Sex Differences in Soccer Related Brain Injuries

More than four years ago, prompted by the World Cup Games of 2014, we wrote about new pediatric concussion guidelines.  Now, the  NFL season is about to get underway, and lots of the football fans we know are dismayed at the frightening statistics about head injuries to players, both professionals and those who play in school. Moviegoers who saw the 2015 film Concussion saw this issue dramatized in a compelling way. Because no women play in the NFL and only a handful play football at college and high school levels nationally, there have been no comparisons between how blows to the head might affect male and female football players differently.

Such is not the case with soccer. Both boys and girls play in schools, in leagues, and informally and it is possible to look at differences in how blows to the head -- from "heading" the ball or otherwise -- might differ between male and female players.

Research findings reported last month in the journal Radiology that looked at the results of  sophisticated neuroimaging of approximately 100 soccer players in their twenties, evenly divided between men and women, suggest that "women may be more sensitive than men to the effects of heading at the level of tissue microstructure". The researchers noted that their findings "add to a growing body of evidence that men and women express distinct biologic responses to brain injury."  The research team noted that they had controlled for sex-based differences in frequency of heading among players.

It is clear that football isn't the only sport in which repeated head injuries can have a significant impact over time. And it isn't only boys who are at risk. Parents and coaches of female athletes, especially soccer players, need to be aware not just that girls can suffer from repeated blows to the head when they play, but that girls appear to be even more vulnerable to the effects of such impacts than are boys. The researchers in this study express the hope that, "A focus on sex-based vulnerability to brain injury may inform care of injured athletes and enhance guidelines for safe play." We hope so too.

Photo by Jeffrey Lin on Unsplash

High School Athletes: Thinking Ahead to College

Applying to colleges can be an overwhelming proposition for most students, but those hoping to play sports in college have an additional series of factors to consider. This is especially true for students hoping to play for universities and colleges known for their academic standards, which tend to allocate fewer resources to athletic recruitment. However, athletic skill can be powerfully influential in the admissions process, so it's worth students' time to learn about the process and develop and implement a strategy.

First, students should familiarize themselves with the National Collegiate Athletic Association's many rules and regulations. Athletes should check with the Eligibility Center, where they can learn what criteria they must fulfill to play college sports. They can also download a helpful guide for college-bound student-athletes from the website. Finally, they should register for the NCAA to begin making themselves visible to coaches.

Most high school students don't launch seriously into the processes of researching and applying to colleges until at least their junior years. But, according to Amy Rader Kice, assistant dean at St. Edward's University, athletes need to get moving sooner. Rader Kice writes that coaches often begin contacting highly promising athletes during their sophomore years, and many athletes know up to a year in advance which school they'll be attending and representing. It may be best to start narrowing down a list of schools during a student's freshman year of high school, then initiating contact with coaches the following year.

Marketing one's self as a college-level athlete is a lot like applying for a job. Because NCAA rules limit the amount of contact coaches can have with prospective college athletes, students should initiate contact themselves; there's no penalty for that. Again, this is particularly important for students who want to attend academically rigorous schools, says Keith Blackwell, founder of a subscription-based website designed to connect student-athletes and college coaches called Elite College Sports.

Students should submit whatever evidence of their prowess they can—videos of them playing, statistics, times, etc.—along with evidence that they can perform in the classroom as well. GPA, standardized test scores, and recommendation letters from teachers as well as coaches are all useful to coaches, who don't want to risk recruiting athletes who may lose eligibility if their grades aren't up to par.

Any serious athlete knows that training in the off-season is important. By the same token, summers can be critical periods for athlete recruitment, too. Many universities offer summer workshops in which coaches work with high school athletes; start looking for postings in February and March. For those who can afford to attend, it's a win-win: coaches are on the lookout for promising talent, and the athletes can benefit from coaches' wisdom and tips at the same time.

Finally, students should remember that a super-sonic fastball or a perfect three-pointer aren't the only things that turn coaches' heads. Coaches want to recruit students who demonstrate leadership, initiative, and resilience. Good sports who are enjoyable to have in the locker room are a pleasure to coach and can buoy a whole team's spirits. Demonstrating good citizenship may be just as important as demonstrating athletic skill.

New Pediatric Concussion Guidelines

Watching the amazing players on the World Cup teams, we suspect that the high level of play and the drama of many of the games will help make soccer more popular here in the U.S., especially among young people. But we can't help but notice the frequent and often traumatic contact between the players' heads and the ball and the lack of any sort of protective headgear. Parents are understandably concerned about this.

