UPDATED
There is mounting evidence that traumatic brain injury to youth and high school athletes in contact and collision sports can result not only from a single violent hit but from the cumulative effect of repeated low-grade or sub-concussive hits [1] (now more commonly referred to as repetitive head impacts or RHI). [1,18,19]
[2]While head injuries in sports cannot be prevented entirely, experts believe - and emerging science supports the view - that there are seven principal ways to reduce the risk of brain injury from playing contact and collision sports:
All seven present challenges, suggesting that adopting an "all-of-the-above" approach is likely the best way to reduce the risk to youth and high school athletes from brain injury, both in the short- and long-term.
A 2009 study [3] [2] found that high school football players are at greater risk for concussive events in part because they haven't learned how to tackle correctly [4]. The finding by researchers in a 2014 study of impact locations in high school football players suffering concussions [30] that players had their head down at the time of impact in a higher proportion of concussions caused by top-of-the head impacts (86.4%) than concussions from impacts to other areas of the head (24%), likewise led the authors to recommend improved teaching of "heads-up" tackling.
Coach Bobby Hosea teaches a heads up tackling technique he calls "Dip n' Rip" [5] in which a defensive player stops the ball carrier with an upward thrust across the chest and shoulders, not by leading with his helmet. Hosea, whose technique is the basis for USA Football's "Heads Up Tackling" program [6], and who demonstrates his approach in MomsTEAM's PBS documentary, The Smartest Team [7] believes that widespread adoption of a standardized approach to tackling might eliminate up to half of concussions in youth and high school football.
Sports concussion neuropsychologist, Rosemarie Scolaro Moser, Ph.D. [8], another MomsTEAM expert featured in The Smartest Team, agrees. "A big consideration in all high risk sports is that at whatever age the youth transitions to contact or collision, whether 12, 14, 16, or 18 years of age, youth athletes will need to be trained to engage in safe, proper contact," she says.
"Otherwise, lack of a proper program of training safe contact skill development will essentially defeat the purpose of setting an age designation. That means we will need educated coaches to teach safe and proper skill contact development in practices, so that when the youth athlete transitions to game contact, he or she will be ready, at any age.
We know that kids' brains are vulnerable, that youth concussion is a public health problem, and that the effects of concussion can be devastating. We also know that sports can play an important role in a child's overall development as a person. The question is, 'Can we provide the resources and support necessary to make all youth sports safer, whether the sport is considered a collision, contact, or noncontact sport?'"
Teaching hockey players how to absorb body contact [9] is something expert groups, like the American Academy of Pediatrics, recommend as a way to reduce the risk of brain injury in the sport, which, at the high school level, has the second highest concussion rate next to football.[3]
A 2010 study [4] found that teaching players to anticipate body-checks may reduce the youth ice hockey concussion risk. The study focused on body position prior to collision (good anticipation, poor anticipation, and unanticipated), collision location (open-ice or along the boards), and the magnitude of rotational and linear forces to the head sustained in collisions. Sixteen male, Bantam-level ice hockey players wore standard helmets fitted with special sensors, which sent data through a telemetry link.
The researchers found open ice collisions resulted in a statistically significant increase in forces to the head compared to collisions along the boards. Most importantly, players in the "ready" position who anticipated collisions, e.g. those whose knees and trunk were flexed with feet shoulder-width apart, who used their legs to drive their shoulders through the body check - suffered significantly less severe impacts to their head during collisions.
Youth athletes participating in collision sports, such as hockey, are at particular risk for concussions. Skill development is often limited, because parent volunteers frequently serve as coaches and lack the expertise necessary to educate athletes on proper collision techniques.
The study's authors recommended that hockey coaches possess the necessary training and certification to ensure safe player development by teaching young hockey players to anticipate collisions more effectively, including spending time during practices educating players on how to deliver and receive body collisions in all areas of the ice, including along the boards and in open ice, and continuing to teach them the "ready" position and to "skate through the body check", as encouraged by USA Hockey and has long been taught by coaches to young players in the United States and other countries.
Coaches should practice game-related drills with full contact to help players to adapt to constantly changing conditions during game play, including "small games" drills, which emphasize high speed, quick movements, and game-related tasks (e.g. passing, shooting, and checking) in small, confined spaces (i.e. corner of the rink). Such drills are "excellent at forcing athletes to play with a heightened sense of awareness that allows them to anticipate incoming body collisions.
As MomsTeam blogger and longtime Minnesota hockey coach, Hal Tearse, puts it, "Coaches need to do a better job of teaching players the right way to body check and how to absorb contact. It cannot be taught in a two-day clinic; it needs to be an important part of regular practices, and consistent messaging from coaches to players is required. The language we use needs to change, Instead of 'hit him', maybe words like "zero gap', 'take him', or 'box him/her out' might be better. Language is a funny thing in that words have power and meaning beyond what might be intended. Coaches need to choose their words carefully with young people."
