Yesterday, I had the honor of being a guest at the groundbreaking ceremony for the Micheli Center For Sports Injury Prevention, which is being built next to Children's Hospital Boston's Waltham, Massachusetts facility.

There isn't a person working in the field of youth sports injuries who does not immediately recognize the name Lyle Micheli, MD.  He founded the first youth sports injury clinic at Children's Hospital in 1974.  Dr. Micheli was also one of the first, if not the first, doctor to sound the alarm bells about overuse injuries.  He has seen first hand how year-round sports and early specialization have taken their toll on the bodies of our kids, and has worked tirelessly over the years to make youth sports safer.  It is not a stretch to say that Lyle is one of the truly great sports medicine doctors of this or any generation.

Kicking off the event was MomsTEAM expert William Meehan, MD, Director of the Sports Concussion Clinic in the Division of Sports Medicine at Children's Hospital Boston, and the Director of the new Micheli Center. Bill spoke about the need to prevent injuries in kids sports and the role of the Micheli Center will play in that mission, one which MomsTEAM has shared from its inception. 

Speaking of sharing, Dr. Micheli told us a wonderful story about his mother, who used to collect coal on the train tracks as a young woman and carry them in a large basket on top of her head. She was a soccer player, but managed to avoid the ACL injury problems that have reached epidemic levels among the young female soccer players of today.

Lyle believes that the reason the number of sports injuries is so high today is that our children do not have the opportunity to build up their muscles the correct way as kids once did while working on family farms, doing chores around the home, walking or riding their bikes to school, and in unstructured play in the neighborhood.

He also believes that, to avoid crippling ACL injuries, our sports-active daughters need to begin strength and conditioning training earlier (at the ages of 8, 9 or 10), even earlier than recently recommended by the authors of a new study on the benefits of neurmuscular training (NMT) for female athletes, who suggest that the best time to begin NMT may be in their mid-teens.

Micheli declared that the new center named in his honor will be, as the name states, all about preventing injuries, and he told us that it will do in three important ways:

1. By providing access to young athletes so they can train correctly to prevent injuries (look for three new gymnasiums and training rooms when construction is complete in 2013);
2. By developing a customized, individual profile for each young athlete to determine what they need to strengthen in order to avoid sports injuries; and
3. Through cutting-edge injury prevention research, an area in which we do not have enough good data.

In addition to Drs. Micheli and Meehan, we also heard from special guest speaker, former New England Patriot, three-time Super Bowl winner and cancer survivor, Joe Andruzzi.  He spoke about the importance of taking the rehabilitation process after injury slowly under the guidance of experts who are able to help determine the best way to structure rehab so that an injured athlete ramps up weight training gradually in order to rebuild muscles to stabilize joints. Joe's story about how he used a positive attitude and a sense of humor to beat cancer is truly inspirational.

Inspiring, too, is the work of people like Lyle Micheli and Bill Meehan in making youth sports safer.  It was such an honor to be invited to the event.

The other day I was asked in a radio interview what I thought were the biggest recent developments in concussion safety, and what I saw happening in the near future to protect our kids from the dangers of brain injury in contact and collision sports.  Here are the five developments that I view as the most significant, and a seven-point "wish list" for what I hope to see in the not too distant future to make such sports even safer:

Recent developments 

1.  Concussion safety laws.  This one, pardon the pun, is a no-brainer.  The passage of strong youth sports concussion safety laws by 40 states and the District of Columbia over the past two years promises to do more than anything that has ever been done to improve the safety of contact and collision sports.  Each law contains three components that MomsTeam and I have long been advocating:  First, that the education of parents and athletes about concussion safety before every season be made mandatory if the child is to play.  Second, that athletes suspected of concussion be immediately removed from the game or practice (as all current expert guidelines provide), and, third, that they not be allowed to return to the game or practice field until a health care professional with concussion training and expertise gives the okay.

Such laws will go a long way to protecting against athletes, not only from death from second impact syndrome (uncontrolled bleeding in the brain from a blow to the head before the brain has fully healed from an earlier injury) such as in the well-publicized cases of Ryan Dougherty of New Jersey, Jake Snellenberg in Colorado and Matthew Gfeller in North Carolina, but permanent disability, like that suffered by Zack Lystedt, which inspired the first of such laws in Washington State two years ago.

