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A rising fastball. A slap shot to the chest. A wayward elbow as players battle for a rebound.
In the athletic arena, where physical selflessness is an integral part of the culture, injuries are inevitable, and pain has an almost honored standing. But no one is supposed to die.
Yet for the 156 people who have died since 1998 from the mysterious syndrome called commotio cordis, a confluence of unfortunate events combined to take their life in a literal heartbeat.
There has been growing interest in the rare yet almost always fatal condition -- sometimes called cardiac concussion -- but it remains largely veiled in mystery, leaving the governing bodies of youth sports at a loss and sports medicine experts scrambling for answers and funding. And research on the condition has exposed major deficiencies in the standards that govern the manufacture of athletic chest protectors.
Victims often healthy
Commotio cordis takes place when a blunt impact over the heart occurs during a 20-millisecond window of the heartbeat, sending the victim into cardiac arrest. Only 15% of victims survive commotio cordis events.
By its very nature, it sometimes just doesn't make sense -- ''a counterintuitive'' condition, says one expert. The typical victim is young, male and, by all measures, perfectly healthy. In many cases the impact to the chest looks innocent enough. Commotio cordis is triggered by the timing of the blow, not the severity, so it is characterized by its lack of visible trauma to the heart itself. Additionally, there are cases where athletes died even when struck through chest protectors.
While the incidence is still very rare, the number of cases per year is growing, and most experts agree that it is still significantly underreported, often classified simply as cardiac arrest or accidental death.
The death of Cornell men's lacrosse player George Boiardi in March put the national spotlight on that sport, but the biggest chunk of cases is found in baseball. Sixty-three occurred in baseball, 14 in both softball and ice hockey, 12 in football, eight in soccer, and five in lacrosse. No autopsy was performed on Boiardi, but the medical consensus is that the syndrome was to blame.
Addressing the problem
Some governing bodies of youth sports are taking a more proactive approach than others. Officials involved in lacrosse, which has a very tightknit community and a singular governing body, have made it clear they are working to address the issue. They are contemplating a proposed rule change that would make intentionally blocking shots illegal. While shot blocking is not a technique per se, it is something that is either accepted or coached, says Steve Stenersen, president of US Lacrosse.
''There are cultural issues to the game that we've got to address,'' he says, pointing to the popular practice among players of cutting off large sections of padding they feel are restrictive. Little League baseball, with some 2.2 million athletes in the USA, is taking a more conservative approach, despite the fact that baseball and softball account for 77 of the 156 cases documented since the inception of the Commotio Cordis Registry in 1998.
''It's something that we're aware of, but it's not something that is being openly discussed now, just because there isn't enough data,'' says spokesman Chris Downs, who says that the organization's records show that no one has died during official league play.
Unlike athletic helmets, there are no standards to guide the design of chest protectors. There is little, if any, medical input in the designs of most chest protectors, and recent studies show that commercially sold chest protectors offer no protection against commotio cordis, says cardiology expert Mark Link of Tufts-New England Medical Center.
Current standards and claims of effectiveness are ''based on decreased pain, really is what it is,'' says Link. ''If you read the manufacturers' Web sites and labels, they're pretty careful not to promise too much.
''There's not much science behind the chest wall protectors that I've ever seen. I suspect that they're made to market so they look good, and it feels soft and it feels like it should work.''
Calls to several equipment manufacturers were not returned.
Many experts, while accepting the fact that limited research handcuffs youth sports' governing bodies, believe that simple awareness of the condition must be improved.
''I think Little League should be more forthright, as opposed to lacrosse which is taking a real hard look at this. It clearly happens more in baseball than in any other sport,'' says Link.
A group led by Link is looking into the development of a chest barrier to combat commotio cordis, but work is still very preliminary.
''The whole problem with the chest protector standard is . . . the risk of commotio cordis peaks at about 40 mph, and decreases (at higher speeds),'' says Trey Crisco, director of the Bioengineering Lab for Orthopaedic Research at Rhode Island Hospital. ''Typically the harder you get hit, the worse off you are, and this is not consistent with that.''
Crisco, along with the National Operating Committee on Standards for Athletic Equipment, is working to develop a standard for chest protectors. He also recommends that youth baseball use soft-core balls, which have been shown to reduce, though not eliminate, the risk of commotio cordis.
Need for treatment
Some groups feel that because there is no real way to prevent commotio cordis as of yet, the most important thing is to address the condition after the fact. That means having automated external defibrillators on hand at youth sporting events, says Robert Gotlin, director of orthopedic and sports rehabilitation at the Beth Israel Medical Center in New York.
Commotio cordis requires defibrillation within several minutes; you can't wait for ambulances, he says. ''It has to be a jog away, not a drive away,'' says Gotlin, who helped institute a law that mandates AEDs at New York high school sporting events.
''The No. 1 issue is education. No. 2, the only real sure-shot way to attack this is to treat it, not prevent it,'' he says.
For now, both the medical and youth sports communities agree that the most feasible changes have to do with coaching. In baseball, players can be taught to turn away from high pitches and to not creep closer to the batter while fielding. In lacrosse, blocking shots can be discouraged.
''One of the things that (Boiardi's) passing has done is mobilized, more than ever, an interest and concern among coaches,'' says Stenersen. ''For better and worse, coaches have the most impact on their players' behavior and can have the power to impart and change culture, certainly more than anybody else. So I think that's great news.''
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