I like to talk about my work at Sunday brunch with my family (whether they like it is a different question). Impressed by a talk on concussion epidemiology that I attended earlier that week, I brought up a rising rate of sports-related concussions since 2008. “It’s because concussions had not really been recognized as a problem until recently. It never even occurred to me to see a doctor if I hit my head when I was growing up. You used to just get up and go about your business,” my athletic brother-in-law, Alex, responded.
His response made me consider reasons for the recent increase in the rates of concussion. In a way, Alex caught me off guard. I have always “blamed” rising rates of concussion on growing popularity of sports, especially among children and adolescents. Existing evidence supports my assumption: participation in sports indeed increased starting in 2009.1 In 2010, the Let’s move! program was launched to promote activity among youth, possibly feeding the trend.2 This implicates increasing popularity of sports as at least one of the possible reasons.
I also wonder if the prestige of athletic accomplishment and overall attitude towards sports have evolved to a point where they conflict with safety. A conversation with a colleague, a father of a 7-year-old flag football player, comes to mind. He shared his disappointment with his son’s recent game and concluded that “kids of this age are just not violent enough” to do well. Aggression is part of sports that makes them both risky and fun, so balance is key. Pressure to return to play has also been known to interfere with concussion management and contribute to the risk of second concussion. While such change in attitude does not occur overnight, it may ultimately influence the overall rate of concussion in the long term.
Could Alex be right in that concussion is diagnosed more often in the recent years? I think so. Education of the public and clinical community on prevention, diagnosis, and management of concussions has evolved since the beginning 2000s. An example of such educational efforts is HEADS UP, a series of initiatives launched by the Centers for Disease Control and Prevention in 2003.3 Since September 2005, the initiative has released multiple educational resources on concussions in youth sports, which have reached millions of people. In 2009, materials specific to contact sports – lacrosse, hockey, and soccer – have been released.
Concussion care made an important step forward in 2008: the Zurich Concussion Consensus statement was developed during the 3rd International Conference on Concussion in Sport.4 The statement, updated in 2012, has become the standard of concussion care in sports medicine. Sport Concussion Assessment Tool-2 (SCAT-2) was developed as part of the guidelines and represented the best available screening tool at that time. Return to play recommendations were also developed. Guidelines recommend evaluation of any player who shows features of concussion. Perhaps better evaluation translated into a higher rate of concussions since 2008.
The last factor I would like to discuss is prevention. In theory, concussion rates correlate inversely with effectiveness of preventative measures, such as helmets. Considering the attention that concussions have received in the recent years, it is reasonable to expect preventative measures to become more sophisticated, not less (this is just a common-sense assumption not supported by specific data). Nevertheless, concussion rates are on the rise. Evolution of preventative measures should have kept pace with increase in the rate of sports-related concussions, but I doubt that it has.
Increase in the rate of sports-related concussion since 2008 may result from:
1. Increased sports participation
2. Changing attitude towards sports
3. Improved awareness
4. Evolved screening and diagnosis
What other factors may have caused a recent increase in the rate of sports-related concussion?
1. Committee on Physical Activity and Physical Education in the School Environment; Food and Nutrition Board; Institute of Medicine; Kohl HW III, Cook HD, editors. Educating the Student Body: Taking Physical Activity and Physical Education to School. Washington (DC): National Academies Press (US); 2, Status and Trends of Physical Activity Behaviors and Related School Policies. http://www.ncbi.nlm.nih.gov/books/NBK201496/ Published 2013 October 30, 2013. Accessed March 14,2016.
2. White House Task Force on Childhood Obesity Report to the President. Let’s Move! Web site. http://www.letsmove.gov/white-house-task-force-childhood-obesity-report-president Accessed March 14, 2016.
3. HEADS UP in 10 Years. Centers for Disease Control and Prevention Web Site http://www.cdc.gov/headsup/about/viewbook.html Accessed March 14, 2016.
4. McCrory P, et al. Consensus statement on Concussion in Sport 3rd International Conference on Concussion in Sport held in Zurich, November 2008. Clin J Sport Med. 2009;19(3):185-200.