Only a doctor can determine when an athlete can return post-concussion

This article claims that only doctors can help determine when a player returns to play post-concussion.

An editorial published today in The Lancet Neurology calls for sports authorities to take into consideration the long term neurological problems that repeated concussions can cause.

Cerebral concussion is the most common form of sports-related traumatic brain injury (TBI), and the long-term effects of repeated concussions may include dementia, amyotrophic lateral sclerosis, and other neurological disorders, say the journal editors.

However, what is perhaps more concerning, is that even when the symptoms of concussion are delayed, or if they come and go quickly, neurological damage can remain without detection. This can lead to footballers, such as Uruguayan defender Álvaro Pereira during the 2014 FIFA World Cup, overruling doctors' advice to be substituted and returning to play after sustaining a head injury.

The journal editors argue that the decision for players to return to a game after sustaining a concussion should be made only by healthcare professionals, and "should surely be taken out of the hands of those with a vested interest in the player's performance."

According to the journal editors, "Many sporting organisations now acknowledge the potentially serious consequences of mild TBI and have drawn up new protocols to protect athletes who sustain a head injury'. However FIFPro, the world players' union, has called for an investigation of concussion protocols and return-to-play standards following Pereira's injury."

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White House plans to educate the public on youth concussions

The White House and President Obama plan to gather experts to help educate the public on youth concussions.

Concerned that too little is known about the effects of head injuries in young athletes, President Barack Obama is bringing representatives of professional sports leagues, coaches, parents, youth sports players, researchers and others to the White House to help educate the public about youth sports concussions.

Tackling the issue at a White House summit Thursday, Obama also will highlight pledges of money and other support from the NFL, the National Institutes of Health, the Pop Warner Little Scholars and others to do the research, promote safety and speed development of materials designed to provide better protection.

Obama comes to the issue through his well-documented love of sports, and as the father of two daughters active in sports. The president thinks sports are also a good way to keep kids healthy and out of trouble, but he raised some eyebrows last year by saying he would "have to think long and hard" before letting a son, if he had one, play football because of the risk of head injuries.

"He, as a parent, is concerned about the safety of his own daughters," said White House communications director Jennifer Palmieri, who was among officials who previewed the White House Healthy Kids & Safe Sports Concussion Summit for reporters.

In a report last fall, the Institute of Medicine and the National Research Council called for a national system to track sports-related concussions and begin answering questions about the risks of youth sports, such as how often do the youngest athletes suffer concussions or which sports have the highest rates.

Nearly 250,000 kids visit hospital emergency rooms each year with brain injuries caused by sports or other recreational activity, the White House said.

The National Football League is committing $25 million over the next three years on promoting youth sports safety.

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Why no helmet can prevent concussions

This comprehensive article gives an overview of the research that has been done on helmets and concussions, and the article discusses what this research means for football players.

It's a glorious time to be a football fan.

The NFL playoffs are underway, the Super Bowl is just weeks away. The national rite of football gives so many people so many exciting moments. Maybe that's why it can be hard to wrap one's mind around one of the game's huge downsides: what it may do to the brains of the young men who play it.

The spotlight on head injuries in sports, particularly football, has grown more intense in recent years. Last fall, the NFL settled for $765 million dollars in a class action lawsuit by former players over concussions, a case heard in Philadelphia.

Last week, a Mississippi father filed a federal class action suit on behalf of all student athletes asking the bodies governing college and high school sports to provide better and more uniform information on concussion risks.

Many of the sports Americans and young adults in particular love to play – not just football, but hockey, soccer and the rest – risk collisions and jolts to the head that can lead to concussions. Sometimes the signs are obvious, as was the case with Emily Panchak and Patrick Crowley, high school athletes in the Wilmington area.

"I didn't get knocked out, but I was crying, and it hurt really bad," says Panchak, who right after a head collision last spring, couldn't remember the bus ride over to the soccer game that day.

"The way I landed, the way I hit the back of my head on the ground, it just riled me pretty bad," recalls Patrick Crowley, Concord Raiders' football captain, of a concussion that put him out of play for several weeks a few years ago.

Injuries can also be more subtle, cautions Rosemarie Scolaro Moser, a neuropsychologist who runs the Sports Concussion Center of New Jersey.

"The problem with a concussion is true symptoms often don't show till hours or days later," Moser recently told The Pulse. "And with youth, they're more vulnerable to a second hit. So for example, if they haven't fully recovered and they get hit again, that second hit, even if it might not have caused a concussion to begin with on its own, can cause serious damage."

