Heading the Ball and Concussions in HS Soccer: what’s the connection?


soccer headingImage result for soccer header boys

Today JAMA Pediatrics Online (http://bit.ly/1CBHQuX) just reported a very large retrospective study of national high school soccer players.  The objective of the study was to identify common injury mechanisms and to evaluate in detail heading-related mechanisms of injury.

Almost 3 million athlete exposures (AEs) of boys and girls during school-sanctioned soccer games and practices were evaluated between 2005 and 2014.  A total of 1069 concussions were evaluated. Contact with another player was the most common concussion mechanism.  Heading was the most common soccer-specific activity.  Among heading related concussions, contact with another player was the most common mechanism of injury (78% of boys’ injuries and 62% of girls’).

The paper’s authors state that this information can be helpful to “drive evidence-based, targeted prevention efforts to effectively reduce soccer-related concussions.”  Although many have suggested that the solution to soccer concussions would be to ban heading, this study suggests that “reducing athlete-athlete contact across all phases of play” would help reduce all types of injuries.



Pediatricians Advocate Curbs on Body Checking in Youth Hockey

A few years ago, I treated a 13 year old boy who was recuperating from a concussion. Although he no longer had classic signs of slow recovery, he seemed withdrawn and depressed and I couldn’t clear him to go back on the ice even after several weeks.  When I finally thought to ask him if he wanted to play he confided to me that he was actually frightened of the body checking and was only playing to make his parents happy. This young man, it turns out, was in good company, although a silent one.

“Boys who play ice hockey in leagues that allow body checking are two to three times more the (sic) likely to suffer serious injuries and concussions compared to boys in non-checking programs.” So says the new policy from the American Academy of Pediatrics, the major advocacy and policy body of US Pediatricians. http://bit.ly/1pjQK8o

The AAP’s Council on Sports Medicine and Fitness has reiterated its 2000 recommendation that body checking in hockey should only be allowed after age 15 and may be taught as a skill to older boys who may go on to play elite hockey. Fifteen is the cutoff to assure that the wide variability in pubertal development, size and strength has reached a more or less level playing field.

The AAP report, written by a pediatrician who is also a hockey player himself and the father of a Bantam (age 13-14) level son, is quick to point out that hockey can be a lifelong source of exercise and enjoyment and the recommendations are not meant to discourage physical activity but rather to promote injury prevention.

I hope my patient from a few years ago is still skating or has found another way to exercise and to participate on a team if he wants to.

Concussion Management in 2014, Part One

As 2013 draws to a close and attention moves from football and cheerleading to the winter sports, it is a good time to take a look at trends and progress in concussion care and what to look out for in the months and the year ahead.

This year has seen an explosion in position papers on concussion from many professional organizations including US pediatricians, neurologists, school psychologists and athletic trainers associations as well as the Ontario Neurotrauma Foundation which produced a fine document for those 18 and over. And of course the lawsuit was settled between players and the NFL. My Google Alert box is filled on a daily basis with news about concussion and its management across North America.

So what do we have to look forward to? Here are just a few themes to watch for:

How important is aerobic exercise in the recovery phase of concussion? Some researchers have begun to postulate that a gradual increase in aerobic activity following concussion may be beneficial as opposed to the prolonged rest and inactivity that has become common. There are psychological and physical reasons why some aerobic activity may be the better way to go. Athletes become de-conditioned and depressed when they are not allowed to exercise and participate. In addition there is some evidence that increasing cerebral blood flow may contribute to healing. Watch for more on this.

Research will continue to look for bio-markers of brain injury. Imagine if there were a simple blood test that could tell us whether the brain had actually sustained a blow strong or hard enough to correlate with what we call “concussion.” And even better, imagine if we could track such a blood test to tell us if recovery is moving in the right direction and how quickly. This is a long ways off, but is one of many holy grails in concussion research.

Meanwhile, others are developing head gear that tracks the impacts sustained by players. Watch for more data from these inventors, developers and promoters that correlates g-forces of hits with symptoms. Of course this does little for the thousands who sustain concussions in non-helmet sports or off the playing fields all together.

Watch for the continuing debate on whether kids under 13 should be playing contact sports. Look out, America. This conversation has started among pediatricians and neurologists and a few famous folks as well(NFL players and POTUS himself). If data begins to accumulate showing long term damage or consequences of early head injury (or even “sub-concussive” hits) there could be a sea-change in school-sponsored sports.

At the same time, many are now reinforcing the idea that physical education and sports are a good, healthy and important part of growing up. It would be great to have better data to inform this emotional subject.

