A Bump on the Head?

Eight million young people play soccer in the United States every year, often cheered on by parents who assume soccer is safer than other contact sports. In fact, youth soccer players actually have about the same rate of concussions as their peers in football, according to findings presented at an October 2001 Institute of Medicine (IOM) workshop on head injuries in youth soccer.

A concussion is not merely a bump on the head, says Dr. Mark Schwartze, a neurologist and the medical director of Baylor's Health Center. Mild traumatic brain injury, the formal term for concussion, results when the brain moves forcefully inside the skull. This movement can disrupt brain function and damage brain cells, resulting in changes in mental status, he says.

Concussions occur when soccer players collide with one another, run into goalposts or hit their heads on the ground during a fall. Heading soccer balls does not seem to be a frequent cause of concussions in youth soccer, the report found, primarily because youth don't kick the ball hard enough for that result. Due to the lack of studies on heading in youth players, however, the IOM could draw no definite conclusions about the safety of the practice. The American Youth Soccer Organization currently recommends against heading for children younger than 10.

The signs of concussion may include slowness in answering questions, memory loss and incoordination (see sidebar). Other signs -- such as reduced concentration and sleep disturbances -- may not appear until days or even weeks after the injury, according to the report.

Coaches, parents and players often underestimate the seriousness of concussion and are unaware of many of the signs. A common misconception is that unconsciousness always occurs with concussion when, in fact, this symptom occurs only about 10 percent of the time, the IOM reported.

Dr. Schwartze suggests that changes in behavior might be a more accurate indicator of brain injury than loss of consciousness. "If you just use loss of consciousness as your criterion, many concussions will be missed. We need to be more sensitive to changes in behavior and ask ourselves if the player is acting appropriately," he says.

The failure to recognize concussions can have serious consequences, Dr. Schwartze says. Second-impact syndrome, or SIS, is a potentially life-threatening swelling of the brain that may develop when a second concussion occurs before the first has healed. Although rare, SIS also is associated with long-term problems such as the inability to concentrate or impaired hearing or vision. Protecting players from SIS should be an important factor in determining when it is safe to resume play, he says.

Unfortunately, there is no simple test to determine if the brain has healed after a concussion. Two studies presented at the IOM workshop found that mental functioning was impaired for 10 to 30 days after a concussion, even when symptoms no longer were present. This suggests that it may take the brain longer to recover than previously believed.

The lack of certainty about the time it takes for the brain to heal creates a vexing problem for coaches who often are the ones to decide if a player can return to the field. The IOM concluded that many of the "return-to-play" guidelines in use today rely on loss of consciousness instead of other signs. Also, the guidelines place too much emphasis on a player's own assessment of his or her readiness to play.

The IOM encourages youth soccer officials, parents and players to become better educated about the signs of concussion and stresses the need for soccer associations to develop clear and objective guidelines to help decide when it's OK to play again after a head injury.

"Is Soccer Bad for Children's Heads? Summary of the IOM Workshop on Neuropsychological Consequences of Head Impact in Sports" is available online from the National Academies Press at www.nap.edu.

Signs of concussion

• Dazed, vacant stare
• Delayed responses or slowness in answering questions
• Inattention or the inability to follow conversations
• Disorientation or unawareness of time or place
• Slurred or incoherent speech
• Incoordination
• Inappropriate emotionality
• Memory problems
• Loss of consciousness Source: Kelly, J.P. and Rosenberg, J.H. "Diagnosis and Management of Concussion in Sports," Neurology, 48: 575-580, 1997