Opinion
VIEWPOINT
Frederick P. Rivara, MD, MPH University of Washington, Seattle, Seattle Children’s Hospital, Seattle, Washington, and Editor, JAMA Pediatrics. Robert Graham, MD George Washington University, Washington, DC.
Author reading at jama.com
Sports-Related Concussions in Youth Report From the Institute of Medicine and National Research Council The public and scientific views of the effects of concussions on young athletes are changing. In the past, concussions were often viewed as unimportant “dings” to be shaken off and not allowed to interfere with return to play. However, recent literature in both the lay and professional press has caused youth, their parents, coaches, teachers, and physicians to view concussions as more serious threats to the health of young athletes than they have in the past. In response to this increasing level of concern, the Institute of Medicine and National Research Council in October of 2012 convened the Committee on SportsRelated Concussions in Youth to review the available scientific literature on concussions related to the causes, incidence, and biophysiology of concussions in youth; the immediate and long-term consequences of these injuries; and the current state of the art on diagnosis and treatment. This Viewpoint discusses key findings of the Committee’s recently released report.1 Much is known about sports-related concussions, but much is unknown, particularly about concussions in younger athletes. Most studies on sports-related concussions have been conducted at the collegiate and
The culture of sport affects the recognition, reporting, and management of sports-related concussions in youth of all ages.
Corresponding Author: Frederick P. Rivara, MD, MPH, Harborview Injury Prevention and Research Center, 325 Ninth Ave, PO Box 359960, Seattle, WA 98104 ([email protected]).
professional level, some in high school–aged athletes but almost none in middle school and elementary school– aged youth. It is estimated that 1.6 million to 3.8 million sports- and recreation-related traumatic brain injuries, including concussions, occur every year in the United States.2 However, these estimates are almost certainly inaccurate, and no incidence data have been collected on young athletes who participate in intramural and club sports. The Committee called for the Centers for Disease Control and Prevention (CDC) to develop and maintain a surveillance system “to accurately determine the incidence of sports-related concussions, including in youth 5 to 21.” One of the difficulties in accurate assessment of the incidence has been that concussions remain a clinical diagnosisbasedonreportedsymptomsafterahittothehead or body. There is a need for objective diagnostic markers
for concussions and for objective markers of recovery. Guidelines for the diagnosis and management of concussions have been developed, but these are primarily based onclinicalexperienceandnotonscientificevidence.Much oftheinformationcoaches,athletictrainers,andphysicians provide to young athletes and their parents is based on expertopinionratherthanevidence,especiallyevidencefrom studies in this age group. There is some evidence supporting physical rest after concussion but limited evidence for “cognitiverest”andrecommendationsonreturntoschool. There is a need for randomized controlled trials and longitudinal cohort studies in youth of all ages to determine the optimal management of these injuries. The report therefore calls for the National Institutes of Health (NIH) and the Department of Defense (DOD) to “support research (1) to establish objective sensitive and specific metrics and markers of concussion diagnosis and recovery in youth, and (2) to inform the creation of age-specific, evidence-based guidelines for the management of shortand long-term sequelae of concussion in youth.” The availability of football helmets fitted with accelerometers to measure forces to the head during routine play and practices has led to concern about the number of repetitive head impacts without concussion that athletes sustain over the course of their careers. Studies involving athletes with multiple concussions have included limited numbers of patients, have been short in duration, and have not been able to definitively answer the important questions of the duration of brain vulnerability after a concussion; the number of concussions that lead to more permanent disability; and how this may vary with age, sex, race and ethnicity, and pubertal status. The Committee recommended that the NIH and DOD “conduct controlled, longitudinal, large-scale studies to assess shortand long-term cognitive, emotional, behavioral, neurobiological, and neuropathological consequences of concussions and repetitive head impacts over the life span.” There is currently no evidence that concussions in youth lead to the development of chronic traumatic encephalopathy in adults. However, to address these concerns and further the study of the biological consequences of concussions, the Committee also recommended that the NIH maintain a biorepository of brain and biological samples for research on concussions. Because of the concern about the consequences of concussions, attention needs to be paid to ways in which concussions can be prevented, the severity minimized,
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JAMA January 15, 2014 Volume 311, Number 3
Copyright 2014 American Medical Association. All rights reserved.
