Feature

Q&A: ‘No simple answers’ on sports-related concussions

Frederick P. Rivara, MD, MPH 
Frederick P. Rivara
Mark Halstead, MD 
Mark Halstead

In 2018, the AAP issued new guidance on youth sports-related concussions, or SRCs, and voiced concerns about the underreporting of these injuries. The CDC recently published recommendations for mild concussion management in children that same year — noting a lack of evidence-based clinical guidelines for pediatric mild traumatic brain injury diagnosis, prognosis or management in the U.S.

Frederick P. Rivara, MD, MPH, Seattle Children's Hospital Guild Association Endowed Chair in Pediatric Health Outcomes Research and professor and vice chair of academic affairs in the University of Washington’s department of pediatrics, and colleagues convened a panel of 11 experts to summarize existing research on SRCs and develop new recommendations to address youth SRC prevention, assessment and management.

Panel members addressed seven questions via a modified Delphi approach — a consensus method in which panelists developed specific questions via three rounds of communication between members. With the assistance of a reference librarian, they performed a review of relevant studies published by March 30, 2019, which were then drafted into conclusions by the study team. Panelists ranked conclusions from one to nine, with final recommendations confirmed at a meeting with all panel members. Only conclusions with a final mean score of seven or more were adopted.

The panel’s major conclusions included the following points, as described by Rivara and colleagues:

  • There is extensive research addressing overall SRC rates, including data related to age, sex and type of sport;
  • The literature showed a complex association between age and SRC risk depending on the sport, but has not investigated the ways youth sport participants learned or conducted proper contact techniques across different age levels;
  • New SRC assessment and reporting rules may be associated with the increase in SRC reporting during the last decade. This is not due to an increase in the occurrence of concussions but better reporting and care-seeking;
  • Any associations between longitudinal outcomes from studies of former players and those of current athletes are difficult to identify due to changes in rules, equipment and culture surrounding contact sports over time;
  • Available data do not support the idea of risk compensation when protection equipment is used;
  • No peer-reviewed resources could be found addressing the proportion of contact- or collision-sport athletes who participate in non-contact sports after collision or contact options are removed;
  • No evidence was found regarding a specific number of concussions that should require that an athlete discontinue a sport, and limited evidence was found to suggest discontinuation or continuation of participation in a sport was associated with long-term well-being and brain health.

“There has been more research to guide us in recommendations for young athletes but, unfortunately, some of the areas that would provide the most practical guidance for families are still lacking,” Mark Halstead, MD, a pediatric sports medicine physician at St. Louis Children’s Hospital, who was not involved in the project, told Infectious Diseases in Children. “Research is certainly still needed as to the best practices in returning kids to normal learning following concussion. Further research as to which ages are safest to initiate contact or collisions in sport in reducing concussion and other injuries would be helpful practical information.”

Infectious Diseases in Children spoke with Rivara about the implications of these new guidelines and the potential impact of research into youth SRCs. - by Eamon Dreisbach

Q: What are the major takeaways from this analysis ?

A: The point of this is it's a complicated topic and there are no simple answers. We did this study because there's been less information out there about what to do with concussions and information for parents, athletes and clinicians about concussions in younger kids. We tried to put together the available evidence and then make some recommendations based upon that using a consensus process.

Q: Were any of the findings particularly surprising?

A: There’s no evidence that there’s a particular age which is safer or less safe to play contact sports. We know that kids at all ages can learn proper techniques to decrease the risk of injury. So, there isn’t a critical age that came out of the literature which indicates it's best to wait until “X” age before you do contact sports.

The second thing is that rules can make a difference. We particularly looked at ice hockey and at body checking. We saw that if you eliminate body checking in younger leagues for ice hockey it decreases the risk for concussions. I think that emphasizes the point that we really need to look at: What are the different rules and regulations, and how can they be used to decrease the risk of concussions in kids, particularly the younger kids?

I think the third issue here is that there's pretty good evidence to say that having one concussion when you're little is not going to result in you having dementia from chronic traumatic encephalopathy at age 50 years. People who seem to get that have had multiple concussions over many years, and so there isn't a direct relationship with having one or two concussions as a youth and a later risk of these diseases.

I think another thing that comes out of this is about headgear to protect brains. So there clearly are helmets that are used in football and they are effective in decreasing the risk of injuries — and there are some helmets that may be better than others; but on the other hand, the kind of headgear that parents might see advertised in some magazine or on TV to protect their child against head injury when they play soccer, there’s no evidence that those things work.

