By the time Clare Englebert turned 21 years old, she had already been diagnosed with five concussions. Facing the threat of long-term damages and a doctor’s warning that she may never be able to play sports again, Englebert returned to the field against medical advice, unwilling to miss her senior year on the soccer field.

Now a senior at the University of Wisconsin – Madison, Englebert still has difficulty concentrating and has lost her ability to multi-task – a direct result of multiple concussions.

Stories like Englebert’s are increasingly being discussed across college campuses, amongst high school coaches and concerned parents and physicians alike. Researchers are pooling their efforts into learning more about the symptoms, recovery time and the end result of multiple traumas to the brain.

According to the Center for Disease Control and Prevention (CDC), United States emergency departments treat close to 175,000 sports and recreation-related traumatic brain injuries among children and teens every year.

The CDC describes a concussion as, “A forceful bump, blow, or jolt to the head or body that results in rapid movement of the head and causes a change in the athlete’s behavior, thinking, or physical functioning.” Symptoms can range anywhere from feeling dazed to having mood swings, to losing consciousness.

Englebert’s first concussion occurred during a basketball game her sophomore year of high school. After knocking heads with another girl, she described having a headache and feeling confused.

“I don’t remember much about it[,] but when I got up I was doing silly things like playing on defense when we were supposed to be on offense,” Englebert recalls. “By the time I was to warm up for the varsity game, I had a huge headache. All of a sudden, on the bench, I just started crying and I had no idea why. Many people who get concussions experience emotional side effects.”

Although the initial symptoms of brain injuries can be frightening, the long-term effects have urged researchers to revisit the science of concussions, called on schools and coaches to enhance their rules, and brought greater focus on the risk of brain trauma in children and teens.

Brain trauma in young athletes

Marie-France Wilson, an expert in sports law and a graduate from Marquette University’s Law School, published a paper highlighting the risk of concussions in young athletes. According to her study, young athletes are more vulnerable to concussions and take longer to recover from blunt traumas to the brain than adults.

“Children between the ages of six and fourteen are at a higher risk of head injuries than any other age group,” Wilson says. “Brain swelling and cerebral edema occur more frequently in children with head injuries, and because they are still developing, the structure of their brains may be damaged, with evidence not always observable until years later.”

Wilson goes onto say that young athletes are oftentimes, less likely to go through medical screening prior to participating in group sports, a practice required in professional sports.

Wilson’s observation may be true among youth recreational leagues but Pre-Participation Physical Exams (PPPE) are becoming an increasingly common requirement for participation in middle school and high school sports. Still, if a family cannot provide a routine checkup and the school or league does not provide baseline medical testing for all of their athletes, preseason check-ups can be overlooked, a dismissal that can have dire consequences.

When treated properly with extensive rest, concussions can heal and future side effects can be all but erased. It is when concussions go unnoticed and untreated that they become extremely dangerous, with the potential to permanently disable those affected, or even result in death.

Secondary impact syndrome (SIS) is a rare but deadly condition resulting from a second brain injury before the original concussion has healed. Swelling, increased pressure, and an excess accumulation of water, or cerebral edema, are all symptoms of brain injury. Without the proper time for these symptoms to go away, the brain is much more vulnerable and susceptible to injuries like SIS. According to SportsMD, “The brain’s ability to self-regulate the amount of blood volume to the brain is damaged resulting in increased cerebral blood volume which can result in brainstem herniation and death.”

Doctor Robert Harbaugh, Director of the Institute of the Neurosciences at Penn State University, published the original paper on SIS and coined its name. He explains that, “No one knows exactly why some players have this catastrophic outcome with a second impact…it is, thankfully, a rare occurrence.”

Although researchers have speculated on the causes and conducted a series of case studies with people who have had concussions and even suffered from SIS, the reasons behind the exact causes of secondary impact syndrome remain largely unknown. Dr. Harbaugh goes on to explain that the condition’s rarity makes advances in the field of knowledge difficult.

Even with ample healing time, concussions can cause a lifetime of negative ailments. A recent study in the journal Brain Injury led by researchers at Boston University’s School of Medicine found that a percentage of people who suffer chronic head injuries, including professional athletes and war veterans, show signs of chronic traumatic encephalopathy (CTE), a progressive degenerative brain disease similar to Alzheimer’s.