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239
Opinion Viewpoint
and the safety of players improved. Although there is some evidence that rules and playing standards can affect the incidence of concussions, there is a need for more research. The Committee recommended that national governing bodies for youth sports “undertake a rigorous scientific evaluation of the effectiveness of ageappropriate techniques, rules, and playing and practice standards in reducing sports-related concussion and sequelae.” Despite the ability to monitor forces sustained to the helmets of football players during practices and games, current data are inadequate to determine thresholds for sports-related concussions in youth of different ages, and there are no data on other sports such as soccer or basketball. It is unknown how these thresholds might vary by age, if they vary by sex, and what the force threshold for a repeat concussion is during the period of brain vulnerability after the prior concussion. Although helmets are designed to prevent skull fractures and more serious intracranial injury, there is limited evidence that currently available helmets prevent concussions. The report calls for research to determine the biomechanical thresholds for concussions in different ages in both males and females and to generate data that are “critical to inform the development of rules of play, effective protective equipment and equipment safety standards, impact monitoring systems, and athletic and military training programs.” The culture of sport affects the recognition, reporting, and management of sports-related concussions in youth of all ages. ARTICLE INFORMATION Published Online: November 1, 2013. doi:10.1001/jama.2013.282985. Conflict of Interest Disclosures: Both authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. Additional Information: The sponsors of the recently released report1 from the Institute of Medicine and National Research Council were the Centers for Disease Control and Prevention (CDC),
240
The maxim of not letting the team down, “manning up,” and winning at all costs has led to athletes not reporting their concussive symptoms to others, athletes covering up the injuries of their team members, and parents and coaches minimizing the injuries of the players. These factors may lead to prolonged recovery times, repeated injuries within short periods of time, and disability. Parents need to be aware of the symptoms of concussion and the tendency for young athletes to not report these injuries to them or to their coaches. Although there are indications that this culture is changing, the shift is not complete. Therefore, the report calls for athletic association governing bodies, in conjunction with the CDC, Health Resources and Services Administration, Department of Education, and DOD, as well as the National Athletic Trainers’ Association, to “develop, implement, and evaluate the effectiveness of large-scale efforts to increase knowledge and change culture” about concussions among youth, their parents, athletic personnel, and health professionals. Any athlete with symptoms of concussion should be removed from play and not return until evaluated by a health care professional competent in the care of patients with concussions. It is the hope of the Committee that the specific recommendations offered in the report will provide a framework for a more thorough and extensive study of the epidemiology, biophysiologic processes, clinical effects, and long-term consequences of concussions in young athletes.
Departments of Defense and Education, Health Resources and Services Administration, National Athletic Trainers’ Association Research and Education Foundation, and National Institutes of Health; in addition, support for this study was provided to the CDC Foundation by the National Football League.
Council. Sports-Related Concussions in Youth: Improving the Science, Changing the Culture. Washington, DC: National Academies Press; 2013. 2. Langlois JA, Rutland-Brown W, Wald MM. The epidemiology and impact of traumatic brain injury: a brief overview. J Head Trauma Rehabil. 2006;21(5):375-.
REFERENCES 1. Committee on Sports-Related Concussions in Youth, Institute of Medicine, National Research
JAMA January 15, 2014 Volume 311, Number 3
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of St. Andrews Library User on 05/15/2015
jama.com
VIEWPOINT
Frederick P. Rivara, MD, MPH University of Washington, Seattle, Seattle Children’s Hospital, Seattle, Washington, and Editor, JAMA Pediatrics. Robert Graham, MD George Washington University, Washington, DC.
Author reading at jama.com
Sports-Related Concussions in Youth Report From the Institute of Medicine and National Research Council The public and scientific views of the effects of concussions on young athletes are changing. In the past, concussions were often viewed as unimportant “dings” to be shaken off and not allowed to interfere with return to play. However, recent literature in both the lay and professional press has caused youth, their parents, coaches, teachers, and physicians to view concussions as more serious threats to the health of young athletes than they have in the past. In response to this increasing level of concern, the Institute of Medicine and National Research Council in October of 2012 convened the Committee on SportsRelated Concussions in Youth to review the available scientific literature on concussions related to the causes, incidence, and biophysiology of concussions in youth; the immediate and long-term consequences of these injuries; and the current state of the art on diagnosis and treatment. This Viewpoint discusses key findings of the Committee’s recently released report.1 Much is known about sports-related concussions, but much is unknown, particularly about concussions in younger athletes. Most studies on sports-related concussions have been conducted at the collegiate and
The culture of sport affects the recognition, reporting, and management of sports-related concussions in youth of all ages.
Corresponding Author: Frederick P. Rivara, MD, MPH, Harborview Injury Prevention and Research Center, 325 Ninth Ave, PO Box 359960, Seattle, WA 98104 ([email protected]).