Watch for Part 2 of this discussion for more upcoming products, strategies, resources and practices.

Ann Engelland, MD
Adolescent and Young Adult Health
School and College Health

When Do We Stop Sacrificing Our Kids to the Game?

Damon Janes

Damon Janes

Here is another story about a young adorable smiling teenager struck down trying to make a touchdown.  Although the exact circumstances of Damon Janes’ death this past Monday are not known, it is another loss of life to a mere kid who was “just” playing the game he loved.

As pointed out in a Village Voice blog post about the teen’s death, more than ten kids have died while playing football in the last ten years.  And while the country is reeling from the NFL lawsuit and from weekly concussions that bench the pros, one has to ask whether enough is being done on the playing field to recognize and respond to head injury in young athletes.  What may be most disturbing is that some of these deaths have undoubtedly been preceded by “sub-concussive” blows or concussions that have gone unrecognized only to be followed by a lethal condition called Second Impact Syndrome.  In SIS, an apparently “light” hit may set off a deadly cascade of events in the brain if the conditions are right. These conditions include young age and possibly undiagnosed and relatively minor head injuries in the days or possibly weeks prior to the fatal blow.

What to do?  Change the way football is practiced and played. Recognize a blow that may be hiding a potential brain injury.  Respond to such hits with a time out and an assessment of the situation by someone trained to know what he or she is looking at.  The next step is to Rest the athlete, maybe as much as a week or ten days before Reassessing. Some cannot go back, maybe ever.  This is a reality that kids, parents, coaches, agents, and schools need to face up to.

How many more senseless deaths do we need to catalogue (this is the second one this month I have learned of on Twitter and from my Google alerts) before real change starts to happen?  Should kids be playing sports like gladiators?  It’s time to man up and take stock. When do we stop sacrificing our kids to the game?

Parents, Coaches & Others Must Catch Up With Current Knowledge About Concussions

Ann Engelland, MD

Ann Engelland, MD

When I started out in pediatric practice I often took phone calls in the evening from parents with all sorts of questions about their children who were sick or had fallen or weren’t sleeping. A typical call went something like this:

“Doctor, my son was jumping on the bed and fell off and hit his head. There’s a big bump on his scalp. Could he have a concussion? What should I do?”

“How does he feel now?” I would ask.

“He seems fine. Maybe a little sleepy, but it’s bed time.”

“Did he pass out, even for a few seconds?”

“No, he cried right away and I put ice on the bump.”

“OK,” I would say, “he doesn’t have a concussion then. I suggest you keep him awake for the next four to six hours and then wake him every two hours to check on him.” Some doctors would even suggest shining a light in the child’s eyes to check whether his pupils were “even”—as if parents really knew what that meant.

We now know that most of that advice was wrong.

Here’s why:

• The absence of loss of consciousness does not rule out a concussion

• The severity of a head injury or concussion can not be judged at the time of the event

• If a person has a headache after a mild head injury the most important things to do are to rest, be quiet, and sleep.

• Allowing complete rest — both physical and cognitive (meaning in the mind) — is the right thing to do. Checking on a person is natural; awakening him or her is harmful.

• Shining a light in the eyes of a head-injured person is not only annoying, but painful and is likely to disrupt the healing process.

It is critical that everyone—parents, friends, teachers, work colleagues, coaches, bosses, therapists, tutors, and siblings—understand the ramifications of a concussion for the victim. If they do not, the treatment and rest required by the victim will be accelerated or skipped altogether and recovery could be prolonged, sometimes indefinitely.

cropped-mc_orange_header_full2.pngThe above has been excerpted from It’s All in Your Head: Everyone’s Guide to Managing Concussions, a book by Dr. Ann Engelland, a seasoned pediatrician and adolescent medicine physician who works as a school and college physician. It’s All in Your Head: Everyone’s Guide to Managing Concussions will walk you through the steps of evaluating a head injury and will assist in diagnosing, managing, and recovering from a concussion.  Based on the simple principle of The Four Rs: Recognize, Respond, Rest, and Reassess, It’s All in Your Head will empower you to support the injured and advocate for the best possible treatment and outcome, whether the injured person is you or someone you care about.

It’s All in Your Head Can be ordered in paperback or for the Kindle on Amazon today.

“Concussion-proof” Football Helmets may be Misleading & Dangerous says NYS AG

NYS Attorney General Eric Schneiderman

NYS Attorney General Eric Schneiderman

Last week, New York State’s Attorney General Eric Schneiderman released a statement essentially debunking the myth that football helmets can prevent concussions.  He even went a step further and offered the power of his office to help people who may have been duped by false advertising related to helmets and the ever-increasing number of “add ons” that manufacturers claim will help.

