Posts Tagged ‘youth athlete concussions’

Latest on Youth Concussions from American Academy of Pediatrics

The American Academy of Pediatrics just released an update on Sport-Related Concussions in Children and Adolescents. This 24-page report highlights the major developments in new concussion knowledge and treatment since the first report, which was published in 2010.

To follow are the points that I find to be of particular interest. Some the conclusions and actionable recommendations may be contrary to what is being disseminated by various bloggers and vendors of products related to concussions. But always remember that true science can be a very slow process and future studies may ultimately prove contrary results. If these topics are of interest, you should read the entire article for more information.

Concussions: Mechanical vs Chemical/Cellular Injury

There is no universally-accepted definition of a concussion and there are a wide range of symptoms which require individual management.

After a biomechanical injury to the brain due to either direct impact or whiplash effect, a cascade of chemical changes occur resulting in injury on a cellular level. Some of the medical terms for these are potassium efflux from neurons, increase in extracellular glutamate, upregulation of sodium-potassium ion pumps, depletion of intracellular injury reserves, and increased use of adenosine triphosphate and hyperglycolysis. All of these biochemical reactions result in decreased blood flow and increased energy demand which leads to an energy crisis.

In other words, concussions are a lot more complicated than just a bump to the head, making future research and studies necessary.

Rest After Concussions

After a concussion, an immediate reduction in physical and mental activity can be beneficial to recovery. However, prolonged restrictions of physical activities and delayed return to school can have negative effects on recovery and symptoms. A graduated return-to-play protocol should be followed under the supervision of a healthcare professional.

Reporting of Concussions Over the Past Decade

Studies indicate that the reporting of youth concussions has increased dramatically over the last decade with increases ranging from 57% to 200%. This is likely caused by the increased overall awareness of coaches, participants, and parents due to media exposure and education initiatives.

Concussions in Girls vs Boys

Female athletes are more likely to report symptoms to an authority figure than male athletes, despite Concussions in Girls soccerboth having the same knowledge.

Studies indicate that concussion rates from highest to lowest for boys are as follows: American tackle football, lacrosse, ice hockey, and wrestling. For girls: soccer, lacrosse, field hockey, and basketball.

Girls have higher concussion rates than boys in soccer and basketball.

The reasons that girls seem to be more susceptible are not entirely clear, but it has been suggested that it is due to weaker neck musculature and estrogen.

In school sports, for boys and girls combined, the following have the highest concussion rates: middle school tackle football, girls soccer, cheerleading, and girls basketball.

A study of youth tackle football for ages 8 to 12 indicates that the concussion rates are higher than in high school athletes and that 11 to 12 year olds have a nearly 2.5 increased risk as compared to 8 to 10 year olds.

Concussion incidence is higher in competition than in practice for males and females across nearly all sports.

Most Frequent Signs and Symptoms

Headache 86% to 96%
Dizziness 65% to 75%
Difficulty Concentrating 48% to 61%
Confusion 40% to 46%

Problems to Watch Out For in Post-concussion Diagnostic Tests

The most frequent sideline test used by athletic trainers is the Sport Concussion Assessment Tool (SCAT) and is available in following forms: Child SCAT 5 (ages 5 to 12) and SCAT 5 (ages 13+). These tests, which only take about 10 minutes to perform, are being constantly updated. They consist of observable signs of concussion, symptoms assessment, memory questions, neurological assessment, and balance assessment.

Symptoms can mimic pre-existing problems such as migraine, headache disorders, learning disorders, ADHD, mental health conditions, and sleep disorders. As a result, the examiner should be informed of any such condition.

Some sideline diagnostic assessment tools and checklists are not appropriate for children ages 5 to 12. Younger athletes perform worse on questions such as naming months or numbers in reverse. Concussions in youth sportsVariations are available for younger children such as the Child SCAT 5..

Tests that measure visual deficits, such as the King-Devick Test, show promise but not enough evidence from studies yet to recommend their inclusion in the SCAT.

While healthcare professionals find sideline assessment tests to be helpful, they are not to be used in isolation in diagnosing a concussion. Not enough studies exist at this time to recommend widespread use in children. Also, the value of sideline tests is minimized without a baseline test for comparison. See HitCheck for an example of an affordable sideline assessment app.

Are CAT Scans and MRIs Necessary? Which One Is Superior?

CAT scans and MRIs are critical when a severe intracranial injury or structural lesion (skull fracture or hemorrhage) is suspected, but they are not effective in diagnosing a concussion. Despite this, the use of neuroimaging increased 36% between 2006 and 2011.

Recent literature indicates that it is highly unlikely that significant intracranial hemorrhaging occurs after six hours without a deterioration in the level of consciousness. As a result, prescribing a CT without any deterioration of consciousness after six hours is unlikely to be helpful.

