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 Although he no longer had classic signs of slow recovery, he seemed withdrawn and depressed and I couldn’t clear him to go back on the ice even after several weeks.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 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!

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


NCAA’s dirty archives. Now what?


Here is an article, short and sour, about the NCAA’s history of its internal discussions on concussion management.  “The NCAA’s History with Concussions: A Timeline” is a quick primer and will jet you into the conversation about what the Association should be doing to support its athletes.  It will also make it clear why the NCAA is facing a lawsuit, possibly a class action one.

Compiled and written by Travis Waldron on thinkprogress.org, the brief piece is a shocking timeline of the paranoia and recklessness of the NCAA manifested in its hands-off approach to concussion management in its member schools. This is just the beginning of a much larger conversation that deserves to be in the public realm.

image from sportsonearth.com

Why are we seeing more concussions?


Friends and family who have been serious athletes their whole lives have been asking me: What’s this concussion stuff all about anyway?  Is this just another health fad like Omega 3 Fatty acid, Acai, gluten-free food, or yoga?

To help sort out some of this I recommend the article from January 2013 Rolling Stone magazine by Paul Solotaroff called This is Your Brain on Football.  

In addition to being beautifully and soulfully written and a real pleasure to absorb, it makes the following points about the dangers of long term damage and persistent symptoms from too much head trauma:

…PCS (post concussion syndrome) is a crisis of molecular scale, a firestorm of ions leaking in and out of neurons to wreak havoc on their tiny connections. You can’t catch that on an MRI and won’t be able to in the near future. The only way to detect it is through a thorough examination by a concussion-savvy doctor or neurologist.

By way of explaining the cumulative effects:

“.…every hit mattered, from peewees on, and counted toward an unknown threshold number past which brain cells began their die-off.”


By way of explaining why so many more now:

“Kids now play and practice one or more sports eight to 10 months a year, so there’s much more exposure to blunt-force trauma – and much less downtime to heal.”


By way of explaining how the rules of play themselves need amending:

“When eight-year-olds are hitting each other – in tackle practice – with roughly the same G-forces as college players, what’s badly needed is a paradigm shift, a universal up-draft in thinking.”


And the piece ends with a poignant and disturbing story of a “football dad” who is unconvinced by Dr Robert Cantu, considered the guru of concussion and a mom who lost her son to second impact syndrome, a devastating and fortunately rare sudden death following recent concussion. A major problem is a cultural one, acted out by parents,  “many of whom insist on toughening their sons for NFL careers they’ll never have.”

Do you have an NCAA athlete in the family?

What happens to a college athlete who sustains a head injury while playing for the school?With all of the recent publicity about concussions one might think these athletes would be protected and served the way most high school athletes are now mandated to be cared for by laws to that effect in almost every state in the Union.  But no.  The NCAA has long maintained that each school should develop its own policy rather than promulgate standard Association guidelines.  As a result NCAA athletes can really be “on their own” to figure out how to get the best care following a head injury.  And they may experience intense pressure from respected and beloved coaches to get back in the game much sooner than medical experts recommend.

In a remarkable short article on CBSSports.com, Mike Freeman reveals how resistant the NCAA has been to promulgating policy about head injury. He quotes from a recent survey of concussion management by the NCAA.

Most disturbing was that fewer than 50 percent of the NCAA schools, the NCAA’s own documents show, stated a physician was required to see an athlete post-concussion. Also, 39 percent of schools did not have an established return-to-play guideline.


Many NFL athletes are involved in a well publicized class action suit over their symptoms and dysfunction and since many of them probably concussed in high school and college before going Pro, Freeman contends that this  might create the thorny situation in which “the NFL could possibly be in an awkward position of attacking its feeder system.” Will the NFL blame middle age dementia, depression and cognitive dysfunction on college concussions rather than assume responsibility for their own poor care?  Will these two organizations duke it out or will they begin to recognize that they have both erred and begin to change their protocols, practices and patterns?

Until we have confidence that the NCAA is shouldering the responsibility for these young lives, every parent of an NCAA athlete needs to ask about concussion management in their child’s sport.  Here are some questions to consider:

Is an athlete allowed to return to the game after a head injury?

What are the sideline diagnostic tools used?

Who makes the call about a head injury and who can over-ride that call?

How does the team determine when an athlete is clear to play again?

Who makes that determination?

What if recovery is prolonged?

How does the team coordinate with the academic community to help the athlete while his or her cognitive (thinking) skills clear up?

Sometimes those collegiate athletes who are on their own following injury need to have a helpful roadmap for recuperation.  My book It’s All in Your Head: Everyone’s Guide to Managing Concussions has proven time and time again to be helpful for people in recovery.  The anecdotes and stories ring true because they are.  Each concussed person knows that only he or she perceives what doesn’t feel right.  Although reading is never a recommended activity in the first few days, a caregiver can read the book aloud and learn at the same time what to expect in the days ahead.

Above all, loved ones need to advocate for the injured person.  This “invisible injury” will soon enough be on the radar of the NCAA in a way the organization may not even be able to imagine.  It’s a new ballgame and they better figure out the plays.