1


Introduction

In the past decade, few issues at the intersection of medicine and sports have had as high a profile or have generated as much public interest as sports-related concussions. Historically most concussions were not considered serious, and athletes who sustained them might be said to have been “dinged” or had their “bell rung.” The injured player would “shake it off” and return to play. Recent years have seen an increasing awareness and understanding that all concussions involve some level of injury to the brain and that athletes suspected of having a concussion should be removed from play for further evaluation (Aubry et al., 2002; CDC, 2013a; Halstead et al., 2010; Harmon et al., 2013; McCrory et al., 2005, 2009, 2013a).

The acknowledgment of the seriousness of sports-related concussions has initiated a culture change, as evidenced by campaigns to educate athletes, coaches, physicians, and parents of young athletes about concussion recognition and management (e.g., CDC, 2013c; NCAA, 2013; NFHS, 2013; USA Football, 2013a; USA Hockey, 2013); rule changes designed to reduce the risk of head injury (e.g., Pop Warner Little Scholars, 2012, p. 44; USA Hockey, 2011, p. 58); and the enactment of legislation designed to protect young athletes suspected of having a concussion (NCSL, 2013). Despite such efforts, there are indications that the culture shift is not complete. For example, a 2012 survey of high school football players suggests that even when knowledgeable about the symptoms and dangers of concussions, a majority of players thought it was “okay” to play with a concussion and agreed they would “play through any injury to win a game” (Anderson et al., 2013). Some youth baseball rules pertaining to the use of a continuous batting order, in which all available players are in



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1 Introduction In the past decade, few issues at the intersection of medicine and sports have had as high a profile or have generated as much public inter- est as sports-related concussions. Historically most concussions were not considered serious, and athletes who sustained them might be said to have been “dinged” or had their “bell rung.” The injured player would “shake it off” and return to play. Recent years have seen an increasing awareness and understanding that all concussions involve some level of injury to the brain and that athletes suspected of having a concussion should be removed from play for further evaluation (Aubry et al., 2002; CDC, 2013a; Halstead et al., 2010; Harmon et al., 2013; McCrory et al., 2005, 2009, 2013a). The acknowledgment of the seriousness of sports-related concussions has initiated a culture change, as evidenced by campaigns to educate ath- letes, coaches, physicians, and parents of young athletes about concussion recognition and management (e.g., CDC, 2013c; NCAA, 2013; NFHS, 2013; USA Football, 2013a; USA Hockey, 2013); rule changes designed to reduce the risk of head injury (e.g., Pop Warner Little Scholars, 2012, p. 44; USA Hockey, 2011, p. 58); and the enactment of legislation de- signed to protect young athletes suspected of having a concussion (NCSL, 2013). Despite such efforts, there are indications that the culture shift is not complete. For example, a 2012 survey of high school football players suggests that even when knowledgeable about the symptoms and dangers of concussions, a majority of players thought it was “okay” to play with a concussion and agreed they would “play through any injury to win a game” (Anderson et al., 2013). Some youth baseball rules pertaining to the use of a continuous batting order, in which all available players are in 19

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20 SPORTS-RELATED CONCUSSIONS IN YOUTH the line-up, penalize teams if a player must leave the game for any reason, including injury (USSSA Baseball, 2013, p. 10, Rule 7.02.D.1[c]). There are also anecdotal reports of players attempting to subvert pre-season baseline neurocognitive tests (Pennington, 2013). Despite the increased attention to and recent proliferation of research on sports-related concussion, confusion and controversy persist in many areas, from agreement on how to define a concussion and the effects of multiple concussions on the vulnerability of athletes to future injuries, to when it is safe for a player to return to sports and the effectiveness of protective devices and other interventions in reducing the incidence and severity of concussive injuries (Wilde et al., 2012). Parents worry about choosing sports that are safe for their children to play, about selecting the equipment that can best protect their children, and, if a child does receive a concussion, about when is it safe for him or her to return to play or when it might be time to quit a much-loved sport entirely. It is against this background that the Institute of Medicine (IOM) and National Research Council (NRC) convened the Committee on Sports- Related Concussions in Youth to review the science and prepare a report on sports-related concussions in youth from elementary school through young adulthood, including military personnel and their dependents (see Box 1-1 for the statement of task). The 17-member committee included experts in the areas of basic neuroscience, neuropathology, clinical exper- tise with head trauma in pediatric populations, sports medicine, emergency medicine, cognitive and educational psychology, psychiatry, bioengineering with an emphasis in pediatric biomechanics, youth sports organization representatives, active duty military training, epidemiology, statistics or statistical analysis and evaluation, and health communication (Appendix B). The committee was charged with reviewing the available literature on concussions, within the context of developmental neurobiology, regard- ing the causes of concussions, their relationship to impacts to the head or body during sports, the effectiveness of protective devices and equipment in preventing or ameliorating concussions, screening for and diagnosis of concussions, their treatment and management, and their long-term conse- quences. Specific topics of interest included • the subacute, acute, and chronic effects of single and repetitive concussive and non-concussive head impacts on the brain; • risk factors for sports concussion, post-concussion syndrome, and chronic traumatic encephalopathy; • the spectrum of cognitive, affective, and behavioral alterations that can occur during acute, subacute, and chronic posttraumatic phases; • physical and biological triggers and thresholds for injury;

