A question and answer session with Dr. Frank Webbe on heading and head injuries in youth soccer (from SportingKid Magazine)
Q7: Is there anything else that would be important for coaches or parents to be aware of?
Responses
Q1) How serious of a problem are head injuries and concussions at the youth sports level and why is the topic getting so much attention now compared to so little just a few years ago?
ANSWER: Based upon national data from the CDC and the Consumer Product Safety Commission, there does no appear to be an increase in the rate of concussions and other head injuries in youth sports. However, the participation numbers go up each year so the total frequencies of injuries also goes up. More to the point perhaps, there has been more research interest in concussions in sport generally, and this interest has been noted and publicized by the media. My own thinking is that we now have a great deal of data on head injuries and concussions in college and professional athletes, and we know that very serious problems can and do arise (such as we are now seeing with NFL players). Since more children engage in sport activities than adults, and since children’s bodies, heads, and brains are in a developmental phase, simple logic suggests that significant problems could also occur in this arena. However, the least amount of research has been accomplished with children. (Why, you ask?) Checking on whether children’s neurocognitive function is normal, or whether it has been impaired by sport activities can be somewhat like hitting a moving target with a dart. Since the brains and abilities of children are in flux, identifying other than serious deficits is challenging. In the area of sport-related concussion management, the gold standard for assessment is to collect pre-season baseline data on functioning so that comparisons can be made later if some traumatic insult has occurred or if there is suspicion for any reason that a problem may have happened. With children, baseline performance does not remain stable or predictable. During childhood, maturational changes correlate with improved neurocognitive abilities. If a baseline has been taken at age 10, and then a repeat test is administered at age 11 following a suspected head injury, determination of a functional impairment must be made against a baseline of expected improvement. The researcher or clinician must determine if the new measurement represents a normal increase or one that is lower than expected. That is a difficult task.
Q2) Regarding your Florida Tech Sport-Related Concussion Project, what were some of the most important findings from it?
ANSWER: The Florida Tech Sport-Related Concussion Project is a five-year, longitudinal study of concussions as well as heading in young youth soccer players. (Most previous studies of youth soccer actually used adolescent players.) The role of repetitive sub-concussive head impacts in causing neurocognitive impairment is an open question. Some studies with adults have reported affirmatively and some have reported negatively. Only one study has been reported with young children and those data were inconclusive. In the past two years, Trent DeVore, Christine Salinas, and I have collected full neurocognitive baseline information as well as playing and demographic histories on about 100 elite boy and girl soccer players (age 9-13). We have used direct observation of competitive games to gather our data so we are not relying on self report. We have had only two concussions occur which is good news for all concerned. Thus far, we find that overall frequency of heading behavior is low – lower than we expected and much less than we have seen with adolescent and adult players. Moreover, intense heading events occur very infrequently, although they tend to occur reliably in a small subset of players. For example, not surprisingly, the heading frequency correlates with the child’s height. We have not seen any consistent impairment in the neurocognitive tests that would correlate with heading frequency but we do not yet have enough observations to make a firm statement. We have noted, however, that children report headache and dizziness from heading the ball about 50% of the time, which is much greater than reported in studies of adolescents and adults. (Headache and dizziness are two hallmark symptoms of concussion, but also occur very commonly in non-concussed people.) As our sample size increases and the next three years pass we feel that we will be able to provide some definitive information on the questions of heading and concussions in youth soccer.
Q3) In a sport like soccer, at what age is it appropriate for children to start heading the ball and how can coaches and parents ensure that the youngster isn’t being exposed to the risk of a concussion or head injury?
ANSWER: There are both scientific and opinion answers to this question. The scientific answer has several parts. First, children should not be using their heads (and the brain inside) as a tool until and unless the supporting structures have sufficient mass and strength to withstand such treatment. Exactly when a child will develop sufficient underlying support varies with age, gender, and individual factors. A few might be ready by age 12, many won’t be ready until after age 15. Second, in most leagues the size of players varies tremendously. Some 11 year olds are as big as adults; some are very small and petite. When a very large child kicks a ball with full force and a very small child with poorly developed neck musculature attempts to head it, a concussive injury could ensue. Third, anyone who heads should receive good technical instruction from a knowledgeable coach. Proper technique can prevent many injuries.
My own opinion, based upon the existing data and common sense, is that children under 14 should not be heading the ball in league games. Many will learn and practice the technique, but practice headings are rarely of the intensity and with the prospect of injury that occurs in games. Moreover, anyone who heads should receive good technical instruction from a knowledgeable coach. Proper technique can prevent many injuries.
Q4) Are kids involved in sports at greater risk of suffering concussions as they get older? Basically, is a 10-year-old soccer player less likely to suffer a concussion than a 15-year-old soccer player? If so, is it possible to quantify how much the risk increases as they get older?
ANSWER: Previous research has shown that children are more prone to injury, including head injury, than are adults. However, “children” describes a broad range of ages and sizes. Within the age range of 5-18, there is a greater risk of injury and concussions for the older cohort (>15) than the younger cohort. As an example, the National Electronic Injury Surveillance System of the US Consumer Product Safety Commission estimated that there were about 1.6 million pediatric soccer injuries in the US from 1990-2003. About 8% of these (or 126,000) were head and neck injuries.
Q5) Are there specific sports that youngsters are more likely to suffer head injuries in that should concern parents more when signing their child up to play?
ANSWER: Obviously, contact sports where the head may be involved are the most likely candidate sports for head injuries. Soccer is the widest played sport and the likelihood of head injury there has ranged from 5% to 22% in previous studies. About 20% of the head injuries are concussions. Youth football and ice hockey have similar same head injury rates to soccer. Some sports may have higher risk but much lower participation rates. For example, equestrian sports have been found to have very high rates of head injury but only a small percentage of children of involved.
Q6) There are new products on the market, such as headbands for young soccer players, which are touted as ideal for preventing concussions. Do these really help prevent head injuries and concussions and how do parents know what works and what doesn’t?
ANSWER: Many unbiased researchers, biomedical engineers, and clinicians (i.e., not paid consultants by manufacturers) have concluded that the current crop of protective head gear does little to protect against concussion. They may prevent cuts and abrasions; they may offer some protection against focal brain injuries caused by linear acceleration (straight on hits) but they do little to protect against the rotational forces that impart damage to the brain and which is the mechanism for concussion. Headgear cannot substitute for undeveloped muscular and connective tissue support of the head and neck. Thus, helmets might reduce the impact of a head smashing into a goal post, but not to the twisting of the head (and the brain inside) when the head was hit from the side by the ball or another player.
Q7) Is there anything else that would be important for coaches or parents to be aware of?
ANSWER: Parents need to remember that active sports, particularly contact sports like soccer, always carry some risk of injury. Originally, soccer was marketed in the US as a “low-injury” alternative to football. The truth is that injury rates in soccer are quite similar to American football. This does not mean that parents should withhold their children from contact sport, just that they need to exercise good judgment when it comes to participation. There is no substitute for having qualified coaches in structured leagues that are governed by well-developed rules and guidelines. Parents also should take the time to observe their child’s practice sessions as well as games. In this way they can be assured that the level of coaching is appropriate and that rules are being applied and guidelines followed. If a child plays in a risky manner his or her chance of injury is certainly higher than those who play with greater restraint. Good coaching not only transmits proper technical skill, but also smart playing tactics.