Parents' vigilance can head off kids' concussion risk

• Concussion symptoms not always obvious
• Head injuries that don't result in concussion appear to raise CTE risk
• Helmets for girls who play field hockey, lacrosse recommended

Concern about concussions and how these brain injuries affect children's health, has never been higher, and rightly so, says neurosurgeon Robert Cantu, one of the nation's leading concussion experts.

According to the Centers for Disease Control and Prevention, emergency department visits for sports and recreation-related traumatic brain injuries (TBIs), including concussions, increased by 60% among children and adolescents (from birth to 19 years old) over the past decade.

And the CDC estimates that almost 4 million sports and recreation-related concussions are recognized every year, with many times more going unrecognized.

In his new book,Concussions and Our Kids, Cantu, chief of Neurosurgery at Emerson Hospital in Boston and medical director of the National Center for Catastrophic Sports Injury Research, offers parents advice on keeping kids safe from this "silent epidemic." He spoke with USA TODAY'S Michelle Healy.

Q: You say that physiologically, kids and teens are more vulnerable than adults to concussions. Why?

A: They don't have fully myelinated brains, so the nerve cells and their connections don't have the coating and insulation of adult brains. In addition, they have disproportionately weak necks compared to adults, and disproportionately large, heavy heads, so they're like bobble-head dolls. This sets them up for brain injuries that are more serious than those sustained at a later age from the same amount of force. Girls appear more susceptible to concussions and post-concussion symptoms than boys and are often slower to recover, which is why I recommend that helmets be required in field hockey and girls' lacrosse.

Q: Concussions trigger a chain of chemical and metabolic reactions in the body, but you say there's growing evidence that they also can cause structural damage to the brain?

A: As co-director of the Study for Traumatic Encephalopathy at Boston University, I work with neuropathologist Dr. Ann McKee and her team and have seen firsthand the concussed brains of diseased athletes, in which there have been structural damage. I (expect) that as our abilities to image injured brains gets better, we're going to see that concussion, at least in some instances, and maybe most, is not only a metabolic injury, but also a structural injury.

Q: One of your goals is empowering parents to play a role in detecting concussion symptoms that coaches and trainers may have missed. How?

A: I'm not asking them to be a doctor or asking them to make the diagnosis, but asking them to have their antennas up for the subtle mood and behavior changes that could signal a concussion. They known when their kid is "off." When the kid is off, is it necessarily a concussion? No, but you might ask, 'Did you get whacked in practice today?' 'Did you have a fall?' or whatever. If they say yes, in those situations the parent should bring the kid to the doctor to be checked out.

Q: You rely on a checklist of 26 symptoms that help determine the severity of a concussion and the pace of recovery? What are some of them?

A: They fall into four (categories): Cognitive symptoms, where someone is having problems with concentration, memory, insight, judgment, attention, things you need for school work, to take exams and so on. Sleep symptoms, such as sleeping more or less than usual or having difficulty falling asleep. Emotional symptoms, such as feeling anxious, having panic attacks, depression or loss of impulse control. And somatic symptoms, including headaches, blurred or altered vision, dizziness or balance symptoms.

Q: Most kids will recover from a concussion, but how long does it take for symptoms to disappear?

A: Properly managed, roughly 80% of people will recover within seven to 10 days; 20% will go on and have symptoms that last beyond that time. Somewhere between 5% and 10% will go on to have post-concussion syndrome, in which symptoms last beyond a month. Most of those with post-concussion syndrome will recover, but some will take even over a year to recover and a very small number will never recover.

Q: What's known about the link between the degenerative brain disease CTE (chronic traumatic encephalopathy), which is so much in the news these days, and concussions sustained during adolescence?

A: I call concussion the poster child for CTE, but what's very important to know is that we have cases of CTE in people who have never had a "recognized" case of concussion. So just because you have had a very low number of concussions, or even no recognizable concussions, doesn't mean that you're not at risk for CTE. The risk factor is really all about total brain trauma, which includes concussions but also sub-concussive blows, those hits to the head that don't result in concussion symptoms or a recognized concussion. They're the blows that happen on every single play when two people hit heads but keep going -- it's just thought of as no big deal, just part of the sport. An individual sub-concussive blow isn't a big deal, but 10,000 of them over the course of a lifetime may be a big deal.

Q: Short of preventing your child from participating in any collision-type sport, what's a parent to do?

A: I don't want to stop sports from being played. I do want people to be very well aware that no brain trauma is good brain trauma. No hit to the brain is a good hit. If your child is going to play a sport in which brain trauma is inherent with the activity, please start at a later age. Arbitrarily I say 14 because that's when high school starts, and if you're going to play at the next level you've got to start somewhere. Ideally, I wouldn't have them start until 18, because it would have them taking less brain trauma over the course of their lives.

