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Suggested Citation:"Front Matter." Institute of Medicine and National Research Council. 2014. Sports-Related Concussions in Youth: Improving the Science, Changing the Culture. Washington, DC: The National Academies Press. doi: 10.17226/18377.
×

SPORTS-RELATED
CONCUSSIONS IN YOUTH

Improving the Science, Changing the Culture

Committee on Sports-Related Concussions in Youth

Board on Children, Youth, and Families

Robert Graham, Frederick P. Rivara, Morgan A. Ford,
and Carol Mason Spicer, Editors

         INSTITUTE OF MEDICINE AND
NATIONAL RESEARCH COUNCIL
                          OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS
Washington, D.C.
www.nap.edu

Suggested Citation:"Front Matter." Institute of Medicine and National Research Council. 2014. Sports-Related Concussions in Youth: Improving the Science, Changing the Culture. Washington, DC: The National Academies Press. doi: 10.17226/18377.
×

THE NATIONAL ACADEMIES PRESS      500 Fifth Street, NW      Washington, DC 20001

NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.

This study was supported by contracts between the National Academy of Sciences and the Centers for Disease Control and Prevention (CDC) (200-2011-38807); the CDC Foundation (Unnumbered Award) with support from the National Football League; the Department of Defense (HT0011-12-C-0023); the Department of Education (ED-OSE-12-P-0049); the Health Resources and Services Administration (HHSH250200976014I); the National Athletic Trainers’ Association Research and Education Foundation (0512SETGRANT); and the National Institutes of Health (HHSN263201200074I). Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the views of the organizations or agencies that provided support for the project.

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Suggested citation: Institute of Medicine (IOM) and National Research Council (NRC). 2014. Sports-related concussions in youth: Improving the science, changing the culture. Washington, DC: The National Academies Press.

Suggested Citation:"Front Matter." Institute of Medicine and National Research Council. 2014. Sports-Related Concussions in Youth: Improving the Science, Changing the Culture. Washington, DC: The National Academies Press. doi: 10.17226/18377.
×

THE NATIONAL ACADEMIES

Advisers to the Nation on Science, Engineering, and Medicine

The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences.

The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. C. D. Mote, Jr., is president of the National Academy of Engineering.

The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine.

The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. C. D. Mote, Jr., are chair and vice chair, respectively, of the National Research Council.

www.national-academies.org

Suggested Citation:"Front Matter." Institute of Medicine and National Research Council. 2014. Sports-Related Concussions in Youth: Improving the Science, Changing the Culture. Washington, DC: The National Academies Press. doi: 10.17226/18377.
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Suggested Citation:"Front Matter." Institute of Medicine and National Research Council. 2014. Sports-Related Concussions in Youth: Improving the Science, Changing the Culture. Washington, DC: The National Academies Press. doi: 10.17226/18377.
×

COMMITTEE ON SPORTS-RELATED CONCUSSIONS IN YOUTH

ROBERT GRAHAM (Chair), Director, National Program Office, Aligning Forces for Quality, and Research Professor of Health Policy, School of Public Health and Health Services, George Washington University, Washington, DC

FREDERICK P. RIVARA (Vice Chair), Seattle Children’s Guild Endowed Chair in Pediatrics and Professor, Pediatrics, School of Medicine, University of Washington, Seattle

KRISTY B. ARBOGAST, Engineering Core Director, Center for Injury Research and Prevention, Children’s Hospital of Philadelphia, and Associate Professor of Pediatrics, University of Pennsylvania

DAVID A. BRENT, Academic Chief, Child and Adolescent Psychiatry, Western Psychiatric Institute and Clinic, and Professor of Psychiatry, Pediatrics, and Epidemiology, School of Medicine, University of Pittsburgh

B. J. CASEY, Sackler Professor of Developmental Psychobiology and Director, Sackler Institute for Developmental Psychobiology, Weill Medical College of Cornell University, New York, New York

TRACEY COVASSIN, Associate Professor of Kinesiology and Undergraduate Athletic Training Program Director, Michigan State University, Lansing

JOE DOYLE, former Regional Manager, American Development Model, Rocky Mountain and Pacific Districts, USA Hockey, Colorado Springs, Colorado

ERIC J. HUANG, Professor of Pathology and Neuropathology, Department of Pathology, School of Medicine, University of California, San Francisco

ARTHUR C. MAERLENDER, Director, Pediatric Neuropsychological Services, and Assistant Professor, Department of Psychiatry, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire

SUSAN S. MARGULIES, George H. Stephenson Professor in Bioengineering, Department of Bioengineering, University of Pennsylvania, Philadelphia

