Take a look behind the scenes of a recent commentary in the journal Concussion entitled, ‘Benefits of team sport participation versus concerns of chronic traumatic encephalopathy: prioritizing the health of our youth‘. In this peek behind the paper series, we ask first author of the study, Scott Zuckerman (Vanderbilt University Medical Center, TN, USA), about how information around sports-related concussion in the media has influenced attitudes towards sport participation, including what more needs to be done to ensure clarity in how studies on chronic traumatic encephalopathy (CTE) are reported in order to prevent research dissuading people from participating in sport.
Could you briefly describe the arguments set out in your commentary?
Our group at Vanderbilt University Medical Center (VUMC) studies the acute and long-term outcomes of sport-related concussion and how to improve the safety of head injuries in sports. One topic that has gotten perhaps the most attention in recent years is the long-term effects of contact sport participation and sport-related concussions. We view the science on the long-term effects of contact sport participation, which includes many later-life neurologic diseases but is most commonly referred to as CTE, as young and evolving – the jury is still very much out. Conversely, as we summarize in our article, the scientific data regarding the benefit of team sport participation for a young person’s development is overwhelmingly positive. Team sport participation leads to a myriad of positive physical and mental health outcomes and imparts many leadership traits such as a work ethic, perseverance and selflessness.
The primary arguments of our editorial call attention to the declining health of our youth and the positive impact of team sport participation. For the first time in nearly three decades, there has been a decline in the number of high school students participating in school-sanctioned sports . Concomitantly, the physical health of our youth is waning, with high rates of obesity and metabolic syndrome. Mental health trends have followed suit, with rates of anxiety and depression similarly increasing. Additionally, a strong relationship has been found between increased depressive symptoms and increased screen time and digital media use .
In the face of worsening health among our youth, numerous studies have touted the physical, emotional and social benefits of team sport participation. In our article, we cite several studies that show physically active adolescents engaged in team sports have improved cardiovascular fitness , higher self-esteem , decreased psychological distress  and higher mental health scores  compared with their non-team sport counterparts. Behavioral studies have also confirmed that successful teams model shared leadership and reinforce the values of working together for a common goal, rather than an individualized approach. We’re currently working on a systematic review and meta-analysis summarizing this literature.
Sometimes empirical, scientific findings are less relatable than personal, anecdotal experiences. Results from the aforementioned studies are supported by the authors’ own experiences about the importance of team sports. Personally, as a starting senior on my high school varsity basketball team, two talented juniors unexpectedly blossomed and took on leading roles, relegating me to the bench. Instead of quitting or dwelling on my own decreased playing time, the importance of the team’s success became apparent, and as a result, I was part of a winning team and partook in one of the most formative experiences of my youth. As far as my co-authors, Aaron Yengo-Kahn (VUMC) remains forever shaped by his high school football coach who instilled virtues of integrity, positivity, accountability and gratitude over the course of a 4-year relationship. Andrew Kuhn (VUMC) started and captained his high school ice hockey team, leading them from a 0–16 inaugural season to a winning percentage above 0.500 upon graduation, instilling values of leadership and perseverance. Daniel Wolfson (VUMC) transitioned from individual high school fencing to a collegiate team sport, teaching him humility, selflessness and the importance of esprit de corps.
These are themes that for those of us who played sports as children and young adults, though we may not have realized it at the time, provided some of the most formative and impactful lessons for how to function as an adult, how to be a good colleague and friend, and how to be a good teammate in any situation. Few life experiences can impart the profound lessons learned through meaningful team sport experiences. We can each imagine how our lives would be different if instead of playing team sports or participating in group activities, those hours were spent isolated, playing video games or hunched over a computer program.
How do you think misinformation about sports-related concussion in the media has influenced the next generation’s attitude to sport participation?
I want to be careful with the word ‘misinformation’ – I don’t think anyone is trying to intentionally ‘trick’ or ‘misinform’ athletes and parents about brain injuries in sports, but rather the wide range of sometimes conflicting information is a byproduct of each party’s competing interests. We all arrive at the sport-related concussion topic from different vantage points. Frankly, we think that the media and lay public may be susceptible to the availability cascade [6,7] – where individual, widely publicized cases readily available to the public receive disproportionate attention and supersede the findings of established empirical data.
