Tuesday, January 28, 2014

Concussions: What the athletes say

My passion for youth sports coaching has led me to several articles on this blog about the dangers of concussions, sensible practices that should be followed when players are hurt during games, and sometimes about the poor behavior demonstrated by some coaches.  Somehow, though, I missed an article from August 2013 in Neurology Clinical Practice by Daniel M. Torres and his colleagues from NYU's Department of Neurology and others.* It offers some insights that should be recognized and understood by coaches.

Unfortunately, this is a journal that requires a subscription, even for articles of general public interest, so I'll have to summarize the main points.  (As a side comment, this practice is infuriating.  Why these journals can't follow the lead of the NEJM and make such general articles available widely is beyond me.)  Here's the summary:

Studies suggest that a lack of standardized knowledge may lead to underreporting and undertreatment of sports-related concussion. However, there has been little work done to establish how this knowledge may affect athletes’ behaviors toward reporting their concussions and removing themselves from play. We conducted an anonymous online survey to assess athletes’ knowledge of signs and symptoms of concussion, and also sought to estimate the potential frequency of underreporting in a collegiate athlete cohort. Among 262 athletes who responded to the survey, 43% of those with a history of concussion reported that they had knowingly hidden symptoms of a concussion to stay in a game, and 22% of athletes overall indicated that they would be unlikely or very unlikely to report concussion symptoms to a coach or athletic trainer in the future. These data suggest that there may be a substantial degree of underreporting of concussion among collegiate athletes, despite most acknowledging that they have been formally educated about the risks of concussion. 

As you dive into the article, you find documentation of the result that the likelhood of athletes to report a concussion is lower for those athletes with a history of concussion.  Here's the chart:

You might think that these athletes' previous experience and knowledge would make them more likely to report concussion sysmptoms, but no.

An accompanying editorial by Brian Hainline and others (again, inexplicably unavailable to the world at large) is entitled "Truth be told."  The authors ask, of the study mentioned above:

Should we be concerned? Absolutely. Concussion is not a singular event, but rather a pathophysiologial process that can threaten the physical and mental health of the involved athlete.

There are many potential reasons for underreporting that needed to be addresses comprehensively by all governing bodies of sport in a consistent and enforceable manner.

They then list several such measures:

1 -- Consistent and reliable education for all athletes, coaches, officials, stakeholders and parents;
2 -- Removal of any conflict of interest in the medical management team;
3 -- An ongoing evaluation and implementation of rules of sport to help assure student-athlete safety and fair play;
4 -- Greater involvement of officials in concussion management through consistent training and application of rules that pertain to safe play;
5 -- Coaching decisions that reflect best practices for all athlete with concussion;
6 -- Student-athletes need to embrace a culture that demands that their safety, excellence, and wellness are always the top priority.

The authors also note that, "if neurologists and sports medicine physicians are to become part of the solution, they must also be at the forefront of understanding the problem."  They then offer a list of actions to be taken by the profession.

They conclude:

We have made considerable progress, and must not lose momentum.  Torres et al. soberly remind us that we still have much work ahead of us.

Indeed.  Well presented and well argued.  Let me publicly ask one more thing of the publisher and editors of this journal. Please change your website to let these two articles be available to the thousands of coaches and parents and players around the world who need to read it.  By restricting its circulation, you are undercutting the very recommendations you make.

* Disclosure:  The lead author is my nephew.


Anonymous said...

Unfortunately, it's just like trying to educate teenagers about smoking, or texting while driving. They think they are invincible and don't think of long term consequences. Plus the 'I'm tough" mentality that pervades sports teams, and coaches who don't want to pull their best player.
It would seem some serious strategizing might be in order among referees as to giving them the power to order a child removed from a game, rather than leaving it to the coach.

This from a non-player, non-coach, non-soccer mom - but sometimes outside observers are good, no?


Janice said...

My now 12-year old son had a concussion last year after jumping from tire swing to leaves--later learned he was unconscious, but his buddy did not get me because Ian was "asleep but breathing". Doctor ordered 48-hours of brain rest, which meant doing nothing--I could not read to him, play music, nothing. He must have cried for half the time, which surely stressed his brain.

A few months later, Ian had a head-on collision at recess, but did not tell me. The school did not notify me either. I found out the next day when he had vision trouble.

He had not told me about it due to fear of more brain rest. By the time we saw a doctor, the window for that treatment had shut. And the doctor agreed that the stress of brain rest was not healing, and mentioned that guidelines were changing as well.

Mitch said...

I worked with a scientist a few years ago (Dr. Ann Glang) who was an expert in the subject, and it was just coming to the fore of public consciousness. She pointed out something that I think is helpful in articles like yours and for broader discussion.

The term concussion is almost clinical in nature, sterile and unemotional. Sort of like CI instead of using the more graphic and attention getting and emotionally descriptive Heart Attack.

The better term for concussion is Brain Injury. Use that term and everyone involved will pay more attention. And reinforces the danger. It is not like a bruise or some other minor inconvenience one expects from sport. It is brain injury, serious and should be dealt with as such.

#1 Son said...

One potential solution to under reporting by athletes would be the availability of mobile applications that can empirically test an athlete in seconds on the sideline. I don't know of the viability of the technology - but one of the winners (HOMEfield) of last weekend's H@cking Medicine event at Tufts Medical School is trying to build exactly such an application - check them out at http://medtechboston.com/boston-blue-button-innovation-challenge-meet-the-winners-armme-homefield-preventativehealthtools-com-and-simplyid/