Wednesday, December 28, 2011

Concussions, Our Patients, and You

Gregory Lawton, MD, Pediatrics, General, 09:24AM Dec 19, 2011 Recently, the New York Times chronicled the life and death of hockey's premier enforcer, Derek Boogaard, who died at the age of 28 in April from an overdose of pain killers. His brain, subjected to hundreds of bare-knuckle fights over from the age of fourteen years, demonstrated pronounced evidence of chronic traumatic encephalopathy (CTE). I was dumbfounded at how matter of fact, even nonchalant, his parents were, as they described their late son's career, and their acceptance of his job, to deliver (and receive) physical punishment. His father was more concerned about the toll of fighting on his hands. Last month, a new study detailed the potential destructive effects on the brain's white matter resulting from the frequent heading of soccer balls. According to the study, adults who actively played soccer and acknowledged heading the ball more than 1,100 times in the previous twelve months had radiological and cognitive evidence of a decline. While the study was on adults, it raises more than a few questions concerning the effects of heading on the developing brains of children and adolescents. Finally, a December National Geographic piece visually quantifies the 537 head shots a college football player sustained during a single season. Two hits resulted in concussions, and interestingly enough, the hits that resulted in concussions were not the hardest of the bunch. This adds to the complexity of concussions and their prevention, with the notion of rotational as well as direct forces. What to do? We are parents, coaches, as well as pediatricians. We go to hockey and football games and pay good money for the tickets. Some measures are within our reach but are quixotic in nature. Others are hopelessly naïve. Let's start small. As parents, just say no to some things. My father forbade me to play football (so I became a baseball catcher instead). Ditto for my son. Is this a bit inconsistent, trading a blitzing linebacker's helmet for a foul ball off the facemask? Probably, but I would like to think that neither myself nor my parents were as "bewildered" by their son's activities as Derek Boogaard's parents. Life and sports are both associated with risks. The only risk-free option is not to play. To choose one sport over another is to exercise our judgment and choose one set of risks over another. As coaches, we have the opportunity to combine personal interest and professional knowledge as it relates to developing athletes. A growing consensus seems to be developing that heading should be discouraged in players under the age of twelve. For older players, teaching chest trapping (especially on punts) may make for better ball control as well as fewer concussions. Keeping an eye out for concussive symptoms such as headaches, dizziness, or nausea in our players should decrease the incidence of second concussion syndrome, regardless of the sport. As pediatricians, we need to continue to educate parents and players about the signs, symptoms, and CONSEQUENCES of concussions. We need to impress upon them that no practice, scrimmage, game, or playoff, is worth the risk of a second concussion. How many kids in our practices have gone on to professional football, lacrosse, or hockey careers? Compare that to the number of future teachers, business owners, or managers we see. The reality is that the vast majority of our patients will make their future mortgage payments not with their athletic prowess, but with their more prosaic communication, organization, decision-making skills. Brain cells are our patients' most precious collateral. We must emphasize this fact with regard to concussions as strenuously as we do with drug and alcohol counseling. Finally, what are we to make of our football season tickets or our interest in a Flyers-Rangers game? Both sports are physical, often violent. Both are also punctuated with moments, indeed entire sequences that are mesmerizing for their grace, speed, and superb athleticism. What is closer to the essence of each sport, the violence or the elegance? Perhaps we should aspire to cheer that which is closer to the essence. Chris Nowinski, of the Center for the Study of Tramatic Encephalopathy at Boston University Medical School, is a former Harvard football player (as well as professional wrestler). He has suffered post-concussion syndrome. He still loves his Bruins; however, he tends to remain seated during the fights. Enforcers in hockey, football players who lead with their helmets and soccer players who take the hard shots out of the air with their heads are doing one thing, according to Nowinski. "They are trading money for brain cells." We don't see professional athletes in our offices. We see student athletes. Let's asked them to be smart, to play tough, but to play fair. Concussions will happen, but we need to be proactive in both prevention and treatment. When we counsel about second concussions, we need to modify the Nowinski's quote. Don't trade brain cells for glory. Look for me on Facebook at A Musing Pediatrician,

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