The media has widely disseminated findings from a small number of reports in former professional athletes that have really changed the behavior of parents and young athletes. One recent study of parents of youth soccer players reported that nearly all youth soccer parents (96.5%) believe there are long-term effects from sport-related concussions . Parents of children that had previously sustained a concussion were over eight-times more likely to be concerned their child would sustain a concussion, and parents with a personal history of concussion were twice as likely to consider not allowing their child to participate in youth sports. And frankly, we empathize with these sentiments.
Based on the information dispersed by most media outlets – what parent would want their child to have any risk of future neurologic problems from sports? This notion has been propagated to the lay public for many reasons, as some members of the media have taken an aggressive approach to covering CTE-related articles. But we can’t blame them – that is the media’s job – to get the best story, the most reads, the most clicks, the most attention. Unfortunately, the science, which takes time, is slow and requires methodical, labor-intensive reading of primary articles, takes a back seat to the one sentence tweet summarizing a scientific study, where the strengths and limitations of these studies are not discussed. The best researchers in the world conduct flawed studies – no perfect scientific study exists.
We also found in a recent paper led by Daniel Wolfson (VUMC) that a scientific paper received more public and media attention (measured through Altmetric scores) if the study promoted a link between CTE and contact sports, whereas if the study was neutral or concluded no link, it received less attention . The disproportionate coverage of ‘positive studies’ results in parents and kids being scared to play certain sports, which has resulted in a decline in team sport participation. In reality, the science is very much evolving. CTE is not a universally agreed-upon diagnosis among neuropathologists, and in fact, there is much debate about how to diagnose it in the post-mortem setting. All that said, evidence of long-term neurologic problems has been seen in certain populations, but this has mostly been restricted to former elite, professional athletes. We do not dismiss the credible work of researchers in this area, but rather we emphasize that the science behind contact sport participation and CTE is very much an active and evolving area of research.
What advice would you give to clinicians who are advising parents on team sport participation options for their child?
Look at the child in front of you, and if that child enjoys playing sports, if the sport is done in a safe environment with adequate health and safety resources (which includes most school sanctioned events), then there is no reason for that child to stop playing for fear of long-term neurologic risks. Second, be very cautious when extrapolating study results conducted in former elite, professional athletes to the average youth or high school athlete. These are very different populations. If you’ve ever sat close at a professional sporting event, you will quickly realize that professional athletes have strength, size and speed rarely encountered in everyday life. The physical differences between an elite athlete and your average former high school athlete or weekend warrior are apparent – these are starkly different populations and extrapolating data from elite athletes to a youth or high school population can be problematic.
What more needs to be done to ensure clarity in how studies on CTE are reported in order to prevent research dissuading people from participating in sport?
A balanced collaboration between scientists and the media is needed. Given the declining sport participation rates and the worsening health of our youth, as international brain injury expert Willie Stewart (University of Glasgow, UK) stated in a recent paper , not playing team sports due to fear of CTE may do more harm than good. As physicians, researchers and scientists, we understand (or make our best effort to understand) what’s really going on in the brain after a concussion and after repetitive head impacts, but we don’t always know how to translate that in a way the public can appreciate. The media is an expert in the latter, they have a keen understanding on how to capture wide audiences and disseminate information. Just as colleagues from VUMC, the University of North Carolina (NC, USA) and the Medical College of Wisconsin (WI, USA) worked together in this editorial, I hope one day reporters from major news outlets will have an open, fair and truly symbiotic relationship with sports concussion scientists, and we can all come together for the common good of the health of our youth.
What are your top tips for minimizing concussion risk and maintaining safe sport participation?
Safe sport participation is crucial, and though we are focusing on concussion and brain injury in our recent article, safe sport participation concerns all injuries and all safety precautions. Making sure the team and league employ educated coaches, have access to experienced certified athletic trainers and healthcare providers, and engage in safe practices (adequate hydration, monitored conditioning, appropriate equipment, etc.) are important.