 “Any claims suggesting that a particular helmet is “anti-concussive” or “concussion-proof” may be misleading and potentially dangerous by giving players and parents a false sense of security.”

In his official statement he makes several points.  In effect, he used the very robust state Concussion Management and Awareness Act that went into effect in June 2012 to bolster the following statements:

Players, parents and coaches must be trained to see the symptoms and risks of concussion.

  • It is extremely important to recognize the signs of concussion and remove the player immediately from the game.

  • New York State law requires that players be removed from play until they are asymptomatic for a minimum of 24 hours and have written approval from their physician to return to play.

  • The number of concussions can be significantly reduced with modifications to practice format – such as learning to avoid head-on “collisions” on the field of play.

  • Reducing the number of hits is instrumental to reducing the risk of concussion because of the cumulative risk from repeated hits. Limit the amount of contact in practice and forbid drills that involve full-speed, head-on blocking and tackling that begins with players lined up more than three yards apart.

  • Players need to be trained to focus on techniques that minimize head-to-head hits. Coaches and referees must strictly enforce penalties against such behavior.

It is refreshing to see someone of the stature and at the level of the State AG come out and protect consumers and our youth.  The writing should be on the wall as the number of lawsuits against the NFL, NCAA, helmet manufacturers and others begin to mount.  I am afraid it’s only a matter of time before the state’s schools, athletic departments, and recreation leagues take a hit as well.  Questions that might generate such a lawsuit:

“Why did you invest in expensive helmets that we know are useless?”

“Why are you not changing and adapting practice and play techniques to be current with known risks?”

“Why did you buy gizmos and gadgets with our restricted budget when there is no evidence that they are effective?”

“Why didn’t you sit out my daughter when she clearly had signs of a concussion?”

“Did you really think it couldn’t be a concussion because she was wearing a helmet?”

Says Schneiderman: “Ensuring that manufacturers don’t mislead the public and endanger young New Yorkers is a key concern for my office. Just as important, we must work to educate young athletes and their parents about how to reduce the risk of concussion and detect early warning signs on the field.”

Holding those in positions of responsibility to account is, in my opinion, government working at its best.

And then the final zinger in the last line of the attorney general’s statement should really make those with commercial interests in brain injury sit up and listen:

“If you feel you’ve been a victim of this type of situation or any other type of consumer fraud, contact the Attorney General’s Consumer Helpline at 1-800-771-7755.”

What Matters Now in Football…

ath trainerIn light of the controversial NFL settlement with its 4,500 players, it is important for parents and young athletes to keep a perspective on the issues.  We are lucky to live in a country where individuals and interest groups can effect change. Change is what will be required at all levels of contact sport and in the minds and practices of those who care for, coach, raise and nurture young athletes.

The NFL suit may be a good step and provide some much needed financial assistance for many of the suffering players and families, but it is just a small step in what needs to be a veritable cultural shift.

So, a few things to keep in mind:

  • Exercise is good for kids (and adults).  Obesity and its complications are far more common than concussions and also have life-altering side effects. We don’t want to prevent folks from being active
  • Team sports are good for kids of all ages.  Comeraderie, responsibilities, the ability to sacrifice (one’s time and effort, but not one’s mind or future) and the resulting fitness are all important aspects of the team experience.
  • Concussions are not completely preventable (don’t be swayed by helmet makers; they don’t have the answer yet and probably won’t ever) but their frequency can be reduced and their severity diminished.  How? By altering the way athletes play, for one.
  • Will there be enough trickle-down effect from the NFL suit to make a difference in sports culture? Will colleges, schools, and rec leagues adopt new approaches?
  • Can we continue to make the changes in how we respond to injuries so that we practice primary prevention (e.g.different rules of the game in various contact sports) as well as secondary prevention (preventing complications of head injury once they have happened)?
  • The Four Rs: Recognize, Respond, Rest and Reassess are the cornerstones of managing concussions well and preventing future head injury.  At this point in time we have no other tried and tested means of treatment.  But one thing we know for sure: going back in the game, the physical as well as the mental game (school, work, college) prematurely is asking for trouble.

Concussion Cuts Short Wann’s Soccer Career at Richmond

Becca Wann

University of Richmond soccer star Becca Wann

This morning I had mixed feelings over reading about Becca Wann’s decision to withdraw from playing soccer.