The importance of "heads up" play and of teaching lacrosse players to take a heads up approach, as is being done in boys' hockey and football, was emphasized by the authors of a 2013 study [10] [5] finding that the principal cause of concussions in boys' high school lacrosse was the widespread and intentional use of helmets during player-to-player contact, often to defenseless players, and usually without a penalty being called.
Lead author Andrew E. Lincoln, ScD, MS, Director of the Sports Medicine Research Center, MedStar Health Research Institute at Union Memorial Hospital in Baltimore, said the 2010 youth hockey study [4] reporting on the importance of heads up play may "suggest ways to help decrease the incidence of concussions in boys' high school lacrosse" by emphasizing the "importance of situational awareness and readiness for contact ... to players, coaches, and officials."
The most recent international consensus statement on concussion in sport [20] states that "consideration of rule changes to reduce the head injury incidence or severity may be appropriate where a clear-cut mechanism is implicated in a particular sport."
Recent years have seen stricter enforcement of existing rules and numerous rule changes at the professional, college and high school level, all designed, at least in theory, to reduce the risk of concussion and long-term injury, such as chronic traumatic encephalopathy (CTE), including:
But tougher enforcement is needed, particularly of rules [15] against helmet-to-helmet contact. A 2014 study finding that most top-of-the-head impacts causing concussion in high school football occurred when players had their heads down [30] is just the latest in a string of studies calling for better enforcement of that rule.
Recent years have seen greater emphasis on efforts to penalize illegal hits at all levels of football, but much more enforcement is needed [16]. Some suggest that, if an official is unsure whether an illegal hit has occurred, they should err on the side of caution by calling a penalty. "You can look at a hold a hold and say it didn't affect the play and pass on that," a veteran college official and Texas high school football rules interpreter, Cooper Castleberry, recently told The Dallas Morning News [17]. "You can't do that on a targeting foul. You can get somebody injured for life with something like that. If there's any doubt in your mind," he suggests to referees that they "go for it. That's the attitude refs need to have."
Some concussion experts are also suggesting new rules be adopted to better protect football players against head injuries. "We've got to look at rules and rule enforcement and maybe even rule creation," said Gerard Gioia, Ph.D., Division Chief in Pediatric Neuropsychology and Director of the Concussions - Safe Concussion Outcome Recovery & Education (SCORE) Program at Children's National Medical Center in Washington, D.C., at the Aspen Insitute's November 2012 football roundtable [18]. "From my perspective in football, a rule that would suggest that if you make no effort to wrap in a tackle, then a flag gets thrown because otherwise you're just using your body as a torpedo."
One rule that should be adopted immediately at all levels of football is the one passed [19] by NFL owners on March 20, 2013 banning ball carriers in the open field from lowering their head and exposing the crown of their helmet.
Because the risk of concussion triples [20] among younger hockey players in leagues where body checking is allowed, [7] USA Hockey has banned [21] the practice at the Pee Wee level (11- and 12-year olds), and in 2013 body checking was also banned in Canada. in Pee Wee hockey. In his 2012 book, "Concussion and Our Kids," [8] Dr. Robert C. Cantu recommends that bodychecking only be allowed after age 14; a ban until age 15 is supported by the Canadian Paediatric Society and other groups, and a leading Canadian concussion expert, Dr. Charles Tator, goes one step further: he argues [22] for a ban in bodychecking until age 16.
"Those are important years for the brain to develop normally for a full life," said Dr. Tator in an interview with Global News. "To have it bashed around by bodychecking is just not a good idea."
"The brain has billion of cells and those cells are all connected in very precise ways. During adolescence a lot of those connections are being made," said Dr. Tator. "So if you have repeated concussions, that means those connections aren't going to be made. Some people with multiple concussions will have life long consequences."
At levels where checking is allowed, the risk of concussion and catastrophic injury in hockey could be reduced not only by strictly enforcing existing rules against such violent and dangerous infractions as checking from behind, boarding and contact to the head, but by stiffening the penalties for such infractions, as the Minnesota State High School League recently [23] did in the wake of the several high-profile catastrophic injuries to hockey players in the state.
One leading concussion expert suggests that heading in soccer be delayed until age 14. In his 2012 book, Concussion and Our Kids, Dr. Robert C. Cantu acknowledges that "[w]e can't say whether heading a soccer ball over and over for many years increases a person's risk of one day developing chronic traumatic encepholapathy, but he says, "We can say with authority that if heading simply vanished from youth soccer the sport would go from being risky from the standpoint of head truma to one of the safest." The reason, says Cantu, isn't trauma from head meeting ball, but rather from head meeting head, or elbow, or shoulder.
