From 2001 to 2018, there were roughly 3.9 million emergency room visits for TBIs related to sports and recreational activities involving children and teens, according to the Centers for Disease Control and Prevention (CDC) study published in July 2020 in the Morbidity and Mortality Weekly Report. Contact sports accounted for 41 percent of these cases. Contact sports — and football in particular — accounted for the steepest growth in these TBIs over the first decade of the study and the sharpest subsequent decline. “Decreased participation in tackle football, implementation of contact limitations, and use of tackling techniques to reduce concussions are likely factors contributing to this decline,” says Lindsay Womack, PhD, a TBI researcher at the CDC’s Injury Center. Football-related TBI rates roughly doubled from 2001 to 2012 among children 5 to 17 years old, then declined 39 percent from 2013 to 2018. Injury rates also dipped for soccer and basketball over the final years of the study, but these changes were too small to rule out the possibility that they were due to chance. RELATED: 5 Ways Concussion Is Different in Women
What’s Changing in Youth Football
Waning participation in football is one factor contributing to the to the recent drop in ER visits for sports-related TBIs, the CDC researchers noted in their report. Even though football remains among the most popular youth sports, participation has declined 24 percent since 2010, according to the CDC. Changes to the game designed to make it safer have also played a role. Tackling, for example, is responsible for about two-thirds of TBIs and concussions in high school football, according to a study in the American Journal of Sports Medicine cited by the CDC in its report. Restricting contact in football and requiring tackling techniques designed to reduce the risk of head injuries — like shoulder tackles — can cut the risk of concussions by up to 33 percent and reduce the potential for other types of head injuries by 42 percent, according to a study published in March 2019 in the Clinical Journal of Sport Medicine, also cited by the CDC. A growing number of football coaches have received training in how to teach young players safer techniques for tackling, and many youth leagues also restrict tackling in practices to limit how often players are at risk for this type of collision, says Tamara Valovich McLeod, PhD, a certified athletic trainer, and professor and director of athletic training programs at A.T. Still University in Mesa, Arizona.
Other Sports Making Safety Changes
Other youth sports have also made moves to shift policies for practices and rules for competition to minimize the risk of concussions and TBIs, says Dr. McLeod, who wasn’t involved in the CDC study. USA Soccer, for example, has implemented heading restrictions for athletes under 10 years old, McLeod notes. Trends seen in ER visits for TBIs sustained during contact sports during the study period moved in similar directions for both male and female athletes, suggesting that some factors that aren’t unique to football — a male-dominated sport — are at least partly responsible. Among males, TBIs rates for contact sports roughly doubled from 2001 to 2012, then dropped 31 percent from 2013 to 2018, the study found. Over these same timeframes, contact sports-related TBIs surged by 250 percent among females, then decreased 38 percent. “I think the rates may have declined partially because of increased awareness of concussion and where best to have these injuries managed, and due to some of the rule changes imposed in the various sports,” McLeod says.
Many Concussions Treated Outside ERs
One limitation of the CDC study is that researchers calculated injury rates based on how many children were treated in ERs for every 100,000 kids in the U.S. population. A more accurate measure of sports injury rates can be calculated by examining how many athletes sustain concussions or other types of TBIs out of the total number of athletes participating in the sport, and accounting for the total number of hours they spend on the field during practices and competitions. Another limitation of the study is that it focused only on TBIs treated in emergency rooms. Many children who sustain a TBI are seen by pediatricians or other primary care providers or go to urgent care clinics, or don’t get medical care at all, the CDC research team noted. For the majority of sports concussions when young athletes have no obvious signs of a severe injury, children don’t necessarily need to go to the ER, McLeod says. Often, they can be evaluated by an athletic trainer on the sidelines, then sent for a follow-up exam at an outpatient clinic. “Concussion is best managed by a primary care sports medicine physician, licensed athletic trainer, or concussion specialist,” McLeod says. Coaches and parents increasingly recognize this, and there has been a proliferation of specialty sports concussion clinics opening up in many parts of the country to be the first point of care for young athletes with head injuries.
When to Go to the ER for a TBI
While not every head injury needs to be treated in the ER, any of these symptoms do require immediate emergency medical attention, according to the Weill Cornell Medicine Concussion and Brain Injury Clinic:
Unusual behavior or confusionProgressive or worsening symptomsWeakness, numbness, slurred speechDifficulty with eye movementsWorsening or severe headacheSeizureVomiting multiple timesDifficulty waking up or arousingDischarge of clear fluid or blood from the nose or ears
“Any brain injury that involves the established red flag signs or symptoms, such as prolonged loss of consciousness, vomiting, slurred speech, and worsening symptoms should be seen in the ER to rule out more serious brain injury,” says Anthony Kontos, PhD, research director at the Sports Medicine Concussion Program at the University of Pittsburgh Medical Center in Pennsylvania. “However, absent these potentially more serious signs and symptoms, a majority of suspected concussions can be evaluated and treated by trained, licensed clinicians at concussion specialty care and similar point of care settings,” advises Dr. Kontos, who wasn’t involved in the CDC study.