We were particularly interested, therefore, when we learned of the release last week of the first comprehensive pediatric concussion guidelines from pediatric emergency medicine researchers at the Children's Hospital of Eastern Ontario (CHEO) together with the Ontario Neurotrauma Foundation (ONF). The guidelines were developed by an expert panel including over 30 members across Canada and the United States, and included representation from the full spectrum of pediatric health disciplines (emergency medicine, family practitioners, neurologists, rehabilitation professionals, etc.) which worked for over two years and reviewed more than 4,000 academic papers.

"These are the first comprehensive pediatric guidelines that we're aware of; they reflect the very best available evidence today," said Dr. Roger Zemek, who led the panel. "It was fascinating to see how recommendations have changed over time. Years ago, children were told to 'rest' after concussion, which means something entirely different today with the onset of technology – now, rest also includes a break from screen time."

The guidelines include numerous tools and instructions for parents, schools, physicians, and coaches. For example, the guidelines provide a pocket tool to be used by a coach or parent at the sideline to recognize concussion and offer advice on when to remove kids from play and when to seek emergent medical attention. For the emergency department physician, algorithms are provided to guide the decision whether or not to obtain CT scans, and examples of written discharge handouts for patients and families are included. For family physicians and nurse practitioners in the community, the guidelines provide recommendations for ongoing symptom management and decision tools to help navigate 'return-to-learn' and 'return-to-play'. For school boards, the guidelines provide an example of a policy statement regarding pediatric concussion.

We have long been concerned about the impact of concussions on learning  It is encouraging to see the expertise of so many researchers and clinical physicians come together to offer practical guidelines that reflect the best current knowledge. 

Recommended Reads: Heat by Mike Lupica

Heat by Mike Lupica

Grades: 5-8

The Plot –  Spoiler alert!: Twelve-year-old Michael Arroyo’s pitching arm is incredible – so incredible that he should have it made. It seems that he shouldn’t have a care in the world, but nothing could be further from the truth. In the first pages of Heat, readers are introduced to Michael, his seventeen-year-old brother Carlos, and many of the friends he’s made in his neighborhood in the South Bronx. But although his sons talk about him often, Michael’s father never makes an appearance, and eventually we learn why: Michael’s father died suddenly several months before. It was his final wish that his sons stay together. But there is no one to take them in, since the Arroyos left the rest of their family behind when they fled Cuba for New York, and Carlos and Michael worry that Children’s Services will split them up if they go into the foster care system. So, they craft an elaborate lie, trying to hold out until Carlos turns eighteen in a few months and can serve as Michael’s legal guardian. Meanwhile, Michael’s fastball is causing jaws all over New York State to drop, earning him lots of attention as his team dominates the local competition in their quest to make it to the Little League World Series. But a formal complaint is lodged by jealous coaches of rival Little League teams, claiming that Michael must be older than he says he is. Michael’s father left much of the family’s paperwork behind when they fled Cuba, and without his birth certificate Michael is banned from playing with his team. After having a spat with a new girl in the neighborhood, the first who has ever turned Michael’s head, it seems that everything in Michael’s life is going wrong. But, with the help of his friends, things turn around for Michael just in the nick of time, and all of his problems are solved in one immensely satisfying, if somewhat improbable, scene.

  

Our Take: Mike Lupica serves up a winner with Heat. Michael is, perhaps, a little too good to be believed -- honest, athletically gifted, kind, funny, humble, grounded -- but you could hardly ask for a better role model for young athletes. And his commitment to maintaining all these admirable qualities, even while dealing with the anguishing hard knocks life has dealt him, will be inspiring to young readers. Parents don’t need to worry about whether they should let their child read another sports book or make him/her read a “quality” book instead; Heat has it all. Lupica’s descriptions of games are nail-bitingly vivid, revealing his “other” job as an ESPN commentator and sports columnist. Young baseball fans will relate to Michael’s fixation on the sport and learn a lot about the importance of practice, tenacity, sportsmanship, and friendship. But this book will appeal even to those who aren’t captivated by America’s pastime. The book is filled with humor, in large part thanks to Michael’s irrepressible best friend and catcher Manny.  Its plot is compelling and its writing is exceptional. We highly recommend Heat to baseball lovers, dreamers, and everyone who loves a well-told tale. 

Adult themes: None.

Interesting Background: Lupica was inspired to write Heat by the Danny Almonte scandal. In 2001, it was discovered that all-star South Bronx pitcher Almonte had lied about his age, saying he was twelve instead of fourteen so that he could star on a Little League team of younger players. The scandal is mentioned several times in the book.

