Dec. 11, 2019 -- Charlie Farfaras was a promising football player in Thousand Oaks, CA, when his high school season started this year. The junior, who has long loved football and has played since he was a boy, was a preseason All-Star selection for wide receiver and strong safety for his league. He had three strong games and then, in his fourth, he was hit by a player his dad says he never saw coming.
“I thought it was a really bad hit, but he popped right up, went to the sidelines and after two plays, he gave us a thumbs-up and went back in,” says his father, Chris, who was watching from the stands. “I figured it must not have been as bad a hit as I thought.”
That’s what the 16-year-old thought at first too. “It wasn’t until I went into the locker room at halftime that I really noticed something was off. It just felt different. It’s hard to explain.”
His athletic trainer pulled him off the field and sat him for the rest of the game. His parents took him home and later followed up with a doctor. Charlie was put on the league’s concussion protocol that mandates rest for a minimum of 7 days, followed by a slow return to practice. He knew he couldn’t return to football until he felt 100% better and the team trainer cleared him to play.
Charlie and his family expected that would happen quickly since this was his third concussion and they were familiar with the process. But this time, the days stretched on and he wasn’t improving.
“This one, though, made me feel strange and off,” Charlie says. “I had a really hard time keeping my focus in class. It just didn’t feel like I was getting any better the first or second week after the hit.”
Other people noticed too. His athletic trainer saw it in weekly baseline tests. A school counselor then reached out to the family -- surprised when Charlie failed a math test. His outside tutor expressed concern that Charlie suddenly couldn’t focus. His parents, too, saw big changes. Their son was forgetful. He wasn’t as upbeat as usual, and he complained frequently of headaches.
“Charlie initially had every intention of going back to football, but it just became evident over time that something wasn’t right. We all had a gut feeling that this was different,” Chris says. “So I sat him down after about 2 weeks and said, ‘Son, you are done with football.’ He understood and agreed. ‘Dad,’ he said. ‘I’m disappointed, but I definitely don’t feel right after this one.’”
Charlie hasn’t been back on a football field since.
The Latest Research on Concussion Prevention
There has been an enormous amount of research in recent years related to the impact of concussions on young athletes, how best to treat them, and how to lessen the effects of these head injuries.
Even so, doctors say diagnosing and treating young patients -- and knowing how long it will take for them to feel “normal” again -- is still an unpredictable process.
“What is striking is there is still a lot we don’t understand,” says Christina L. Master, MD. She’s co-director of the Minds Matter concussion program at Children’s Hospital of Philadelphia and has been treating concussions for nine years.
The CDC defines a concussion as a type of traumatic brain injury that causes the brain to twist in the skull -- injuring neurons by stretching, resulting in chemical changes in the brain.
CDC data published in March 2019 found that from 2010 to 2016, an estimated 283,000 children came to emergency rooms each year for sports- or recreation-related traumatic brain injuries. Injuries from contact sports accounted for nearly half (45%) of those visits. And football, bicycling, basketball, playground activities, and soccer were the leading causes of the most ER visits.
But it’s estimated that children get between 1.1 million and 1.9 million sports- and recreation-related concussions each year and that most aren’t seen in health care settings.
Research shows children are more at risk for concussions. That’s not only because their brains are still developing, but also because coaching and management policies in youth sports may be less consistent than they are at the collegiate and professional levels. Plus, players at the college and pro levels are taught how to run and tackle in ways most likely to avoid concussions. There are stiff penalties, too, for hitting another player in ways likely to produce head injuries.
Doctors say clinically managing head injuries is also tricky in children because kids are always changing.
Despite the challenges in this field, new research is shedding greater insight into who is affected by concussions and how. That includes:
- There are racial differences when it comes to the diagnosis of concussion. Black children who come to the ER with a head injury are less likely than non-Hispanic white children to be diagnosed with a concussion.
- Children with attention deficit hyperactivity disorder perform differently on concussion assessments -- including doing worse on balance assessments.
- Rates of concussion were significantly higher in girls than boys, especially in soccer and basketball.
- Girls between the ages of 7 and 18 take longer to recover from concussions than boys, a difference that disappears if girls go for specialty care within a week of injury.
“Girls may get more concussions if you compare sports that have similar rules,” Master says. “They may have more symptoms when they have the concussion, and they may take longer to recover.”
Studies by Master and her colleagues show those longer recoveries, which she says could have a biological basis ranging from genetics to hormones, can be significant. Her research found it took girls:
- Longer to return to school: 4 days, vs. 3 for boys
- Longer to return to exercise: 13 days, vs. 7 for boys
- Longer for nervous system functions to get back to normal: 68 days, vs. 40 days in boys
- Longer to get normal vision: 77 days, vs. 34 in boys
- And longer to get full clearance by a doctor to get back to playing their sport: 119, compared with 45 days in males
Master says their study raises the question as to why girls might wait to see a brain doctor. Her team was surprised, she says, since data shows they’re more likely to share their symptoms than boys.
“They may not be recognized as having concussions at the same rates as boys, because most girls’ sports don’t have athletic training coverage at the same rates as boys,” Master says. “As a limited resource, when there is only one athletic trainer, inevitably they cover football or boys’ lacrosse. They are less often found on the field for girls’ soccer or lacrosse, and we feel that this may lead to a delay in diagnosis, treatment, and referral.”