To parents, coaches, administrators, legislators, and governors in the other states, some which have weak concussion safety laws (Idaho, Vermont, and Wyoming), and some where legislation is pending or about to be reintroduced, but especially in the six states where no concussion safety bills whatsoever have even been introduced (Arkansas, Georgia, Kentucky, Mississippi, Montana and West Virginia), I ask, what are you waiting for? Help enact a law in your state now!  We owe to it the kids.

2. Exciting new technology:  Athough we are a long way off from seeing helmets or other equipment that can prevent all concussions, and, frankly, that day may never come, there is a lot of exciting new technology coming on the market. 

Helmet sensors

The latest product to hit the market is the Shockbox^TM wireless impact sensors from Impakt Protective.*  Once attached to a player's helmet (a hockey version is available now, versions for football, lacrosse, and ski and snowboard helmets will be introduced in 2012) a sensor measures the G-Force of a hit to the helmet from any direction, and then sends the data wirelessly via Bluetooth to the athletic trainer, coach or parent's smart phone to alert them when the athlete suffers a traumatic head impact that may be concussive so they can be removed from the game or practice for evaluation on the sideline using standard concussion assessment tools, such as the Standardized Assessment of Concussion, Sports Concussion Assessment Tool (SCAT2) or King-Devick test.

It essentially gives parents, trainers, coaches and team doctors a set of electronic of eyes with which to watch out for concussions that might otherwise go undetected, either because the signs were too subtle to be seen by officials, coaches, athletic trainers,  team doctors or parents on the sports sideline, or because the player, out of a desire to stay in the game, failed to self-report experiencing concussion symptoms such as headache or dizziness that warrant, at the very least, further evaluation.

Another is Battle Sports Science's Impact Indicator,* a football chinstrap that flashes red when a force is transmitted to the head that may be enough to cause a concussion, alerting game officials and sideline personnel to check an athlete for signs or symptoms of concussion (even if they haven't observed any signs and/or the athlete hasn't self-reported experiencing any symptoms). Chinstraps are now available for football helmets, and versions for hockey and lacrosse - two sports with high concussion rates - will be in stores soon. 

Smart phone apps

In addition, there are now five concussion apps for smart phones on the market for parents and coaches:

1. the CRR (Concussion Recognition and Response) app developed by concussion experts at the National Children's Hospital in Washington, D.C., and at the University of North Carolina;
2. The Concussion App from Sports Safety Labs LLC
3. An app called Play It Safe developed at the University of Texas;
4. An app based on the SCAT2 sideline assessment test;  and
5. The ImPACT concussion awareness tool (ImCAT) from the same folks at the University of Pittsburgh who developed the ImPACT^TM computerized neurocognitive test in widespread use at the professional and college level and, increasingly, at the high school level as well.

For a review by the MomsTeam staff of the new concussion apps, click here.   

3. Exciting old technology with a new use: another tool that is being added to the concussion toolbox to help in the sideline assessment of concussion is the King-Devick test, a 25-year old test of rapid eye movements that two studies at the University of Pennsylvania, one of kick boxers and mixed martial arts athletes and a second more recent one of college athletes at Penn, show can be used to help identify athletes that may have suffered a concussion and warrant further evaluation away from the sports sideline. As with the Impact Indicator, the King-Devick won't prevent concussions, but, used in conjunction with other assessment tools in use on the sports sideline (e.g. SCAT2, Balance Error Scoring System), Post-Concussion Symptom Scale), identify athletes who should be referred for further evaluation.  And, speaking of old technology with a new use, a new campaign called BeUnstoppable, a collaboration between  Chicago-based Healthy-TXT and the STOP Sports Injuries Campaign (of which MomsTeam is a proud member), is using text mesages - which studies show are the best way to reach kids these days - to educate parents and kids.  Subscribers are sent free text messages on simple text messages about concussions, sports performance, injury prevention, and motivational tips from leading sports medicine experts and professional athletes.