Searching for the magic bullet

Trying to change how games are played to avoid collisions has proven difficult and controversial. It has led to a search for the magic bullet, in hopes of sharply reducing the risk of concussion: better equipment. In football, this often means the helmet.

Some companies have marketed claims to young athletes their headgear could be the better mousetrap.

At Schuylkill Valley Sports in Easton, Pa., Mike Morris estimates two to three high school football players per team have come in to buy their own, more expensive, helmet this past season.

"They're looking to get something better," says Morris. "They're just looking for something that will minimize the risk of concussion."

But do any football helmets really cut down the risk of concussion? And are certain models worth the extra money?

What role do helmets play? 

Halfway across the country, Alison Brooks had a similar experience to Mike Morris at Schuylkill Valley Sports. Brooks specializes in sports medicine at the University of Wisconsin. Parents and young athletes kept asking her which helmets they should get. Many were feeling pressure at school to buy newer ones.

So she designed a prospective study, observing over 1,000 high school football players last year who wore the three most common helmets, including some of the newest models. She parsed out the number of reported concussions based on helmet brand, model and age, to see if there was any big variation.

There wasn't.

"You know as best we can tell they all adequately do what they were designed to do, which is prevent skull fractures, prevent intracranial bleeds, prevent superficial scalp and face injuries," Brooks recently told The Pulse. "But there's not any evidence that any one of them is particularly going to reduce your concussion risk."

Brooks' findings are preliminary, and may not account for other possible external factors. But the results don't surprise Robb Rehberg, a concussion specialist and professor of athletic training at William Patterson University in New Jersey. Rehberg thinks some helmets are doing a better job at protecting the head and "attenuating the forces that typically cause concussion," but while helmet design has improved a lot compared to ten years ago none can, nor should, claim to prevent a concussion.

Other research points to similar takeaways.

Evidence limited

In general, scientists don't know how effective helmets are when it comes to concussions in kids ages 5 to 21.

Kristy Arbogast and Susan Margulies reviewed all the evidence to date for a recent Institute of Medicine Report: Sports-Related Concussions in Youth – Improving the Science, Changing the Culture. Margulies, a bioengineer at the University of Pennsylvania, says part of the challenge is the science behind concussions isn't there yet. There's no standard, objective way for actually identifying and reporting them.

"Evidence that a concussion has occurred is really entirely based on the athlete saying that I think I've had a head injury," says Margulies.

So imagine trying to diagnose an ACL tear and come up with a rehab plan solely on the athlete's description of knee pain rather than an MRI, where the actual injury can be objectively visualized. The IOM report points to another major challenge when it comes to identifying concussions: the culture of sports and pressure to hide injuries.

"Probably one of the most important things we stress to the kids is you have to be honest," George Kasonovich recently told The Pulse.

Kasonovich, head football coach at Concord High School in Delaware, says schools have much better protocols nowadays,thanks to improved education, regulations and awarenessregarding concussions. If one is even suspected on the field, a player's out and can't return without a physician's note.

But Kasonovich's mindset isn't universal. And, athletes also face a lot of pressure to hide injuries. Seniors Patrick Crowley and Keyon Powell are Concord's co-captains. Both have suffered from concussions in the past, and had to sit out for several weeks.

"Some of the worst people to talk to about that are your teammates and your friends because they're always going to want you go out there no matter what you're feeling," says Crowley.

"It's basically the pride of it, you don't want to sit on the sideline, you always want to be out there helping your teammates," says Powell.

It makes the job of the school's athletic trainer, Scott Klabunde even trickier. He doesn't joke around.

"I'm not going to lie, I've threatened them," says Klabunde. "It was 'hey, if you really screw this up, you could die.'"

Technology outpacing science

While helmets do protect against head injuries like skull fractures, relying on them to prevent concussions is problematic for another reason: the limitations in how helmets are assessed.

Arbogast, with the Children's Hospital of Philadelphia, says helmet standards and effectiveness have historically been based on a drop test.

"They take a helmet, they put a humanoid head form - a plastic rubber head form in the helmet - and they drop it a given height and measure its acceleration," says Arbogast. "And there are thresholds below which every helmet must meet."

But in the real world you don't always hit your head in a straight line that way. Arbogast and Margulies both say the manor and direction your head moves are big factors in developing a concussion.

"We know it's a combination of linear movements along a straight line and rotational movements," says Arbogast. "But we don't know the specific level, the magnitude of those movements."