On that point, the statistics, at least in high school soccer, support Cantu's assertion, with a recent study of concussions in high school sports [3] reporting that heading the ball was the activity most frequently associated with concussion (31.1% for boys, 27.7% for girls), that 60.8% of injuries sustained by heading the ball were concussions, and that concussions sustained while heading the ball occurred as a result of player-to-player contact (boys: 74.2%; girls: 58.1%), player-equipment contact (i.e. goalpost)(boys: 12.9%; girls: 34.9%) and player-playing surface contact (boys: 12.9%; girls: 7.9%).
In terms of the long-term effects of heading in soccer, a new study linking frequent heading of a soccer ball with changes to the white matter of the brain and poorer performance on a neurocognitive test of memory [29] is likely to add fuel to the fire of a 30-year-old debate [24] about the effects of heading.
The study by researchers at the Albert Einstein College of Medicine in New York is believed to be the first to quantify subconcussive heading and to assess the association of heading with imaging evidence of brain injury and impaired neurocognitive function.
The findings suggest that may be a heading threshold above which the risk of short- and possibly long-term brain injury dramatically increases.
Establishing such thresholds, the scientists say, could ultimately lead to identification of a 'head count' (see #7 below) above which a player's heading should be curtailed for a specific recovery period, an approach akin to the pitch counts implemented in youth baseball [25] to reduce the risk of arm injuries, and an approach that has been proposed by some concussion experts as a way of reducing the risk of long-term brain injury from repetitive head impacts in contact and collision sports. (For more on the proposal by Dr. Cantu and others to modify the rules of soccer to ban heading at levels below U-14, see #7 below)
[Update: On November 9, 2015, U.S. Soccer, the national governing body for soccer in the U.S., announced that it was banning heading for ages 10 and below and imposing limits on heading in practices for athletes ages 11 through 13 [26]. Those rules apply only to development programs and academies under its control; for youth soccer programs it does not directly control, the rules are recommendations.]
A 2013 study [10] [5] found that in 19 out of 34 (56%) player-to-player collisions resulting in concussions in boys' high school lacrosse, the struck player did not appear to anticipate contact and was deemed "defenseless" (defined by US Lacrosse, the National Football League, and National Hockey League rules as a struck player who was "blind-sided" or unable to see and therefore anticipate and prepare his or her body for an impending collision), but penalties were called in 26.5% of the time.
The study's findings were consistent with those showing that the majority of injuries in boys' high school lacrosse, and specifically concussions, were the result of player-to-player contact, which were considered "legal" collisions in that no penalty was called in 70% of the head injury cases analyzed.
"The absence of penalty calls on most of these plays suggests an area for exploration, such as the extent to which rules governing player to player contact are enforced and how effective these rules are for the prevention of head injury at various levels of the sport," the study concluded.
As in boys' hockey and football, rules against intentional contact to the head are only as good as the officials charged with enforcing them. Commenting on the study in an email to MomsTEAM, Steve Stenersen, CEO of US Lacrosse, expressed support for the study's recommendation about ways to reduce concussions in the sport, expressing the view that "violent collision should be removed from boys'/men's lacrosse."
In response to the growing body of scientific evidence [1] showing that repetitive head impacts (RHI) can have both short- and long-term effects on the brain (including CTE), rules limiting RHI exposure have been adopted over the past several years at every level of fooball:
The National Football League has eliminated off-season full-contact practices and now allows only 14 full-contact practices during the season, less than one per week.
Limits on full-contact practices is coming more slowly at the college level:
Limits on full-contact practices have been enacted or recommended at the high school level:
Interestingly, a recent study by Purdue researchers provides support for such a progression. finding that cerebrovascular reactivity (CVR) - a measure of the ability of blood vessels in the brain to dilate to compensate for increased levels of carbon dioxide in the blood, such as occurring during exercise - was significantly reduced in almost all football athletes during the first six weeks of the contact season, findings which the researchers viewed as demonstrating that the onset of subconcussive blows had "at least a transient effect on the brain, but also suggest[ing] that the brain can adapt to [the contact] with an eventual return to baseline."The researchers expressed concern that athletes may be at risk of incurring symptomatic injury during period their brains were trying to adapt to contact at the beginning of the season. Noting that in most states football teams typically switch from limited contact levels during the preseason to two practices a day, at least one of which includes contact, they expressed concern that, based on their findings, "the brain may not be able to adjust quickly to this change, leaving players at increased risk for injury" at the beginning of the football season. They thus suggested that it might be better for teams to increase the amount of contact more gradually to allow players' brains to adapt so as to reduce the risk of serious injury. This is what the new rules in Illinois, Alabama, Minnesota, and Kansas appear to address. Whether they go far enough is another question.
One potential way to address the concussion and RHI problem is to develop better equipment (e.g. helmets and mouth guards) to attenuate the force associated with brain trauma.