4. New rules and stricter enforcement of existing rules: Not only is the NFL more strictly enforcing the ban on intentional helmet-to-helmet tackling of defenseless wide receivers, but the NHL is finally tightening substantially its rules against head shots, although it is too bad implementation came only after a concussion sidelined its biggest star, Sydney Crosby from January to November 2011.  Two recent rule changes are particularly noteworthy: first, the Ivy League's reduction of the number of full-contact practices in football, which came in response to recent studies by researchers at Purdue and Boston University showing that the cumulative effect of blows that aren't enough to result in concussion may be doing short-term and, unfortunately, long-term damage, including CTE, and, second, the adoption by USA Hockey in June 2011 of what it calls its Progressive Checking Skill Development Policy, which tightens the standard of play for intimidation hits in the legal body checking age categories, and only allows, beginning in the 2011-12 season, legal body checking in games at the Bantam age level (ages 13-14).

What next?

I don't have a crystal ball, but, based on where we have come, I believe, or at least hope, the future will bring the following improvements in concussion safety:

1. Limits on contact practices. Look for adoption of the Ivy League rule limiting the number of contact practices to spread across all of college sports and, sooner rather than later, down to the high school level and below.
2. Stricter enforcement of existing safety rules, and adoption of new rules in contact and collision sports.  We are never going to eliminate all the risk, but we need to do even more to reduce the risks.  Chances are, hopefully sooner than later, strict youth sports concussion safety laws will be put in place in all 50 states. Rules governing contact and collision sports at the youth level will also be modified to make the sports safer and reduce the risk of concussion.
3. More and better education of coaches, parents, and athletes.  Education has been a cause to which MomsTeam has been totally committed for over a decade.  Increased awareness by parents, coaches, and athletes of the critical importance of physical and cognitive rest after concussion will help speed the recovery process.  A better understanding not only of the signs and symptoms of concussion, and of the risks from returning to play before symptoms have not only cleared, but the need for athlete's cognitive functioning (memory, concentration, reaction time, reasoning processing) to return to baseline before return to play is permitted, will put fewer athletes at risk of delayed recovery and long-term injury.
4. More baseline and post-concussion neurocognitive testing. Even if the tests, (e.g. ImPACT^TM) in current use aren't perfect, when properly administered and evaluated by a health care professional with the appropriate training and expertise (e.g. neuropsychologists), studies are showing that they clearly help make sports safer, both by identifying athletes who have suffered concussion but, because they have either failed to self-report their symptoms or escaped detection in the initial instance because the signs of injury were so subtle as to avoid detection through other means, have fallen between the cracks, and by keeping athletes on the sidelines until their cognitive function has returned to their individualized normal, even if they themselves believe they have sufficiently recovered to return or, out of a misguided belief that it is safe to play while still experiencing symptoms, simply lie.  A 2011 study reports that, in the 42% of U.S. high schools that have at least one athletic trainer on staff, the use of computerized neuropsychological tests continues to rise rapidly, increasing to 41.2% of all concussions recorded from 25.7% just a year earlier.¹ 
5. More athletic trainers. Less than half of all high schools in this country have access to or a certified athletic trainer on staff. Legislation at the federal and state level to require and/or fund more ATCs hasn't gone anywhere so far, but we need to get to the point where communities and school boards see devoting resources to hiring ATCs, instead of building fancy stadiums and hiring more assistant coaches for a football program, as the best way to use the limited funds available and to protect our kids, who, after all, are our future.
6. Continued research. There have been lots of studies of concussed athletes at the pro and college level, and even of high school athletes, but we still don't know much about the effects of concussion on the developing brain of younger athletes, and what we do know is prompting at least some concussion experts to suggest that kids delay playing contact or collision sports until middle school or later, or that, at the very least, the rules be modified for the younger athlete to reduce the risk. We still don't know whether mouth guards do anything to reduce the risk of concussion, and research on the cumulative effect of concussions and sub-concussive blows is still in its infancy.
7. Culture change: Ultimately, I hope to see a change in the very culture of sports itself, including elimination of the "code of silence," leading to more honest self-reporting by athletes about symptoms.  One of the major, ongoing problems in the concussion area is the chronic under-reporting of concussions by athletes.  As the risks of not reporting concussion symptoms are more widely known, I think we will see more parents, coaches, and athletes come to their senses, literally, about the dangers of concussions.

* MomsTeam sponsor.

1.  Meehan WP, d'Hemecourt P, Collins C, Comstock RD, Assessment and Management of Sport-Related Concussions in United States High Schools. Am. J. Sports Med. 2011;20(10)(published online on October 3, 2011 ahead of print) as dol:10.1177/0363546511423503 (accessed October 3, 2011).

