• Slug: Sports-Soccer Headers Youth. 3,000 words.
• Photos available

By JORGE RAMOS
Cronkite News

LOS ANGELES – Jazmarie Mader, a former Arizona State women’s soccer player, was on a flight back home to Phoenix in 2016 when she started feeling nauseous. She headed to the back of the plane toward the bathroom and tried to push the door open.

The next thing she remembers was waking up on the floor of the bathroom with flight attendants gathered around her.

Mader believes she fainted as the result of a concussion she suffered in a match seven days earlier, striking her head again.

“It was like a movie almost … where there’s a black screen. You can watch the screen and hear things that people are doing but you can’t see anything,” Mader said. “I could feel that and I was touching it with my hand but I still couldn’t see anything.”

The result was Mader’s second concussion in a week. The second was more severe and ended her junior year season at ASU.

Mader’s first concussion occurred in a 2016 match against Pac-12 rival Colorado. The ball had struck Mader in the head as the opposing player attempted to play a ball over her head.

“I just didn’t brace for it,” Mader said. “I think if I would have braced for it, I would have been fine.”

Her experience isn’t unusual. Between 1.6 million and 3.8 million sports-related and recreation-related head injuries occur in the United States each year, according to Children’s Hospital Los Angeles.

After her two head-related incidents, Mader was bedridden for three weeks and underwent vision therapy for two months. When she finally was allowed to return to the soccer pitch, she experienced episodes of anxiety.

Mader did not return to action until her senior year when she was cleared to play before the start of the season. Her story is familiar among soccer players and athletes involved in other contact sports, in which concussions are common.

The effects of concussions on soccer players like Mader, 22, are dangerous enough. But concussions among youth soccer players can potentially be more life-changing.

As the result of growing concern about concussions and the potential for liability, the U.S. Soccer Federation made a dramatic cultural change in 2015. The federation implemented safety initiatives in youth soccer competition that include a ban on heading the ball in games or practices involving players 10 years old or younger. Players 11 to 13 are allowed to head the ball in games, but are limited to no more than 30 minutes of practice time heading the ball and no more than 15 to 20 headers during that time each week.

The moves came in the wake of a class action lawsuit in which a group of families sued the U.S. Soccer Federation and FIFA — the governing body of international soccer — along with other American soccer organizations, accusing them of negligence because they failed to implement policies that would protect youth soccer players from concussions.

A federal court judge in California dismissed the case against FIFA without prejudice — meaning it cannot be re-filed — in July of 2015. However, the judge ruled that other organizations, such as youth leagues, could sue if the plaintiffs show they have standing to file suit, such as evidence of injuries.

U.S. Soccer made the dramatic rule changes, but debates remains about whether the changes have made a difference.

Recording data

The federation has no current all-encompassing system to record data on head-related injuries in its youth players and ultimately cannot definitively state that its rule changes have reduced injuries.

Researchers have some possible solutions to help alleviate the number of concussions that occur in soccer and to deal with the lack of a surveillance system.

Yet, if concussions are such a large problem in soccer, why doesn’t U.S. Soccer, which did not respond to a request for an interview, have an injury surveillance system to track head-related injuries?

The answer is two-fold said Dr. Dawn Comstock, associate professor of epidemiology at the University of Colorado-Denver’s School of Public Health and a board member of the Center for Disease Control’s National Center for Injury Prevention and Control (NCIPC).

Comstock said it is expensive to the track data and that there is a lack of certified people to report such data accurately.

“It always comes down to money,” Comstock said. “A surveillance system is a pretty labor-intensive effort and there is just no research funding. Who are you going to get accurate information from?

“Even if I have a system set up to collect information about injuries in a youth soccer population, who is going to give me that information if there’s no trained sports medicine clinician available to give it to me? We don’t expect the 7-year-old soccer player to tell us accurate information.”