"Nodding your head yes verses 'I don't know' are two rotational motions," says Margulies. "They could have very different risks associated with concussion.

Those concussion risks could also vary based on a kids' age and individual experience. No one hit and reaction is alike. The science, they say, just hasn't caught up with the product development.

"And so without that fundamental data we can't really answer a question about whether a given helmet protects against concussion or not," says Arbogast.

"Current helmets may mitigate rotational accelerations, but we're not measuring it now," Margulies adds.

For the recent IOM youth concussion report, Margulies and Arbogast also examined other kinds of protective equipment, like facial masks and mouth guards. They found no evidence those devices reduce concussion risk, though they are important when it comes to protecting against other kinds of injuries.

Their chapter notes that solely relying on helmets as a way to reduce concussions might have another unintended effect, a phenomenon called "risk compensation" which has been studied a lot in safety literature: "the athlete may be emboldened by the increased protection to take additional risks, thus mitigating any benefits of the protective device."

More to preventing concussions

Despite helmet limitations, concussion specialists caution against relying only on that bit of equipment to prevent or lessen the risk of getting a concussion, anyway.

"The helmet isn't all of the story here," says Arbogast. "We need to understand how particular practice methods or aspects of the game might be able to be modified to protect the head."

Arbogast says that includes teaching different tackling techniques, and developing strategies that go well beyond the playing field, in terms of education and following up for when a concussion occurs, to ensure a full a recovery.

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NIH and NFL will research long-term effects of concussions

This article outlines research that will be done on the long-term effects and consequences of concussions. This research will be done as a partnership between the National Institutes of Health (NIH) and the National Football League (NFL).

The U.S. National Institutes of Health is teaming up with the National Football League on research into the long-term effects of repeated head injuries and improving concussion diagnosis.

The projects will be supported largely through a $30 million donation made last year to the Foundation for the National Institutes of Health by the NFL, which is wrestling with the issue of concussions and their impact on current and former players.

There's growing concern about the potential long-term effects of repeated concussions, particularly among those most at risk, including football players and other athletes and members of the military.

Current tests can't reliably diagnosis concussion. And there's no way to predict which patients will recover quickly, suffer long-term symptoms or develop a progressive brain disease called chronic traumatic encephalopathy (CTE), according to an NIH press statement released Monday.

"We need to be able to predict which patterns of injury are rapidly reversible and which are not. This program will help researchers get closer to answering some of the important questions about concussion for our youth who play sports and their parents," Story Landis, director of the National Institute of Neurological Disorders and Stroke (NINDS), said in the news release.

Two of the projects will receive $6 million each and will focus on determining the extent of long-term changes that occur in the brain years after a head injury or after numerous concussions. They will involve researchers from NINDS, the National Institute of Child Health and Human Development and academic medical centers.

One of the projects will attempt to define a clear set of criteria for various stages of CTE. It will also seek to distinguish it from Alzheimer's disease, amyotrophic lateral sclerosis (Lou Gehrig's disease) and other degenerative brain diseases that as of now can only be determined in brain tissue samples collected after death. The objective is to find medical signs of CTE that might eventually be used to diagnose the illness in living people.

The other project will seek to identify the long-term effects of mild, moderate and severe traumatic brain injury (TBI) and compare them with features of CTE. The goal is to identify signs that could be used to diagnose brain degeneration linked to traumatic brain injury in patients.

While the two projects focus on different aspects of traumatic brain injury, "their combined results promise to answer critical questions about the chronic effects of single versus repetitive injuries on the brain, how repetitive TBI (traumatic brain injury) might lead to CTE, how commonly these changes occur in an adult population, and how CTE relates to neurodegenerative disorders like Alzheimer's disease," Landis said.

Six other pilot projects will receive a total of just over $2 million and last up to two years. They will concentrate on improving the diagnosis of concussions and identifying potential medical signs that can be used to assess a patient's recovery. If the early results are promising, these projects may form the basis of more extensive research, the news release said.

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Reasons why the NFL's new concussion rules aren't working

This article details issues with the NFL's new concussion rules and determines that the issues in football safety lie inherently within the sport.

In January, the NFL announced that, starting with the 2013 season, all games would be played with an independent neurologist on the sidelines to assist with the evaluation and treatment of head injuries. It looked like the league had done a good thing. It was establishing a new, unbiased procedure to promote player safety—an effort made all the better by the fact that it didn't involve placing the burden on the players themselves.

But the fundamental problem with football safety is football, and the league's new program is proving it.

