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In-Depth Discussion of Concussions In The Age Of Twitter: Is It Possible?

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One of my biggest gripes about the media in the age of Twitter and ever-shorter attention spans is that it doesn't lend itself well to an examination of issues in the depth they deserve.  

Recently, I was asked a series of questions by a newspaper journalist for a story on a concussed athlete who had decided to quit football despite being cleared by the team doctor to return to play.

Even though I knew that 95% of what I said in my emailed response would never make it into the story, I nevertheless spent the time formulating thoughtful responses, hoping that at least some of what I offered would avoid the cutting room floor.

I was wrong.

Here, for those of you out there who are interested in the full responses (with links for further reading) are the questions I was asked and the answers I gave: 

Question:  The player I'm writing about made the decision to quit football (even though a team doctor said he could still be cleared to return) due largely to the emotional and mental effects (rather than the physical ones) the concussion had on him. He found himself dealing with depression and struggling with his studies. How common is it for concussion sufferers to deal with such issues? Is this a part of concussion treatment that often goes overlooked in sports?

Answer: Depression is common after concussion, especially when the symptoms of concussion linger, but clinicians say it is often difficult to determine whether such depression is pathological or psychological. A 2013 study by researchers at the University of Washington also found that a history of concussion in teens was linked with a 3-fold increase in risk of depression. I'm not a psychologist, of course, so I'm not in a position to say how depression in a concussed athlete should be treated, but I do note that some experts criticize the symptom scales currently in use because some of the symptoms attributed to concussion, such as depression, can be the result of non-brain related conditions that were present before the athlete suffered his/her concussion. A 2014 study in the journal Pediatrics, for instance, found that some children and adolescents who continue to report symptoms weeks and months after suffering a concussion may be exaggerating or feigning symptoms in order to get out of schoolwork or sports, or for other reasons unrelated to their injury (a phenomenon called "secondary gain"), including underlying depression.  As Dr. Rosemarie Moser points out in that article, neuropsychologists "know that whenever symptoms do not improve and the recovery period is longer than expected, the possibility of emotional/psychological factors affecting symptoms should be considered."

Question: What role can or should a coach play in assisting a player in dealing with concussions -- both from a mental/psychological and physical standpoint?

Answer: Like the athlete's parents, treating physician, and athletic trainer, a coach should make sure the athlete understands that he or she should not try to rush back to play before they are symptom-free, and that he or she has not only completed the program of gradually increased exercise experts recommend without symptoms returning, but is psychologically ready. Coaches need create an environment in which athletes feel safe, not only in reporting concussion symptoms so that they can be removed from play to minimize the risk of further, potentially catastrophic injury but of a longer recovery, but in which athletes feel safe in telling the coach that they aren't ready to return, either because they are still experiencing physical symptoms or because they aren't ready from a psychological standpoint. In practical terms that means that the coach should never question a player's toughness, masculinity, competitiveness, or attitude, either directly or indirectly because doing so contributes to the prevailing "culture of resistance" to honest concussion symptom reporting by athletes that makes early identification of concussed athletes so difficult. Unfortunately, at least two studies has shown that athletes are not very good at assessing their own readiness to return to play after a concussion. A growing body of evidence suggests that psychological factors play an important role in determining whether an athlete makes a successful return to sport following injury. Clinicians, not the coach, need to take such considerations into account during injury rehabilitation and the period before an athlete returns to competition.  But even if a doctor or athletic trainer has cleared an athlete to return to play, if a coach has any doubt about the athlete's psychological or physical readiness to return to play, he or she should not let him play.

Question: Despite his situation, the player in question has no regrets and said he would encourage his own future children to play football. What kind of advice or counsel do you provide to parents whose children want to play football?

Answer: There is no simple answer to that question, but the most important thing a parent can do in deciding whether to allow their child to play football or any contact or collision sport is become educated: about the risk factors (including whether their child may be at greater risk of injury because of pre-existing neurological conditions, such as ADHD or a history of migraines, about what the program is doing, or not doing, to minimize the risk of concussion or repetitive brain trauma, to identify concussed athletes as quickly as possible, and to make sure they do not return to play before their brains are fully healed. A child may want to play football, but, ultimately, it is up to his or her parents to be ... well ... parents, weighing the individualized risks of participation versus the benefits and deciding whether football, when all of the pluses and minuses are added up, is right for their child.

Question: There's a perception in some places that concussions can only happen at the highest levels of football (NFL, college, competitive high school), and that young children can't hit each other hard enough to cause concussions or other injuries (an NFL QB made a fairly passionate speech to me making this very argument a year ago). Is there truth to that? What risk of concussions is there for children, and contact at a young age have a cumulative effect that could contribute to a player dealing with continued and chronic issues into adulthood? It is a myth that children can't and don't suffer concussions playing youth football or can't and don't hit each other hard enough to cause concussions.

Answer: A pair of studies by researchers at Virginia Tech, one in 2012, the second in 2013, found that young kids playing tackle football do indeed sustain hits just as heavy as high school, college and pro football players, although not as frequently, and that they do get concussed. One recent study of former NFL players found that those who started playing football before age 12 were more cognitively impaired later in life than players who started later, but the scientific literature on the cumulative effect of repetitive brain trauma, and whether children, because their brains are still developing, are at much greater risk, is in its infancy and there is still a lot we simply don't know. The evidence does seem to be clearly pointing in the direction of establishing that cognitive difficulties later in life are dose-related; in other words, that the more hits a player sustains over time, the greater the risk that he or she will suffer some form of early cognitive impairment or, worse, a degenerative neurological condition such as chronic traumatic encephalopathy (CTE). But there are many, many factors, including genetics, use of alcohol, recreational or performance-enhancing drugs, the number of concussions, the way in which they were managed, even playing position, that may affect that risk. Science is a long way from determining if there is a so-called hit count or threshold above which continuing to play a contact or collision sport such as football puts an athlete at substantially increased risk. Until then, caution, not panic, should be the byword.

Brooke de Lench is Executive Director of the MomsTEAM Youth Sports Safety Institute, a 501(c)(3) tax-exempt non-profit youth sports safety education and watchdog organization, Founder and Publisher of MomsTEAM.com (now in its 15th year as a leading source of youth sports health and safety information for parents, coaches, and sports medicine professionals), producer of The Smartest Team: Making High School Football Safer (PBS), and author of Home Team Advantage: The Critical Role of Mothers in Youth Sports (HarperCollins). You can follow Brooke on Twitter @brookedelench.