Comstock is in charge of the Program for Injury Prevention Education and Research (PIPER) a high school sports injury surveillance study that records data from hundreds of high school athletes and tracks injuries including concussions through athletic trainers. She admitted that even with her system a lack of funding is difficult to overcome.

“In my 13 years running my system, I have had 10 different funding sources,” she said. “That’s how hard it is to get consistent funding for this kind of program. Nobody wants to pay for the work to collect the data.”

Researchers are left with a few ways to collect data.

One way is tracking emergency room visits for sports related head injuries. However, although emergency room visits provide some insight into the the frequency of soccer-related head injuries, it doesn’t paint the whole picture.

Comstock pointed out that parents don’t always take their child to an emergency room because of the expense.

“They can take them to their own pediatrician, they can take them to an urgent care clinic, they can take them to a pediatric sports medicine facility and they can take them to a concussion clinic,” Comstock said.

Tracking insurance records is another option for researchers, but that method also has shortcomings. For instance, pediatricians that specialize in younger children might not diagnoses concussion symptoms that can differ depending on the age of the child. Also, parents might not seek medical treatment for their child for every head-related injury, meaning there will be no insurance claim recorded.

Some of the obstacles to tracking data for youth soccer don’t exist for high school and college athletes because at that level, healthcare professionals such as a team doctor or a certified athletic trainer are present at matches.

Athletic trainers at the high school and collegiate level track all injuries, and the NCAA has a system that also compiles data on head injuries, making the information readily available.

With the exception of a few studies tracking youth sports head injuries at the hyper-local level, reliable data is limited.

Getting their head around it

Concussions can often be an abstract concept for parents of young children to grasp.

Dr. Tracy Zaslow, medical director of the Children’s Orthopaedic Center Sports Concussion Program at at Children’s Hospital Los Angeles, said that when a concussion occurs, the brain moves around in the head and causes a change at the cellular level.

“There is more a biochemical change,” Zaslow said. “You can compare it to a computer that crashes. When a computer crashes, it has got to reboot. Recovery is kind of the reboot period after the head trauma.”

It can become especially difficult to treat younger athletes because they might present different symptoms that their older counterparts.

“It’s the opposite of most other injuries. You break a bone as a 5-year-old, you’re going to get better faster than your 30-year-old,” Zaslow said. “When it comes to concussion and brain injuries, it is slower.”

She said seven to 10 days is a normal recovery time for adults who suffer a concussion, but three to four weeks of recovery is considered normal for some children.

Many parents whose children play contact sports fear that their child could someday suffer from Chronic Traumatic Encephalopathy or CTE, a degenerative brain disease often found among athletes and military veterans.

The disease was highlighted in the 2015 blockbuster film “Concussion” that starred Will Smith as Dr. Bennet Ifeakandu Omalu, a Nigerian-American forensic pathologist and neuropathologist who identified the disease in several deceased former NFL players while working in the Allegheny County Coroner’s office in Pittsburgh, beginning with former Steelers center Mike Webster.

According to the Mayo Clinic, CTE may include symptoms such as cognitive impairment, impulsive behavior, short-term memory loss, depression or apathy, loss of executive function, emotional instability, substance abuse and suicidal thoughts. It is most commonly found among athletes who play or previously played contact sports such as football, hockey, rugby and soccer.

Currently, CTE cannot be detected until after a person has died and physicians are able to inspect their brain. Research into the links between contact sports and CTE is in its early stages.

“So we don’t have a direct causation. It is a correlation,” Zaslow said, adding “with the science that we have, we are doing the best that we can to manage it.”

While the notion of a 6-year-old suffering effects from heading a soccer ball might seem simple, there is no study that definitively supports the idea that removing heading from youth soccer reduces short-term brain damage such as concussions or prevents long-term problems such as CTE.

Comstock’s research into the effects of heading surprised her after she conducted a study on the rate of concussion among boys and girls playing high school soccer from 2005 through 2014.