Let's start with some background on the new rule. The players union had long demanded that the league require the presence of independent neurotrauma specialists who could evaluate players without interference or influence from any teams. To wit: On the same day the NFL made its announcement, the NFLPA cited a poll indicating that 78 percent of players didn't trust their own teams' medical staffs.

The league's decision to require these unaffiliated consultants was announced at a news conference held just before the NFLPA's annual Super Bowl week news conference. Also on that same day, NFLPA executive director DeMaurice Smith said the union had not been notified of the league's plan to make the change. And all this was at a time when the NFL was still preparing for a court battle against the concussion-related lawsuits involving thousands of former players who accused it of distorting information about the long-term effects of head trauma. Those suits have since been settled.

The two sides eventually smoothed over their differences, and soon the NFLPA was on board with the plan to have independent neurologists on the sidelines. An NFLPA spokesman told me the league and the union have since worked out an agreement by which they both have input in selecting those independent sideline consultants. Those consultants are picked from a list of experts in all 31 NFL cities. The consultants must not be affiliated with any NFL teams. TheNFL's concussion protocol also spells out that the each consultant must be "board certified or board eligible in neurology, neurological surgery, emergency medicine, physical medicine and rehabilitation or any primary care CAQ sports medicine certified physician and [have] documented competence and experience in the treatment of acute head injuries." Since last year, the protocol also mandates that an athletic trainer must be present up in the booth serve as a "spotter" for both teams by reviewing video and replay technology.

So what could go wrong? Why would there be any problems with diagnosing and handling concussions? Let's look at three situations involving three players in three games. Each one illustrates what the NFLPA spokesman told me was an "area of concern" for the players association after the first month of the new season.

The scenario: In Week 1, Jeremy Kerley of the Jets was concussed when he caught a pass over the middle toward the end of the first half against the Bucs. Kerley was hit by three different players, and Tampa's Mark Barron was flagged for unnecessary roughness:

Kerley was taken to the locker room and given the concussion tests, but he later returned to the game. The following day, he was held out of practice when he was evaluated again and diagnosed with concussion symptoms. The Jets had a short week heading into their next game, and Kerley missed their Week 2 game against the Patriots before returning to play in Week 3 against the Bills. 

The problem: Players don't always show concussion symptoms immediately.

The scenario: In Week 3, the Raiders' Terrelle Pryor took a helmet-to-helmet hit from the Broncos' Wesley Woodyard. Pryor had tucked the ball and made himself a runner, and the hit occurred inside the tackle box, so Woodyard was not penalized:Pryor lay on the turf momentarily but played two more snaps. After the Raiders turned the ball over on downs, he started showing symptoms during a sideline evaluation and was removed from the game. The next day, Pryor tweeted, "I don't remember much!" He returned to practice in a limited role later in the week and was ultimately held out of Sunday's game against the Redskins. The league's concussion protocol says that "if the occurrence of a concussion is unclear, or a player sustains a mechanism of injury ('big hit') that is reasonably expected to give rise to a concussion... the player shall be removed immediately from the field by Club medical personnel." The hit Pryor took certainly seems to fit that definition, and the NFLPA isinvestigating the Raiders' handling of Pryor to determine why he remained in the game. Per Mike Florio, the NFLPA does not want the typical sideline chaos to be used as an excuse for any failure to be properly vigilant in following the mandated protocols. The union spokesman told me that, depending on the outcome of its investigation, the NFLPA could consider filing a grievance.

The problem: A possible breakdown in protocol.

The scenario: In Week 2, Steelers running back Isaac Redman was injured on the opening kickoff after taking a helmet-to-helmet hit from the Bengals' Jayson DiManche. Redman was blocking on the play, and the collision happened away from the ball. Here, you can see Redman go down around the 30-yard line just as the action stops:

The problem: The tendency of players to not want to come out of the game.

These aren't rare, exotic scenarios. They're all things that come up normally in the course of play, like two-point conversions and onside kicks, and that's the issue. The new program is designed to keep concussed players from playing, yet that's not what's happening. These are problems that can't be solved via fiat and bureaucracy, and there's a simple inference to be drawn from that fact: you can't really fix football without turning it into another sport.

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Concussion protection from helmets: There is no safest football helmet

Regardless of how new or old and expensive or inexpensive a helmet is, they all provide the same level of protection from concussions.

Given the recent controversies over concussions in the NFL, you're probably a little leery about letting your kid play football. We can't blame you. Even future Hall of Famer Kurt Warner told the "Dan Patrick Show" last year that he'd be scared for his sons' safety if they followed their gridiron dreams.

