Some reassurance about football and your child’s brain

The Pediatric Insider

© 2017 Roy Benaroch, MD

Concussions and football have come up before on this blog, and the news so far has been discouraging. We want kids to stay active, and football is one of the most popular boys’ sports out there. But we know that some prominent professional athletes have had serious, cumulative brain damage from years of football – sometimes brain damage that has destroyed their lives. What about high school football, or football starting even earlier? Are we encouraging a sport that’s a cause of serious, lifelong disability?

A recent publication gives at least some reassurance. From the August 2017 issue of JAMA Neurology comes a study titled “Association of Playing High School Football with Cognition and Mental Health Later in Life.” It’s not a perfect, definitive study, but it’s got some solid long term data.

Researchers have been studying a cohort of about 10,000 Wisconsin high school graduates – students who graduated in 1957, so they’re now about 78 years old. Of those, about 2700 have complete data, including formal testing of their mental condition at age 65 and 72. Tests were done of intelligence and brain functioning using several standard assessments, as well as testing for things like depression, anxiety, and alcoholism. They also went through the high school yearbooks to figure out which of these students played football (it turned out to be about 30%. Football was, and still is, big in Wisconsin.)

When the data was analyzed, it looks like football players were no more or less likely to have problems with dementia or mental illness 60+ years later; nor were they more likely to consume too much alcohol. What was different was that they were somewhat more likely to stay physically active (which may have protected them from memory problems as they became older.)

There are some shortcomings of a study like this. We don’t know which if any of the participants played football starting younger than high school, or which positions they played, or whether they had one or more concussions. And, I think even more significantly, it’s apparent that football now is played quite differently than in 1957. Players are bigger and stronger and faster, and collisions are more high-energy. It may be that there are more brain injuries happening now on high school football fields than there were back then.

Still, 60+ years is some great long-term follow-up. It’s good to know that at least one long term study shows that football in high school isn’t associated with later cognitive or mental health problems. We still need to minimize concussion risks and identify and treat them correctly, but this study should provide some reassurance that high school football might not be so bad for high school brains.

Football and your child’s brain

The Pediatric Insider

© 2014 Roy Benaroch, MD

Since every second of my life, and then some, seems preoccupied with the transition to the New and Improved ICD-10 code set — I can’t imagine how I lived so long without being able to code for someone bitten by a pig in a prison swimming pool – I’ve had no time to write anything new. So today you get a refurbished, classic post. And by classic, I mean old. I put a new photo somewhere in the text to freshen it up, so I promise it’s worth a read. I’m hoping to get back to writing new stuff soon. Enjoy!

Eat your vegetables. Be good to your momma. Change your underwear.

Good, solid advice. Maybe we need to add: “Don’t damage your brain. You’re going to need it someday.”

More and more evidence is accumulating that football, or at least football as it’s currently being played in high schools and colleges, is causing irreversible brain damage. The latest study was published in JAMA this week. Researchers looked at 25 collegiate football players (who had played in high school), and compared both brain imaging and cognitive performance with students who hadn’t played college. They correlated their findings with the number of years of football experience, and the number of recalled concussions.

Bottom line: more concussions correlates with a loss of brain volume in the hippocampus, an area of the brain involved with memory recall and the regulation of emotions. Not only were concussions correlated, but the number of years playing football also correlated with this change in MRI scans and with deficits in cognitive testing, including tests of reaction time and impulsivity.By the way—if you think helmets prevent concussions, think again.

Waddles!

The study itself wasn’t large, and relied only on the students’ recall of concussions. And it does not establish causality—maybe people with smaller hippocampi are more attracted to football, or tend to have more concussions (though no other research suggests this). Still, studies like this add to the considerable evidence that the kind of high-impact head trauma that occurs during football is causing real damage to real brains.

What can we do about it? There are steps individual families can make to protect their own children, especially by recognizing and treating concussions when they occur. Beyond that, we’ll have to see if coaches, athletes, and families are willing to risk brain damage to continue traditional football programs. Are the benefits worth the risk? It’s time to talk about it.

Concussions are brain injuries

The Pediatric Insider

© 2015 Roy Benaroch, MD

Many parents (and even some teenagers) realize that kids are going to be using their brains at some point in their lives. I’m getting more and more questions about the effects of concussions—are they going to lead to trouble, down the road? How can they be prevented and treated?