Her team is now analyzing data of women’s sports at the college level -- where athletic trainers are more common -- to see if their hypothesis holds up.
The Search for Solutions
Rochelle E. Haas, MD, is co-director of the concussion program at Nemours/Alfred I. duPont Hospital for Children in Wilmington, DE. She says it is challenging to diagnose a concussion because no one tool can be used on its own to do that, and symptoms may not always appear just after an injury. Different tests are required for physical, cognitive, and psychological functioning.
“A concussion by definition is a change in how you feel or function after force is transmitted to the head. It does not have to be associated with a loss of consciousness,” she says. “What tells you about injury severity is how long it takes to get better.”
Haas says in addition to a good neurological exam, evaluation of people who have a concussion should also include a review of symptoms and assessment of their balance, vision and hearing, mood, and thinking and memory.
Researchers are looking at a variety of ways to better treat concussions in young patients, including a new classification system for physical therapy, improving concussion reporting, and trying to agree on definitions to better track concussion rates in youth sports.
There’s also a great emphasis on concussion prevention education and awareness among coaches and parents. The CDC stresses that when an athlete continues to play with a concussion, it increases their chance of getting another one. Repeat concussions that happen while the brain is still healing from an original injury can also “affect an athlete for a lifetime,” the agency warns.
“Concussion research is in its infancy, but you’ll hear people say three strikes and you are out. What they mean is … after three concussions, you are at risk of it taking less force to get a concussion, longer time to recover from one, and your recovery is less likely to be complete,” Haas says.
The CDC created an online concussion training program for youth sports coaches and parents in 2010 called HEADSUP. The agency has created posters for athletes about the leading causes of concussion in many sports, and a CDC spokesperson says its Injury Center’s Traumatic Brain Injury Team is working on ways to better protect athletes.
A variety of suggestions have been explored in recent research, including:
- A September 2019 study that found that disallowing body checking reduces injuries in youth hockey by 56%.
- A study published in August in the American Journal of Sports Medicine that says there is a 57% decrease in head injuries when high schools eliminate full-contact football practices.
- Other reviews have looked at the protective effect of helmets in skiing and snowboarding and the effectiveness of helmet padding in football, mouth guards in contact sports, and rule enforcement to reduce head contact in ice hockey and soccer.
- Best practices are also being refined for diagnoses of concussion on the sidelines, to include assessment of symptoms, physical and mental status, cognitive function, and balance -- in addition to looking for spine or skull injuries or bleeding in the skull.
Calling for Athletic Trainers
Douglas Comeau, DO, director of the Concussion Clinic at Boston Medical Center, finds concussion diagnoses are enhanced when athletic trainers are on the sidelines, especially ones who are familiar with the players.
“Athletic trainers are the eyes and ears of sports medicine physicians. Having an athletic trainer on the sideline can assist with the evaluation and eventual diagnosis of concussion,” he says.
But a study published in November 2019 showed that one-third of all secondary schools had no access to athletic trainer services. That number is even higher (45%) when you look at private schools alone.
“Despite an increase in the number of legal cases, court-ordered overhauling of health and safety policies, and awarding of large settlements, school districts, school education boards, state legislators, and state athletic associations continue to take a reactive, rather than proactive, approach to addressing safety concerns,” says lead author and athletic trainer Robert Huggins, PhD.
“Providing appropriate care for student athletes comes down to priorities. The safety of student athletes must be the top priority for schools with athletic programs, not just in rhetoric, but in allocation of resources to put the appropriate personnel in place,” echoes Tory Lindley, president of the National Athletic Trainers’ Association.
“Schools need to see athletic trainers are an essential requirement to having an athletics program -- similar to how they see the coach,” Lindley says. “While coaches oversee play on the field, athletic trainers are responsible for injury prevention and addressing the physical and mental effects of playing the game. Athletic trainers should not be a luxury, but rather a necessity for all programs.”
Master says it’s also important that parents and coaches educate all children --especially girls -- on what to look out for. “It can be a hard fall or whiplash. It doesn’t have to be a direct hit to the head. If young athletes can recognize it when it happens, then they can advocate for themselves -- even if an athletic trainer isn’t present,” she says.
The Emotional Impact
In Charlie’s case, his focus and concentration have improved, and he has been cleared by doctors to return to sports play. Since he gave up football, he’s gone back to his other sport -- baseball. He joined his school’s fall team and is now a pitcher. “The likelihood of an injury happening there seems far less,” his father says.
Chris, who played football himself in college, says his family is still a big fan of the game and continues to support his son’s former team by watching them on Friday nights. But he also admits there has been an emotional impact to manage for his son throughout this experience, too.
“He doesn’t want to be a quitter, and as a parent, you have to step in and explain -- that isn’t what’s happening here at all. We’ve really had to stress to him that he didn’t so much quit football as let it go, and that isn’t a sign of weakness. It’s a sign of strength to recognize that it’s time to walk away because he’s still young, and continuing to play could put his health at risk.”
“Emotionally, I think I’m past the depression of knowing I will never play football again,” Charlie says. “I do stop and think from time to time about what could have been. I was really looking forward to doing something special this fall on the football field. I realize I have to move on, though. There is nothing else I can do.”