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INTRODUCTION 21 • the effectiveness of equipment and sports regulations for the pre- vention of injury; • hospital- and non-hospital-based diagnostic tools; and • the treatment of sports-related concussions. BOX 1-1 Statement of Task An ad hoc committee will conduct a study and prepare a report on sports- related concussions in youth, from elementary school through young adulthood, including military personnel and their dependents. The committee will review the available literature on concussions, in the context of developmental neurobiology, in terms of their causes, relationship to hits to the head or body during sports, effectiveness of protective devices and equipment, screening and diagnosis, treatment and management, and long-term consequences. Specific topics of interest include •  he acute, subacute, and chronic effects of single and repetitive concus- t sive and non-concussive head impacts on the brain; •  isk factors for sports concussion, post-concussive syndrome, and chronic r traumatic encephalopathy; •  he spectrum of cognitive, affective, and behavioral alterations that can t occur during acute, subacute, and chronic posttraumatic phases; • physical and biological triggers and thresholds for injury; •  he effectiveness of equipment and sports regulations for prevention of t injury; • hospital- and non-hospital-based diagnostic tools; and • treatments for sports concussion. Based on currently available evidence, the report will include findings on all the above and provide recommendations to specific agencies and organizations (governmental and nongovernmental) on factors to consider when determining the concussive status of a player. The report will include a section focused on youth sport concussion in military dependents as well as concussion resulting from sports and physical training at Service academies and recruit training for military personnel between the ages of 18 and 21. Recommendations will be geared toward research funding agencies (NIH, CDC, AHRQ, MCHB, DoD), legislatures (Congress, state legislatures), state and school superintendents and athletic di- rectors, athletic personnel (athletic directors, coaches, athletic trainers), parents, and equipment manufacturers. The report will also identify the need for further research to answer questions raised during the study process.

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22 SPORTS-RELATED CONCUSSIONS IN YOUTH COMMITTEE’S APPROACH TO ITS CHARGE Terminology and Parameters of Study Recognizing that concussion is a subgroup of mild traumatic brain injury (mTBI) (see Figure 1-1), the committee chose to use the term “con- cussion” throughout the report. However, given the variable use of the terms “concussion” and “mild traumatic brain injury” in the literature, the committee decided to use whichever term was used by the source when referring to specific studies or articles. For a specific definition of concussion, the committee chose to follow the current international consensus definition (McCrory et al., 2013a). Not only does it capture and provide more detail on the common elements of concussion, but the definition was developed through a formal consensus process and has been subject to review and revision on a regular basis (Aubry et al., 2002; McCrory et al., 2005, 2009, 2013a), which has permitted it to evolve along with the science of concussion. It is the com- mittee’s expectation that this definition will continue to evolve. The current international consensus definition of concussion, as de- termined at the Fourth International Conference on Concussion in Sport (McCrory et al., 2013a), is Concussion is a brain injury and is defined as a complex pathophysiologi- cal process affecting the brain, induced by biomechanical forces. Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilised in defining the nature of a concussive head injury include: 1. Concussion may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an “impulsive” force transmit- ted to the head. 2. Concussion typically results in the rapid onset of short-lived impair- ment of neurologic function that resolves spontaneously. However, in some cases, symptoms and signs may evolve over a number of minutes to hours. 3.  oncussion may result in neuropathological changes, but the acute C clinical symptoms largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies. 4.  oncussion results in a graded set of clinical symptoms that may C or may not involve loss of consciousness. Resolution of the clini- cal and cognitive symptoms typically follows a sequential course. However it is important to note that in some cases symptoms may be prolonged.

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INTRODUCTION 23 Spectrum of Traumatic Brain Injury Mild Moderate Severe Concussion FIGURE 1-1 Relationship of concussions to the spectrum of traumatic brain injury. In approaching its charge to examine many facets of sports-related concussions in youth, the committee first identified the age range of young people upon which it would focus and what types of activities it would recognize as a being “sports related.” On the question of age range, the committee chose to focus on children and youth ages 5 to approximately 21 years (i.e., elementary school through college age). Five years is the approxi- mate age of most children entering elementary school (kindergarten) in the United States (Mulligan et al., 2012). Around that age, children also are becoming more developmentally ready to begin participation in organized sports and recreational activities (Purcell et al., 2005). In selecting the upper boundary for the age range, the committee agreed that, despite the continu- ation of brain development into the mid-twenties (see Chapter 2), sufficient development occurs by age 21 to use that as a convenient cutoff. Although there is a significant body of literature on sports-related concussion among college athletes, there is little that uniquely captures post-college-age indi- viduals (approximately ages 21 to 23 years) through age 26 years. This age group tends to be included in studies that capture older adults as well. For this reason the committee chose “college age” (approximately 21 years) as the upper age boundary. On the question of which activities should be regarded as “sports related,” the committee recognized that sports can be competitive or recre- ational, including everything from football and cheerleading to mountain climbing and extreme sports, and it further recognized that concussions can result from other types of physical activity that are not traditionally consid- ered sports, such as playground activities, physical education classes, and ropes and combatives courses during military training. Thus, the committee