“It makes sense that if you ban heading we should have a positive affect,” Comstock said. “In both boys and girls, the heading is the phase of play in which most concussions occur. But if you look more closely, it’s not the ball striking the head, it is two athletes colliding while they are trying to head the ball. It’s athlete-(to)-athlete contact that’s causing the concussions.”

The results of Comstock’s study found that in girls, 627 concussions (4.50 concussions per 1,000 athletic exposures) occurred in 1,393,753 athlete exposures and in boys 442 (2.78 concussions per 1000 athletic exposures) were sustained during 1,592,238 athletic exposures.

However, 68.7 percent of concussions among boys and 51.3 percent among girls occurred as a result of athlete-to-athlete contact rather than heading the ball itself.

More numbers

In another study published in 2015 in the Journal of Biomechanics, researchers examined the short-term and long-term impact of acceleration that the head experiences in both women’s high school and collegiate soccer, rather than strictly the rate of concussions.

Purdue University researchers studied 29 high school soccer girls aged 14 to 18 years and 24 college women in the sport aged 17 to 22 and among their findings, they saw that the gravitational force experienced by the women in college soccer when heading back a goal kick was the equivalent of the forces experienced by college football players during a tackle.

Gravitational force or “G force” is a measure of acceleration, with 1 G equal to the force of gravity at the Earth’s surface. So, 2 Gs is twice the force of gravity, and so on.

“To be perfectly honest, women’s college soccer looks just like (college) football,” said Dr. Eric Nauman, director of Purdue’s Human Injury Research and Regenerative Technologies Laboratory, who led the study. “That surprised us because I didn’t think that we would get to the 120-, 140-G’s range.”

The study took place over a season where both female high school and college level players had MRI scans of their brain in preseason, mid-season and postseason. Each player wore an X2 patch behind the ear for training sessions and games, which allowed Nauman and his fellow researchers to record the G-force of every impact as well as the rotational acceleration of the brain after any blow greater than 20 Gs.

“Based on the data that we’ve seen, the hit distributions are the same in women’s soccer (and tackle football),” Nauman said. “A lot of the brain changes in the physiology are very similar.”

Although the study examined soccer players older than the U.S. Soccer Federation’s age group of players prohibited from heading the ball, Naum said that acceleration the head experiences is similar.

“I am sure the forces are lower at the middle school level, but the accelerations that the head experiences are almost identical because these middle school kids are still growing. Some of them are going to be tall and lanky with long thin necks,” Nauman said. Nauman added that the disparity between the body types of young adolescents can be especially dangerous as their ability to absorb the impact can differ from child to child.

Unlike Comstock’s study, Nauman found that player-to-player contact was the worst in terms of Gs recorded but was not as common of an occurrence and did not always result in a concussion.

“Some of the worst ones are head to head,” Nauman said. “We had one head-to-head impact where each player was over 200 Gs. But only one of them had a concussion as a result because only one of them had accumulated enough previous head impacts that it got them over the threshold.”

A force of 60Gs is considered to be the threshold of concussions in adults.

Both studies highlight how dangerous the act of heading can be, whether the contact is head-to-ball or athlete-to-athlete. However, both looked only at players 14 and older, and neither addressed the possible effects of subconcussive blows, especially in younger soccer player.

A subconcussive blow is any impact on the head that is below the threshold which induces a concussive symptom or a concussion.

However, a study presented in May at a convention of the American College of Sports Medicine, found that subconcussive head trauma negatively affected cognitive function in youth soccer players ages 9 to 11 in Puerto Rico.

Zaslow said research on whether subconcussive blows are harmful at all, or likely to cause CTE, is still in its infancy.

“The short answer is we don’t know,” Zaslow said, adding that Children’s Hospital Los Angeles is conducting a study that will compare magnetic resonance imaging and cognitive tests on athletes in contact sports against athletes who do not experience subconcussive blows in their sport.

