The issue of concussions and their long-term effects have been thrust into the spotlight in recent years, plucked from the realm of more specialized medicine and placed in the forefront not only of medical care but society at large. There have been books and movies, not to mention various forms of snake oil that are peddled to the masses with dubious promises of protection from concussions or speedy recovery.
All this attention is well deserved. Concussions are much more common than was once thought and may have more significant long-term consequences than was once realized. Although the breadth of research into this area seems to expand on a daily basis, there are still more questions than answers when it comes to advising patients and their families.
Take, for instance, two recent studies. The first, published in JAMA, was a retrospective study that examined the brains of 202 deceased football players for evidence of chronic traumatic encephalopathy (CTE). The condition was diagnosed in 87 percent of brains overall and 99 percent of 111 brains from NFL players.
The study also noted a trend toward increasing severity of CTE related to higher levels of the sport. However, connecting these pathologic findings with clinical disease is difficult, given that the study included retrospective telephone interviews that have limited reliability and bias. There is also inherent bias in the sample of donated brains (i.e. brains may be more likely to be donated if the athlete or player had clinical symptoms) and there was no control sample.
The second study was published in Frontiers of Neurology and evaluated 65 asymptomatic college athletes with MRI scans. This study noted changes in white matter in the brains of those athletes in contact sports compared to athletes in noncontact sports. This study again noted no clinical syndrome to correlate with the findings on MRI, so the actual impact on the athlete in terms of function remains unclear.
Although these studies help advance our understanding of how concussion and subconcussive impacts may affect the brain, there is little to help us counsel patients in their daily lives. As family physicians, we are increasingly in positions to diagnose and manage concussions, but there is a dearth of evidence to guide us when patients ask questions like, "Should I allow my son to play football?" Or, "My daughter has had two concussions. How will this affect her?"
More on that in a minute.
Simultaneously there is another concerning trend in the wide world of sports, one that has managed to remain mostly in the shadows but threatens to compound the concerns raised by recent concussion research. That trend is early sport specialization. An increasing number of young athletes participate in only one sport year-round. When I was a child, we played football in the fall, basketball in winter and baseball in the spring or summer. Recently, I have provided care for athletes as young as 6 or 7 who play one sport year-round, on multiple teams at the same time. This trend is fueled, in part, by parents' dreams of college scholarships or misguided notions that this type of training is required for their child to become a professional athlete. There also is increased pressure from coaches, travel teams and other sports organizations seeking to capitalize on this trend.
In reality, stories like that of Tiger Woods, who started golfing at age 2, are the exception rather than the rule with professional athletes. And one cannot help but wonder, given his numerous off-the-course problems, if there were negative effects connected to the pressure and expectations he experienced at a young age. There is a growing body of evidence that early specialization in a sport could increase the risk of injury, leads to less enjoyment and often makes these children more likely to quit the sport.
So what happens when we combine the facts that A) research suggests that even subconcussive impacts can cause changes to the brain on MRIs, B) that athletes with histories consistent with more impacts have higher risk of CTE and C) some children are devoting themselves to one contact sport at earlier and earlier ages?
It's not good, people.
So how do we counsel our patients and parents? I recommend counseling routinely at annual wellness visits and also taking advantage of teachable moments. Johnny has Little League shoulder? Take that moment to ask about participation on multiple teams, playing a single sport year-round, pitch counts, etc. I recommend that athletes have at least one or two days a week off from sports and participate in a single sport no more than nine months out of the year.
Most of my counseling for concussions is done along with management of a concussion. I think there is enough data to support counseling parents and athletes that multiple concussions can be harmful and that perhaps even long-term participation in contact sports could pose dangers both in mental and psychological function.
It's worth noting that the AAFP has resources related to head injuries and safe sports participation. The American Academy of Pediatrics has a good clinical report on sports specialization in young athletes.
However, I feel there is little helpful prospective data concerning routine counseling at annual visits at this time, but such counseling may be worth it for those at higher risk. If an athlete has history of multiple concussions, then I have a discussion with the athlete and family about what their aspirations are in life and in sports to determine if changing to noncontact sport may be in the athlete's best interests. I advise them of the risks but am honest about the need for more research. This lends itself well to a shared decision-making model where the decision is tailored to each athlete and family.
In short, despite the many questions we still have regarding concussions, family physicians can be effective in counseling athletes and parents about safe sports participation. We need to keep our finger on the pulse of new research that will continue to expand our understanding of these issues and refine our ability to guide our patients down a path of better health.
Peter Rippey, M.D., enjoys outpatient family and sports medicine practice in a hospital-owned clinic in South Carolina.