As far as concussion-specific tips, we would provide three simple messages here. First, if a concussion is suspected or diagnosed, immediate removal from play must occur – that athlete is done for the day. In an injury with much ambiguity, this is a concrete maxim that should never be violated. Once removed and diagnosed, the child does not return to play that same day.
Second, encourage an athlete that if he/she has symptoms, to disclose them and remove him/herself from the game immediately. Data suggests that if an athlete tries to “play through” a concussion, recovery can be prolonged, and the concussion can be more severe. The idea of “toughing it out” is a thing of the past and can hurt the athlete and his/her teammates.
Third, in order to be cleared for return to school and return to play, an athlete should see an experienced healthcare provider (physician, neuropsychologist, nurse practitioner, etc.) with experience treating concussion for the return-to-play process. Less important is the ‘degree’ or ‘specialty’ of the healthcare provider, and more important is their familiarity and experience treating sport-related concussions.
 National Federation of State High School Associations. Participation in high school sports registeres first decline in 30 years.  Hoare E, Milton K, Foster C, Allender S. The associations between sedentary behavior and mental health among adolescents: a systematic review. Int. J. Behav. Nutr. Phys. Act. 13(1), 108 (2016).  Carlisle CC, Weaver RG, Stodden DF, Cattuzzo MT. Contribution of organized sport participation to health-related fitness in adolescents. Glob. Pediatr. Health 6, 2333794X19884191 (2019).  Guddal MH, Stensland SO, Smastuen MC, Johnsen MB, Zwart JA, Storheim K. Physical activity and sport participation among adolescents: associations with mental health in different age groups. Results from the Young-HUNT study: a cross-sectional survey. BMJ Open 9(9), e028555 (2019).  Snedden TR, Scerpella J, Kliethermes SA et al. Sport and physical activity level impacts health-related quality of life among collegiate students. Am. J. Health Promot. 33(5), 675–682 (2019).  Schatz P, Corcoran M, Kontos AP, Elbin RJ. Youth soccer parents’ perceptions of long-term effects of concussion. Dev. Neuropsychol. 45(3), 110–117 (2020).  Wolfson DI, Kuhn AW, Kerr ZY et al. Chronic traumatic encephalopathy research viewed in the public domain: what makes headlines? Brain Inj. 34(4), 528–534 (2020).  Stewart W, Allinson K, Al-Sarraj S et al. Primum non nocere: a call for balance when reporting on CTE. Lancet Neurol. 18(3), 231–233 (2019).
[Accessed 8 February 2020]
 National Federation of State High School Associations. Participation in high school sports registeres first decline in 30 years.
 Hoare E, Milton K, Foster C, Allender S. The associations between sedentary behavior and mental health among adolescents: a systematic review. Int. J. Behav. Nutr. Phys. Act. 13(1), 108 (2016).
 Carlisle CC, Weaver RG, Stodden DF, Cattuzzo MT. Contribution of organized sport participation to health-related fitness in adolescents. Glob. Pediatr. Health 6, 2333794X19884191 (2019).
 Guddal MH, Stensland SO, Smastuen MC, Johnsen MB, Zwart JA, Storheim K. Physical activity and sport participation among adolescents: associations with mental health in different age groups. Results from the Young-HUNT study: a cross-sectional survey. BMJ Open 9(9), e028555 (2019).
 Snedden TR, Scerpella J, Kliethermes SA et al. Sport and physical activity level impacts health-related quality of life among collegiate students. Am. J. Health Promot. 33(5), 675–682 (2019).
 Schatz P, Corcoran M, Kontos AP, Elbin RJ. Youth soccer parents’ perceptions of long-term effects of concussion. Dev. Neuropsychol. 45(3), 110–117 (2020).
 Wolfson DI, Kuhn AW, Kerr ZY et al. Chronic traumatic encephalopathy research viewed in the public domain: what makes headlines? Brain Inj. 34(4), 528–534 (2020).
 Stewart W, Allinson K, Al-Sarraj S et al. Primum non nocere: a call for balance when reporting on CTE. Lancet Neurol. 18(3), 231–233 (2019).
The opinions expressed in this interview are those of the interviewee and do not necessarily reflect the views of Neuro Central or Future Science Group.
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