Football helmets
The problem is that, although helmets have been shown to decrease the incidence of facial injury as well as moderate and severe traumatic brain injury (TBI), and mouth guards help p [39]rotect against dental and orofacial injury [39], there is no evidence to date that the newest helmets [13] or mouth guards [40] reduce the incidence of concussions, or the severity of concussion symptoms.[20]
Indeed, the findings [13] of a study, originally presented as research papers to the 2012 and 2013 meetings of the American Orthopaedic Society for Sports Medicine [21,32] and later published in the American Journal of Sports Medicine,[33] found no definitive data to support the view that advanced football helmet technology and design provides any additional protection against concussion or intracranial hemorrhage.
Researchers at the University of Wisconsin found that the risk of sustaining a concussion in high school football was not affected by the brand or age of the helmet or by the type of mouth guard worn. [21,32,33]
"According to our research, lower risks of sustaining a sports-related concussion (SRC) and its severity were not improved based on a specific manufacturer. In addition, the SRC rates were similar for players wearing new helmets, as compared to those wearing older ones," said lead author, Timothy McGuine, PhD, ATC.
"It is also interesting to note, that players who wore a generic mouth guard provided by the school had a lower rate of SRC compared to players with more expensive mouth guards.
The bottom line is that there are no "concussion proof" helmets currently on the market. Nor have mouth guards [40] been shown by any peer-reviewed study to reduce the risk of concussions [20, 21] So, while researchers are hard at work to design helmets and mouth guards that mitigate the collective impacts absorbed by the brain in such a way as to dissipate the harmful energy that occurs during repeated impacts, such equipment appear to be a long way off.
This is not to say that equipment doesn't play a part in concussion prevention. As a research paper [13] found [20], football players wearing poorly-fitted helmets, especially those with under-inflated air bladder liners, are at increased risk of concussion, so making sure that football helmets fit properly, and that those with air bladder linings are properly inflated, may be two of the simplest but most effective ways to minimize the risk of concussion and catastrophic brain injury.
Despite the players' smaller size and undeveloped neck muscles, notes the 2012 Virginia Tech study of head impacts among young football players,[6] youth helmets are remarkably similar in size, mass and design materials to those worn by adult football players. This fact, combined with data showing that a substantially higher percentage of hits to the helmets of youth players are to the side of the helmet - which the researchers attributed to a differences in the styles of play between the different age groups, as well as the fact that youth players have a tendency to fall to the side when tackled - may result in a youth player being more susceptible to impacting his head on the ground while being tackled than a high school or college player," says the study, knowledge which could aid in the design of youth-specific football helmets.
Unfortunately, the development of a youth-specific football helmet standard has been excruciatingly slow, hampered by a lack of research and public demand for action. While NOCSAE notes that, "Research continues into a separate standard for youth helmets... [and] that youth-sized helmets have a lower helmet-weight to head-mass ratio than adult-sized helmets", the fact that "preliminary pneumatic ram testing indicates that small-sized helmets which have less mass don't perform as well in rotational tests as medium or large helmets of the same model, which is likely due to their lighter weight" led the standard-setting group to conclude that, "At this time, there is not enough data to suggest a helmet mass limit for youth-sized helmets."
If anything, development of a youth-specific standard seems to be going in reverse. After deliberation and consideration of input from multiple interested parties, the NOCSAE board voted in January 2012 to change the Youth Football Helmet Standard from "Proposed" to "Draft" so that more input can be received, and to permit development of that standard to follow a separate track. "Significant hurdles remain to the development of a youth football helmet standard that will address the specific injury risks and biomechanical forces involved in youth football, and that data has not yet been well developed," NOCSAE said.
There may, however, be light at the end of the tunnel. In October 2015 came the announcement [38]that Virginia Tech had been awarded a g $3,3 million grant by the National Institutes of Health's National Institute of Neurological Disorders and Stroke to lead a five-year, multi-center study to track on-field head impact and accelerations using sensors installed in hundreds of 9- and 10-year old youth football players' helmets and mouth guards, and to track them via neuropsychological testing.
Commenting on the study, Dr. Duma said collecting of data "will allow for evidence-based decisions across a range of applications, including improved clinical detection techniques [see #6 below on the use of sensors] as well as a solid foundation for our helmet rating programs and offer ways potentially to improve youth football helmet design."