Updated and revised October 2, 2012

A couple of weeks ago a team and league management technology provider and a neurocognitive testing company announced a partnership to provide online testing for athletes. The announcement prompted emails to MomsTEAM from parents asking for my opinion on how and where to have their children's baseline neurocognitive tests done, and whether they could do them at home.  While I have been fielding similar e-mails for years, the uptick in emails prompted me to do some digging to come up with an answer.

In formulating a response, as with so many other aspects of youth sports, I was able to draw on my own personal experience as a sports parent and the past 12 years of covering the concussion beati. Back before they were computerized, one of my sons (the one who played football) took the old "paper and pencil" neurological exam. The test was administered by a neuropsychologist who had been trained to give the tests, and who had given them to hundreds, if not thousands, of children before she switched over to using a computerized exam.  I also asked MomsTeam's concussion experts for their opinions.

I recalled a conversation I had with my son's pediatrician when he explained why he was referring him for testing in Boston by a neuropsychologist.  He told me that, when it comes to matters involving the brain - the most delicate and important of all organs - one needed to "work with those who are highly trained in the field of neuropsychology; that even we [pediatricians] defer to their results."

The more things change ...

Yes, a lot of time has past since then, and a lot has happened over the past decade in terms of what science knows about concussions, and in technological advances. We know so much more than we ever did. 

But, in some ways, things haven't changed all that much.  Yes, paper and pencil tests have largely given way to computerized tests (you may have heard of the Immediate Post-Concussion Assessment and Cognitive Testing, or ImPACT tests, for short), which are now being administered in stand-alone concussion treatment centers all across the country or in a hospital setting.

We also know that, increasingly, baseline tests (which can include, not only computerized neurocognitive tests, but balance tests, and of vision) are being administered by trained personnel at the nation's high schools, especially those that have an athletic trainer on staff.  And now, a child can even log on to a website of a youth sports organization, testing company, or a sporting goods store to take a baseline test, and he and his parents can get the results with a click of a mouse.  It is these tests, taken online without any supervision, which seem to be the ones parents are asking me if they are "safe" and "ok" for their children to take.

It is not up to me, of course, to tell parents what they can or cannot do. The "dash board" types of tests are an option.  But based on the research I have studied, the opinions of experts I have consulted, and, frankly, my own personal experience, I come down strongly on the side of those who feel the taking of an online baseline test is not the way to go.

Looking back on the time and care that my own sons' neuropsychologist took in administering the test, interpreting the results, and then going over them with me and my son in detail, and how much I counted on the reliability of the test results, which I needed not only in working with his school on an individualized education plan (IEP) but to compare against the results obtained after he suffered concussions, I cannot square in my mind how a "dash board" take at home test can achieve the necessary degree of reliability to be of much use, beyond perhaps giving parents a sense that the blow to the head their child suffered in yesterday's soccer game wasn't so bad because, comparing his baseline to post-injury test results doesn't show much of a difference.

... the more they stay the same.

My recommendation to parents is to leave the concussion testing where it has always been: in the hands of concussion professionals.  While it may be tempting for parents to think that the technology has advanced so far as to eliminate the need for trained professionals in administering and interpreting neurocognitive test results, and while home concussion testing may be all the rage, I don't think we have reached that point.  We may someday, but, in my view, we aren't there yet.  Not by a mile. I just don't think parents of athletes in contact and collision sports can afford to take a chance.  We're talking about our kids' brains, here, after all.

Should every child playing sports or engaging in activities in which concussion is a possibility, such as winter sledding or even riding their bike, have access to affordable, reliable neurocognitive testing? You bet. I hope to see a day in the not too distant future when periodic baseline computerized neurocognitive testing will become a routine part of a child's pre-participation or sports physical.  But neurocognitive tests need to be administered by professionals with appropriate training and experience (e.g. Credentialed ImPACT Consultant). Period.  End of story.

Don't have to take my word for it. If you aren't inclined to believe me (after all, while MomsTeam and I have been at the forefront of concussion prevention and education for more than a decade, I don't have any initials after my name), I invite you to read what Rosemarie Scolaro Moser, Ph.D., a leading sports concussion neuropsychologist, MomsTeam expert, has to say about the challenge, even for trained experts, of obtaining valid baseline test results, and why parents should exercise caution in buying baseline tests on line for their child to take at home. *

Look before you leap, so the saying goes.  In the case of neurocognitive testing, it couldn't be more true.

