March is Brain Injury Awareness Month

Want to learn more about the brain, especially the developing brain of children and adolescents, check out brainfacts.org.  In this blog post, we’ll be talking about sport-related concussions, chronic traumatic encephalopathy, and what is all means for your young athletes.

Sport-related concussions have increasingly become a hot topic in the media and in medicine.

At Bee Well, we treat concussions weekly, sometimes daily, depending on the athletic season. Bee Well believes prevention is always the best medicine. We strive to give our patients the most up to date information to help guide decision making, including sports participation.

Not long ago, concussion was considered only a minor injury, if considered an injury at all.

But evidence from extensive research in recent years suggests that concussions pose a  greater risk of potential long-term complications than previously thought.

Football gets most of the attention, because it has the highest incidence of concussion. According to sources cited by the American Academy of Pediatrics, football is also the most popular sport among male high school athletes, and also among those who play in youth leagues, ranging in age from 5 to 15.

Other sports with high rates of concussion are soccer, gymnastics, ice hockey, and lacrosse.

In this post, we offer a summary of facts and opinions on the subject, starting with a definition of concussion, its possible long-term effects, and proposed methods of prevention.

What is concussion?

The Boston University School of Medicine provides the following definition:

A concussion has occurred any time you have had a blow to the head that caused you to have symptoms for any amount of time. You do NOT need to have lost consciousness to have a concussion. These symptoms include blurred or double vision, seeing stars, sensitivity to light or noise, headache, dizziness or balance problems, nausea, vomiting, trouble sleeping, fatigue, confusion, difficulty remembering, difficulty concentrating, or loss of consciousness. A concussion has also occurred when a person gets a “ding” or gets their “bell rung.” Sometimes these symptoms might not be apparent right away. They may develop within the following 24-48 hours.

What is Chronic Traumatic Encephalopathy (CTE)?

We now know that a concussion is much more than just “getting your bell rung.”

In 2002, a breakthrough in the understanding of the long-term risk of concussion occurred when forensic pathologist Dr. Bennet Omalu performed an autopsy on the retired Pittsburgh Steeler, Mike Webster.

Webster won four Super Bowls in the 1970s as the Steelers’ starting center. After retiring, his mental health severely deteriorated, leading to an early death at age fifty.

When examining Webster’s brain, Dr. Omaulu discovered a previously unknown disorder that he named Chronic Traumatic Encephalopathy, or CTE.

The story is dramatized in the 2013 movie Concussion, starring Will Smith as Dr. Omalu.

How do you get CTE?

The CTE Center at Boston University says:

We believe CTE is caused by repetitive brain trauma. This trauma includes both concussions that cause symptoms and subconcussive hits to the head that cause no symptoms. At this time the number or type of hits to the head needed to trigger degenerative changes of the brain is unknown. In addition, it is likely that other factors, such as genetics, may play a role in the development of CTE, as not everyone with a history of repeated brain trauma develops this disease. However, these other factors are not yet understood.

Concussion and the NFL

On July 25, 2017, the Journal of the American Medical Association published a study led by Dr. Ann McKee, director of the Boston University CTE Center. (The article is titled “Clinicopathological Evaluation of Chronic Traumatic Encephalopathy in Players of American Football.”)

The study examined the brains of 111 former NFL players who donated their brains to the Center.

Of the 111 brains, 110 were diagnosed with CTE.

Andrew Hawkins, a 31-year-old wide receiver for the New England Patriots, announced his retirement the day the study was released.

Two days later, Baltimore Ravens offensive lineman John Urschel, 26, announced his retirement also. (He was already a doctoral candidate at MIT, and he decided to devote his brain to mathematics instead of football.)

In 2015, San Francisco 49ers hard-hitting linebacker Chris Borland retired at age 24, also citing concerns about CTE. “If there were no possibility of brain damage, I’d still be playing,” Borland told ESPN at the time.

The authors of the study acknowledge that the outcome is biased, because families have donated brains of those who were already displaying signs of CTE.

However, as Dr. McKee asserts, “the fact that we’ve been able to gather this high a number of cases in such a short period of time says that this disease is not uncommon … In fact, I think it’s much more common than we currently realize. And more importantly, this is a problem in football that we need to address and we need to address now in order to bring some hope and optimism to football players.”