First: let’s abandon the term “concussion.” It’s a weird word that waters down a much simpler term: traumatic brain injury. A concussion is a mild brain injury caused by trauma. So let’s just call it that, “mild traumatic brain injury.” Wordy, but those words say a lot more to parents and children than “concussion.”

How do you know a brain has been injured? Simply enough, it stops working right. A person who’s had a blow to the head followed by a period of brain-not-working has had a brain injury, a “concussion”. The symptoms could include, after the injury, a period of confusion or dizziness or a feeling that you’re “not all there.” Sometimes, but not usually, there’s a brief loss of consciousness. That worth saying again: people who’ve had a mild traumatic brain injury usually do not get knocked out. They just feel knocked around. Later, there are continued symptoms like headache, dizziness, a “fuzzy brain” feeling; sometimes there are also problems with moodiness or irritability, or trouble with sleep cycles. Again, remember, these are all symptoms of an injured brain.

People understand the concept of injuries. You injure your ankle, you expect to need to rest it. Everyone knows rest is the best way to prevent an injury from getting worse, and rest is the best way to prevent an even-worse re-injury. We instinctively know that during rehabilitation for an injured ankle, you’ll kind of walk and run funny—which puts you at risk for other injuries, too.

All of these concepts are exactly the same for concussion, and that’s easy to explain if you remember to think of a concussion as a “traumatic brain injury”. Rest is the key, to allow the brain to heal, to prevent worsening damage from continued trauma, to prevent re-injury of the brain, and to prevent injury of other body parts because you’re not performing well with an injured brain. See? Easy as an ankle to explain.

Of course, resting a brain isn’t exactly as simple as resting an ankle. We can’t use a sling or an ACE wrap (well, you can, but you’ll look weird and it won’t help.) Resting a brain means, well, brain rest: no intellectual work, no school, no physical exercise. Just like you’d rest an ankle until it felt better, resting a brain after it’s injured should continue until there are no symptoms of injury. No headaches, no sleep problems, no fuzzy brain, no dizziness, no trouble focusing. When all of these symptoms have abated, people with mild traumatic brain injuries should gradually advance to more-intense schooling and activities, step by step, until the patient is back up to full activity. If there’s a step backwards—if brain symptoms begin—do exactly what you’d do if your ankle starts to hurt again. Back off the activity and allow more time to heal.

There’s good evidence that allowing a period of time to rest and heal after a mild traumatic brain injury can help prevent re-injury and longstanding symptoms—but we don’t know exactly how long the rest should be. One recent study showed that to a point, too much rest for too long can actually worsen and extend symptoms. Once symptoms improve, it’s a good idea to start back on activities (start slow and advance step by step) rather than continue through a fixed number of days of rest. We have some work to do to fine tune and individualize the best concussion care advice.

While a single concussion, especially with appropriate treatment, is unlikely to lead to long term problems, there are some sobering concerns about people who’ve had multiple concussions. There’s an increased risk of long term cognitive decline, movement disorders, and depression. And we know many athletes under-report concussions. In one study, 30% of high school football players reported a history of concussion, but only half of those had reported the injury. There may be far more concussions injuring far more high school brains than we appreciate.

As I said, many of those brains are going to be used later. Maybe we ought to try to do a better job keeping them in good shape.

The best helmet to prevent football concussions is….

The Pediatric Insider

© 2014 Roy Benaroch, MD

Marshall wrote in: “My son has just had his 6^th concussion this season in football. What’s the best helmet to use? I want to keep him safe.”

Marshall, football helmets are there to protect the scalp and the cranium—the bones outside of the brain. They prevent scalp lacerations (cuts), and probably prevent skull fractures. But helmets do not protect the actual brain. There is no helmet, and has never been a helmet, and never will be a helmet, that actually prevents brain injury from concussions.

Concussions aren’t caused by the head hitting another head, or a head hitting a wall. They occur inside the skull, when the brain slams into the inside of the cranium during a rapid deceleration. The brain is a soft, squishy, and very important organ suspended in essentially a bowl of water. If you drop that bowl off of your roof, say, the bowl might shatter on the ground (like a skull fracturing). But even if the bowl doesn’t break, the brain suspended in the water will suddenly go from moving very fast to not moving at all as it slams against the side of the bowl. That causes brain damage, and that’s what a concussion is. It’s not a broken bowl. It is a broken brain.