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24 SPORTS-RELATED CONCUSSIONS IN YOUTH took a broad view of sports, defining it for the purpose of this report as any sort of vigorous physical activity that does not involve motorized vehicles. Information Gathering Process The committee conducted an extensive review of the literature pertain- ing to sports-related concussions. The committee began with an English- language literature search of online databases, including Academic Search Premier, the Cochrane Database of Systematic Reviews, Embase, Google Scholar, Lexis Law Reviews Database, Medline, PsychINFO, PubMed, Science Direct, Scopus, Web of Science, and WorldCat/First Search. Addi- tional literature and other resources were identified by committee members and project staff using traditional academic research methods and online searches. Attention was given to consensus and position statements issued by relevant experts and professional organizations. The current evidence base (i.e., research and publications in peer re- viewed journals) has notable limitations. As noted already, the poorly defined and inconsistent use of terminology (e.g., “concussion,” “mild trau- matic brain injury”) often makes it difficult to determine the applicability of the literature specifically to concussion. In addition, there is relatively little literature devoted specifically to concussion, compared with the published research available on more severe traumatic brain injury (TBI), especially in the younger age groups (i.e., 5 to 12 years). There are few rigorous evalua- tions of interventions to reduce the incidence of concussion, there is limited analysis of outcomes associated with the implementation of “concussion” laws, and there are relatively few data on the psychometric properties of sideline screening tools. The committee focused its review of the literature on research published in peer-reviewed scientific literature and consensus or position statements from groups of experts and professional organizations relevant to the diag- nosis and management of sports-related concussion. The committee found considerable variation in the quality of the research studies it reviewed. However, given the current paucity of research in the field, the committee determined that even studies of limited strength could provide some useful information. The committee was careful to include appropriate qualifica- tions when it cited such research. In addition, the committee made every effort to include the most current research. However, strong evidence was sometimes found in older studies, and as some of these studies had not been replicated in recent years, in some cases they were the only available sources of data. In some areas, large-scale studies have not been done, and so the committee looked for whatever data were available from smaller-scale stud- ies. Ultimately, the committee included in this study what it judged to be the best empirical literature available.

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INTRODUCTION 25 Given the limitations of the published literature, the committee used a variety of sources to supplement its review of the literature. The commit- tee met in person five times and held two public workshops to hear from invited experts in areas pertinent to sports-related concussions in youth. Speakers included experts in the diagnosis, management, and rehabilitation of concussed athletes, including their reintegration into academic and ath- letic settings; genetic and neurogenetic sources of increased risk; the devel- opment of biomarkers and imaging technologies for concussion diagnosis and evaluation; protective equipment safety standards and effectiveness; and the role of sports rules and training in the prevention of sports-related concussion. The committee also heard from active duty military experts specializing in concussion policy and care and a representative from service academies specializing in training programs; stakeholder representatives, including athletes, parents, coaches, and officials; and representatives from youth sports organizations, such as the National Collegiate Athletic As- sociation, the National Federation of State High School Associations, and the Amateur Athletic Union. (See Appendix A for open session agendas and speaker lists.) The committee’s work was further informed by the work of bodies such as the international Concussion in Sport Group (McCrory et al., 2013a), the American Academy of Neurology (Giza et al., 2013), the American Academy of Pediatrics (Halstead et al., 2010), and the American Medical Society for Sports Medicine (Harmon et al., 2013), as well as by previous IOM and NRC reports, including Is Soccer Bad for Children’s Heads?: Summary of the IOM Workshop on Neuropsychological Conse- quences of Head Impact in Youth Soccer (IOM, 2002); Cognitive Rehabili- tation Therapy for Traumatic Brain Injury: Evaluating the Evidence (IOM, 2011); Systems Engineering to Improve Traumatic Brain Injury Care in the Military Health System Workshop Summary (NAE and IOM, 2009); Gulf War and Health: Volume 7: Long-Term Consequences of Traumatic Brain Injury (IOM, 2008); Early Childhood Development and Learning: New Knowledge for Policy (IOM and NRC, 2001); From Neurons to Neighborhoods: The Science of Early Childhood Development (IOM and NRC, 2000); and How People Learn: Brain, Mind, Experience, and School (NRC, 1999). OVERVIEW OF CORE ISSUES Variability in Defining Concussion The lack of reliable biomarkers for concussions and the reliance on a subjective symptom-based definition, combined with variations in terminol- ogy (e.g., “concussion” versus “mild traumatic brain injury”) and in the