Questions/Comments? Reach me at delench@momsteam.com 

*Important April 18, 2012 update: The Centers for Disease Control and Prevention's recently issued "FAQs about Baseline Testing among Young Athletes¹ supports my position stating that: (1) Baseline tests should only be conducted by a trained health care professional; and (2) "[o]nly a trained health care professional with experience in concussion management should interpret the results of [a] baseline exam.  When possible, ideally, a neuropsychologist should interpret the computerized or paper-pencil neuropsychological test components of a baseline exam."

1. http://www.cdc.gov/concussion/pdf/baseline_testing_FAQs-a.pdf)(accessed April 16, 2012) 

If you saw the recent stories  about the preliminary results of the two-year, $6 million dollar high school steroid testing program in Texas, you might be confused.

On the one hand, the program didn't catch many users: of the 10,117 students tested in 2008 under a state-mandated program in Texas, only four tested positive for steroids (resulting, for the first offense, in a 30-day suspension of the student from playing his or her sport), although another 22 cases were classified as "positive" because students either refused to provide urine samples, were absent from school without excuse on the day they were supposed to be tested, or left the testing area without approval.

On the other hand, proponents of the testing program called it "an incredible success" because the point was to deter drug use, not catch offenders; as Texas Republican state representative, Dan Flynn, who sponsored the testing bill in 2007, told reporters, "We don't have a bunch of pelts hanging on the wall. The success is that we haven't had a lot of positive tests."

Testing programs in a handful of other states have yielded similar results: A one-year, $100,000 program in Florida tested 600 student-athletes in 2007 was discontinued after only one student tested positive for steroids. Random testing in 2006 in New Jersey produced one positive result from 500 athletes screened. Results from Illinois, which is testing athletes at its state championship events, are not yet available.

The testing programs undoubtedly act as a deterrent to some, but few athletes are tested, the tests only detect certain steroids, and the Internet is full of tips on how to avoid detection.

My position, as it is with respect to so many safety issues in youth sports, has always been that education is the key; that the best way to reduce steroid use among teen athletes is through straight, honest talk in a setting that allows for give-and-take with student-athletes.

While I like the award-winning public service campaign called "Don't Be An Asterisk" about the dangers of steroid use, I think the best way is for high schools themselves to do the education. After all, they are in the education business. 

Fortunately, high schools don't have to reinvent the wheel when it comes to steroid education: there are already programs on the shelf, including a multimedia educational initiative called "Make the Right Choice" from the National Federation of State Athletic Associations (NFHS) , and, most notably, the award-winning ATLAS (Athletes Training & Learning to Avoid Steroids) and ATHENA (Athletes Targeting Healthy Exercise & Nutrition Alternatives) programs from Oregon Health & Science University they can use.

More and more schools seem to agree with me.

At the very least, parents have, in my view, a responsibility to be proactive when it comes to the use of performance-enhancing drugs.

• Talk to your kids about the risk of permanent injury and criminal consequences (including up to a year in jail and a minimum $1,000 dollar fine).

• Scare them with a horror story or two. 

• Become educated about the visible signs of steroid use and be on the lookout! 

• And, finally, don't ignore the problem. If you suspect your child is using steroids, seek help immediately before it's too late.

"I spend more time on health and safety than any other issue."

~~ Roger Goodell, National Football League Commissioner

Last week I attended a luncheon in New York City hosted by the National Football League and its youth football partner, USA Football. In Part Two of my "Summer of Football" blog series, I will focus on some of the important information I took away from the luncheon.

Much of what the speakers told the gathering of thirty or so journalists, bloggers, and experts, including a lot of what they said parents needed to know about concussions and football safety, is advice that MomsTEAM has been giving parents for years, including:

• recognizing the signs and symptoms of concussion;
• educating their child on the importance of honest self-reporting;
• appreciating what a properly fitted helmet can and can't do;
• being skeptical of product claims, such as those which the subject of the FTC's settlement with mouth guard manufacturer, Brain-Pad;
• appropriately weighing the risks and rewards of playing a particular sport and whether to retire from a contact or collision sport;
• ways to reduce their child's risk of injury, including overuse injuries, such as by not playing on two or more teams in the same sports season;
• making sure their child's coach puts the safety of players above winning, and talking to the coach or going over their head to the league commissioner where necessary; and
• knowing their state's concussion safety law.