We diagnose a concussion if there’s been a blow to the head immediately followed by a period of altered brain functioning—dizziness, headache, foggy thinking or disrupted memory, or sometimes a loss in consciousness. Most concussion do not knock the athlete out—the immediate symptoms are more subtle. Even without unconsciousness, any concussion means that there has been brain damage. The damage is on the cellular level—you can’t see it on a CT scan or MRI, and those tests are not helpful and not needed after an ordinary concussion unless there’s a suspicion of a skull fracture or other problems.

The brain damage from a concussion will often heal, with appropriate rest and rehab; but repeated concussions or concussions with little time for recovery will lead to permanent brain damage. With more concussions Marshall’s son will develop lifelong problems with depression, fuzzy or easily-distracted thinking, movement disorders, and a genuine, marked drop in IQ. Good sleep and normal mood regulation can become impossible. These symptoms are, by and large, untreatable.

Marshall, your son will probably need his brain to work well as he grows older. If you’re serious about protecting his brain and mental abilities, he doesn’t need a new helmet. He needs to quit football.

Related posts:

Football and your child’s brain

Protecting your child from concussions

Football and your child’s brain

The Pediatric Insider

© 2014 Roy Benaroch, MD

Eat your vegetables. Be good to your momma. Change your underwear.

Good, solid advice. Maybe we need to add: “Don’t damage your brain. You’re going to need it someday.”

More and more evidence is accumulating that football, or at least football as it’s currently being played in high schools and colleges, is causing irreversible brain damage. The latest study was published in JAMA this week. Researchers looked at 25 collegiate football players (who had played in high school), and compared both brain imaging and cognitive performance with students who hadn’t played college. They correlated their findings with the number of years of football experience, and the number of recalled concussions.

Bottom line: concussions correlate with a loss of brain volume in the hippocampus, an area of the brain involved with memory recall and the regulation of emotions. Not only were concussions correlated, but  the number of years playing football also correlated with this change in MRI scans and with deficits in cognitive testing, including tests of reaction time and impulsivity.

The study itself wasn’t large, and relied only on the students’ recall of concussions. And it does not establish causality—maybe people with smaller hippocampi are more attracted to football, or tend to have more concussions (though no other research suggests this). Still, studies like this add to the considerable evidence that the kind of high-impact head trauma that occurs during football is causing real damage to real brains.

What can we do about it? There are steps individual families can make to protect their own children, especially by recognizing and treating concussions when they occur. Beyond that, we’ll have to see if coaches, athletes, and families are willing to risk brain damage to continue traditional football programs. Are the benefits worth the risk? It’s time to talk about it.

Protecting your child from concussions

The Pediatric Insider

© 2013 Roy Benaroch, MD

A concussion is a brain injury resulting from a blow to the head. Not the kind of injury you can see on a CT scan or MRI—there’s no broken bones and no squashed or visibly damaged brain. But nonetheless, the brain is damaged. Symptoms tell you immediately after a concussion that the brain has been affected. Sometimes, a person is knocked out cold, but a concussion can occur without unconsciousness. Milder symptoms can include disorientation, confusion, and problems with memory and balance. With time and rest, these symptoms will usually improve, especially after a first concussion.

But sometimes concussions can cause real, lasting brain damage. After a concussion, athletes (both professional and student) can suffer from poor attention, headaches, memory problems, and depression—symptoms that may or may not get better with time. Unfortunately, young athletes may be more at-risk than the pros. Young brains are still developing, and are more likely to be injured. There’s also some genetic variability—some people are more resilient than others to the effects of concussions. Repeated concussions can be dangerous to anyone, and a “second hit” after a concussion that hasn’t completely healed can be deadly.

As I tell the teenagers: “Protect your brain. You may need to use it later.”

What can parents and coaches do to help keep their kids safe?

• Provide good training so young athletes know how to play safely. Support coaches who teach student athletes well, and take potential brain injuries seriously.
• Make sure that athletes have good protective equipment, including helmets and mouth guards. These don’t prevent all (or even most) concussions, but using them consistently and correctly is still important.
• School systems should have mandatory, science-based concussion management systems, developed in accordance with national guidelines.
• Officials and referees need to call fouls, and discontinue play when it’s dangerous. Players who put themselves or others at risk should be sent off the field without hesitation.
• Coaches on the sidelines need to look for even subtle signs of concussion in their players, and pull them out of the game if there are any signs at all. When in doubt, players should sit out.
• Players themselves need to know that they should never tough it out—any “dinger” needs to be reported, even if that means they’ll be pulled from the game. Brains are far more important than scores.
• If your child does have a concussion, be sure to follow the guidance of his physician. A gradual return to sports should begin once symptoms have improved. It’s not necessary — and may be a bad idea — to wait until all signs and symptoms of concussion have resolved. If symptoms worsen with activity, back off again.
• If your child has had more than one concussion, or a concussion with prolonged symptoms, consider working with a neurologist to ensure that there’s no lasting damage.