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26 SPORTS-RELATED CONCUSSIONS IN YOUTH definition of those terms, as well as evolving descriptions of the severity of concussion (e.g., grading scales, simple versus complex) pose challenges not only for understanding the epidemiology of sports-related concussion but also for interpreting the information on concussions that is available in the lay and professional literature. Recognition of the need for common definitions and terminology has led to recent efforts to develop consensus definitions and common data elements for TBI research, including adult and pediatric concussion/mTBI research (Aubry et al., 2002; Hicks et al., 2013; McCrory et al., 2005, 2009, 2013a; Menon et al., 2010; NINDS, 2013; Thurmond et al., 2010). The Federal Interagency Traumatic Brain Injury Research (FITBIR) informatics system, developed by the Department of Defense and the National Institutes of Health, is a federal database designed to promote data sharing across the field of TBI research (NIH, 2013). The common data elements for TBI research that have been identified through an ongoing federal interagency initiative (Hicks et al., 2013; Thurmond et al., 2010) form the cornerstone of the FITBIR informatics system data dictionary (NIH, 2013). Participation in such collaborative research efforts may help to advance TBI research through the use of common definitions and standards. A 2010 position statement issued by a working group of the interagency initiative to develop common data elements for TBI research defines TBI as “an alteration in brain function, or other evidence of brain pathology, caused by an external force” (Menon et al., 2010). This definition of TBI has been adopted by the National Institute of Neurological Disorders and Stroke, the National Institute on Disability and Rehabilitation Research, and other members of the International and Interagency Initiative toward Common Data Elements for Research on Traumatic Brain Injury and Psy- chological Health as well as by the Brain Injury Association of America (BIAA, 2011; Menon et al., 2010). The term “TBI” does not represent a single, uniform condition, but rather refers to a myriad of brain injuries of different types and severity that may result from varied causes. Even within traditional classifications of TBI as mild, moderate, or severe, there are dif- ferent types of injury and different degrees of severity. This great variation helps to explain why there are no simple answers to the definition, diagno- sis, or treatment and management of TBI. Although some sources explicitly use the terms “mild traumatic brain injury” and “concussion” synonymously (CDC, 2009; DoD, 2012a), the committee has found it most useful to view concussion as a subset of mTBI (see Figure 1-1; Giza et al., 2013; Harmon et al., 2013; McCrory et al., 2013a,b). Even among concussions, one finds variation in the symptoms experienced by individuals as well as differences in the severity and dura- tion of symptoms. Efforts to standardize a definition of concussion date back to the mid-1960s (Congress of Neurological Surgeons, 1966). More

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INTRODUCTION 27 recently, a number of professional groups, including the American Academy of Neurology; governmental bodies, such as the U.S. Centers for Disease Control and Prevention (CDC) and the Department of Defense; and a consensus group organized by international sporting bodies (Concussion in Sport Group) have advanced working definitions of concussion (CDC, 2012; DoD, 2012a; Giza et al., 2013; McCrory et al., 2013a). Although the specifics of the definitions differ, there are common elements. A con- cussion is understood to be a clinical syndrome involving a disturbance in brain function that is generally time-limited and results from biomechanical forces, such as a bump, blow, or jolt to the head or body (DoD, 2012a; Giza et al., 2013; Harmon et al., 2013; McCrory et al., 2013a,b). In addition, a concussion may, but usually does not, involve loss of consciousness and typically does not result in structural changes observable using standard imaging techniques, such as computed tomography or magnetic resonance imaging. These elements are captured in the consensus definition of concus- sion adopted by the committee (McCrory et al., 2013a). Epidemiology The estimates of sports-related concussions provided by published epi- demiologic data are most likely conservative, given that many concussions go unreported (Daneshvar et al., 2011; McCrea et al., 2004). Moreover, the lack of consensus on the definition of “concussion” and the reliance on athletes to self-report their symptoms, combined with various method- ological differences, including varying study designs (retrospective versus prospective) and sources of data (emergency departments, athletic trainers, coaches, parents) and differences in what is being measured (concussions, mTBIs, all TBIs), have made estimating injury rates difficult, and the ac- curacy of much of the existing data is unknown (Daneshvar et al., 2011; McCrea et al., 2004). In the interest of accuracy, the following discussion uses the terms (e.g., TBI, mTBI, concussion) employed by the papers cited. The variations in terminology highlight one of the challenges for under- standing the epidemiology of sports-related concussion. One frequently cited paper estimated that as many as 1.6 million to 3.8 million sports- and recreation-related TBIs may occur annually in the United States, although the authors note that this number might be low because many such injuries may go unrecognized (Langlois et al., 2006). The figure is based on estimates generated from the unintentional injury supplement1 to the 1991 National Health Interview Survey (NHIS), which estimated that the annual number of sports- and recreation-related TBIs 1  NHIS supplements are designed to capture data beyond those generated by the core ques- tionnaire. Supplements may be used only once or repeated as needed (CDC, 2013d).