Other sports

Soccer is one of several contact sports facing concussion-related issues. Leagues in sports such as hockey and football also have taken steps to prevent head-related injuries.

The Los Angeles Kings High School Hockey League launched a partnership with CHLA to make player safety the league’s highest priority beginning in 2015. Currently, the league has an athletic trainer at every hockey event.

Golden Empire Youth Tackle Football, an independent organization in Bakersfield, Calif. that involves about 3,000 youth players from 6 to 14 years of age, adopted heads-up, rugby-style tackling, limited contact in practices and instituted a two-part concussion protocol.

Players are pulled from games or practices if there is any suspicion of concussive symptoms, parents are contacted and a report is filed through the league.

The player must see a specialist and if a concussion is diagnosed, the player must sit out a minimum of seven days.

The second principal of the protocol is to inform the child’s school about the incident within what is allowable under health information privacy laws. The idea is to keep an eye out for potential concussion-related complications.

“That’s an aspect that’s often overlooked,” said Ron White, executive director of the league. “If a player is concussed, how is that impacting him in the home and in an educational setting?”

White is among the leaders of a California save youth football coalition  that is taking the lead in trying to make the sport safer — despite the fact that he is skeptical about the correlation between contact sports and CTE.

Meanwhile, U.S. Soccer is taking steps beyond the heading rules, hoping to raise awareness and educate parents, coaches and players about player safety.

While research continues into the effects of heading soccer balls on the brain, those studying the effects agree there are simple steps that can be taken that might help until more is known.

Comstock believes simply enforcing existing rules will help.

“Our conclusion from our paper was that if you really want to try to eliminate concussions in soccer, you should just better enforce the rules and reduce the athlete-athlete contact that is occurring,” Comstock said. “It was intriguing to me that U.S. Soccer was willing to make such a big culture shift as their first effort rather than simply trying to reinforce the rules.”

There also are efforts to put more certified athletic trainers on sidelines at all levels of soccer, although funding is a challenge.

Others, including Nauman, agree with U.S. Soccer’s approach on heading balls, and would like to see the practice of banning or limiting headers expanded.

“I have to applaud soccer for going that step,” Nauman said. “I’d say anything below high school, no headers just to make sure… just to hedge your bet.”

He also believes that making sure balls are properly pressurized and dry will reduce concussions.

“They all absorb water,” Nauman said of soccer balls. “They all get heavier in the rain. To be perfectly honest, I wouldn’t allow any soccer in the rain because those balls turn into bricks.”

Nauman said that if lighter balls are used and pressurized to factory settings, and the number of impacts on the brain are tracked then there should not be any physiological changes.

Mader said she remembered noticing a difference in ball pressure between practice and games.

“We had to pump up the balls everyday for practice. For practice they would be at 8 (pounds per square inch of pressure) and then on game days we would pump them up to 10 (PSI),” Mader said. “Ten was so hard, and we would all complain about it. It would be so hard and so painful to the point that I did not not want to head it.”

Mader said she doesn’t regret playing soccer, despite lingering effects from the her concussions. She said her memory is not as good and she constantly writes things down to reminder herself.

“You can tell me something and I will be full blown paying attention and three minutes later, I cannot remember for the life of me what you said,” Mader said. “I take notes for everything now. I record people because I can never remember.”

Madder added that now she suffers from panic attacks, which she never suffered from before to the concussions and will also occasionally faint.

“I get the same feeling that I am going to pass out… I  never had passed out or anything before, and now I have passed out while I was working,” Mader said. “I pass out in the weirdest places. My heart rate jumps through the roof, and I have maybe 10 seconds. Then my whole body gives out, and I black out.”

Mader said she is not certain sure that these symptoms are related to her concussions but she knows one thing.
“I have never had anything like that happen to me (before).”

Follow us on Twitter.

For more stories from Cronkite News, visit cronkitenews.azpbs.org.