Talking past each other?
Closer examination of the positions staked out by Kontos and Collins, on the one hand, and by Bailes, Omalu, and Butler, on the other, suggests. however, that, despite the overheated rhetoric, their positions are not as diametrically opposite as first appears, and that the solution, as if often the case, probably lies somewhere in the nuanced middle.
Kontos was quick to tell USA Today that Bailes was misreading what the study said. "We don't want more head-to-head contact. What we want is more contact practices where we teach proper technique to avoid head-to-head collisions in games. And, if we don't have good practices to teach that, we're sending kids out unprepared to make those tackles."
This is precisely what experts on the teaching of tackling recommend, including Coach Bobby Hosea, whose heads-up tackling technique has been adopted by USA Football and is featured in MomsTEAM's high school football concussion documentary, "The Smartest Team."
Sadly, such are the high stakes in the politically-charged world of concussions in football that, even when there is general agreement, in this case, that kids need to learn how to tackle safely, the UPMC researchers and the study's critics come off sounding like arch-enemies.
Limiting contact to reduce exposure to sub-concussive hits
Also lost in the back-and-forth between Kontos and Bailes et al is another very important point: that reducing the amount of contact during practices - as is now being done, to a greater or lesser extent, at all levels of football - from the pros to college football (e.g. Ivy League, and, the Pac-12, and, most recently, in a recommendation from the NCAA) to the high school level (Arizona, Washington State, Iowa, Texas, and California, among others, have all recently moved to limit the number of full-contact practices in spring football or during the regular season, or eliminate them altogether) to Pop Warner - is intended not just to reduce the number of concussions during practice, but also to limit the amount of total brain trauma sustained as a result of repetitive sub-concussive hits.
Repetitive, low-impact hits have been linked in a number of recent studies in football (7,8,9) and in soccer (10) to short- and possibly long-term brain damage. A 2012 Virginia Tech study found that youth football players are sometimes subjected to hits as hard as their bigger, faster and older counterparts at the high school and college level. (11)
To be fair, Kontos and his co-authors do make a point of noting in their study that "we know little about the potential for long-term effects from repetitive exposures to subconcussive impacts that might occur in practices and games. As such, we cannot discount the potential effects of reducing practice exposures on effects related to repetitive subconcussive impacts." Yet, one wonders why, if that was the case, they elected to take such an obvious swipe at Pop Warner without all the facts.
Taking into account both the risk of injury from concussion and that from repetitive sub-concussive blows, the challenge for both scientists and youth sports organizations is thus to find a way to somehow perform a delicate balancing act: to reconcile two competing demands: to minimize contact practice in order to reduce the number of concussions sustained in practice and repetitive sub-concussive impacts that emerging science suggests may have a deleterious long-term health effects, while at the same time maximizing the amount of contact practice, time that is needed to maximize the protective effect of proper tackling on the number of concussions players sustain in game action.
Study limitations
Kontos admitted that the study, believed to be the first of its kind to study concussion rates at the youth football level, was limited by several factors:
- the sample size (468 players on 22 teams; 11,338 AEs of which 8,415 were practice and 2,923 were games) was small for a epidemiologicall study [Note: a much larger study commissioned by USA Football, the results of which are expected to be issued in the first quarter of 2014, involves nearly 2,000 youth football players on more than 100 individual teams, and generated more than 60,000 AEs in just its first year alone);
- it was geographically limited (youth football players in Western Pennsylvania) and thus may not reflect trends in other geographic regions of the country [Note: the USA Football study is monitoring 10 youth football leagues of varying size and demographics in six states: Arizona, Indiana, Massachusetts, Ohio, South Carolina, and West Virginia];
- the surveillance period was short (only a single season)[Note: The USA Football study is being conducted over two years];
- concussion injury rates in practice may have been underestimated because access to medical personnel during practices was much more limited than during games, when licensed medical professionals (e.g. emergency medical technicians, physicians) were present to assess and manage athletes suspected of having sustained a concussion, forcing researchers to rely on potentially unreliable reports from coaches - who all received preseason concussion education and were contacted 2 or 3 times per week to determine if any suspected concussion occurred during practices - instead of the certified athletic trainers or physicians who recorded data for the high school and college studies of concussion rates (2-5)
- observation during games was hampered by the fact that personnel was typically at field level or just 1 to 3 meters above field level, which likely explained the inability to identify the injury mechanisms in fully 45% of the concussions.