Concussions are a problem for football players, from the pro ranks right on down to pony leaguers. Teenage boys suffer the most sports-related traumatic brain injuries – including concussions – each year, most of which stem from playing football or crashing bicycles. No question: There's risk involved in sending your son out to get pummeled at the 50-yard line, so you want him to sport the best helmet available. Just don't get lured into shelling out big bucks or pressuring his school to buy the latest and greatest helmet. According to a new study, safest does not mean newest, flashiest, or most expensive.

Researchers tracked more than 1,300 high school football players throughout the 2012 season and found that all helmets, regardless of brand, model, or whether they were shiny-new or up to 10 years old, offered the same protection from concussions. Which means that when one brand claims its helmets are safer than the competitors' – or that its spendiest model is the best you can get – it's basically an empty ploy for your pocketbook, says lead researcher Timothy McGuine of the University of Wisconsin Health Sports Medicine Center.

According to McGuine, football helmets are tested and strictly regulated by the National Operating Committee on Standards for Athletic Equipment. To make sure they stay in prime working order, all helmets sold to schools must be serviced by the manufacturer every two years and pitched after 10. The result: "Not one NOCSAE-approved helmet is bad," McGuine says. "They're all hard shells with slightly different padding and fixation systems, but to say one is better than another just isn't true."

Given his findings, McGuine says to rest easy when it comes to helmet quality and your kid's concussion risk. Yes, brain injuries are always possible in contact sports, but he's confident football players' heads are as safe as they can be with today's helmets, regardless of whether they cost $250 or $850.

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One fifth of 7th-12th graders claim to have had traumatic brain injury

An interesting study shows that one out of five 7th through 12th graders said they have had traumatic brain injury during their lives.

One in five adolescents surveyed in Ontario said they have suffered a traumatic brain injury that left them unconscious for five minutes or required them to be hospitalized overnight, a statistic researchers in Toronto say is much higher than previously thought.

Sports such as ice hockey and soccer accounted for more than half the injuries, said Dr. Gabriela Ilie, lead author of the study and a post-doctoral fellow at St. Michael's Hospital.

Traumatic brain injuries, such as concussions, were reported more often by males than females, by those with lower school grades and by those who used alcohol or cannabis in the previous 12 months, she said.

The study was to be published Wednesday (June 26) in theJournal of the American Medical Association.

Dr. Ilie said this is one of the first studies of traumatic brain injury to focus only on adolescents and to include all of their self-reported TBIs. Most previous studies based their reporting only on hospital records. Concussion is the most common form of traumatic brain injury.

The data used in the study were from the 2011 Ontario Student Drug Use and Health Survey (OSDUHS) developed by the Centre for Addiction and Mental Health. The survey, one of the longest ongoing school surveys in the world, contains responses from almost 9,000 students from Grades 7-12 in publicly funded schools across Ontario. The OSDUHS began as a drug use survey, but is now a broader study of adolescent health and well-being. For the first time in 2011, questions about traumatic brain injury were added to the survey.

"The questions about TBI were added to the OSDUHS because there were no current data on prevalence in the adolescent population," said Dr. Robert Mann, a senior scientist at CAMH and director of the OSDUHS. "Early research has indicated that there may be links between TBIs and mental health and substance use during adolescence -- we plan to study this in the near future."

The survey found that 20 per cent of adolescents in Ontario said they had had a traumatic brain injury in their lifetime. It found that 5.6 per cent of them had had such an injury in the past 12 months.

Dr. Ilie said this suggests the prevalence of TBI among young people is much higher than previously known, because many head injuries remain uncounted when they are not being reported to parents, teachers, sports coaches or health care workers. In Canada, 50 per cent of all injuries that kill and disable youth involve a TBI.

This new research found that 46.9 per cent of the TBIs reported by adolescent females occurred during sports (e.g., hockey, skate boarding); the figure was 63.5 per cent for males.

Students who reported drinking alcohol occasionally/frequently and those who reported using cannabis 10 or more times over the past 12 months had more than five times and more than three the odds, respectively, of acquiring a traumatic brain injury in the past 12 months than students who reported abstinence. The survey also showed that students who reported overall poor grades at school (below 60 per cent) had almost four times the odds of a lifetime acquired brain injury than students who reported grades at or above 90 per cent.

"Traumatic brain injury is preventable," said Dr. Ilie. "If we know who is more vulnerable, when and how these injuries are occurring, we can talk to students, coaches, and parents about it. We can take preventive action and find viable solutions to reduce their occurrence and long-term effects."

