Apply ThinkFirst approach to education research in sportsrelated injuries

The ThinkFirst National Injury Prevention Foundation identifies and provides evidence-based programs to help people learn to reduce their risk for injury from motor vehicle crashes, violence, falls and recreational sports. It was started in 1986 as the National Head and Spinal Cord Injury Prevention Program after the American Association of Neurological Surgeons and the Congress of Neurological Surgeons directed two neurosurgeons to develop a national injury prevention program.

Based on education, ThinkFirst took on the message of bike helmet safety, and as a neurosurgeon, you were unable to leave an American Association of Neurological Surgeons or Congress of Neurological Surgeons meeting without having this message clearly communicated. Today, based in part on ThinkFirst’s efforts, bike helmets worn by youth and adults are well established as safety measures to prevent concussion and severe head injuries.

John C. Liu

The message delivered was simple, yet effective, and educational efforts, including online instruction and other safety-related messages, continue to be presented to reduce injury risks with equally effective results.

Sports-related safety

This same approach should be applied to sports-related safety to elevate our current understanding and awareness of common sports injuries for not only players and parents, but also for coaches and trainers. Serious sports-related injuries are rare, but do occur. As we go to press, the most recent death from a high school football injury was reported in Chicago.

Soft tissue and ligament injuries, as well as bone fractures, occur much more frequently in all youth-related sports, especially contact-heavy sports like football and soccer. More insidious injuries, like concussions, occur frequently and may have devastating future repercussions as witnessed by a seeming epidemic of concussion-related chronic brain injury reported in National Football League (NFL) and college football players. Often these chronic injuries were acquired years before starting high school play, or even at a much younger age. Unrecognized concussions to a young developing brain may prove to be more problematic than previously thought. This includes not only sports like football, but also soccer where headers are a common technique for controlling a ball.

Watching my son playing soccer and going up for headers when he was 10 years old always concerned me. Not infrequently, he seemed a bit stunned after a header or heavy contact with other players. One particularly scary incident occurred when an opponent fell to the ground with momentary unconsciousness after receiving a high header. He was subsequently transported and evaluated in the hospital with moderate concussion. The number of unrecognized minor concussions can potentially be much more serious than one may think.

Parents are usually told by the soccer coaches that headers do not cause concussion, but who really knows? Are we certain repeated mini-head traumas will not cause cumulative cognitive issues in the future in young developing brains?

In football, concussion and spine injuries can certainly be major issues. Ten years ago, there was little or no news about football and brain injury, but now it seems almost common to identify yet one more high-profile former NFL or college football player who suffers from previously unrecognized cumulative brain damage. Junior Seau, of the University of Southern California and San Diego Chargers was one unfortunate former football player who succumbed to the brain damage he accumulated during years of playing high-level football.

Promote recognition, safety

The ThinkFirst approach to education, research and promotion should be applied to promote recognition and safety of sports-related injuries. The targeted audience would include coaches, trainers, players and parents to identify and prevent the most common injuries in a particular sport.

There have been new rules and regulations developed in the NFL and in collegiate play regarding high-risk tackling techniques, and these rules should be extended to all high school and younger tackle football played. Teaching proper tackling techniques in football to avoid concussion and spinal injuries should be mandatory for youth and high school football coaches. Common injuries and their prevention should be mandatory information that all parents and players should know–just as wearing bike helmets has become intrinsically associated with safe riding habits.

Soccer coaches with the American Youth Soccer Organization or other youth clubs are often taught by parents and non-professional coaches. Information on when to use headers and the proper technique for heading a soccer ball should be taught to anyone who coaches youth soccer players. Proper recognition of concussions and other common injuries should be common knowledge through the education of coaches and trainers. Parents should be trained to identify post-concussive symptoms. Avoidance of multiple hits related to concussion has been found to be of upmost importance in avoiding permanent brain damage.

Return-to-play decision

Preseason cognitive testing discussed in the Cover Story, as developed by Joseph C. Maroon, MD, and colleagues and used by the NFL and many college football teams, should be implemented for high school and youth sports teams where there is a likely risk of concussion. Players should not return to contact sport if they are not back to their cognitive baseline.

Focused research would benefit from better understanding of the physiology of concussions and what works to prevent permanent brain damage. One wonders whether children younger then a certain age who play youth soccer should completely avoid headers while their brains are developing.

There are also some soccer experts who advocate the use of helmets, but others feel the use of a helmet does not prevent concussion, and a false sense of security that may lead to otherwise aggressive play tactics. Rugby is played without any form of head protection and seems to have less issues with concussion as compared with football. Perhaps without helmet protection, a rugby player takes a safer approach to tackling vs. a football player who wears full pads and helmets, both of which may give a false sense of security that the protective gear will prevent serious injuries. The current epidemic in chronic brain injury among former NFL players suggests otherwise.

For more information:
John C. Liu, MD, is the Chief Medical Editor, Neurosurgery for Spine Surgery Today. He can be reached at Spine Surgery Today, 6900 Grove Rd., Thorofare, NJ 08086; email: spine@healio.com.

Disclosures: Liu reports no relevant financial disclosures.