Only one piece of concussion puzzle
Preventing concussions and reducing the amount of trauma resulting from repetitive sub-concussive blows is also just one piece of a larger concussion puzzle.
Just as daunting a challenge is to identify athletes with suspected concussion so they can be removed from practice or game action, and not allowed to return to play (RTP) until their brains have been given a chance to fully heal.
This is an issue of particular concern in youth football, where there generally are no certified athletic trainers or other medical personnel on the sideline trained to spot the often subtle, sometimes even undectable, signs of concussion, and make the all-important decision to remove a player from a practice or game designed to minimize the risk of a delayed recovery and long-term problems.
No wonder that, as the Post-Gazette put it, "the conclusion on whether parents should allow or encourage children to play tackle football remains stuck in a place nobody wants it to be -- without a definite answer and with more research still needed."
In other words, to paraphrase The Eagles, the more we know, the less we understand.
Update: In a 2013 study (12), researchers at Wake Forest Baptist Hospital and Virginia Tech found that less contact during practice could mean a lot less exposure to head injuries among young football players and the kind of repetitive subconcussive blows that some researchers suggest can lead to long-term brain injury, but does not result in exposure to higher impact hits during games. [
Researchers measured the number, force, location, and effect of blows to the head in 50 youth-league players ages 9 to 12. Their study followed a 2012 study (11) of small group of youth players, ages 7 to 8, in which they found that most high impact hits occurred during practice, not games. That study prompted Pop Warner to swiftly move to impose limits on the time spent in full-contact practice.
The new study involved one team that, while not affiliated with Pop Warner, chose to follow its new practice rules, and two others that did not. Significantly, the data showed that reducing the number of head hits in practice did not, as the study by the UPMC discussed in this article (1) predicted, lead to higher force impacts during games.
1. Kontos P, Fazio V, Burkart S, Swindell H, Marron J, Collins M. Incidence of Sport-Related Concussion among Youth Football Players Aged 8-12 Years. J Pediatrics 2013. DOI 10.1016/j.jpeds.2013.04.011
2. Gessel L, Fields S, Collins C, Dick R, Comstock RD. Concussions among United States high school and collegiate athletes in 20 sports. J Athl Train 2007;42:495-503.
3. Marar M, McIlvain N, Fields S, Comstock R. Epidemiology of concussion among United States high school athletes in 20 sports. Am J Sports Med 2012;40:747-755.
4. Lincoln AE, Caswell SV, Almquist JL, Dunn RE, Norris JB, Hinton RY. Trends in concussion incidence in high school sports: a prospective 11-year study. Am J Sports Med 2011;39:958-63.
5. Hootman J, Dick R, Agel J. Epidemiology of collegiate injuries for 15 sports: summary and recommendations for injury prevention initiatives. J Athl Train 2007;42:311-319.
6.http://www.popwarner.com/About_Us/Pop_Warner_New/Rule_Changes_Regarding_Practice___Concussion_Prevention_s1_p3977.htm
7. Talavage T, Nauman E, Breedlove E, et. al. Functionally-Detected Cognitive Impairment in High School Football Players Without Clinically-Diagnosed Concussion. J Neurotrauma 2010; DOI: 10.1089/neu.2010.1512.
8. Bazarian JJ, Zhu T, Blyth B, Borrino A, Zhong J. Subject-specific changes in brain white matter in diffusion tensor imaging after sports-related concussion. Magnetic Resources Imaging 2012; 30(2): 171-180.
9. March N, Bazarian JJ, Puvenna V, Janigro M, Ghosh C, et. al. Consequences of Repeated Blood-Brain Barrier Disruption in Football Players. PLoS ONE 2013;8(3): e56805. doi: 10.1371/journal.pone.0056805.
10. Lipton M, Kim N, Zimmerman M, Kim M, Stewart W, Branch C, Lipton R. Soccer Heading Is Associated with White Matter Microstructural and Cognitive Abnormalities. Radiology 2013;DOI:10.1148/radiol.13130545.
11. Daniel R, Rowson S, Duma S. Head Impact Exposure in Youth Football. Ann. Biomed Eng 2012;40(4):976-981.
12. Cobb BR, Urban JE, Davenport EM, Rowson S, Duma SM, Maldjian JA, Whitlow CT, Powers AK, Stizel JD. Head Impact Exposure in Youth Football: Elementary School Ages 9-12 Years and the Effect of Practice Structure. Ann Biomed Eng ( 2013): DOI: 10.1007/s10439-013-0867-6 (online ahead of print)
Posted June 25, 2013, upated August 2, 2014