Brain injuries among adolescents are particularly concerning because their brains are still developing. There is growing evidence that people who have had one or more concussions are at greater risk of future concussions, and evidence that multiple brain injuries can result in lasting cognitive impairment, substance use, mental health and physical health harms.

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Heading Soccer Balls and Brain Injury

A study shows that heading a soccer ball can result in brain injury resembling a concussion.

Researchers at Albert Einstein College of Medicine of Yeshiva University have shown that soccer players who frequently head the ball have brain abnormalities resembling those found in patients with concussion (mild traumatic brain injury). The study, which used advanced imaging techniques and cognitive tests that assessed memory, published online today in the journalRadiology.

"We studied soccer players because soccer is the world's most popular sport," said Michael L. Lipton, M.D., Ph.D., associate director of Einstein's Gruss Magnetic Resonance Research Center and medical director of MRI services at Montefiore, the University Hospital and academic medical center for Einstein. "Soccer is widely played by people of all ages and there is concern that heading the ball -- a key component of the sport -- might damage the brain." Dr. Lipton is also associate professor of radiology, of psychiatry and behavioral sciences and in the Dominick P. Purpura Department of Neuroscience at Einstein.

On average, soccer players head the ball six to 12 times during games, where balls can travel at speeds of more than 50 miles per hour. During practice drills, players commonly head the ball 30 or more times. The impact from a single heading is unlikely to cause traumatic brain damage such as laceration of nerve fibers. But scientists have worried that cumulative damage from heading's repeated subconcussive impacts might be clinically significant. "Repetitive heading could set off a cascade of responses that leads to degeneration of brain cells over time," noted Dr. Lipton.

To study possible brain injury from heading, the researchers used diffusion tensor imaging (DTI), an advanced MRI-based imaging technique, on 37 amateur adult soccer players (median age 31 years) who had all played the sport since childhood. Participants reported playing soccer for an average of 22 years and had played an average of 10 months over the previous year. Researchers ranked the players based on heading frequency and then compared the DTI brain images of the most frequent headers with those of the remaining players. All participants also underwent cognitive testing.

DTI "sees" the movement of water molecules within and along axons, the nerve fibers that constitute the brain's white matter. This imaging technique allows researchers to measure the uniformity of water movement (called fractional anisotropy, or FA) throughout the brain. Abnormally low FA within white matter indicates axon damage and has previously been associated with cognitive impairment in patients with traumatic brain injury.

"The DTI findings pertaining to the most frequent headers in our study showed white-matter abnormalities similar to what we've seen in patients with concussion," said Dr. Lipton. "Soccer players who headed the ball above a threshold between 885 to 1,550 times a year had significantly lower FA in three areas of the temporal-occipital white matter." Dr. Lipton noted that players with more than 1,800 headings per year were also more likely to demonstrate poorer memory scores compared to participants with fewer yearly headings.

"Our study provides compelling preliminary evidence that brain changes resembling mild traumatic brain injury are associated with frequently heading a soccer ball over many years," said Dr. Lipton. "While further research is clearly needed, our findings suggest that controlling the amount of heading that people do may help prevent brain injury that frequent heading appears to cause."

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If in doubt, sit out: Athletes with suspected concussion should be removed from play

Updated sports concussion guidelines claim that if a player is suspected of having a concussion, he or she should be removed from play.

With more than one million athletes now experiencing a concussion each year in the United States, the American Academy of Neurology (AAN) has released an evidence-based guideline for evaluating and managing athletes with concussion. This new guideline replaces the 1997 AAN guideline on the same topic. The new guideline is published in the March 18, 2013, online issue of Neurology®, the medical journal of the American Academy of Neurology, was developed through an objective evidence-based review of the literature by a multidisciplinary committee of experts and has been endorsed by a broad range of athletic, medical and patient groups.

"Among the most important recommendations the Academy is making is that any athlete suspected of experiencing a concussion immediately be removed from play," said co-lead guideline author Christopher C. Giza, MD, with the David Geffen School of Medicine and Mattel Children's Hospital at UCLA and a member of the AAN. "We've moved away from the concussion grading systems we first established in 1997 and are now recommending concussion and return to play be assessed in each athlete individually. There is no set timeline for safe return to play."

The updated guideline recommends athletes with suspected concussion be immediately taken out of the game and not returned until assessed by a licensed health care professional trained in concussion, return to play slowly and only after all acute symptoms are gone. Athletes of high school age and younger with a concussion should be managed more conservatively in regard to return to play, as evidence shows that they take longer to recover than college athletes.