When neuroimaging is necessary, CT’s are more cost effective and can usually be arranged more quickly. However, children’s exposure to radiation may increase the risk of certain cancers over the long term. After the emergency period is over, MRIs are superior to CTs in detection of cerebral contusion, petechial hemorrhage, and white-matter injury.

Baseline Neurocognitive Testing

Studies conducted independently by developers of paper and online testing platforms have questioned the reliability of baseline tests from year to year. It is important for the reviewer who compares baseline to post- injury tests to understand modifiers that could alter results, such as depression, lack of sleep, failure to take ADHD medication, and athletes with musculoskeletal injuries.

The best environment for baseline and post-injury testing is a quiet, distraction-free environment, which can be very difficult to achieve for most schools and organizations.

Concerns about athlete “sandbagging” and intentionally under-performing on baseline tests are exaggerated as this can be detected.

Neurocognitive tests should not be used as the sole determining factor in return-to-play decisions.

Retirement After Multiple Concussions

The decision to retire an athlete after multiple concussions should not be tied to any specific number of concussions.

An athlete who has suffered multiple concussions should be referred to a specialist with expertise in this area for guidance.

Prevention of Concussions: What Can Be Proven By Studies

  • Mouth guards: After an initial 1954 study suggesting a connection between mouth guards and reduction of concussions, several larger studies refuted this assertion. Evidence of an advantage of custom mouth guards over non-custom remains inconclusive.
  • Helmets: Helmets were designed to reduce severe injuries such as skull fractures, subdural Football helmets and concussionshematomas, and brainstem contusion or hemorrhage. The goal of reduction of concussions has not proven to be productive. Several studies show no difference between several brands and models of helmets, both new and refurbished, in terms of severity of symptoms, frequency, and recovery time. Helmet improvements are not likely to ever be the solution to the concussion problem.
  • Aftermarket Helmet Attachments: No study has ever shown that aftermarket helmet attachments such as pads, shock absorbers, and sensors prevent or reduce the severity of concussions. The use of sensors to clinically diagnose or assess concussions cannot be supported at this time and do not have a role in decision making. See our article “Add-on Helmet Products.”
  • Other Headgear: Soccer headgear has not proven beneficial in the reduction of head-to-head or head-to-ball impact. Such headgear may actually increase the incidence of injury by encouraging more aggressive play.
  • Education: Education and awareness of concussions has proven effective in diagnosing, treating, and making return-to-play decisions. This finding is consistent with Sadler Sports Insurance injury data on concussion rates in youth baseball and football prior to 2012 and after 2012.
  • Biomarkers: Biomarkers have been investigated in playing a role in concussion evaluation. These include predisposition factors, delayed recovery, and increased catastrophic risk. These investigations are preliminary and none have advanced to use in a clinical setting.
  • Supplements: Numerous supplements have been investigated as to playing a role in preventing or in speeding up the recovery time from concussions. There are currently no studies in humans to support a benefit from supplements.
  • Neck Strengthening: Strengthening the cervical muscles and activating those muscles prior to impact has been found to reduce forces from head impact. Poor neck strength has been shown to correlate with the incidence of concussions. One study showed that each additional pound of neck strength resulted in a 5% reduction in concussions.
  • Rule Changes: Rule changes and enforcement of rules by officials may help to reduce the likelihood of concussions. Recent initiatives in youth sports look promising. These include elimination of checking in ice hockey and heading soccer in younger age groups, and reducing contact in football practice.

I hope you enjoyed my summary of this very informative article. At Sadler Sport Insurance, we have an excellent risk management library on the topic of concussion and brain injury risk management that you should check out.


Skip practice and the books following a concussion (Infographic)

Concussion recovery: rest, rest, and more rest

Recent concussions treatment research reveals that taking a break from the classroom is as important as taking time off the field while recuperating from head injuries. Doctors had long suspected this and advised their patients accordingly, and now research backs up their advice.

Researchers found that concussion patients who took a brief period of complete rest shortened their recovery time. The study included 335 patients ranging in age from 8 to 23. These are significant findings for treating head injuries in children. Youth are the segment of the population most at-risk for long term damage because of their still-developing brains.

Infographic Concussion Warning Signs

Want to display this Infographic on your own site? Just copy and paste the code below into your blog post or web page:

Recent research study and findings

The study found that half of kids who did not take complete rest immediately following their injury took 100 or more days to fully recuperate. Nearly all who took the time to rest fully before slowly returning to daily activities recuperated in less than 100 days, some as quickly as two months. Evidence also indicates that the reduction of mind activity after a concussion lessens the symptoms associated with head injuries.

The severity of the symptoms determines how much time each child needs to rest the brain.Three to five days is usually sufficient, according to study co-author William Meehan of the Sports Concussion Clinic at Boston Children’s Hospital. “Then you can gradually reintroduce them to cognitive activity. They should do as much as they can without exacerbating their symptoms,” said Meehan.