Hockey helmets
If anything, the news on hockey helmets is even worse. According to the recently released report by Virginia Tech on the ability of hockey helmets to attenuate the forces that cause concussions, none of the 32 popular hockey helmets tested were found good enough in protecting against concussion risk to earn four (very good) or five stars (best available), with only 1 rating 3 stars, or "good" in its STAR ratings [41], 6 rating 2 stars, or "adequate" . 16 earning 1 star, or "marginal" and 9 getting no stars, or "not recommended." (By comparison, twenty of the 26 football helmets [42] most recently tested by Virginia Tech received ratings of 4 or 5 stars, a significant improvement from 2011, the first year the ratings were issued, when only 6 receiving four or five stars)
Because, compared to football helmets, hockey helmets are smaller, have much thinner padding systems (two thin layers of relatively rigid padding versus a football helmet's three thick layers of soft padding) and less "offset" (which allows for more compression during impact), that they performed poorly in the tests was widely predicted (see, for example, a New York Times article [43] from July 2014 in which one sports equipment testing executive is quoted as saying that the ratings would "hit hockey like a ton of bricks.").
While the STAR methodology for hockey helmets,[36] has its critics (including USA Hockey [44]), just as there are critics of its football helmet ratings [45], and come with most of the same limitations [42] as those ratings, the issuance of the ratings, as they did with football, will likely force hockey helmet manufacturers to start to make helmets which can perform better in the Virginia Tech tests. "It's time for hockey to start catching up" with football, said Dr. Stefan Duma, a Virginia Tech professor and the head of the university's biomedical engineering department which issues the STAR ratings.
Stay tuned.
A growing number of concussion experts [46] [9], strength and conditioning trainers, and physical therapists [47], believe that one important way to reduce the risk of sport-related concussion is by strengthening the neck, the theory being that stronger neck muscles will help cushion against and lessen the linear and rotational forces that cause concussion.
The preliminary results of a pilot study [10] presented at the 4th Annual National Youth Sports Safety Summit in Washington, D.C. in February 2013, and subsequently reported in July 2014 in the journal Primary Prevention [34] backs up that theory, suggesting that overall neck strength is a statistically significant predictor of concussion, with the odds of concussion falling by 5% for every one pound increase in aggregate neck strength. The data also showed that the quarter of the subject group of more than six thousand high school athletes playing boys' and girls' soccer, basketball, and lacrosse with the weakest necks suffered the greatest number of concussions, while the quartile with the strongest necks suffered the fewest.
"The evidence [suggests] that neck strengthening programs may be an effective primary concussion prevention mechanism that is inexpensive, easy to adopt, widely available, and fully within the athlete's control," says R. Dawn Comstock, PhD. associate professor in the Department of Epidemiology at the Colorado School of Public Health and principal investigator for the High School RIO TM (an internet-based data collection tool used in the National High School Sports-Related Injury Surveillance Study) from which the study results were drawn.
"We focus so much on how to properly diagnose concussions," Comstock told Time magazine's Sean Gregory. "That's obviously important, but preventing concussions is a much better outcome. We're not saying you won't get a concussion if your neck is stronger. But the data shows that neck strengthening has strong potential as a key concussion prevention tool."
"The results are promising and support what those of us caring for athletes believed to be true, based on our observations, who see strengthening the neck musculature as a means of reducing the risk of sport-related concussion, said William P. Meehan, III, M.D., [48] Director of the Micheli Center for Sports Injury Prevention in the Division of Sports Medicine at Children's Hospital Boston, and a former MomsTEAM concussion expert featured in its PBS high school football documentary, "The Smartest Team. [7]"
Writing in the March 2012 Clinical Journal of Sports Medicine,[11] the developers of HITSTM (Head Impact Telemetry System) - widely used by researchers in biomechanical studies to measure the force and direction of helmet impacts and the technology now incorporated into Riddell's new helmet featuring what it calls its InSite Impact Response System [49] - advocate for widespread use of helmet sensors at all levels of football, and in other sports where practical, to allow real-time monitoring by sideline personnel of impact exposure, either from a single, forceful blow which may cause concussion or the accumulation of repetitive sub-concussive impacts, which puts an athlete at risk for brain injury.
"The identification of a potentially injurious impact or series of impacts via real-time monitoring of head impact exposure in athletes may [not only] facilitate the early recognition and management of brain injury in helmeted sports," says lead author, Richard M. Greenwald, PhD, of the Thayer School of Engineering at Dartmouth College and co-founder of Simbex LLC, the manufacturer of HITSTM, but "permit early intervention, potentially in advance of an injury, rather than simply as a management tool postinjury."
Greenwald is not alone in trumpeting the potential benefit of impact sensors in identifying athletes for sideline screening for concussion. Writing about head impact sensors in the March 2013 issue of the British Journal of Sports Medicine, [22] Jeffrey S. Kutcher, MD, of the Department of Neurology and Michigan Neurosport at the University of Michigan, concurs that the "development of easily deployable sport equipment-based accelerometer systems ... provide[s] [a] potentially useful, clinical information."