DENNIS L. MOLFESE, Mildred Francis Thompson Professor and Director, Center for Brain, Biology, and Behavior, Department of Psychology, University of Nebraska, Lincoln

MAYUMI L. PRINS, Associate Professor in Residence and Director, Brain Injury Research Center Education Program, David Geffen School of Medicine, University of California, Los Angeles

Suggested Citation:"Front Matter." Institute of Medicine and National Research Council. 2014. Sports-Related Concussions in Youth: Improving the Science, Changing the Culture. Washington, DC: The National Academies Press. doi: 10.17226/18377.
×

NEHA P. RAUKAR, Assistant Professor of Emergency Medicine, and Director, Division of Sports Medicine, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island

NANCY R. TEMKIN, Professor, Departments of Biostatistics and Neurological Surgery, University of Washington, Seattle

KASISOMAYAJULA VISWANATH, Associate Professor of Social and Behavioral Sciences, Harvard School of Public Health, and Director, Health Communication Core, Dana-Farber/Harvard Cancer Center, Boston, Massachusetts

KEVIN D. WALTER, Associate Professor, Departments of Orthopaedic Surgery and Pediatrics, Medical College of Wisconsin, Milwaukee

JOSEPH L. WRIGHT, Senior Vice President, Community Affairs, Children’s National Medical Center, and Professor of Pediatrics (Vice Chair), Emergency Medicine and Health Policy, George Washington University, Washington, DC

Study Staff

MORGAN A. FORD, Study Director

CAROL MASON SPICER, Associate Program Officer

WENDY KEENAN, Program Associate (through April 2013)

SAMANTHA ROBOTHAM, Senior Program Assistant

PAMELLA ATAYI, Administrative Assistant

KIMBER BOGARD, Director, Board on Children, Youth, and Families

Suggested Citation:"Front Matter." Institute of Medicine and National Research Council. 2014. Sports-Related Concussions in Youth: Improving the Science, Changing the Culture. Washington, DC: The National Academies Press. doi: 10.17226/18377.
×

Reviewers

This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:

Gordon Bloom, McGill University

R. Dawn Comstock, University of Colorado, Denver

Joseph J. Trey Crisco, Brown University

John DiFiori, University of California, Los Angeles

Corey S. Goodman, venBio LLC

Michael V. Johnston, Johns Hopkins University

Matthew W. Kreuter, Washington University

Brad G. Kurowski, University of Cincinnati

Karen McAvoy, Rocky Mountain Youth Sports Medicine Institute

Tamara C. Valovich McLeod, A.T. Still University

Barclay Morrison, Columbia University

Cara Camiolo Reddy, University of Pittsburgh

Thomas L. Schwenk, University of Nevada

Page viii Cite
Suggested Citation:"Front Matter." Institute of Medicine and National Research Council. 2014. Sports-Related Concussions in Youth: Improving the Science, Changing the Culture. Washington, DC: The National Academies Press. doi: 10.17226/18377.
×

CAPT Jack W. Tsao, Uniformed Services University of the Health Sciences

Keith O. Yeates, Nationwide Children’s Hospital

Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Bradford H. Gray, The Urban Institute, and Floyd E. Bloom, The Scripps Research Institute. Appointed by the National Research Council and the Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

Suggested Citation:"Front Matter." Institute of Medicine and National Research Council. 2014. Sports-Related Concussions in Youth: Improving the Science, Changing the Culture. Washington, DC: The National Academies Press. doi: 10.17226/18377.
×

Acknowledgments

The Institute of Medicine-National Research Council (IOM-NRC) Committee on Sports-Related Concussions in Youth and its supporting staff thank the colleagues, organizations, and agencies that shared their expertise and information during the committee’s information-gathering meetings (see Appendix A for the names of the speakers). Their contributions informed the committee’s deliberations and enhanced the quality of this report. The study sponsors gladly provided information and responded to questions. The committee also thanks the National Collegiate Athletic Association and the Datalys Center for Sports Injury Research and Prevention, Inc., and Dawn Comstock (University of Colorado, Denver) for responding to questions and providing concussion incidence data for use in the committee’s report. The IOM-NRC staff, including board director Kimber Bogard, study director Morgan Ford, associate program officer Carol Mason Spicer, as well as Wendy Keenan, Samantha Robotham, Pamella Atayi, Colin Fink, and Daniel Bearss, were central in shepherding the report though all its stages. The committee would also like to thank study consultant Stefan Duma (Virginia Tech–Wake Forest University), for preparing a background paper to inform the committee’s deliberations on the effectiveness of helmets to reduce sports-related concussions in youth. The committee and staff extend their gratitude to Laura DeStefano, Nicole Joy, and Abbey Meltzer, IOM Office of Reports and Communications, and Jennifer Walsh, Office of News and Public Information, for their assistance with report release and communication activities. Last but not least, the committee and staff thank Clyde Behney, Interim Leonard D. Schaeffer Executive Officer of the IOM, for the guidance he provided throughout this important study.