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28 SPORTS-RELATED CONCUSSIONS IN YOUTH involving a loss of consciousness was approximately 300,000 across all age groups (Thurman et al., 1998). Citing studies suggesting that only 8 to 19.2 percent of sports-related concussions involve loss of consciousness (Collins et al., 2003; Schultz et al., 2004), Langlois and colleagues (2006) used these percentages to scale up the 300,000 TBIs involving loss of consciousness to 1.6 million to 3.8 million sports- and recreation-related TBIs annually. A study using data from 15 National Collegiate Athletic Association (NCAA) sports found that between the 1988-1989 and 2003-2004 aca- demic years, the overall reported concussion rate doubled, from 1.7 to 3.4 per 10,000 athletic exposures2 (AEs), with an average annual increase of 7.0 percent (Hootman et al., 2007). A study of high school athletes in a large public school system showed an increase in the overall rate of reported concussions from 1.2 to 4.9 per 10,000 AEs between the 1997-1998 and 2007-2008 academic years, with an average annual increase of 16.5 percent (Lincoln et al., 2011). There was a substantial increase in reported concus- sion rate beginning in 2005, the same year that more training staff were added at each of the high schools in the study (Lincoln et al., 2011). Simi- larly, the CDC has estimated that between 2001 and 2009 the number of children and adolescents age 19 years and younger in the United States who were treated in emergency departments (EDs) for concussions and other nonfatal, sports- and recreation-related TBIs increased from approximately 150,000 to 250,000 (Gilchrist et al., 2011).3 The rate of ED visits for such injuries increased 57 percent, from 190 to 298 per 100,000 population dur- ing that time period (Gilchrist et al., 2011). During the same time period, the number of ED visits for TBIs that required hospitalization varied, but did not show an increasing trend over time (Gilchrist et al., 2011).4 A num- 2  Athletic exposures are the number of practices and competitions in which an individual actively participates (i.e., in which he or she is exposed to the possibility of athletic injury). 3  The NEISS Coding Manual contains a specific diagnostic code for “concussion” while coding other closed head injuries (TBIs) (e.g., subdural hematoma) as “internal organ injury” with “head” coded as the body part affected (CPSC, 2013b). The CDC report discussed here includes both types of injury. 4  Using data from the National Hospital Ambulatory Medical Care Survey, another study examined a 5-year sample (2002-2006) of ED visits for diagnosed concussion in children and adolescents age 19 years and younger (Meehan and Mannix, 2010). The study found that 30 percent of all the diagnosed concussions (approximately 43,200 annually) were sports-related. A higher percentage of concussions in adolescents (11 to 19 years) was attributed to sports than in children under 11 years of age (41 percent versus 8 percent), although percentages do not take rates of participation in sports activities into account. The inclusion criteria for this study were more restrictive than in the CDC report. Only patients with a diagnosis of concussion were included. Patients with other diagnoses, such as skull fractures or unspecified intracranial injury, were included only if they also were diagnosed with concussion. Patients diagnosed with an intracranial hemorrhage were automatically excluded.

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INTRODUCTION 29 ber of factors may have contributed to the increases in reported concussion rates, including increased awareness and recognition of such injuries. Surveillance Systems Appropriate epidemiological surveillance can provide valuable data on the incidence, causes, and other information pertinent to the occurrence of sports-related concussions. Such data are important for informing the development of appropriate interventions to reduce the incidence of con- cussions in youth sports and enabling the assessment of the effectiveness of such interventions. Currently most of the reported epidemiologic data on sports-related concussions in youth come from three surveillance systems (see Table 1-1): 1. National Electronic Injury Surveillance System—All Injury Pro- gram (NEISS-AIP) 2. NCAA Injury Surveillance System (NCAA ISS) 3. High School RIOTM (Reporting Information Online) The CDC data that were previously reported come from the NEISS- AIP, which captures data for individuals treated for injuries in emergency departments (CPSC, 2013c; Gilchrist et al., 2011; Hinton, 2012). NEISS- AIP is the only ongoing surveillance system that captures sports injury data from nonacademic settings and for children younger than high school age. Operated by the U.S. Consumer Product Safety Commission, NEISS-AIP is an expansion of the National Electronic Injury Surveillance System (NEISS), which was originally launched in the early 1970s and captures data from a national probability sample of approximately 100 hospitals with emergency departments in the United States and its territories (CPSC, 2013a,b,c). NEISS data inform national estimates of the number of injuries associ- ated with, although not necessarily caused by, specific consumer products. This distinction is important because a head injury might be attributed to “baseball” even though it occurred during a backyard “sword fight” with baseball bats. In 2000 NEISS-AIP was developed as a subset of NEISS to capture information on all injuries treated in the emergency departments, not only those related to products (CPSC, 2013a). Like NEISS, NEISS-AIP captures data on individuals’ age, sex, race, ethnicity, injury diagnosis, and affected body parts as well as the incident locale and product involved (if any), where injured person goes when released from the ED, and also a brief narrative description of how the injury occurred (CDC, 2013b; CPSC, 2013a; Hinton, 2012). Although NEISS-AIP includes data on race and eth- nicity, an analysis of the NEISS data found that race and ethnicity were not