What’s involved in the healing process

A jolt to the head can result in what’s tantamount to a mini seizure. The brain cells fire up all at once, depleting their fuel. To recover, the brain shuts down as it begins the process of restoring the cells. That recovery time is prolonged when brain activity is resumed too early.

“[I]t can take days to weeks for processes in the brain to mop up the mess from a concussion,” said Douglas Smith of the Center for Brain Injury and Repair at the University of Pennsylvania Medical Center.

Taking it slow

The litmus test for returning to activities is being able to do whatever doesn’t aggravate the symptoms. Start with 15 minutes of reading or computer time. But if a headache or other symptoms start up, it’s time to take a break and rest. Increase activity time as the child is able without triggering symptoms or pain.

For more information and to find out more about concussion risk management you can check out our concussion resources.

Source: Linda Carroll, “Skip the Homework,”, 06 Jan. 2014.

Are Concussions the Next Asbestos?

Insurers looking at long-term damage liability

The recent NFL concussion settlement (as well as prior media publicity over the past year) has spooked General Liability insurers about the potential for long term concussion damage liability.

One insurance broker specializing in the school district niche stated that concussions could be the next asHead Injurybestos due to the potential for long range damages.  Another General Liability carrier for NCAA Div I schools tested the waters for the Concussion Exclusion for its July renewals but other competing carriers did not fall in line.

While tackle football is currently receiving the most scrutiny, other sports produce a large number of concussions as well and will be on the radar screen.

In my discussions with insurance carrier executives regarding the youth tackle football General Liability market, I have heard of the following approaches being taken:

  • No change in policy forms.
  • A special aggregate that caps concussion lawsuit payouts on a per association or per program basis.
  • A special endorsement that voids coverage for concussion lawsuits unless risk management controls such as mandatory coach concussion training have been put in place.

Source: High School Football Concussions Could Be Next Asbestos.” Sept. 9, 2013.

Football Helmet Add-on Products

| Injury

Their use can trigger legal defenses

When an athlete suffers a serious head or neck injury, this or her attorney will likely sue the helmet manufacturer/distributor, add on product manufacturer/distributor, team/league, individual administrators, coaches, managers, trainers, and referees, and possibly the sanctioning body organization. Each will likely point the finger at the others and will plead every legal defense possible, such as the absence of negligence, the other defendants were negligent, assumption of risk, waiver/release, etc.

Here’s what product liability case law say about the potential legal defenses helmet manufacturers can use when lawsuits are triggered by the unauthorized use of add-on products:

  • Improper Use Defense. Helmet was not used in manner intended by the helmet manufacturer when plaintiff (the injured party) was injured.
  • Product Labeling and Directions Defense. The plaintiff or other responsible parties (parent, coach, team, league, etc.) ignored the written warnings, directions, and risks that were communicated in the helmet manufacturer’s materials.
  • Altered Product Defense. The helmet manufacturer is not responsible for plaintiff’s damages if the plaintiff or other party altered the product once it left the helmet manufacturer’s control. Furthermore, the alterations caused the plaintiff’s injury rather than the original unaltered helmet.

Use of add-on helmet products in light of concussion concerns

Based on the analysis above, from a legal and risk management perspective, it is safest to follow the recommendations of the helmet manufacturers as to the use of add-on products. If you follow their recommendations, they will be the deepest pocket defender in the event of a catastrophic head or neck injury in your program. The major helmet manufacturers likely carry a combined General Liability/Excess Liability insurance limit in the range of $10 million to $25 million. On the other hand, the add-on product manufacturers likely carry much lower limits of liability insurance due to their restricted start-up budgets.

However, if your sports program is going provide or allow the use of add-ons that the helmet manufacturer declares will void the NOCSAE certification, despite the liability risks of doing so, it is recommended that your program carry its own General Liability /Excess Liability policy with combined each occurrence limits of at least $5 million, such as the insurance program provided by American Youth Football. In addition, the requirement that players and parents sign an appropriately worded waiver/release agreement that specifically warns of the dangers of violating the manufacturer’s instructions regarding add-on products should be considered.

Additional research may vindicate many of the add-on product manufacturers to the point where public demand will force the major helmet manufacturers to accept their products if they are proven to promote safety. In the meantime, we encourage you to read our other articles regarding helmet safety and add-on products.

Soft Cover Football Helmet Add-ons

Liability issues result in add-ons being banned

The Colorado High School Activities Association ruled that the helmet shell called the  Guardian Cap can’t be worn in games and that schools may void protection from helmet manufacturers’ warranties if they allow the use of such helmet shells during practices. Approximately 15 high school and youth teams in Colorado were using the Guardian Cap.