The guideline was developed reviewing all available evidence published through June 2012. These practice recommendations are based on an evaluation of the best available research. In recognition that scientific study and clinical care for sports concussions involves multiple specialties, a broad range of expertise was incorporated in the author panel. To develop this document, the authors spent thousands of work hours locating and analyzing scientific studies. The authors excluded studies that did not provide enough evidence to make recommendations, such as reports on individual patients or expert opinion. At least two authors independently analyzed and graded each study.

According to the guideline:

• Among the sports in the studies evaluated, risk of concussion is greatest in football and rugby, followed by hockey and soccer. The risk of concussion for young women and girls is greatest in soccer and basketball.

• An athlete who has a history of one or more concussions is at greater risk for being diagnosed with another concussion.

• The first 10 days after a concussion appears to be the period of greatest risk for being diagnosed with another concussion.

• There is no clear evidence that one type of football helmet can better protect against concussion over another kind of helmet. Helmets should fit properly and be well maintained.

• Licensed health professionals trained in treating concussion should look for ongoing symptoms (especially headache and fogginess), history of concussions and younger age in the athlete. Each of these factors has been linked to a longer recovery after a concussion.

• Risk factors linked to chronic neurobehavioral impairment in professional athletes include prior concussion, longer exposure to the sport and having the ApoE4 gene.

• Concussion is a clinical diagnosis. Symptom checklists, the Standardized Assessment of Concussion (SAC), neuropsychological testing (paper-and-pencil and computerized) and the Balance Error Scoring System may be helpful tools in diagnosing and managing concussions but should not be used alone for making a diagnosis.

Signs and symptoms of a concussion include:

• Headache and sensitivity to light and sound

• Changes to reaction time, balance and coordination

• Changes in memory, judgment, speech and sleep

• Loss of consciousness or a "blackout" (happens in less than 10 percent of cases)

"If in doubt, sit it out," said Jeffrey S. Kutcher, MD, with the University of Michigan Medical School in Ann Arbor and a member of the AAN. "Being seen by a trained professional is extremely important after a concussion. If headaches or other symptoms return with the start of exercise, stop the activity and consult a doctor. You only get one brain; treat it well."

The guideline states that while an athlete should immediately be removed from play following a concussion, there is currently insufficient evidence to support absolute rest after concussion. Activities that do not worsen symptoms and do not pose a risk of repeat concussion may be part of concussion management.

The guideline is endorsed by the National Football League Players Association, the American Football Coaches Association, the Child Neurology Society, the National Association of Emergency Medical Service Physicians, the National Academy of Neuropsychology, the National Association of School Psychologists, the National Athletic Trainers Association and the Neurocritical Care Society.

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Cognitive Deficiencies Following Concussion Present After Two Months

This article discusses the cognitive effects of concussions which shows that the negative effects last at least two months.

The ability to focus and switch tasks readily amid distractions was compromised for up to two months following brain concussions suffered by high school athletes, according to a study at the University of Oregon.

Research team members, in an interview, said the discovery suggests that some athletes may need longer recovery periods than current practices dictate to lower the risk of subsequent concussions. Conventional wisdom, said lead author David Howell, a graduate student in the UO Department of Human Physiology, has typical recovery at seven to 10 days.

"The differences we detected may be a matter of milliseconds between a concussed person and a control subject, but as far as brain time goes that difference for a linebacker returning to competition too soon could mean the difference between another injury or successfully preparing to safely tackle an oncoming running back," Howell said.

The findings are based on cognitive exercises used five times over the two months with a pair of sensitive computer-based measuring tools -- the attentional network test and the task-switching test. The study focused on the effects of concussions to the frontal region of the brain, which is responsible for working, or short-term, memory and executive function, said Li-Shan Chou, professor of human physiology and director of the UO Motion Analysis Laboratory.

The study was published online ahead of print by Medicine & Science in Sports & Exercise, the official journal of the American College of Sports Medicine.

"If a person goes back to the playing field without a full recovery, that person is put into great danger of being re-injured," Chou said. "In any given season, if you suffer a concussion, the chances of your suffering a second one is three to six times higher and suffering a third is eight times higher. There are accumulations in this kind of injury. It doesn't go away easily."

A big unknown, the researchers said, is just how serious such injuries are for adolescents, whose brains are still developing. It could be the brain can recover more easily, or such injuries could continue to produce deficits that last a lifetime. "We just don't know," Chou said, adding that most previous studies have involved college-aged athletes and older adults.