As reported this morning in the online Richmond-Times Dispatch, the University of Richmond senior is a star player:

She played last fall on the U.S. Women’s National team that won the FIFA U-20 World Cup in Japan. She is second all-time at UR in goals (34) and fourth in points (55).” But stardom is no match for at least four career concussions and she has bravely-and smartly-thrown in the towel on her soccer career. She plans to go on to continue in college basketball.

Of note is the fact that this latest injury was not very dramatic, apparently not even noted by her trainer or bystanders. But Wann knew.

She said she did not immediately report the injury to UR’s sports medicine staff. “But as the week went on, the symptoms didn’t get any better. That’s when I told the trainer.”

Such a scenario is often the case with strong athletes. As it turns out, there is a cumulative effect of “sub-concussive” blows to the head and body. Sometimes enough is enough and the symptoms will far outweigh any experienced previously. This is the time when it is smart to recognize the serious potential long-term consequences to the brain and one’s life. Leaving the team at any level of play is a difficult decision but one that should be applauded. Her courage should be an example to all NCAA players and others who often have to make this choice against a great deal of pressure.

Best of luck to Becca Wann as she moves on to different and hopefully healthier activities!

Prayers Not Enough For Victims of Second Impact Syndrome

Tyler Lewellen

Tyler Lewellen, 16, died after being involved in a tackle in a scrimmage football game last week.

I am a spiritual person.  Active prayer is not a part of my everyday, but I understand prayer. I understand that we can pray for forgiveness, for something we want or need, for solace or for understanding.

I was stunned today by a YouTube video entitled “Pray for Tyler” (no longer available on YouTube). Tyler Lewellen, 16 years old, is a California high school football player who lost consciousness shortly after a pileup tackle in a scrimmage last Thursday and died five days later, never having regained consciousness.  He and his family certainly deserve the prayers of those around them along with their devastated community.

But as they seek solace in their grief, the wider world also needs to seek understanding of a less spiritual variety.  What the hell happened to Tyler?  It’s okay to be angry. Because Tyler represents the 25th high school football player in the U.S. to die as a direct result of his football-related injury in the past nine years.  We need medical and legal answers, not just prayer for metaphysical questions.

Some things we know.  It may not be just an accident. It may not be a mere fluke.  Unless a post mortem investigation shows an unusual cardiac or other abnormality, there is a good chance it’s called second impact syndrome.  It’s a known quantity and what we need to find out is whether Tyler’s brain was injured prior to this apparently inconsequential hit during the pileup.  Second impact syndrome can happen hours, days or weeks following an initial hit (to the head, neck or body) that may induce “sub concussive” injury to the brain.  For reasons that are not well understood, a subsequent blow or blows then puts in motion a dramatic cascade of metabolic and anatomic shifts that can lead to brain hemorrhage, seizures, loss of consciousness and death.

It is precisely scenarios like these that have been the impetus for almost every state in the United States to mandate the development of concussion policies in public schools.

So what the coaches, the parents, the trainers, the lawyers and the community in California need to do is not to look at the video of the final scrimmage, but at any evidence from plays and games, on the field and off, that there may have been a primary injury.  Was an apparently minor hit missed?  Did he show any signs or symptoms of “minor” head trauma before that final day of practice?  Should he have been resting, on the bench, recuperating?  How was he doing academically?  Was he forgetful? Was he different?

We may never know, but we have to go looking for the evidence.  This way the community will learn along with the whole country.   Only then will the possible disgrace that this represents be turned into grace.

Concussion Course for Coaches Hits a Million Views


As concussion awareness has risen, it has become clear that all members of the community– from the unaffiliated bystander to the parents, coaches, athletes, school personnel and medical providers–play an important role in the prevention, detection, diagnosis and management of head injuries in our students.

The National Federation of State High School Associations announced last week that the million mark was passed by coaches taking an online concussion course.  The course, “Concussion in Sports – What You Need to Know,” was designed by the Centers for Disease Control and is free of charge. In some states such a course is now one of the mandated steps required by public school districts to comply with concussion policies.

A brief introduction to the course by the NFHS can be seen here. The CDC course itself is available online here. The CDC also has a free online course for medical providers available here.

More and more communities are requiring sideline personnel to be trained in the new guidelines for concussion management.  With all of the recent publicity it may be hard to believe that many medical providers as well as lay people are still thinking that the old ways are OK.  But we no longer put anyone even suspected of a concussion back in the game or let them “run it off.” And that’s just the start of how things are changing.

The CDC courses have helped raise awareness and should continue to be an integral part of community programs. But often they are just a starting point in what is really a change in our culture that has glorified athletics and sports even if the price has been too steep.

image from Momsteam.com