Weighing the risks

In 2015, the American Academy of Pediatrics (AAP) issued a position statement on football-related concussion.

“Most injuries sustained during participation in youth football are minor, including injuries to the head and neck,” the statement says.

It also cites numerous sources that “have argued that football is a generally safe sport that carries with it the substantial benefits of regular exercise on health as well as social and academic outcomes that outweigh the risks involved, pointing out that the risk of catastrophic injury is low, that most concussions resolve within a few days or weeks, and that there are substantial limitations to the current understanding of CTE.”

Whatever the risk factor actually is, the AAP argues that “repetitive trauma to the head is of no clear benefit to the game of football or the health of football players.”

The APP’s position statement therefore is focused on how to prevent such trauma.

Preventing concussion

Should tackling be banned in youth football?

“The majority of concussions result from tackling or being tackled,” the statement asserts. “Head-to-head contact is one of the leading causes of concussions sustained by youth football players.”

From our clinical experience at Bee Well, about half the football injuries we see are from head-to-head contact. However, whiplash from one large mass slamming into another large mass is enough trauma to cause a concussion, even if their helmets don’t hit each other.

One preventive option considered by the AAP would be to ban tackle football in favor of “flag football,” in which tackling is substituted by pulling a “flag” from the ball-carrier’s belt.

But the AAP acknowledges the inherent controversy in such a plan: “The American Academy of Pediatrics recognizes, however, that the removal of tackling from football would lead to a fundamental change in the way the game is played. Participants in football must decide whether the potential health risks of sustaining these injuries are outweighed by the recreational benefits associated with proper tackling.”

A compromise would be to have tackle football for older players, and flag football for younger players.

However, the AAP speculates that players accustomed to only flag football might be unprepared for tackle football once they get older.

“Lack of experience with tackling and being tackled may lead to an increase in the number and severity of injuries once tackling is introduced,” the AAP writes. “Therefore, if regulations that call for the delaying of tackling until a certain age are to be made, they must be accompanied by coaches offering instruction in proper tackling technique as well as the teaching of the skills necessary to evade tackles and absorb being tackled.”

Is safer tackling the answer?

“Proper tackling” — or “textbook tackling” as it is often called — uses the shoulder instead of the head as the primary point of contact. The tackler’s head is positioned to one side of the ball-carrier’s body, with a shoulder delivering the hit and absorbing the impact, while the arms are wrapped around the body.

“Not only are textbook tackles more effective, but they’re also safer,” explains an NFL website that’s designed to teach young players how to tackle. “By training and teaching young players on proper technique, the hope is to establish proper tackling habits and make the game even safer.”

However, while textbook tackling is easy to practice, it’s not always possible during an actual game. Obviously, ball-carriers try to evade defenders, and don’t stand still waiting for them to get into position to make textbook tackles.

Plus, textbook tackling is relevant only in one-on-one situations. But there are often numerous tacklers involved in a play, and such “gang tackling” rarely makes textbook tackling a possibility.

In reality, tacklers usually do whatever is necessary to bring a ball-carrier to the ground.

As for teaching safer tackling, former professional linebacker Chris Borland is skeptical. “I wouldn’t want to be charged with the task of making violence safer,” he said. “I think that’s a really difficult thing to do.”

Furthermore, he doesn’t agree that safer tackling is necessarily more effective. He told ESPN: “Some of my best tackles were the most dangerous!”

Are better helmets the answer?

Some players think that better helmets would prevent concussions, but there’s little evidence to support this belief.

A 2013 study by the AAP concluded:

“Our preliminary findings suggest that neither any specific brand of football helmet nor custom mouth guards result in fewer concussions in kids who use them. Despite what manufacturers might claim, newer and more expensive equipment may not reduce concussion risk.”

Final Thoughts

Bee Well’s position is that tackle football and other high-risk sports put athletes at risk for repetitive traumatic brain injury that may have long-term cognitive damage.

We believe it is important that young people stay active and enjoy their exercise of choice, but keeping your child safe and healthy is our biggest priority.

We are here to help parents and athletes weigh the risks and make an informed decision.