Children, Football, and Concussions

As a parent, pediatrician, and lifelong football fan, I was naturally drawn to the article on the first page of yesterday’s New York Times, “A 5-Concussion Pee Wee Game Leads To Penalties for the Adults.” The article was particularly timely as we embark on a major initiative at The Yellin Center to better understand and address how concussions affect academic performance. As I read the Times article, I followed the narrative as the litany of concussions in this single football game in Massachusetts unfolded. As Chris Nowinski, president of the Sports Legacy Institute aptly noted, there were undoubtedly many more concussions than those that were diagnosed. While I do believe that adults need to be held accountable for their decisions when they are responsible for children’s safety, I think we are fooling ourselves if we believe that this alone is an effective way to address this problem.

As a former Chief Medical Officer of a hospital, this football game is what we would call a “sentinel event.” Like the canary in the coal mine, sentinel events often tell us that there are big problems that need to be confronted. In almost every case, individual errors in judgment can be identified. However, when one looks closely through a process called a “root cause analysis” one usually finds that these kinds of errors in judgment are often more widespread and that the sentinel event represents a “perfect storm” of causes. Taking an immediate punitive approach often short-circuits the root cause analysis and discourages people from coming forward in the future to report minor problems before they become major ones.

It’s clear that concussions are not only a problem for the youngest players. A follow-up article in today’s paper about concussions in high school football refers to a study from the Pediatric Brain Trauma Lab at Massachusetts General Hospital that found that 486,000 combined head impacts had been recorded over a five-year period among players from the football teams at Brown, Dartmouth and Virginia Tech, as well as two men’s and two women’s hockey teams.

Was I the only one that was stunned when I read that based on the rules of “safety” the weight limit for 10 year olds in the Pee Wee game was 120 pounds? 120 pounds is more than 20 pounds above the 95th percentile for 10 year olds! Furthermore, as the Times notes, “rules are only as effective as the adults charged with enforcing them. Four of the five injured boys have resumed playing football…”

So, I think that we all have some serious work ahead of us in examining the safety of contact sports for young children. We need to begin with a root cause analysis of the Massachusetts sentinel event. And we have to seriously entertain the question about whether it is ever possible to make these contact sports safe enough for young children.

Photo: woodleywonderworks / Creative Commons (modified)

Dyslexia No Bar to Sports Success

Dr. Yellin is an avid fan of the New York Jets and has been since he was a kid.

So, it was with a good deal of interest that we noted a recent article in New Jersey's Star Ledger that revealed that both Jets head coach Rex Ryan and new team addition Tim Tebow each struggle with dyslexia, a language-based learning disability. The article notes that the coach and quarterback learned about their dyslexia at very different points in their lives. Tebow has a family history of dyslexia and both his father and brother have the same learning difficulty. Researchers know that there is a genetic predisposition to dyslexia in some families. Tebow learned about his dyslexia when he was in elementary school and was home-schooled through high school, moving on to the University of Florida.

Coach Ryan did not discover that he had dyslexia until he was in his forties but was able to rely upon his other areas of strength to earn his college and masters degrees in physical education.

Whatever the fortunes of the Jets this season, young people with dyslexia should be aware that there are numerous successful athletes with this learning disorder and, in fact, some experts believe that the ways that individuals with dyslexia need to adapt to read effectively can be helpful to them in a number of future careers, including business and the arts. Read a longer discussion of this phenomenon.

Forty Years of Title IX

Next week marks the 40th anniversary of Title IX, the Education Amendments Act of 1972 whose key language provided that " No person in the United States shall, on the basis of sex, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any education program or activity receiving Federal financial assistance..."

Since it was signed into law on June 23, 1972, Title IX has transformed the landscape for women's education and women's sports, providing for such sweeping changes as the formation of women's sports teams, and the right of pregnant girls and women to remain in school. The law does still permit single sex schools and colleges, so long as public schools do not use them to limit access to programs to only one gender, such as having special math or art programs only available to students in a single sex school.

The protections of Title IX have not been enjoyed equally by all women. A recent New York Times article points out that women of color in sports still face challenges in reaching equality in athletics and that white girls participate in high school sports at higher rates than other groups.

Still, the progress under Title IX has been substantial in the last 40 years. One place that is celebrating these decades of growth for women is the Charles M. Schulz museum in Santa Rosa, California, which is running an exhibit called "Leveling the Playing Field" which celebrates the athletic exploits of Schulz's comic strip girl characters in sports from football to figure skating. It turns out that Schulz was very impressed by tennis great Billie Jean King and was inspired by his friendship with her to create a series of strips celebrating women in athletics. They certainly make a point, and are sure to bring a smile as well. Take a look for yourself.

Photo by Ingy via Flickr Creative Commons