"The first is the ability to monitor impacts during the course of an athletic event for the purpose of screening for potential injury. Although many researchers have analyzed impact counts and characteristics across a variety of settings in the hopes of establishing force 'thresholds' for injury, no such threshold has been discovered. As efforts to improve impact-monitoring accuracy continue, however, so will the search for the 'concussion threshold.'"
"Although an on-board accelerometer system may not be able to accurately predict injury," says Kutcher, "it may have utility as a screening device by alerting sideline personnel of an impact that has occurred above a predetermined magnitude that triggers either observation or clinical evaluation of an athlete."
Not surprisingly, some concussion experts take a more cautious approach to the use of impact sensors. Despite finding that under-reporting continues what she wrote in two 2013 studies to be an "alarming" [23] and "overwhelming" problem [24], Johna Register-Mihalik, Ph.D, LAT, ATC, of the Matthew Gfeller Sport-Related TBI Research Center at the University of North Carolina at Chapel Hill, told MomsTEAM that the the reason the use of impact sensors was not among the recommendations she and her co-authors made to address the problem was that she viewed "the use of impact sensors in concussion detection, as the science, although a growing field of information, is just not quite there in how these may best be used from a clinical standpoint and across all sport settings."
"As it stands, there is no absolute threshold for concussive injury and while these sensors may identify individuals who receive a certain type of hit or impact, we do not yet know if those impacts not identified by a set threshold may lead to concussion. In many ways, this may provide a false sense of security, in that 'if the sensor didn't go off, I must not have a concussion.'"
Register-Mihalik recognized that "there is certainly potential for this type of technology to have great implications in the identification of concussion as the science advances," but, she argued, "we need more scientific and unbiased evidence of their ability to detect concussion before they are widely used and recommended in all settings. Until that time, there are some good examples of identification techniques of having trained observers, a parent advocate and continuing to promote concussion education that we know will increase identification rates."
The recent decision by the National Football League to suspend a pilot program [50] in which sensors were installed in players' helmets may also slow down the push towards more widespread adoption of sensor technology, not because their use is unlikely to make sports like football safer (MomsTEAM thinks it will), but for fear that it may open Pandora's box by making it clear just how hard and how often players are getting hit, and scare off parents from letting kids play the sport.
One way to prevent brain trauma is to limit an athlete's exposure to the impacts that might result in traumatic brain injury by delaying the start of contact sports or changing the rules for younger players, as suggested by some concussion experts and commentators.
Football
In his 2012 book, Concussions and Our Kids, [8] Dr. Robert Cantu recommends that kids delay playing tackle football until age 14. A delay in starting such contact sports or eliminating or vastly reducing contact, argues Cantu, will reduce the risk of athletes developing chronic traumatic encephalopathy (C.T.E.) [51], which leads over time to personality changes, memory loss, even dementia. Early signs of C.T.E. have been detected in the brains of 17- and 18-year olds, says Dr. Cantu, who showed no symptoms when they were alive. Dr. Cantu was not the first to make such a recommendation: the American Academy of Pediatrics has long recommended that children wait until middle school to play collision sports like football.
Dr. Cantu's views aren't shared, however, by all concussion experts, most notably, Dr. Kevin Guskiewicz of the University of North Carolina. In an article in the Charlotte News and Observer [52], Dr. Guskiewicz said he believed it was important for young athletes to learn how to safely handle contact at an early age and develop those skills against competition of the same size and age.
"Bob and I don't disagree on much, but we do on this," Guskiewicz told the News and Observer.
The question, however, is whether the safety advantage gained by learning to perform athletic skills at an early age is offset by the risk of brain trauma caused by repeated blows.[1]
Guskiewicz believes it is much safer for young players to learn how to safely play games when they are small, rather than wait until they enter high school."The youth league players generally are close to the same size and are about the same age," Guskiewicz said. "If you wait until the kids are freshmen in high school, you might have a 130-pound player competing with a 300-pound player. The forces can be tremendous. I believe it is safer for the players to learn at younger ages."
Dr. Cantu nevertheless believes, after treating many young athletes with concussions, that it is essential to find ways to avoid blows to the head.
"That's where Kevin and I differ," Cantu said. "I'm treating these children and I've seen them miss school for a week, a month, a semester, even a year because of post-concussion symptoms [53].
"It doesn't make sense to me to be subjecting young individuals to traumatic head injury. There's no head injury that's a good one, and you can't play collision sports without accumulating head injuries. To allow children to play with no informed consent of the dangers is inexcusable. To allow children to play in collision sports with the rules as they are written should not be allowed."
[For a video of Dr. Guskiewicz explaining his position at the NATA youth sports safety summit in Washington, D.C. in December 2011, click here [54].]