The final area that we looked at was, “Is there an age at which kids should be retired from a sport because they have ‘X’ number of concussions?” And the answer to that is that there’s no magic number of concussions at which a child should be retired. That's a complicated decision that depends upon the time period in which the concussions happened, the symptoms from those concussions, the desires of the child, the parent and the recommendations of the physician. It's a complicated decision, there is no magic number at which we can say, “Definitely after this number of concussions, kids should retire from playing a sport.” I think those are the major issues. As we pointed out throughout the paper, there's still a lot of areas that need more research so that we can make better recommendations to help parents and physicians.

Q: What did you not have the opportunity to cover in this analysis?

A: There is the question of, “Are there other kinds of rules that are done in play that would make a difference in the frequency of concussions, particularly for kids, like the rule change in ice hockey? Are there other rules that should be changed?”

I think that there's more information that needs to be obtained about these repeated head impacts and exposures. Are they harmful or not? Is there a threshold in which they are harmful or not? How are they even best measured? It has to be longitudinal to look at these effects over time — it can’t be just at the beginning and end of the season.

Finally, I think we need more information about the long-term consequences of multiple concussions so we can we arrive at the number which we probably should advise parents to have their kids stop playing a contact sport.

Q: Did you see any overlap or differences between this research and the AAP guidelines on this topic, or similar concussion guidelines?

A: There certainly is a lot of overlap in all these concussion statements. The difference may be in the process: organizing a group of experts to look at the evidence in the literature and then using the Delphi process to arrive at a consensus on the conclusions and recommendations.

Q: What should pediatricians tell patients and parents about sports-related concussions?

A: Pediatricians need to get informed themselves if they are going to be taking care of children and adolescents with concussions. They need to understand what the state-of-the-art is right now for concussions. What we recommend now is different than what was recommended even 5 or 10 years ago. So, I think that's the most important thing.

Secondly, I think that if they feel uncomfortable, or have a kid who has had multiple concussions, it may be appropriate to refer these patients to sports medicine physicians or neurologists or medicine physicians who have a lot of experience with dealing with them.

I think it's a careful discussion that parents and physicians should have together. I think it requires an informed approach.

Disclosures: Rivara reports receiving gifts from USA Football, U.S. Lacrosse, USA Rugby and the American College of Sports Medicine for this study; grants from the NIH; and being employed as the editor in chief of JAMA Network Open during the conduct of the study. Halstead reports no relevant financial disclosures.

Frederick P. Rivara, MD, MPH 
Frederick P. Rivara
Mark Halstead, MD 
Mark Halstead

In 2018, the AAP issued new guidance on youth sports-related concussions, or SRCs, and voiced concerns about the underreporting of these injuries. The CDC recently published recommendations for mild concussion management in children that same year — noting a lack of evidence-based clinical guidelines for pediatric mild traumatic brain injury diagnosis, prognosis or management in the U.S.

Frederick P. Rivara, MD, MPH, Seattle Children's Hospital Guild Association Endowed Chair in Pediatric Health Outcomes Research and professor and vice chair of academic affairs in the University of Washington’s department of pediatrics, and colleagues convened a panel of 11 experts to summarize existing research on SRCs and develop new recommendations to address youth SRC prevention, assessment and management.

Panel members addressed seven questions via a modified Delphi approach — a consensus method in which panelists developed specific questions via three rounds of communication between members. With the assistance of a reference librarian, they performed a review of relevant studies published by March 30, 2019, which were then drafted into conclusions by the study team. Panelists ranked conclusions from one to nine, with final recommendations confirmed at a meeting with all panel members. Only conclusions with a final mean score of seven or more were adopted.

The panel’s major conclusions included the following points, as described by Rivara and colleagues:

  • There is extensive research addressing overall SRC rates, including data related to age, sex and type of sport;
  • The literature showed a complex association between age and SRC risk depending on the sport, but has not investigated the ways youth sport participants learned or conducted proper contact techniques across different age levels;
  • New SRC assessment and reporting rules may be associated with the increase in SRC reporting during the last decade. This is not due to an increase in the occurrence of concussions but better reporting and care-seeking;
  • Any associations between longitudinal outcomes from studies of former players and those of current athletes are difficult to identify due to changes in rules, equipment and culture surrounding contact sports over time;
  • Available data do not support the idea of risk compensation when protection equipment is used;
  • No peer-reviewed resources could be found addressing the proportion of contact- or collision-sport athletes who participate in non-contact sports after collision or contact options are removed;
  • No evidence was found regarding a specific number of concussions that should require that an athlete discontinue a sport, and limited evidence was found to suggest discontinuation or continuation of participation in a sport was associated with long-term well-being and brain health.
PAGE BREAK

“There has been more research to guide us in recommendations for young athletes but, unfortunately, some of the areas that would provide the most practical guidance for families are still lacking,” Mark Halstead, MD, a pediatric sports medicine physician at St. Louis Children’s Hospital, who was not involved in the project, told Infectious Diseases in Children. “Research is certainly still needed as to the best practices in returning kids to normal learning following concussion. Further research as to which ages are safest to initiate contact or collisions in sport in reducing concussion and other injuries would be helpful practical information.”