Suggested Citation:"Front Matter." Institute of Medicine and National Research Council. 2014. Sports-Related Concussions in Youth: Improving the Science, Changing the Culture. Washington, DC: The National Academies Press. doi: 10.17226/18377.
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Suggested Citation:"Front Matter." Institute of Medicine and National Research Council. 2014. Sports-Related Concussions in Youth: Improving the Science, Changing the Culture. Washington, DC: The National Academies Press. doi: 10.17226/18377.
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Suggested Citation:"Front Matter." Institute of Medicine and National Research Council. 2014. Sports-Related Concussions in Youth: Improving the Science, Changing the Culture. Washington, DC: The National Academies Press. doi: 10.17226/18377.
×

4-3    Postural stability recovery curve

6-1    Injury risk curve relating a mechanical parameter such as head acceleration to the probability of injury

6-2    Bar graph showing the types of health care providers permitted to make return-to-play decisions, according to state laws as of December 2012

C-1    Standardized assessment of concussion

C-2    Demonstration and test cards for King-Devick (K-D) test

C-3    Page one of the acute concussion evaluation form

C-4    Concussion symptom inventory

C-5    Graded symptom checklist

C-6    Post-concussion scale

TABLES

S-1    Reported Concussion Rates by Sport, Sex, and Competition Level (High School and College) (Rates per 10,000 Athletic Exposures)

1-1    Primary Surveillance Systems for Sports-Related Concussion Data

1-2    Reported Concussion Rates by Sport, Sex, and Competition Level (High School and College) (Rates per 10,000 Athletic Exposures)

1-3    Sports- and Recreation-Related Activities Most Commonly Associated with Emergency Department Visits for Nonfatal TBIs by Age and Sex—NEISS-AIP, United States, 2001-2009

3-1    Signs and Symptoms of Concussions Relevant to Sideline Assessment

3-2    Sideline Concussion Screening Tools

3-3    Concussion Symptoms by Category

3-4    Measures of Post-Concussion Symptomatology

3-5    Common Computerized Neuropsychological Tests

3-6    Reliability Studies on Common Neuropsychological Tests

3-7    Validity Studies on Common Neuropsychological Tests

3-8    Graded Return-to-Play Protocol

C-1    Glasgow Coma Scale

Page xvii Cite
Suggested Citation:"Front Matter." Institute of Medicine and National Research Council. 2014. Sports-Related Concussions in Youth: Improving the Science, Changing the Culture. Washington, DC: The National Academies Press. doi: 10.17226/18377.
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Abbreviations and Acronyms

ACE

Acute Concussion Evaluation

AE

athletic exposure

AIS

Abbreviated Injury Scale

ALS

amyotrophic lateral sclerosis

ANAM

Automated Neuropsychological Assessment Metrics

APOE

apolipoprotein E

APP

amyloid precursor protein

ATD

anthropomorphic test device

ATP

adenosine triphosphate


BESS

Balance Error Scoring System


CBF

cerebral blood flow

CBT

cognitive behavioral therapy

CCAT

Computerized Cognitive Assessment Tool

CCI

controlled cortical impact

CDC

Centers for Disease Control and Prevention

CI

confidence interval

CMRglc

cerebral metabolic rate of glucose consumption

CNS

central nervous system

CPSC

Consumer Product Safety Commission

CRI

Concussion Resolution Index

CSI

Concussion Symptom Inventory

CT

computed tomography

CTE

chronic traumatic encephalopathy

Page xviii Cite
Suggested Citation:"Front Matter." Institute of Medicine and National Research Council. 2014. Sports-Related Concussions in Youth: Improving the Science, Changing the Culture. Washington, DC: The National Academies Press. doi: 10.17226/18377.
×
CTP