[Updates: In October 2015, the American Academy of Pediatrics issued a Policy Statement on Tackling in Footbal [55]l in which it declined to endorse a recommendation that tackling be delayed to any particular age]
Soccer
Some concussion experts and former players are also urging middle schools and under-14 soccer leagues to eliminate heading in the sport as a way of reducing concussions. Dubbed the Safer Soccer Campaign, and bearing the tagline "U14 - No Header, No Brainer", the year-old campaign by the Boston-based Concussion Legacy Institute (CLI) (formerly Sports Legacy Institute) and the Santa Clara Institute of Sports Law and Ethics (ISLE) is spearheaded by three former US Women's National Team players (ISLE board member, Brandi Chastain, and teammates Cindy Parlow Cone and Joy Fawcett), along with CLI medical director Dr. Cantu, and co-founder and Executive Director, Chris Nowinski.
In a June 25, 2014 press release [39] Chastain recommends a ban on heading before age 14 and encourages coaches and parents to consider the risks of heading before high school or age 14 in age-based leagues "while we wait for more research to clarify [that] risk."
In an accompanying "White Paper" [40] on the group's website, however, Dr. Cantu, Mr. Nowinski, and CLI's Educational and Research Program Manager, Cliff Robbins, aren't content to wait, asserting flatly that the "scientific evidence paints a clear picture that heading a soccer ball will result in more concussions and repeated subconcussive trauma, which can have long term neurological consequences in both adolescents and adults."
Indeed, in a July 24, 2014 blog post, [41] Jack Bowen of ISLE, relying on what he refers to as "the heavy hitters" from CLI who have provided the science, goes so far as to suggest that the ban on soccer heading before age 14 proposed by CLI and ISLE "is not just in the best interests of children but one of moral necessity." In other words, says Bowen argues, that to fail to do so "would be to act immorally."
A ban on heading in soccer below U-14 is viewed in a 2015 study [42] not only as culturally unacceptable in a sport that has been allowed to become more physical over time, but as a less effective way to prevent concussions than by reducing athlete-athlete contact across all phases of the game through better enforcement of existing rules (see #2 above), enhanced education of athletes on the rules of the game, and improved coaching (see #1 above). Indeed, the study, by a team of researchers headed by the country's leading expert on high school sports injuries, Dr. Dawn Comstock,* and published online in the Journal of the American Medical Association - Pediatrics, flatly concludes, based on a review of ten years of data, that a simple ban on heading is likely not the most effective way to prevent concussions in youth soccer.
On November 9, 2015, U.S. Soccer, the national governing body for soccer in the U.S., announced that it was banning heading for ages 10 and below and imposing limits on heading in practices for athletes ages 11 through 13 [26]. Those rules apply only to development programs and academies under its control; for youth soccer programs it does not directly control, the rules are recommendations only.]
* In the interest of transparency, and to avoid any suggestion of bias in reporting this story, it should be noted that Dr. Comstock is an uncompensated member of MomsTEAM Institute's Board of Advisors [56], which is developing best practice youth sports health and safety checklists, including youth soccer, for the Institute's SmartTeamsTM program [57]. It remains to be seen where the Institute will ultimately come down on the issue of the age at which heading in soccer can safely begin, or whether, as banning heading is the best way to reduce concussions at the youth level, as CLI proposes, or via better rules enforcement, enhanced education of players, and better coaching, as Dr. Comstock recommends.
For a comprehensive review of the research on heading in soccer, click here. [58]
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Updated and substantially revised March 2, 2013; most recently revised and updated November 12, 2015
The substantial contributions to this article and its continued updating by MomsTEAM's Senior Health & Safety Editor, Lindsay Barton Straus, are gratefully acknowledged.