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44 SPORTS-RELATED CONCUSSIONS IN YOUTH sion is too often not fully appreciated by athletes, their teammates, and, in some cases, coaches and parents (see, e.g., Anderson et al., 2013; Coyne, 2013; Echlin, 2012; Kroshus et al., 2013; McCrea et al., 2004; Register- Mihalik, et al., 2013a,b; Torres et al., 2013; Wolverton, 2013). In addition, athletes profess that the game and the team are more important than their individual health and often believe that by admitting to having symptoms of a concussion, they will be “letting down” their teammates, coaches, schools, and even parents (Anderson et al., 2013; Kroshus et al., 2013). A culture that encourages “playing through” a potentially concussive injury or returning to play too soon following a concussion can endanger the physical and cognitive well-being of the young athlete. Perhaps because concussions are “invisible” they are easier to ignore than torn ligaments or broken bones are. But each of these types of injury requires the athlete to be removed from play, cared for appropriately in both the acute stage and during the healing process, and judiciously returned to play only when he or she is demonstrably recovered. Increased knowledge about concussions in the absence of changes in attitudes may not be enough to modify reporting behavior among athletes (Anderson et al., 2013; Coyne, 2013; Kroshus et al., 2013; Register-Mihalik et al., 2013a,b; Torres et al., 2013). If the youth sports community can adopt the belief that concussions are serious injuries and institute behaviors and adopt attitudes that emphasize care for players with concussions until they are fully recovered, then the “culture” in which young athletes perform and compete will become much safer. Similarly, military recruits are immersed in military values and culture, including devotion to duty, commitment, and service before self, and the idea that “there is no greater bond than the one they share with the people ‘to their left and their right’” (Halvorson, 2010), which may make them reluctant to self-report symptoms of concussion. The military has acknowl- edged the need for a culture change, as reflected in such efforts as teaming up with the National Football League to increase awareness about TBI and to effect a culture change in which military personnel and athletes are willing to seek help (and not be stigmatized) if they experience concussive symptoms (AP, 2012; Vergun, 2012). The Policy Environment In light of the potential for returning to play too soon having cata- strophic results, lawmakers in the United States have passed legislation de- signed to address the need for concussion education for young athletes and their parents, particularly at the high school level, along with procedures to protect athletes from returning to play before it is deemed appropriate by health care providers. As of October 2013, 49 states and the District of Columbia had enacted concussion laws of some sort; legislation was intro-

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INTRODUCTION 45 duced in Mississippi, but it did not pass (NCSL, 2013; Network for Public Health Law, 2013; Sun, 2013). In May 2009, Washington became the first state to enact legislation designed to protect student athletes suspected of having sustained a concussion. Named after Zackery Lystedt, a 13-year- old football player who was permanently disabled when he returned to a game after having sustained a concussion, Washington’s law specifies several principles that have come to be viewed as the three tenets of model concussion legislation: (1) education of coaches, parents, and athletes about the nature and risk of concussions in sports and a requirement that parents sign a form ac- knowledging receipt of the information; (2) immediate removal from play of any youth athlete suspected of having sustained a concussion or head injury; and (3) a requirement that an athlete who has been removed from play be evaluated by and receive written clearance from a health care professional trained in the evaluation and management of concussion before returning to play. Although legislation in most of the states that have concussion laws in- cludes some version of the three tenets in the Washington law, there is significant variation among states regarding specific requirements (NCSL, 2013; Network for Public Health Law, 2013). Since 2009, there have been several federal legislative efforts directed at various aspects of sports-related concussions in youth. Legislation in- troduced in the House of Representatives—the Concussion Treatment and Care Tools (ConTACT) Act of 2009, later renamed the ConTACT Act of 2010 (H.R. 1347)—called on the Secretary of Health and Human Services to establish guidelines for “the prevention, identification, treatment, and management of concussions” in children 5 to 18 years of age, including return-to-play standards (H.R. 1347). In addition, the bill called for fund- ing for states to collect data on the incidence and prevalence of sports- related concussion among school-aged children, to adopt and implement the aforementioned guidelines, and to implement pre-season baseline and post-injury testing for school-aged children (H.R. 1347). The bill eventu- ally passed the House and was referred to the Senate (S. 2840), where it stalled in committee. The Protecting Student Athletes from Concussions Act, originally in- troduced in the House in 2010 (H.R. 6172) and reintroduced in 2011 (H.R. 469), was directed toward state and local educational agencies and was, in part, designed to bring some uniformity to the proliferation of state “Lystedt laws.” The bill, which never moved out of committee, would have required as a condition of federal funding the development and implemen-

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46 SPORTS-RELATED CONCUSSIONS IN YOUTH tation of a concussion safety and management plan that would include a concussion education component for students, parents, and school per- sonnel; supports for students during recovery from concussion; and best practices to ensure uniformity in safety standards treatment, and manage- ment (H.R. 6172). Other elements of the bill called on school personnel to remove any student suspected of having sustained a concussion from the activity in which it occurred and to prohibit participation in athletic activities until the student was cleared by a health care provider, including recognition that the provider might specify a gradual, progressive return to cognitive and physical activity. The Children’s Sports Athletic Equipment Act, jointly introduced in the House and Senate in 2011 (H.R. 1127; S. 601), was directed to the Con- sumer Product Safety Commission (CPSC) and addressed issues pertaining to the development of and compliance with standards for “youth football helmets, reconditioned helmets, and new helmet concussion resistance.” The 2011 bills died in committee, but similar legislation, the Youth Sports Concussion Act of 2013, was introduced in the House and Senate in May 2013 (H.R. 2118; S. 1014). The current legislation, which is in commit- tee, is directed to the CPSC and addresses safety standards for protective equipment to reduce the risk of sports-related injury, to improve the safety of reconditioned protective equipment, and to modify warning labels on protective equipment. The legislation also addresses the issue of false or misleading claims in the marketing of protective equipment. In February 2013, a resolution was introduced in the House (H.R. 72) supporting the goals and ideals of the Secondary School Student Athletes’ Bill of Rights (YSSA, 2013), which highlights the importance of proper safety measures and trained personnel, timely medical assessments, and appropriate environmental conditions in ensuring the health and well-being of secondary school student athletes. State legislative efforts are addressed in more detail in Chapter 6. REPORT ORGANIZATION Chapter 2 gives an overview of normal brain development, which pro- vides the basis for understanding the pathophysiology and natural history of concussion. In addition the chapter discusses the mechanics of concus- sive injury, physical and biological thresholds for injury, and physical and behavioral risk and protective factors. Chapter 3 reviews considerations pertaining to the recognition, diagnosis, and acute management of concus- sions, including the reintegration of concussed individuals into academic and athletic activities. Chapter 4 discusses the treatment and management of individuals with concussion symptoms that persist beyond the typical 1- to 2-week recovery period. The chapter also includes a discussion of