So what really stuck with me more than anything was the statement by Roger Goodell that he spent more time on health and safety than any other issue.  While I shouldn't have been surprised at his admission, given the lawsuits that have been filed against the league by former players, and the efforts by N.F.L. to protect the safety of current players, what impressed me the most was what the league and USA Football have done and were doing to improve health and safety of all who play football, from the pros down to the youth level, which fall into 6 general categories:

1. Research: Goodell told us that the N.F.L. has spent over $100 million on football-related medical research; 
2. Equipment: The league is partnering with USA Football, the U.S. Consumer Product Safety Commission, and helmet manufacturers to replace outdated helmets worn by young football players in underserved communities; the pilot program is slated to replace 4,000 program in its first year;
3. Education: In addition to talking about USA Football's Heads Up initiative for teaching proper tackling as a way to reduce the risk of concussion and catastrophic head and neck injuries, Executive Director Scott Hallenbeck gave us a sneak peak at a very promising new smart phone app for coaches that will go on sale as soon as it is approved by the folks at Apple.  The N.F.L. is also a big supporter of the Centers for Disease Control's efforts in raising concussion awareness among coaches and parents.  The C.D.C.'s Kelly Sarmiento told us about its plans to introduce a  "Heads Up: Know Your Concussion ABCs" in time for school this fall, and a new program coming soon which will allow schools and teams to add their colors to handouts (although the CDC no longer sends out concussion kits, so it's best if team administrators (a/k/a 'team moms') print them directly off the CDC website).
4. Rules: Not much was said on this, but the rule changes implemented by the N.F.L. in recent years, such as moving kickoffs from the 30 to 35 yard line, and banning helmet to helmet contact of defenseless players have been well-publicized and seem to be cutting down on concussions and serious head and neck injuries.
5. Advocacy: I will have more to say on this subject in Part Three of the Summer of Football blog series, but the N.F.L. deserves kudos for lobbying in favor of passage at the state level of Zackery Lystedt Laws.  Thirty-six states and the District of Columbia have passed such laws since the league began its lobbying effort, and the N.F.L. promised to continue to lend its support until similar legislation is adopted in every state.  For where each state stands with respect to concussion safety laws, click here.
6. General health and safety:  A long list of accomplishments and ongoing initiatives here, including

• NFL Play It Safe! (educational books and posters about strength conditioning, first aid, nutrition, and psychological health which were distributed to 15,000 high school football programs and more than 10,000 youth football organizations across the country, and available on the USA Football Website;
• ATLAS and ATHENA: $2.6 million to Oregon Health & Science University's nationally-acclaimed Athletes Training & Learning to Avoid Steroids (ATLAS) and Athletes Targeting Healthy Exercise & Nutrition Alternatives (ATHENA) programs to promote healthy living and reduce the use of steroids, human growth hormone and other drugs among high school athletes, which have reached more than 30,000 high school students and 800 coaches;
• Gatorade and Heat and Hydration Safety: N.F.L. support for Gatorade's development of a heat safety kit and Beat the Heat Campaign to educate athletes, parents and coaches about proper hydration in sports;
• NFL PLAY 60: launched by the N.F.L. in 2007, the program tackles childhood obesity by encouraging kids to be physically active for at least 60 minutes a day.  The league has since joined forces with partners such as the American Heart Association, KaBOOM!, National Dairy Council and United Way to create school programs and build new places for kids to be active, and is collaborating with First Lady Michelle Obama's Let's Move Campaign.

Clearly, no matter what you may think about what the league has done, or not done, in the past about health and safety, these initiatives deserve praise.

In Part Three, I will focus on where we have come on football safety, where we are, and where we are headed, discuss the results of MomsTEAM's poll of football parents (over 264 responses so far!), the N.F.L.'s responses to a series of questions that I had hoped to but was unable to ask last week at the luncheon in New York City, and suggest some new safety initiatives the league might consider for the future.  

For Part One in this blog series, click here.