 

Updated 2/5/2017

Which children with head trauma need a CT scan?

The Pediatric Insider

© 2013 Roy Benaroch, MD

Last time, I wrote about the reasons for the overuse of CT scans in children. They’re incorrectly perceived as necessary, the risks are far away, and no one really cares about the costs and consequences. But I don’t mean to imply that CTs are always bad. Sometimes a CT scan really is a good idea.

Pediatric head trauma can cause significant and lasting problems, and sometimes needs urgent neurosurgical intervention. How can physicians and parents tell which children are at high risk for problems, versus children at such low risk that scanning is unnecessary?

Two recent studies have looked at this issue critically, reviewing “clinical decision rules” that help predict what children are more or less likely to have an important finding on a CT scan after trauma. Both studies tried to identify the best ways, based on only the clinical history and exam findings, to know with close to 100% accuracy which children can safely not have CT scan after head trauma. These rules aren’t designed to “rule in” serious illness—even applying these rules, most CT scans will be normal—but they hope to at least identify which children are very, very unlikely to need a CT scan as part of their evaluation.

From these studies, there are several characteristics that make it more likely that serious injury has occurred in a child, necessitating a CT scan.

The first, and probably the most important, is a persistent change in level of consciousness. A child who is running around and playing is unlikely to have had a serious injury; a child who is listless or sleepy in the doctor’s office or emergency department is very concerning.

Another consideration is the mechanism of injury. Examples of higher-risk injuries include a car crash with ejection of the passenger or a rollover, or a cyclist without a helmet being struck by a vehicle. Also, the distance of a fall is important. Though the exact numbers vary, many doctors consider a fall onto the head of more than 5 feet for a child or 3 feet for a baby or toddler to be “high risk.” Head bonks after lo risk mechanisms (such as falling backwards onto the floor or into furniture, or running into a door) are much less likely to result in a serious head injury.

Persistent vomiting or a persistent, severe headache are symptoms that can also raise concern for a more-serious injury. Now, many children get upset and vomit once; and everyone complains of a headache right after an injury. It’s persistent or severe symptoms that are concerning.

On the physical exam, certain findings should prompt increased need for a scan. These include large raised bumps (though NOT bumps on the forehead—those are common and unlikely to represent serious injury unless accompanied by other findings), or palpable depressions in the skull from fractures, or findings that suggest a fracture at the base of the skull like blood behind the ears.

Some people consider loss of consciousness at the scene of the injury to be at least a “minor” sort of red flag. A very brief loss of consciousness is unlikely to be indicative of a problem, but it may be worthwhile to observe patients with a history of even a brief period of unconsciousness to see if other issues develop.

Studies have confirmed that if none of these “red flags” are present, the chance of there being an important finding on CT scan approaches zero. But, of course, there can’t be any guarantees—there may still be a 1 in a million chance that even lacking any of these findings, there may be something on a CT. Making clinical decisions is never 100% ironclad certain.

These rules, of course, have to be individualized. Children who are younger or who have developmental challenges may not be able to tell you about symptoms; children may have complicating health issues that may increase their risk of problems or complications. Also, the exact history is sometimes unclear. So applying these rules isn’t something I’m encouraging parents to do—these are decisions to make with your doctor’s guidance. Still, I think it helps if parents know what kinds of things doctors are looking for.

Even if one or more than one of these “positive predictors” is present, the chance of an abnormal CT is still quite small—so not everyone with one of these findings needs a scan. That ought to be an individualized decision based on the judgment of the physician, the feelings of the parents, how well follow can be assured, the overall health of the child, any many other factors. But by trying to reduce at least some of these CTs when “red flags” aren’t present, many unnecessary studies can be safely skipped.

If your child has had head trauma, go to the ED immediately if there are persistent symptoms including loss of consciousness, altered consciousness, vomiting, or severe headache. Otherwise, it may be best to call your child’s physician to discuss what happened and get guidance on whether an ED eval is needed, and what to look for, and how to help your child be more comfortable. Not everyone benefits from a CT scan, and you can do your child a big favor by keeping him out of the scanner when he doesn’t need it.

Previously: Why are so many unnecessary CTs done?

Next: More about cancer and CT scans. I bet you can’t wait!