The disease occurs after “repetitive mild traumatic brain injury,” and is clinically associated with, “symptoms of irritability, impulsivity, aggression, depression, short-term memory loss and heightened suicidality that usually begin 8-10 years after experiencing mild traumatic brain injury,” the paper reports.

With the threat of life-altering illnesses directly related to concussions continuing to grow, coaches are attempting to make playing contact sports at a young age safer. Baseline testing, an exam that assesses balance, brain function and history of concussions can be used if an athlete gets hurt during the season. The CDC states that “comparing post-injury test results to baseline test results can assist health care professionals in identifying the effects of the injury, making more informed decisions regarding return to school and play.”

Baseline testing is becoming more commonplace across secondary schools in the US. Englebert explains that, “every student, no matter what sport they went out for, had to take what is called a baseline test. This is the test that they would use to compare with the concussion test a student would take if they showed signs of having a concussion.”

Even though baseline testing can be a highly useful tool if used correctly, it does not stop student athletes from under-reporting concussion symptoms or stop coaches from encouraging athletes to return earlier than recommended by doctors and athletic trainers.

The pressure to play

Wilson says that identifying sports-related concussions is one of the biggest challenges sports doctors face because there is no biological marker or test for an accurate diagnosis. Even CT scans don’t always reveal a concussed or healed brain accurately. “This diagnostic difficulty is exacerbated by the tendency of young athletes to underreport or conceal symptoms of concussions in order to return to play more quickly.”

After her second, third and forth concussion, Englebert’s parents became increasingly worried. Still, pressure from her coach to continue playing and her drive to keep playing a sport that defined her high school career, urged her to continue.

“My athletic trainer and my coach, well…they didn’t always see eye to eye,” Englebert says. “I couldn’t even drive because my reaction time was so slow, but my coach would always want me to practice at least a little, if not play in the game. There were times where I felt I needed to lie a little bit to get back in the game, but the results weren’t always the greatest.”

Dr. Harbaugh echoes both Wilson and Englebert saying that players deny symptoms because they want to continue to compete.

In order to preserve the health of young athletes across the nation and globe, those involved are advocating greater education surrounding brain injury and a change in the rules of youth sports.

The CDC offers online courses tailored to both health care professionals and coaches including information on preventing, recognizing and responding to concussions. The “Heads Up: Concussion in Youth Sports” initiative , launched in 2007, distributed 40,000 tool kits, 40,000 fact sheets, 60,000 magnets, and 40,000 posters in its first year to educate people about concussions.

Six months after its launch, Michigan State University’s Institute for the Study of Youth Sports and the National Alliance for Youth Sports evaluated the program, reporting positive changes in coaches’ knowledge and attitude towards brain injuries. According to the study, 77 percent of coaches involved said they were more confident in identifying concussions, 63 percent viewed concussions more seriously, and 72 percent took the information they learned and educated other coaches, athletes and parents.

Beyond educating coaches about what to do after a concussion, organizations like the Canadian Academy of Sports Medicine (CASM) are reevaluating the rules of gameplay. The organization has deemed body checking in ice hockey unnecessary at the minor league level and is continuing to look for ways to decrease youth brain trauma.

Yet, while there has been progress, there is still a long way to go. Hockey Canada, the governing body for more than 500,000 Canadian ice hockey players, allows nine out of its thirteen branches to teach body checking to children age eleven to twelve. Even though CASM feels body checking is unnecessary for young athletes, they recommend that it remain in elite leagues made for athletes with the potential to play professionally.

According to Wilson, “it remains an unfortunate fact that rule changes made at the amateur sports level often follow changes first made at the professional level,” resulting in a stand-still of progressive change in sports health.

Until widespread rule changes occur, coaches and parents are left to make the decision as to when their players and children are healthy enough to return to the field. Increased awareness, and openness from coaching staff to minimize fears of lost playing time is key in increasing safety among youth athletes.

The risks of playing with a concussion far outweigh the gains of a scored goal, a perfect tackle or a recovered puck from a body check.

Englebert says the coaches hold the answer to ensuring safety, “The best way to make sports safer is for coaches not to rush their players back to the game and make sure they are fully recovered.”