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By Jessica Mauzey Since the late 1990s, a significant effort has been made nationwide to raise awareness about con- cussions in youth sports. These efforts are recog- nized through media attention, state and federal government action, and awareness in youth sports and education. A concussion is defined by the Centers for Dis- ease Control (CDC) as a "type of traumatic brain injury – or TBI – caused by a bump, blow or jolt to the head, or by a hit to the body that causes the head and brain to move rapidly back and forth. This sudden movement can cause the brain to bounce around or twist in the skull, stretching and damaging the brain cells and creating chem- ical changes in the brain." Dr. Greg Canty, Medical Director at the Children's Mercy Center for Sports Medicine, ex- plains the definition as difficult to translate due to the continuous evolution of the subject. "It's continued to evolve over the last decade, but basically what we know is it's an injury to the brain and is transient in nature (self-resolving)," he said. "There is no structural damage that we can identify by current imaging using x-rays, MRI's or CT scans – those are all normal so it's a functional injury to the brain." In 2009, an estimated 250,000 youth, below the age of 19, were treated in an emergency depart- ment for a head injury, as a result of recreation or sports, and were diagnosed with a concussion, according to the CDC. Of these injuries, football, ice hockey and lacrosse were the leading causes for boys, while lacrosse, soccer and field hockey dominated the top rankings for girls. "In the Missouri area, the number one concus- sion-leading sport is football, according to the Missouri High School Athletic Association (MH- SAA). Holding second and third place are boys and girls soccer, respectively. We also see it frequently in growing sports such as lacrosse and hockey, in this area," said Dr. Canty. "It's any of your contact sports; in particular, collision sports where there is a lot of force involved." Concussions disrupt normal day-to-day actions, thinking processes and the ability to withstand normal environments. Typical symptoms of con- cussions can last from a few days to weeks, though more serious injuries can result in symptoms lasting from weeks to months. Of the more common symptoms are headaches, dizziness or balance control, confusion and sensitivities to light or noise. Some injuries may also cause memory loss and trouble concentrating. Among the most common misconceptions about concussion prevention is protective gear. "Hel- mets were designed to prevent skull fractures and lacerations and they do a great job of that, but we don't have any solid evidence that hel- mets prevent concussions," Dr. Canty said. "It's clearly been shown that mouth guards do not prevent concussions. They prevent dental inju- ries to the mouth, but they do not prevent concussions. Same thing goes for soccer head gear or rugby head gear. We would like to think of it as preventive, but there is no real evidence so far." While there are no definitive tests used to diag- nose a concussion, there are resources available that Dr. Canty describes as "tools" used to assist in making a proper diagnosis. These tools can include the Balance Equilibrium Scoring System (BESS) test or a variety of computerized neuro- cognitive tests. Another resource commonly utilized is called Sport Concussion Assessment Tool (SCAT3) or childSCAT3 (for children under 13 years of age). This document leads a parent, coach or caregiver through a series of questions. These answers are then given a number score. This score can in- struct someone to seek further medical services or set a baseline for progression to be used throughout the recovery period. So what should parents and coaches do if they suspect a head injury? The first and most vital step should involve immediate withdrawal of the player. "If there is a concern that someone has sustained a concussion, that athlete needs to be immediately removed from play until they are further evaluated by someone who is experi- enced in concussion care," Dr. Canty said. "We know that athletes and adolescents, in par- ticular, are at risk for a more catastrophic type of head injury, sometimes described as second impact syndrome. Everyone needs to understand that these are extremely, extremely rare but when they do happen, they seem to be exclusive- ly in adolescent age athletes," Dr. Canty said. Dr. Canty describes second impact syndrome as a "theory" that occurs after a head injury. Specif- ically, it can happen when an athlete returns to play (before completely healed) and sustains another hit, jolt or blow to the head that could lead to swelling or bleeding in the brain. In 2006, a tragic series of events occurred on a football field to a 13-year old athlete – Zackery Lystedt of Tahoma, WA. Lystedt's head collided with the field after a tackle. He only saw the sideline for three plays before returning to the game. Shortly afterward, Lystedt collapsed and was air lifted to Harborview Medical Center where doc- tors described his condition as "minutes, maybe an hour away from dying," according to an ESPN interview. Lystedt underwent emergency surgery to stop the bleeding on both the left and right side of his brain. His injuries left him permanently disabled. While incidents such as Lystedt's are rare, it was his parents hope that their son's story would be taken seriously and used in a way to reduce injuries. In 2009, the state of Washington passed the "Lystedt Law," that includes a set of criteria for all school-associated youth athletic programs. In July 2011, Governor Jay Nixon signed the Interscholastic Youth Sports Brain Injury Preven- tion Act, Missouri's version of the Lystedt Law. The provisions in both states are simple – imme- diate removal of an athlete if a suspected head injury has occurred. Additionally, written consent from a trained health care provider is required before the athlete returns to play. All states have since followed suit. Dr. Canty adds one more important aspect of youth sports, "One thing we don't talk about is that a lot of concussions and injuries happen on illegal plays," he said. "I try and encourage both families and athletes to support their referees and support and encourage fair play. Learning to play by the rules is not just good sportsmanship, but good for your overall health, too." Dr. Greg Canty (left), Medical Director at the Children's Mercy Center for Sports Medicine, explores the difficult realm of concussions. Concussions are commonly sustained during recre- ational sporting events after direct collisions or contact between players (right).