Infectious Diseases in Children spoke with Rivara about the implications of these new guidelines and the potential impact of research into youth SRCs. - by Eamon Dreisbach

Q: What are the major takeaways from this analysis ?

A: The point of this is it's a complicated topic and there are no simple answers. We did this study because there's been less information out there about what to do with concussions and information for parents, athletes and clinicians about concussions in younger kids. We tried to put together the available evidence and then make some recommendations based upon that using a consensus process.

Q: Were any of the findings particularly surprising?

A: There’s no evidence that there’s a particular age which is safer or less safe to play contact sports. We know that kids at all ages can learn proper techniques to decrease the risk of injury. So, there isn’t a critical age that came out of the literature which indicates it's best to wait until “X” age before you do contact sports.

The second thing is that rules can make a difference. We particularly looked at ice hockey and at body checking. We saw that if you eliminate body checking in younger leagues for ice hockey it decreases the risk for concussions. I think that emphasizes the point that we really need to look at: What are the different rules and regulations, and how can they be used to decrease the risk of concussions in kids, particularly the younger kids?

I think the third issue here is that there's pretty good evidence to say that having one concussion when you're little is not going to result in you having dementia from chronic traumatic encephalopathy at age 50 years. People who seem to get that have had multiple concussions over many years, and so there isn't a direct relationship with having one or two concussions as a youth and a later risk of these diseases.

PAGE BREAK

I think another thing that comes out of this is about headgear to protect brains. So there clearly are helmets that are used in football and they are effective in decreasing the risk of injuries — and there are some helmets that may be better than others; but on the other hand, the kind of headgear that parents might see advertised in some magazine or on TV to protect their child against head injury when they play soccer, there’s no evidence that those things work.

The final area that we looked at was, “Is there an age at which kids should be retired from a sport because they have ‘X’ number of concussions?” And the answer to that is that there’s no magic number of concussions at which a child should be retired. That's a complicated decision that depends upon the time period in which the concussions happened, the symptoms from those concussions, the desires of the child, the parent and the recommendations of the physician. It's a complicated decision, there is no magic number at which we can say, “Definitely after this number of concussions, kids should retire from playing a sport.” I think those are the major issues. As we pointed out throughout the paper, there's still a lot of areas that need more research so that we can make better recommendations to help parents and physicians.

Q: What did you not have the opportunity to cover in this analysis?

A: There is the question of, “Are there other kinds of rules that are done in play that would make a difference in the frequency of concussions, particularly for kids, like the rule change in ice hockey? Are there other rules that should be changed?”

I think that there's more information that needs to be obtained about these repeated head impacts and exposures. Are they harmful or not? Is there a threshold in which they are harmful or not? How are they even best measured? It has to be longitudinal to look at these effects over time — it can’t be just at the beginning and end of the season.

Finally, I think we need more information about the long-term consequences of multiple concussions so we can we arrive at the number which we probably should advise parents to have their kids stop playing a contact sport.

PAGE BREAK

Q: Did you see any overlap or differences between this research and the AAP guidelines on this topic, or similar concussion guidelines?

A: There certainly is a lot of overlap in all these concussion statements. The difference may be in the process: organizing a group of experts to look at the evidence in the literature and then using the Delphi process to arrive at a consensus on the conclusions and recommendations.

Q: What should pediatricians tell patients and parents about sports-related concussions?

A: Pediatricians need to get informed themselves if they are going to be taking care of children and adolescents with concussions. They need to understand what the state-of-the-art is right now for concussions. What we recommend now is different than what was recommended even 5 or 10 years ago. So, I think that's the most important thing.

Secondly, I think that if they feel uncomfortable, or have a kid who has had multiple concussions, it may be appropriate to refer these patients to sports medicine physicians or neurologists or medicine physicians who have a lot of experience with dealing with them.

I think it's a careful discussion that parents and physicians should have together. I think it requires an informed approach.

Disclosures: Rivara reports receiving gifts from USA Football, U.S. Lacrosse, USA Rugby and the American College of Sports Medicine for this study; grants from the NIH; and being employed as the editor in chief of JAMA Network Open during the conduct of the study. Halstead reports no relevant financial disclosures.