cleaved tau protein


DNA

deoxyribonucleic acid

DTI

diffusion tensor imaging


ED

emergency department

EE

enriched environment

EEG

electroencephalogram

ERP

event-related potential


FA

fractional anisotropy

fMRI

functional magnetic resonance imaging

FTLD

frontotemporal lobar degeneration


GCS

Glasgow Coma Scale

GSC/GSS

Graded Symptom Checklist/Scale


HBI

Health and Behavior Inventory

HIT

Head Impact Telemetry


ICC

intraclass correlation coefficient

IEP

individualized educational plan

ImPACT

Immediate Post-Concussion Assessment and Cognitive Testing

iNOS

inducible isoform of nitric oxide synthase

IOM

Institute of Medicine


MACE

Military Acute Concussion Evaluation

MD

mean diffusivity

MRI

magnetic resonance imaging

MRS

magnetic resonance spectroscopy

mTBI

mild traumatic brain injury

MWM

Morris water maze


NAA

N-Acetylaspartic acid

NC

non-concussed

NCAA

National Collegiate Athletic Association

NCAA ISS

National Collegiate Athletic Association Injury Surveillance System

NEISS-AIP

National Electronic Injury Surveillance System—All Injury Program

NFHS

National Federation of State High School Associations

Suggested Citation:"Front Matter." Institute of Medicine and National Research Council. 2014. Sports-Related Concussions in Youth: Improving the Science, Changing the Culture. Washington, DC: The National Academies Press. doi: 10.17226/18377.
×
NFL

National Football League

NFT

neurofibrillary tangle

NHIS

National Health Interview Survey

NHL

National Hockey League

NMDA

N-methyl-D-aspartate

NOCSAE

National Operating Committee on Standards for Athletic Equipment

NOR

novel object recognition

NSE

neuron-specific enolase


OR

odds ratio

OSSAA

Oklahoma Secondary School Activities Association


PARP

poly-ADP ribose polymerase

PCS

post-concussion syndrome

PCSI

Post-Concussion Symptom Inventory

PCSS

Post-Concussion Symptom Scale

PET

positron emission tomography

PR

prolonged recovery

PTSD

posttraumatic stress disorder


QEEG

quantitative EEG


RCT

randomized controlled trial

RIO

Reporting Information Online

ROS

reactive oxygen species

RPCSQ

Rivermead Post-Concussion Symptoms Questionnaire


SAC

Standardized Assessment of Concussion

SAT

Scholastic Aptitude Test

SCAT

Sport Concussion Assessment Tool

SLAM

Sports as a Laboratory Assessment Model

SOT

Sensory Organization Test


TBI

traumatic brain injury

TR

typical recovery


VA

Department of Veterans Affairs

Suggested Citation:"Front Matter." Institute of Medicine and National Research Council. 2014. Sports-Related Concussions in Youth: Improving the Science, Changing the Culture. Washington, DC: The National Academies Press. doi: 10.17226/18377.
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In the past decade, few subjects at the intersection of medicine and sports have generated as much public interest as sports-related concussions - especially among youth. Despite growing awareness of sports-related concussions and campaigns to educate athletes, coaches, physicians, and parents of young athletes about concussion recognition and management, confusion and controversy persist in many areas. Currently, diagnosis is based primarily on the symptoms reported by the individual rather than on objective diagnostic markers, and there is little empirical evidence for the optimal degree and duration of physical rest needed to promote recovery or the best timing and approach for returning to full physical activity.

Sports-Related Concussions in Youth: Improving the Science, Changing the Culture reviews the science of sports-related concussions in youth from elementary school through young adulthood, as well as in military personnel and their dependents. This report recommends actions that can be taken by a range of audiences - including research funding agencies, legislatures, state and school superintendents and athletic directors, military organizations, and equipment manufacturers, as well as youth who participate in sports and their parents - to improve what is known about concussions and to reduce their occurrence. Sports-Related Concussions in Youth finds that while some studies provide useful information, much remains unknown about the extent of concussions in youth; how to diagnose, manage, and prevent concussions; and the short- and long-term consequences of concussions as well as repetitive head impacts that do not result in concussion symptoms.

The culture of sports negatively influences athletes' self-reporting of concussion symptoms and their adherence to return-to-play guidance. Athletes, their teammates, and, in some cases, coaches and parents may not fully appreciate the health threats posed by concussions. Similarly, military recruits are immersed in a culture that includes devotion to duty and service before self, and the critical nature of concussions may often go unheeded. According to Sports-Related Concussions in Youth, if the youth sports community can adopt the belief that concussions are serious injuries and emphasize care for players with concussions until they are fully recovered, then the culture in which these athletes perform and compete will become much safer. Improving understanding of the extent, causes, effects, and prevention of sports-related concussions is vitally important for the health and well-being of youth athletes. The findings and recommendations in this report set a direction for research to reach this goal.

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