journals, Dr. Halstead said, but "we wanted to bring these recommendations to the forefront ... and expand upon the details provided in previous documents published. We have highlighted some of the new research on neuroimaging, balance assessments, long-term complications, education, and neuropsychological testing."
Dr. Walter added, "I think it is also important to recognize that because we have learned more about concussion diagnosis, treatment, and complications, the treatment that coaches and parents received when they had a concussion themselves at a young age is likely different [from treatment] today." Many parents and coaches don't think concussion is a big deal because they had one when they were younger and they "toughed it out" and "are fine now," said Dr. Walter, program director of pediatric and adolescent sports medicine at Children's Hospital of Wisconsin in Milwaukee.
The authors acknowledged the lack of published baseline neuropsychological data on children younger than 12 years, and noted that assessment by a neuropsychologist might be helpful for children who have had more than one concussion, or whose postconcussive symptoms persist for several months.
Dr. Halstead emphasized the following take-home tips for clinicians:
- Young athletes should never return to play on the day of their concussion, nor should they return to play until they are symptom free both at rest and at exertion.
- A concussion is an injury to the brain, and rest is paramount. "If an athlete injures an ankle or knee and cannot run on it, we wouldn't think twice about resting that injury until it healed. Why should we treat the brain any differently?"
- Doctors are interested in getting an athlete back to play and activity as soon as possible. "But we need to be smart about it and make sure it is safe for that young athlete first."
- Continue to educate everyone involved - coaches, parents, teachers, and athletes - in preventing and managing sports-related concussions.
Dr. Collins disclosed that he is a cofounder of ImPACT, a computerized neurocognitive testing tool. None of the other researchers mentioned in this story had any financial conflicts to disclose.