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INTRODUCTION 47 special considerations that arise in the provision of concussion care, such as geographic variation in access to specialized care. Chapter 5 examines the issues surrounding repetitive head impacts that do not produce signs and symptoms of a concussion, as well as multiple concussions. Topics include short- and long-term outcomes, risk factors, neuropathology, and neuroimaging findings. Chapter 6 addresses interventions that may reduce the risk of sports-related concussions and includes discussions of the ef- fectiveness of equipment such as helmets, mouthguards, and other devices; alternative playing surfaces; sport-specific rules and regulations; and legisla- tion directed toward concussion education and athlete protection through policies governing athletes’ removal from and return to play following a suspected concussion. Chapter 7 contains the committee’s conclusions and recommendations. FINDINGS The committee offers the following findings: • The published literature includes numerous working definitions of concussion and inconsistent use of terminology (e.g., concussion, mTBI [despite the latter including more severe brain injury]), which pose challenges for interpreting and comparing findings across research studies on concussion. • Concussion rates tend to be higher during competition than in practice (except for cheerleading), higher among female athletes than male athletes in comparable sports, and higher in certain sports. • The National Collegiate Athletic Association Injury Surveillance System and High School RIO™ (Reporting Information Online) data systems are the only ongoing, comprehensive sources of sports-related injury data, including data on concussions, in youth athletes. Equivalent data are not available for athletes younger than high school age, nor are they available for participants in club sports or for youth engaging in competitive and recreational sports outside of an academic setting. There is no comprehensive system (individually or collectively) for acquiring accurate data on the incidence of sports- and recreation-related concussion across all youth age groups and sports. • Data captured on sports- and recreation-related concussions do not routinely include race and ethnicity. • There are no published data on the incidence of reported concus- sions during basic training for military recruits.

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48 SPORTS-RELATED CONCUSSIONS IN YOUTH • Despite increased knowledge and a growing recognition in recent years that concussions involve some level of injury to the brain and therefore need to be diagnosed promptly and managed appropri- ately, there is still a culture among athletes and military personnel that resists the self-reporting of concussions and compliance with appropriate concussion management plans. REFERENCES Agel, J., and E. J. Harvey. 2010. A 7-year review of men’s and women’s ice hockey injuries in the NCAA. Canadian Journal of Surgery 53(5):319-323. Anderson, B. L., W. J. Pomerantz, J. K. Mann, and M. A. Gittelman. 2013. “I Can’t Miss the Big Game”: High School (HS) Football Players’ Knowledge and Attitudes about Concus- sions. Presented at the Pediatric Academic Societies Annual Meeting, Washington, DC, May 6. AP (Associated Press). 2012. NFL, Army starts concussion program. http://espn.go.com/nfl/ story/_/id/8318684/nfl-teams-us-army-concussion-program (accessed August 5, 2013). Aubry, M., R. Cantu, J. Dvořák, T. Graf-Baumann, K. Johnston, J. Kelly, M. Lovell, P. McCrory, W. Meeuwisse, and P. Schamasch. 2002. Summary and agreement statement of the first International Conference on Concussion in Sport, Vienna 2001. British Journal of Sports Medicine 36(1):6-10. Bakhos, L. L., G. R. Lockhart, R. Myers, and J. G. Linakis. 2010. Emergency department visits for concussion in young child athletes. Pediatrics 126(3):e550-e556. Bazarian, J. J., P. Veazie, S. Mookerjee, and E. B. Lerner. 2006. Accuracy of mild traumatic brain injury case ascertainment using ICD-9 codes. Academic Emergency Medicine 13(1):31-38. Becker, J., A. Runer, D. Neunhäuserer, N. Frick, H. Resch, and P. Moroder. 2013. A pro- spective study of downhill mountain biking injuries. British Journal of Sports Medicine 47(7):458-462. BIAA (Brain Injury Association of America). 2011. BIAA adopts new TBI definition (February 6, 2011). http://www.biausa.org/announcements/biaa-adopts-new-tbi-definition (accessed March 28, 2013). Boden, B. P., R. L. Tacchetti, R. C. Cantu, S. B. Knowles, and F. O. Mueller. 2007. Cata- strophic head injuries in high school and college football players. American Journal of Sports Medicine 35(7):1075-1081. Boden, B. P., I. Breit, J. A. Beachler, A. Williams, and F. O. Mueller. 2013. Fatalities in high school and college football players. American Journal of Sports Medicine 41(5): 1108-1116. Cantu, R. C. 1998. Second-impact syndrome. Clinics in Sports Medicine 17(1):37-44. Cantu, R. C., and R. Voy. 1995. Second impact syndrome a risk in any contact sport. Physician and Sportsmedicine 23(6):27-34. CDC (Centers for Disease Control and Prevention). 2009. Heads up: Facts for physicians about mild traumatic brain injury (mTBI). http://www.cdc.gov/concussion/headsup/pdf/ facts_for_physicians_booklet-a.pdf (accessed April 3, 2013). CDC. 2012. Concussion and mild TBI. http://www.cdc.gov/concussion/index.html (accessed March 28, 2013). CDC. 2013a. Concussion in sports. http://www.cdc.gov/concussion/sports/index.html (ac- cessed March 28, 2013).