professional level, some in high school–aged athletes but almost none in middle school and elementary school– aged youth. It is estimated that 1.6 million to 3.8 million sports- and recreation-related traumatic brain injuries, including concussions, occur every year in the United States.2 However, these estimates are almost certainly inaccurate, and no incidence data have been collected on young athletes who participate in intramural and club sports. The Committee called for the Centers for Disease Control and Prevention (CDC) to develop and maintain a surveillance system “to accurately determine the incidence of sports-related concussions, including in youth 5 to 21.” One of the difficulties in accurate assessment of the incidence has been that concussions remain a clinical diagnosisbasedonreportedsymptomsafterahittothehead or body. There is a need for objective diagnostic markers
for concussions and for objective markers of recovery. Guidelines for the diagnosis and management of concussions have been developed, but these are primarily based onclinicalexperienceandnotonscientificevidence.Much oftheinformationcoaches,athletictrainers,andphysicians provide to young athletes and their parents is based on expertopinionratherthanevidence,especiallyevidencefrom studies in this age group. There is some evidence supporting physical rest after concussion but limited evidence for “cognitiverest”andrecommendationsonreturntoschool. There is a need for randomized controlled trials and longitudinal cohort studies in youth of all ages to determine the optimal management of these injuries. The report therefore calls for the National Institutes of Health (NIH) and the Department of Defense (DOD) to “support research (1) to establish objective sensitive and specific metrics and markers of concussion diagnosis and recovery in youth, and (2) to inform the creation of age-specific, evidence-based guidelines for the management of shortand long-term sequelae of concussion in youth.” The availability of football helmets fitted with accelerometers to measure forces to the head during routine play and practices has led to concern about the number of repetitive head impacts without concussion that athletes sustain over the course of their careers. Studies involving athletes with multiple concussions have included limited numbers of patients, have been short in duration, and have not been able to definitively answer the important questions of the duration of brain vulnerability after a concussion; the number of concussions that lead to more permanent disability; and how this may vary with age, sex, race and ethnicity, and pubertal status. The Committee recommended that the NIH and DOD “conduct controlled, longitudinal, large-scale studies to assess shortand long-term cognitive, emotional, behavioral, neurobiological, and neuropathological consequences of concussions and repetitive head impacts over the life span.” There is currently no evidence that concussions in youth lead to the development of chronic traumatic encephalopathy in adults. However, to address these concerns and further the study of the biological consequences of concussions, the Committee also recommended that the NIH maintain a biorepository of brain and biological samples for research on concussions. Because of the concern about the consequences of concussions, attention needs to be paid to ways in which concussions can be prevented, the severity minimized,
jama.com
JAMA January 15, 2014 Volume 311, Number 3
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of St. Andrews Library User on 05/15/2015
239
Opinion Viewpoint
and the safety of players improved. Although there is some evidence that rules and playing standards can affect the incidence of concussions, there is a need for more research. The Committee recommended that national governing bodies for youth sports “undertake a rigorous scientific evaluation of the effectiveness of ageappropriate techniques, rules, and playing and practice standards in reducing sports-related concussion and sequelae.” Despite the ability to monitor forces sustained to the helmets of football players during practices and games, current data are inadequate to determine thresholds for sports-related concussions in youth of different ages, and there are no data on other sports such as soccer or basketball. It is unknown how these thresholds might vary by age, if they vary by sex, and what the force threshold for a repeat concussion is during the period of brain vulnerability after the prior concussion. Although helmets are designed to prevent skull fractures and more serious intracranial injury, there is limited evidence that currently available helmets prevent concussions. The report calls for research to determine the biomechanical thresholds for concussions in different ages in both males and females and to generate data that are “critical to inform the development of rules of play, effective protective equipment and equipment safety standards, impact monitoring systems, and athletic and military training programs.” The culture of sport affects the recognition, reporting, and management of sports-related concussions in youth of all ages. ARTICLE INFORMATION Published Online: November 1, 2013. doi:10.1001/jama.2013.282985. Conflict of Interest Disclosures: Both authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. Additional Information: The sponsors of the recently released report1 from the Institute of Medicine and National Research Council were the Centers for Disease Control and Prevention (CDC),
240
The maxim of not letting the team down, “manning up,” and winning at all costs has led to athletes not reporting their concussive symptoms to others, athletes covering up the injuries of their team members, and parents and coaches minimizing the injuries of the players. These factors may lead to prolonged recovery times, repeated injuries within short periods of time, and disability. Parents need to be aware of the symptoms of concussion and the tendency for young athletes to not report these injuries to them or to their coaches. Although there are indications that this culture is changing, the shift is not complete. Therefore, the report calls for athletic association governing bodies, in conjunction with the CDC, Health Resources and Services Administration, Department of Education, and DOD, as well as the National Athletic Trainers’ Association, to “develop, implement, and evaluate the effectiveness of large-scale efforts to increase knowledge and change culture” about concussions among youth, their parents, athletic personnel, and health professionals. Any athlete with symptoms of concussion should be removed from play and not return until evaluated by a health care professional competent in the care of patients with concussions. It is the hope of the Committee that the specific recommendations offered in the report will provide a framework for a more thorough and extensive study of the epidemiology, biophysiologic processes, clinical effects, and long-term consequences of concussions in young athletes.
Departments of Defense and Education, Health Resources and Services Administration, National Athletic Trainers’ Association Research and Education Foundation, and National Institutes of Health; in addition, support for this study was provided to the CDC Foundation by the National Football League.
Council. Sports-Related Concussions in Youth: Improving the Science, Changing the Culture. Washington, DC: National Academies Press; 2013. 2. Langlois JA, Rutland-Brown W, Wald MM. The epidemiology and impact of traumatic brain injury: a brief overview. J Head Trauma Rehabil. 2006;21(5):375-.
REFERENCES 1. Committee on Sports-Related Concussions in Youth, Institute of Medicine, National Research
JAMA January 15, 2014 Volume 311, Number 3
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of St. Andrews Library User on 05/15/2015
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