By Taryn Hartman
Among the 25 young patients Dr. Gerard Gioia saw recently at his office in Washington, DC was a six-year-old who plays hockey and lacrosse. Gioia, who runs the Safe Concussion Outcome, Recovery and Education clinic, said the child’s top concern, like most athletes of any age or skill level, was when he could get back on the field.
“The number-one issue continues to be awareness and recognition of concussions. That’s the number-one issue in youth sports,” Gioia, chief pediatric neuropsychologist at Children’s National, said. SCORE specializes in treating concussions in children as young as 4 and Gioia estimates that he sees 1,000 kids in his clinic each year.
When it comes to head injuries and athletics, the studies and the numbers that apply to professional, college and even high school players are growing, and the anecdotes are generally horrifying. Researchers at Boston University’s Center for the Study of Brain Encephalopathy announced this spring that former Chicago Bears safety Dave Duerson, who last February shot himself in the chest so his brain could be studied by researchers at the center, suffered from CTE, a degenerative brain disease caused by repeated head trauma (such as football hits) whose symptoms can mimic Alzheimer’s disease and include depression. The same research group found that Owen Thomas, a 21-year-old football player at the University of Pennsylvania who committed suicide in the spring of 2010, suffered from the disease as well.
CTE is far from the only risk posed by sustained head trauma through sports. In Washington State, where the “Zackery Lystedt Law” dictates that a young athlete can return to play following a concussion only after he or she has been evaluated by a doctor trained in diagnosing and treating concussions. Zackery Lystedt is confined to a wheelchair after sustaining a second concussion in a middle school football game after the first one hadn’t completely healed. The second concussion caused a rare but catastrophic swelling of the brain known as second-impact syndrome. The Lystedt law passed, with Gioia’s help, in 2009, and the NFL has backed efforts to get similar legislation on the books in other states (15 states have passed concussion legislation measures).
But almost no hard scientific data exists on the impact of head trauma on athletes younger than 18, despite the fact that the consequences of a traumatic brain injury “are more severe in younger populations,” according to James Kovach of Athleticode, an athletic training organization that examines an athlete’s DNA in order to prevent injury.
“Young athletes are precisely the right population to study,” Kovach, a former New Orleans Saints and San Francisco 49ers linebacker who holds a medical degree from the University of Kentucky and a law degree from Stanford, wrote in an email message.
But despite doctors and researchers, who, like Gioia, are adamant about concussions being the biggest issue in sports today, virtually little research exists at the youth level, where the population is the biggest—and also the most vulnerable, due to a child’s still-developing brain.
Gioia said between 30 and 45 million kids play some type of youth sports, but the medical care for athletes is the exact opposite. Imagine a diagram of care and the most elite athletes come first, with very little care trickling down to the youth level. That’s where Gioia said the recognition of injuries is usually left to non-medical personnel like parents and volunteer coaches. When it comes to concussions, these adults are most commonly looking for symptoms like a loss of consciousness, even though such symptoms usually only indicate the most severe brain injuries.
As a neuropsychologist, part of Gioia’s training is in behavior and development, and one of his areas of expertise is in developing tests and tools that help diagnose brain injuries in children. His research started with a $2 million grant from the Centers for Disease Control and Prevention in 2003.
“Back in 2003, a lot of kids were being missed—badly,” Gioia said. “It was clear that we needed a program that was multi-dimensional.” To that end, he focused his program equally on the public health element of the topic—training coaches and parents in how to recognize minor concussions, and advocating on behalf of the state-level laws being passed around the country dictating who can clear student-athletes to play again.
Today, the research that does exist on youth athletes deals primarily with how to manage concussions. There’s still very little on the long-term effects or impact of a concussion on a child’s developing brain, said Dr. Lester Mayers, the team physician for Pace University’s athletic teams at the school’s Pleasantville, N.Y. campus. “What happens to them is really poorly studied,” Mayers said in a phone interview.
“If you’re going to do a study, you need subjects,” Mayers said, adding that rounding up enough kids whose parents give consent for them to be studied can be a challenge. Mayers said the typical concussed child, if he or she is seen medically at all, is usually seen by a pediatrician, and not a neurologist or anyone with a specialty in head injuries.
But it isn’t just returning to the field, which athletes of all ages are in a rush to do, that is a concern when talking about concussions. Gioia has been particularly interested in the impact that head injuries have on kids’ learning and performance in school. He said educating school systems in managing concussions is a crucial part of treatment and prevention.
“We also want to support kids going back to school,” Gioia said. “We’ve got a lot of work to do in the school system. That’s the hardest job we have right now.”
One thing doctors and researchers agree on is that youth coaches, parents and even emergency medical responders don’t know enough about recognizing the symptoms of concussions to adequately treat them, and the tests that are used most frequently could be to blame.
Brian Ragan is on the faculty of Ohio University’s athletic training program and has focused his research on the tests and measures used to identify concussions. He has found that the current measurements like baseline testing, which measure an athlete’s brain function and response time when they’re healthy so there’s something to compare them to after sustaining a head injury, apply only to someone who’s been deeply affected by head trauma. Ragan said baseline tests and other frequently used measures don’t do a great job of diagnosing minor concussions.
“The questions are way too easy,” Ragan said of the current tests, and added that when it comes to determining an athlete’s mental function before and after a concussion using baseline tests, “you might as well flip a coin.”
“I don’t think we have a really good way of actually identifying a concussion,” Ragan said. He added that things get even murkier when it comes to diagnosing children. “Their physiology is different. They work differently,” Ragan said, “We can’t assume what’s happening in an adult will be the same in a child.”
Gioia said that while 80 percent of concussions are healed within one month, and 95 percent within three months, there is no average length of time that it takes a brain to recover from a concussion. “I can give you numbers, but your kid is not the average,” he said. “Your kid is your kid.” When asked about an average recovery time for concussions in kids, Gioia said, “Here’s our dirty little secret: We don’t really know the numbers. We’re making our best guess here.”
Many factors play into an athlete’s recovery time from a concussion. Gioia said even suggesting a number of days that it may take a patient to recover is “ludicrous” and even verge on “malpractice.” Gioia said his colleagues always get flustered and nervous when he mentions the dreaded m-word, but the father of three is quick to defend it. “If it’s my kid, I hope to hell you’re scared,” he said.
“Somehow, we have to find a way to make this meaningful and important,” Gioia added. “We need parents to know that they have tools.”