[59]
Links:
[1] https://mail.momsteam.com/sub-concussive/sub-concussive-hits-growing-concern-in-youth-sports
[2] https://mail.momsteam.com/node/4492
[3] https://mail.momsteam.com/node/2744
[4] https://mail.momsteam.com/node/2389
[5] https://mail.momsteam.com/node/4439
[6] http://videos.usafootball.com/video/The-Tackle-The-Heads-Up-Football;Heads-Up-Football
[7] http://www.thesmartestteam.com
[8] https://mail.momsteam.com/node/3468
[9] https://mail.momsteam.com/node/3016
[10] https://mail.momsteam.com/node/5810
[11] http://www.nj.com/rutgersfootball/index.ssf/2013/08/college_football_rules_primer_for_2013_the_eight_major_changes.html
[12] https://mail.momsteam.com/node/4434
[13] https://mail.momsteam.com/node/4427
[14] https://mail.momsteam.com/node/5798
[15] https://mail.momsteam.com/node/597
[16] https://mail.momsteam.com/blog/brooke-de-lench/enforcing-rules-against-helmet-helmet-contact-way-reduce-brain-trauma-in-football
[17] http://www.dallasnews.com/sports/high-schools/football-news/headlines/20120913-avoiding-serious-neck-injuries-head-up-tackling-a-constant-emphasis-for-dallas-area-football-players-coaches.ece
[18] https://mail.momsteam.com/node/5574
[19] http://www.nflevolution.com/article/NFL-owners-approve-crown-of-helmet-rule-abolish-Tuck-Rule?ref=7317
[20] https://mail.momsteam.com/node/3041
[21] https://mail.momsteam.com/node/3284
[22] http://globalnews.ca/news/1816870/toronto-parents-launch-petition-to-ban-bodychecking-in-minor-hockey/
[23] https://mail.momsteam.com/node/4323
[24] https://mail.momsteam.com/node/6208
[25] https://mail.momsteam.com/node/816
[26] https://mail.momsteam.com/soccer-heading/us-soccer-recommends-ban-soccer-heading-before-age-12-practice-limits-12-13-year-olds
[27] https://mail.momsteam.com/health-safety/rules-to-reduce-concussions-subconcussive-hits-in-place-for-2011-ivy-league-football
[28] http://www.usatoday.com/story/sports/ncaaf/2013/06/03/pac-12-limiting-contact-football/2384731/
[29] http://www.ncaa.org/health-and-safety/football-practice-guidelines
[30] http://www.prweb.com/releases/2013/4/prweb10637189.htm
[31] http://www.bellevuereporter.com/sports/204181201.html
[32] http://www.dallasnews.com/sports/high-schools/headlines/20130421-uil-committee-recommendation-limits-in-season-full-contact-high-school-football-practice.ece
[33] http://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=201320140AB2127
[34] https://mail.momsteam.com/health-safety/nfhs-approves-concussion-task-force-recommendations-discussion-with-state-associations
[35] http://www.nfhs.org/media/1014079/2014-nfhs-recommendations-and-guidelines-for-minimizing-head-impact-final-october-2014.pdf
[36] https://mail.momsteam.com/health-safety/pre-season-heat-acclimatization-guidelines
[37] https://mail.momsteam.com/node/4671
[38] http://augustafreepress.com/virginia-tech-to-lead-national-five-year-study-on-head-impacts-in-youth-football/
[39] https://mail.momsteam.com/node/228
[40] https://mail.momsteam.com/node/3858
[41] http://www.beam.vt.edu/helmet/helmets_hockey.php
[42] https://mail.momsteam.com/2014-Virginia-Tech-Star-football-helmet-ratings-helpful-but-view-with-caution
[43] http://www.nytimes.com/2014/07/23/sports/hockey/for-safety-hockey-helmets-going-under-microscope.html?_r=0
[44] http://www.usahockey.com/news_article/show/498353?referrer_id=752796
[45] https://mail.momsteam.com/nocsae-continues-attacks-virginia-tech-star-rating-system
[46] https://mail.momsteam.com/node/5553
[47] https://mail.momsteam.com/node/5501
[48] https://mail.momsteam.com/node/3526
[49] https://mail.momsteam.com/node/6077
[50] https://mail.momsteam.com/blog/brooke-de-lench/impact-sensors-one-step-forward-two-steps-back
[51] https://mail.momsteam.com/node/3289
[52] http://www.newsobserver.com/2012/02/12/v-print/1848278/concussion-experts-differ-on-youth.html
[53] https://mail.momsteam.com/node/3310
[54] https://mail.momsteam.com/node/4423
[55] https://mail.momsteam.com/health-safety/pediatrics-group-refuses-to-endorse-outright-ban-on-tackling-in-high-school-youth-football
[56] http://www.momsteaminstitute.org/momsteam-institute-boards-advisors
[57] http://www.momsteaminstitute.org/smartteams™-0
[58] https://mail.momsteam.com/health-safety/heading-in-youth-soccer-debate-continues
[59] https://mail.momsteam.com/node/3575
[60] http://keepingscore.blogs.time.com/2013/02/21/study-neck-strength-predicts-concussion-risk/
[61] http://www.nfhs.org/articles/concussion-task-force-recommendations-to-be-implemented-in-2015/
[62] http://www.sportslegacy.org/wp-content/uploads/2014/06/Soccer-Heading-Press-Release-062414.pdf
[63] http://www.sportslegacy.org/wp-content/uploads/2014/07/Soccer-Heading-White-Paper-072914.pdf
[64] http://law.scu.edu/sports-law/the-ethics-of-headers-in-youth-soccer-using-our-heads-correctly/
[65] https://mail.momsteam.com/node/9280
[66] https://mail.momsteam.com/5-7/limiting-hits-head-in-youth-sports-aim-innovative-hit-count-program
[67] https://mail.momsteam.com/head-impact-exposure-in-youth-football-surprisingly-high-limits-in-contact-practices-urged
[68] https://mail.momsteam.com/sports/study-finds-head-impacts-among-high-school-football-players-greater-than-collegiate-level