A Time-Out For Athletes And Concussions

A new position statement from the American Academy of Neurology includes the recommendation that any athlete suspected of having a concussion be removed from play and evaluated. Neurologist Jeffrey Kutcher describes the new recommendations and the reasons for the changes.

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IRA FLATOW, host:

This is SCIENCE FRIDAY. I'm Ira Flatow.

If I told you that motor vehicle accidents are the leading cause of traumatic brain injury in young people, you probably would not be surprised, right? But do you know what ranks right behind motor vehicle accidents? Sports - yep, like football, hockey, baseball.

Earlier this week, the American Academy of Neurology said it's time to change the way we deal with concussions in athletes. Included in the new recommendations: Any athlete who gets hit hard should be removed from the game and evaluated by a doctor trained to handle concussions. They also recommend that a certified athletic trainer be present at all sporting events for kids and adults, including practices.

Joining me now to talk about concussions and the new recommendations is my guest, Dr. Jeffrey Kutcher. He is chair of the Sports Neurology Section at the American Academy of Neurology. He's also director of Michigan NeuroSport, and the team physician for the University of Michigan in Ann Arbor.

Welcome to SCIENCE FRIDAY, Dr. Kutcher.

Dr. JEFFREY KUTCHER (Chair, Sports Neurology Section, American Academy of Neurology): Thank you, Ira, great to be here.

FLATOW: Let's talk about - a little bit, some ground-rule definitions. What is a concussion?

Dr. KUTCHER: Sure. A concussion is a physiological injury. We understand when a force is applied to the brain, the brain moves quickly; it disrupts neuronal function. So it is not so much a structural injury in the classic sense. There's no swelling, there's no bleeding. There's no cell death. But there is a disruption of neuronal function, which causes symptoms that we typically, you know, describe as the clinical syndrome of concussion.

FLATOW: And I was surprised to read that it's true that concussions are second only to motor vehicle accidents, sports concussion?

Dr. KUTCHER: Well, that's an estimate from the CDC, and I think it illustrates both how common concussion can be in sport, but also just the vast number of people that play sports in this country.

FLATOW: And what about these new recommendations? You're saying anybody hit hard should be immediately taken off the field.

Dr. KUTCHER: Well, actually, the recommendation is anybody who is suspected to have suffered a concussion. So it's not just being hit hard, but this is where it gets into people who have experience on the sidelines in evaluating athletes, have a much better sense as to what hit, what kind of hit, what symptoms to look for. In those cases, all those athletes should be removed and evaluated further.

FLATOW: And so you're saying, then, that you need those specialized -specially trained people to evaluate the people. So they have to be there during the game.

Dr. KUTCHER: That would be the best-case scenario, sure.

FLATOW: Yeah, but how realistic do you think that is?

Dr. KUTCHER: Well, not very, overall. And I think this highlights that the position statement that we put out on Monday are recommendations. They're the best-case scenarios. They're things that we think we should take as priorities, and we understand that they're not at the level of regulation.

So I think it's something that we have to think seriously about, and try to reorganize our priorities a little bit.

FLATOW: Are you concerned about athletes that suffer multiple concussions, or just one concussion at a time?

Dr. KUTCHER: Well, I think the important thing here is that not only are all concussions different, but all athletes are different, and individuals will respond differently to one or multiple concussions. And we need to move beyond the concept that we treat concussion like a very simple, straightforward injury. Three means you're out, four means you're out - that kind of thing doesn't apply. So it really depends on that individual's story.

But in the general sense, we are starting to feel that there is some evidence that multiple concussions may lead to long-term consequences. But that story is just being told, and we need to do a lot of research to figure that out.

FLATOW: We reported earlier this year about new research into the long-term effects of concussions, what those effects may have on pro athletes. Do these recommendations stem from the pro athlete recommendations?

Dr. KUTCHER: In some ways, they do. I think, you know, our goal, - and I will say it's also the goal of many other physician groups, anybody who takes care of athletes - you know, our goal is to look out for the health of those athletes. And that's from, you know, ages youth sports all the way to the pros.

So in some ways, you know, they're all kind of similar, and we need to be looking out for our junior high kids as much as our high school kids, as college kids and pro kids.

FLATOW: And I remember some of those reports were saying that even Lou Gehrig himself might not have suffered from Lou Gehrig's disease. It might have been from repeatedly getting hit in the head.

Dr. KUTCHER: I think that is that's a little stretch. And I say that because there were some cases described where there were damaged motor neurons in the same way that cortical neurons in the brain were found to be damaged in some athletes who had had multiple hits.

But that certainly doesn't mean that Lou Gehrig didn't have ALS, and it doesn't mean that trauma causes ALS. It's a different entity altogether.

FLATOW: In hockey - there was a recommendation about hockey. People are hit in the head all the time there.

Dr. KUTCHER: Yeah and, you know, it's not always being hit to the head, though, either. I want to emphasize that. You can get a concussion from anytime the brain moves quickly. So whether that's a blow to the body or the head, it has nothing to do with the actual force that hits the skull. So it doesn't have to be just a hit to the head.

FLATOW: There was a story earlier this week that concussions were being under-diagnosed in hockey players.

Dr. KUTCHER: I think we need to be better about diagnosing. I think in some ways - a lot of times, concussions are under-diagnosed. But also, I think they're over-diagnosed in some other instances. And we need to be better at clarifying when somebody has a concussion.

FLATOW: Let me see if I can get a call or two from our listeners. Let's go to Amy(ph) in Kensington, New Hampshire. Hi, Amy.