Q: So suggesting kids play no football or hockey until age 18 has no chance of flying?

A: From a practical standpoint I say don't start until 14. It has got a little chance of flying, but mostly it has a very big chance of putting in place another recommendation: Making rule changes in sports that will reduce the amount of contact allowed in practice and the number of hits that kids take in a game. I've already seen Pop Warner (youth football program) dramatically reduce the amount of contact allowed in practice and eliminate certain drills that involve head-to-head hitting. That's great. It's not good enough, but it's a great start. I would also recommend no heading in soccer until age 14, no body-checking in youth hockey before 14, and eliminating the head-first slide in baseball.

Q: You also say that young athletes, both boys and girls, should work to strengthen their neck muscles as a preventive measure to reduce brain trauma risks?

They should be working on strengthening their core musculature, especially their necks, so if they receive a blow to the head and see it coming, they can at least tense their neck muscles and reduce the acceleration forces the brain will receive. And by strengthening their core muscles, if they get knocked down, they have a greater chance of not having their neck snap back and suffering whiplash. Girls working to strengthen their neck exercises should remember that they don't produce enough testosterone to build big, bulging necks, but they are going to be stronger and that will help protect them.

Q: You note that concussions can occur in sports that we don't traditionally think of as collision-type sports.

A: They can happen in any sport in which there are accidental or non-accidental blows to the head and or blows to the chest or blows to the back that force the head to be snapped backward and forward. A few years ago, the U.S. synchronized swimming national team had a 50% concussion rate, and one member was permanently off the team for severe post concussion syndrome. Sometimes those powerful kicks performed underwater land on someone's head, but because it's buffered by water it's not thought of as a very hard hit.

Q: Is rest the most effective therapy for a concussion, even for patients who have long-lasting post-concussion syndrome who sometimes are also prescribed medications and non-medicinal therapies?

A: Both physical and cognitive rest is needed until the symptoms clear. Traditionally, people have been aware of the need for physical rest and understood that when you physically exert yourself, you greatly exacerbate your symptoms. People have not been so aware of the need for resting the brain. Individuals with cognitive concussion symptoms who exert their brain by doing computer work, reading, doing lengthy homework assignments, playing video games, texting will exacerbate their symptoms in almost every instance. We also recommend patients avoid noisy or bright locations like malls, sporting events and movie theaters.

Q: Many schools now have their student athletes take a baseline cognitive test for comparison should a concussion occur. Should that be required?

A: Such evaluations, which serve as a snapshot of how the brain functions when healthy, are a good first step, but keep in mind that they only measure the cognitive function of the brain, the thinking and reasoning parts of the brain. Other areas of the brain don't get measured on a cognitive test. If you use just one tool in the tool box, you are going to improperly diagnose concussions and possibly let people go back and play when they have not properly recovered.

Q: What about the many new high-tech accessories that are advertised as protecting users from head injuries, like anti-concussion headbands, helmets and chin straps? What's known about how well they work?

A: The Consumer Product Safety Commission and the Federal Trade Commission have already come down on some of these products and some of the claims they make. Those that claim to significantly reduce the risk of concussion haven't been proven to do so. Although the companies have some research, it hasn't been supported by independent labs and passed the mustard of peer review. There's also a plethora of sensor products coming on the market with accelerometers in helmets, on mouth guards, on chin straps. They allege that they will alert you to when a concussion may have occurred, but there is no solid science validating that.

Q: One of your big concerns is that unacknowledged concussion syndrome may be "falling under the radar" and affecting many more young people than we know?

A: In my opinion, we have a public health issue that goes far beyond our athletes, but we don't quite have our hands around it. I think a lot of what goes on in society that has peoples scratching their head, wondering, 'how could this have happened,' is probably related, in some instances, to brain trauma that people have sustained but it wasn't recognized. I'm talking about the behavior where there's a lack of impulse control, some of the of things. Probably in five to 10 years these things are going to be found to have occurred in people with damaged brains, brains that have been injured either on athletic fields or injured in falls, automobile accidents, motorcycle accidents, etc.

Cantu proposes these changes to youth sports programs to reduce the threat of head trauma:

-- No tackle football before age 14

-- No body checking in youth hockey before age 14

-- No heading in soccer before age 14

-- Require chin straps in youth baseball; ban the headfirst slide

-- Require helmet use in field hockey and girls' lacrosse

-- Hold sports officials to a higher standard