The National Operating Committee on Standards for Athletic Equipment issued a statement that read in part: “The addition of after-market items by anyone that changes or alters the protective system by adding or deleting protective padding to the inside or outside of the helmet, or which changes or alters the geometry of the shell or adds mass to the helmet, whether temporary or permanent, voids the certification of compliance with the NOCSAE standard.”

In my opinion

Add-on helmet productsWhen a youth football client asked my opinion on whether or not to experiment with the use of such helmet shell products in the face of concussion concerns, I provided the following response:

It is true that the attorney of a football player who has suffered a serious brain or spinal injury will sue all parties that could be remotely responsible, including the helmet manufacturer, helmet distributor, helmet cover manufacturer, helmet cover distributor,  conference administrators, coaches, sanctioning body, etc. The helmet manufacturer would certainly argue that that it was not responsible for the injury due to the use of the helmet cover product which voided the manufacturer’s warranty. I’m not sure whether the helmet manufacturer could completely escape liability with such an argument. If they were successful, that leaves the General Liability insurance policies of the helmet cover manufacturer including any distributors and the conference on the hook. It’s likely that the helmet manufacturer carries a much higher liability limit than the other parties.

From a common sense point of view, it would seem that the additional padding and shock absorption would lessen the impact. On the other hand, the larger diameter and weight could increase rotational torque which could also impact concussions. But common sense is not always reality. For example, commotio cordis (sudden cardiac arrest due to arrhythmia) is an infrequent but usually fatal occurrence in youth baseball when a ball strikes the heart at the precise millisecond of the heart rhythm. It made common sense that youth players should use padding or a shield to protect against this risk and a number of products were introduced to provide such protection. But, one lab study using pigs being shot in the heart by baseball pitching machines showed that this type of protective device actually made a commotio cordis event more likely. It is best to leave the safety decisions up to the scientists. Of course, scientific progress can be slow and it can be difficult to determine if they have an agenda. Also, scientists can be wrong even if most are in agreement.

So what’s the answer?

The safest play from a liability perspective is to go with the recommendations of 1) your manufacturer, 2) NOCSAE, and 3) the sanctioning/governing body if they have an opinion on the issue. There is always safety in siding with the recognized authorities, though, this does not mean that they are correct.

The manufacturers of soft helmet shell covers and other similar add-on devices claim that the big helmet manufacturers are shutting them out of the process with their influence over the various sanctioning bodies and NOCSAE.  They point out that smaller companies have historically played an important role with scientific research, creativity, and problem solving.

I would like to hear your thoughts on this issue.

Source: Guardian Cap: Controversial Ruling May Mean End To Use In Colorado; Adrian Dater; Denver Post; 8-1-13

Youth Football Concussions During Practice

Results of study surprise many

In a prior blog on concussion rule changes, we stated that the new Pop Warner Football concussion rule to limit contact in practice would have a limited effect as only 28 percent of all youth football concussions occur in practice according to American Youth Football (AYF) injury statistics.

Now, a new study by the University Of Pittsburgh and University of Pittsburgh Medical Center and funded by the NFL has drawn a similar but more compelling conclusion. The study found that youth tackle football players aged 8 to 12 were at a low risk of suffering a concussion in practice.  (.024 incidences per 1000 exposures), but that the risk was 26 times higher in games (6.16 incidences per 1000 exposures).

“This finding suggests that reducing contact-practice exposures in youth football, which some leagues have done recently, will likely have little effect on reducing concussion risk, as few concussions actually occur in practice. Instead of reducing contact-practice time, youth football leagues should focus on awareness and education about concussions,” said Anthony Kontos, an associate professor at UPMC.

Many experts agree that practice time should focus on proper tackling techniques and instruction instead of head contact.

Leaning on science, not the media

These recommendations are exactly what AYF has been preaching. We recommend against knee jerk reactions to the media frenzy on the concussion issue.  Making hasty safety rule decisions that are not backed by science isn’t a wise move. Instead, wait on the results from the ongoing scientific studies.  In the meantime, focus on educating coaches on recognizing the signs and symptoms of concussions, concussed player removal and medical treatment, and return-to-play protocol. In addition, concentrate on proper tackling technique.

AYF has included concussion awareness training in its coach certification program.

More interesting statistics from the study

The incident rate of concussions in practice and games combined is three times higher in the 11 to 12-year-old age category as compared to 8 to 10-year-old age category.  Just as the AYF injury studies have revealed, there is a direct correlation between age and injuries in youth tackle football. The older athletes are stronger, faster, and more coordinated, hitting with harder force. See our prior blog on the issue of age only vs age/weight categories.

Player in the “skill positions of  quarterback, running back, and linebacker make up 95 percent of youth football concussions.

Source: “Study: Kids Get Fewer Concussions In Practices Than In Games.” June 6, 2013.