AMY (Caller): Hi, how are you?

FLATOW: Hi there.

AMY: I had a quick question. My son plays soccer, which normally you wouldn't consider a high-impact sport. But now that they're playing indoors, especially with the concrete floors, he really has taken some hits, and hit his head on the ground.

I've heard that mouth-guards can help protect him against concussion. I was wondering if that was true, and if it's something we should be doing.

Dr. KUTCHER: That's a great question, and it's a common question - and in general, a common misconception that mouth-guards do prevent concussions. They have been shown, in studies I've seen in the laboratory, to decrease the amount of force in a test dummy, for example, that gets through to the test dummy's brain. But nobody has shown clinically in studies with enough data that it makes a difference.

That being said, I always preface that answer with: Wear your mouth-guards because they're great at preventing oral injuries. But I wouldn't expect them to make a difference in concussion at all.

FLATOW: Thanks for calling, Amy.

AMY: Great, thanks so much.

FLATOW: You're welcome. You've said that these are unrealistic. They're sort of the gold standard recommendations, that there should be knowledgeable professionals on the field watching these kids after - you know, for signs of after they're being hit. Could these be like, volunteer parents who are doctors, or are you talking about really assigning people there full time?

Dr. KUTCHER: Well, again, it's sort of a priority. And I think if we could get certified athletic trainers at all events, that would be the best-case scenario and, you know, more feasible than having sports medicine physicians or sports neurologists.

But, you know, in lieu of that, we need to do whatever we can to educate the people that are there - the coaches, the parents, the teammates, the athletes themselves, the school nurses. Whoever is available, we need to raise that bar. And this starts, you know, at all ages, all areas of sport, both in schools and private clubs. We really need to get the word out.

FLATOW: Has the definition of a concussion changed over the years? Are there more subtle symptoms that coaches or trainers should be looking for, that they may not have known in the past to look for?

Dr. KUTCHER: The definition itself may not have changed all that much. But I think our awareness of what concussion can present like has. And it is more than just sort of the obvious, most common presentation of a headache and dizziness and some nausea, sensitivity to light, confusion.

Those are sort of the common ones, but you can also see a personality change. You can see individuals just being more introspective or more manic. You can really sort of scan, you know, the whole brain function list of what the brain does, and anything that can get affected, you can see. And so it can be a lot of different things.

FLATOW: Caroline(ph) in Anchorage, hi, welcome to SCIENCE FRIDAY.

CAROLINE (Caller): Yes, good morning. My question has to do with the young child's brain. I saw, recently, Toyota's promoting a football league for kids under the age it looks like they're under the age of 8 -6- and 5-year-olds, and they're running with full gear.

What is the damage to them, and should we have parents sign a waiver with that as a major possibility - future damage to them because of concussive hits when they are that young? Because it just seemed it was like, this is the worst PR thing I've ever heard anybody do, after all that's been published. Anyway, that's what's happening with a promotion from a major company.

FLATOW: Let's get an answer. Thanks for calling.

Dr. KUTCHER: Thats a great question. And the short answer is: We don't know what these impacts are doing to the younger brains. I mean, one feeling is that as a brain is developing, we want to be more careful, we want to be more conservative and limit the impacts. And it certainly makes sense.

I can't point to any data that makes that statement more clearly. But you know, I think the idea is, we want to look at total dose effect and not just, do you have a clinical concussion? But how many hits is somebody taking over their lifetime? And is it worth having them start hitting at 8 or 9?

They have to learn the game if they want to keep playing it. So at some point, you have to introduce that contact. At that age, I will make the point, though - and this is just from my own clinical experience - the football players at that age typically aren't generating enough speed, and they pretty much just fall over each other.

It's the hockey players at that age that I really worry about because they can skate a little faster, and generate a little more force.

FLATOW: Would that include women's or girls' field hockey? You don't hear much about that.

Dr. KUTCHER: Well, absolutely. You know, any sport where athletes are moving fast, or objects are moving fast around the field of play, you have to be concerned about.

Field hockey has maybe a special consideration because they don't typically wear facial or head protection at all. And so that's a sport that is definitely a concern.

FLATOW: And so where do you go with this research now? Anything else we could expect to hear from...

Dr. KUTCHER: Well, I think there are so many questions that need to be answered, and one of the big ones is: What are the long-term consequences? Do we really know what the risks are? And are all the things we're doing, all these guidelines we're coming up, with making a difference?

And the only way to do that is to follow a population of athletes - a large population - early on, and follow them through their careers. And that, obviously, will take a lot of money and a lot of organization. And we're working with different organizations now to try to set something like that up so that we can get a better sense as to what the long-term effects are.

But beyond that, there's also a lot more research to do with protective equipment and rules and biomechanical forces, and the list just goes on and on.

FLATOW: Well, this is sort of homecoming month, Thanksgiving month. People are playing a lot of football. People will be talking about it.

Dr. KUTCHER: Absolutely.

FLATOW: So this is a good time to get people to think about maybe getting some extra, professional, medical help on the field there if you really care about your kids. Have people on the sidelines who know how to look for those symptoms.

Dr. KUTCHER: That would be great.

FLATOW: All right, thank you, Doctor, for taking time to talk with us.

Dr. KUTCHER: You're welcome. Have a great day.

FLATOW: Have a great day, too. Dr. Jeffrey Kutcher is the chair of the Sports and Neurology Section at the American Academy of Neurology, director of Michigan NeuroSport and the team physician for the University of Michigan, in Ann Arbor.

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