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50 SPORTS-RELATED CONCUSSIONS IN YOUTH DVBIC (Defense and Veterans Brain Injury Center). 2013. DoD worldwide numbers for TBI. http://www.dvbic.org/dod-worldwide-numbers-tbi (accessed June 27, 2013). Echlin, P. S. 2012. Editorial: A prospective study of physician-observed concussion during a varsity university ice hockey season. Part 1 of 4. Neurosurgical Focus 33(6):E1:1-7. Eisenberg, M. A., J. Andrea, W. Meehan, and R. Mannix. 2013. Time interval between concussions and symptom duration. Pediatrics. DOI: 10.1542/peds.2013-0432, origi- nally published online June 10, 2013. http://pediatrics.aappublications.org/content/ early/2013/06/05/peds.2013-0432 (accessed July 18, 2013). Extreme Sport. 2008. Extreme sport growing in popularity. http://xtremesport4u.com/extreme- land-sports/extreme-sport-growing-in-popularity (accessed June 7, 2013). Field, M., M. W. Collins, M. R. Lovell, and J. Maroon. 2003. Does age play a role in recovery from sports-related concussion? A comparison of high school and collegiate athletes. Journal of Pediatrics 142(5):546-553. GAO (U.S. Government Accountability Office). 2009. Consumer Product Safety Commission: Better Data Collection and Assessment of Consumer Information Efforts Could Help Protect Minority Children. Report number GAO-09-731. Washington, DC: Government Printing Office. Gessel, L. M., S. K. Fields, C. L. Collins, R. W. Dick, and R. D. Comstock. 2007. Concussions among United States high school and collegiate athletes. Journal of Athletic Training 42:495-503. Gilchrist, J., K. E. Thomas, L. Xu, L. C. McGuire, and V. Coronado. 2011. Nonfatal traumatic brain injuries related to sports and recreation activities among persons ≤19 years—United States, 2001–2009. Morbidity and Mortality Weekly Report 60(39):1337-1342. Giza, C. C., J. S. Kutcher, S. Ashwal, J. Barth, T. S. D. Getchius, G. A. Gioia, G. S. Gronseth, K. Guskiewicz, S. Mandel, G. Manley, D. B. McKeag, D. J. Thurman, and R. Zafonte. 2013. Evidence-Based Guideline Update: Evaluation and Management of Concussion in Sports. Report of the Guideline Development Subcommittee of the American Academy of Neurology. American Academy of Neurology. Goldman, S. B. 2013. Army TBI Program Overview. Presentation before the committee, Washington, DC, February 25. Halstead, M. E., K. D. Walter, and American Academy of Pediatrics, Council on Sports Medi- cine and Fitness. 2010. Sport-related concussion in children and adolescents. Pediatrics 126(3):597-615. Halvorson, A. 2010. Understanding the Military: The Institution, the Culture, and the People. http://partnersforrecovery.samhsa.gov/docs/military_white_paper_final.pdf (accessed Au- gust 29, 2013). Harmon, K. G., J. A. Drezner, M. Gammons, K. M. Guskiewicz, M. Halstead, S. A. Herring, J. S. Kutcher, A. Pana, M. Putakian, and W. O. Roberts. 2013. American Medical Society of Sports Medicine position statement: Concussion in sport. British Journal of Sports Medicine 47(1):15-26. Hicks, R., J. Giacino, C. Harrison-Felix, G. Manley, A. Valadka, and E. A. Wilde. 2013. Progress in developing common data elements for traumatic brain injury research: Ver- sion two—the end of the beginning. Journal of Neurotrauma. September 9, doi:10.1089/ neu.2013.2938. Hinton, R. Y. 2012. Sports injury surveillance systems. Sports Medicine Update January/ February:2-7. Hootman, J., R. Dick, and J. Agel. 2007. Epidemiology of collegiate injuries for 15 sports: Summary and recommendations for injury prevention initiatives. Journal of Athletic Training 42(2):311-319.

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