Each year, there are 300,000 to 500,000 mild traumatic brain injury incidents, or concussions, with 100,000 tied to football, Chou said. He also cited a 2011 report from the Centers for Disease Control and Prevention that called such injuries a silent epidemic, with sports-related concussions in youths rising by 60 percent in the last decade. Another source of concussions, he added, is improvised explosive devices used in warfare.

Through an arrangement with Eugene-area schools, 20 high school athletes who had suffered a concussion -- primarily football players but also others from soccer, volleyball and wrestling -- were assessed within 72 hours of injury and then again one week, two weeks, a month and two months later. Each of the subjects, whose diagnosis was made by a certified athletic trainer and/or physician, was matched with a healthy control subject of the same sex, body size, age and sport.

"After two months following the concussions, these individuals were still significantly impaired in their executive function, compared to age-matched, activity-matched and gender-matched control populations," said co-author Louis Osternig, professor emeritus of human physiology and a fellow of the American College of Sports Medicine.

Osternig, also a certified athletic trainer, noted that self-reports by the subjects about how they were feeling sometimes were at odds with test results, which continued to show subtle deficits in cognitive functioning. The researchers also noted anecdotal reports from concussed athletes and their parents of declines in academic performance during the two-month period.

Additional data linking the deficits found in cognitive testing to the subjects' gait -- their task-shifting abilities while walking -- currently are being analyzed in the ongoing project, which is funded by the Department of Defense Telemedicine & Advanced Technology Research Center (W81XWH-11-1-0717), National Athletic Trainers Association, Veterans Administration and a translational research award from a joint UO-PeaceHealth Oregon Region collaboration program.

"By using tools from cognitive psychology, neuroscience and human physiology, this interdisciplinary team of scientists is improving our understanding of how brain trauma affects reaction time, and they are helping to create better outcomes for athletes, soldiers and others who are affected by concussions," said Kimberly Andrews Espy, vice president for research and innovation and dean of the graduate school. "UO researchers are working to improve the health and well-being of people in our local communities and throughout the world."

"The brain is the controller of our body movement," Chou said. "If you have a brain injury, are there any differences that we can pick up in the way a subject moves the body? In this lab, we are using motion analysis as a way to detect any deficiencies or abnormalities of body movement."

Chou said that his lab's goal, for now, is to disseminate the findings to the public and to talk to parents, athletic trainers and, perhaps, coaches directly to say: "These are the facts. We may not be able to draw any line on what clinically should or shouldn't be done. However, these are our observations based on our scientific testing."

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Association between lack of sleep and teen sports injuries

A new study shows an association between teenagers not getting enough sleep and the frequency of sports injuries.

Adolescent athletes who slept eight or more hours each night were 68 percent less likely to be injured than athletes who regularly slept less, according to an abstract presented Oct. 21, at the American Academy of Pediatrics (AAP) National Conference and Exhibition in New Orleans.

For the abstract, "Lack of Sleep is Associated with Increased Risk of Injury in Adolescent Athletes," researchers asked middle and high school athletes (grades 7 to 12) enrolled at the Harvard-Westlake School in Studio City, Calif., to answer questions about the number of sports they played and the time they committed to athletics (at school and through other programs), whether they used a private coach, whether they participated in strength training, how much sleep they got on average each night, and how much they subjectively enjoyed their athletic participation. Seventy percent of the student athletes (112 out of 160 students; 54 males and 58 females; mean age 15) completed the survey, conducted in conjunction with Children's Hospital Los Angeles. Researchers then reviewed those students' school records pertaining to reported athletic injuries.

Hours of sleep per night was significantly associated with a decreased likelihood of injury, according to the study results. In addition, the higher the grade level of the athlete, the greater the likelihood of injury -- 2.3 times greater for each additional grade in school. Gender, weeks of participating in sports per year, hours of participation per week, number of sports, strength training, private coaching and subjective assessments of "having fun in sports" were not significantly associated with injury.

"While other studies have shown that lack of sleep can affect cognitive skills and fine motor skills, nobody has really looked at this subject in terms of the adolescent athletic population," said study author Matthew Milewski, MD.

"When we started this study, we thought the amount of sports played, year-round play, and increased specialization in sports would be much more important for injury risk," said Dr. Milewski. Instead, "what we found is that the two most important facts were hours of sleep and grade in school."

The advanced age risk may reflect a cumulative risk for injury after playing three or four years at the high school level, Milewski said, and older athletes are bigger, faster and stronger.

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