Tag: Concussion

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Changing Concussion Culture

It could be because a player doesn’t want to let the team down by stepping off the field.

It could be the fear of getting pulled out of a big game.

Or it could be the pervasive misunderstanding about the severity of an injury to the head.

Whatever the reason, concussion reporting rates across the nation have hardly budged, despite a surge in policy changes, educational efforts and intensive research on the topic, a group of Northern Arizona University researchers said on Wednesday. The four professors, who come from NAU’s psychology department and its athletic training education program, are trying to tackle the issue from another angle.

Thanks to a $400,000 grant from the NCAA and the U.S. Department of Defense, the four women will examine how organizational culture influences concussion reporting and then test different strategies to boost reporting rates.

“It’s a national epidemic with the concussion issue and it’s not being solved with education,” said Debbie Craig, an athletic training education professor. “The NCAA and the Department of Defense had the foresight to say, ‘If these aren’t working then it’s most likely due to culture, so how do we change that culture?’”

NAU is one of eight universities that received grant money to research “How to spur changes in the culture surrounding concussion,” according the grant description.

The Flagstaff group’s study involves visiting four NCAA Division I football programs five times each over the span of two and a half years. They aren’t releasing the names of the schools because the anonymity allowed them to gain access to the universities and helps preserve the accuracy of their results, the researchers said.

The first visit to each university will be spent conducting player surveys, interviewing coaches and observing practices, games and places where the athletes spend time like locker rooms and meeting rooms. The women also will run association tests to gain insight into players’ subconscious beliefs about things like big hits on the field or head injuries, said Ann Huffman, an associate professor in the College of Social and Behavioral Sciences and the W. A. Franke College of Business and chair of the university’s intercollegiate athletics committee.

Pilot research the researchers already did in Arizona found that there are multiple reasons for low concussion reporting rates. Those include misconceptions among athletes about how hurt they are, a sense of brotherhood that discourages reporting on a teammate who looks concussed, and a misunderstanding that a person has to lose consciousness to experience a concussion.

In fact, only 10 percent of concussed cases lose consciousness, said Monica Lininger, an assistant professor in the athletic training education program.

After gathering that baseline data on concussion culture within each program, the NAU research team will develop specialized intervention strategies for each school, then sit down with representatives from each program to see which suggestions they like and what other ideas they may have to address the problem. Research has shown that allowing participant input, instead of imposing the ideas brainstormed by researchers, facilitates creative ideas and buy-in, said Heidi Wayment, a professor of social psychology who has years of athletic experience as a college and professional basketball player.

A possible intervention might be identifying one or two influential people within the team and working with each individual to lead by example in terms of taking concussions seriously and reporting them, Craig said. Another idea might be removing photos or posters that appear to celebrate violent play on the field, Lininger said.

Suggestions for changes may also involve piggybacking on the positive values, like hard work, camaraderie and sacrifice, that athletes and teams already carry, Wayment said.

“It will be helpful for us to understand what motivates them to do this very very exhilarating and difficult work,” she said. “Maybe some of those same values can help nudge behavior in a way that might help them with their own safety and health and their teammates.”

The final three visits to each university, which will kick off in the fall of 2017, will be a pre-intervention assessment, a post-intervention assessment to look for changes in behavior or in the players’ environment, and then a visit to present the study’s results and ask for feedback.

The women’s hope is that their research will provide useful insights for not only college football players but other athletes and age groups as well. Ideally, their recommendations will inspire athletic policy changes among institutions, conferences and even the NCAA, they said.

“We can do research that makes a difference,” Huffman said.

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Connecticut Athletic Trainer Provides Expert Testimony

Legislators are looking to add to the state’s concussion law, in part by requiring a consent form for participation in youth sports leagues on public fields. While there was support for the bill during a public hearing this week, some questioned whether it could be enforced.

A state law passed last year requires a consent form for school-sanctioned athletics, including intramurals.

Under proposed legislation raised this session by the legislature’s Committee on Children, a similar form with information on concussions would be required for youth sports outside of school. The form would have to be signed by a parent to allow their child to participate, said state Sen. Dante Bartolomeo, D-Meriden, co-chairwoman of the Committee on Children. Youth sports organizers would be prohibited from using a state or municipally operated playing field if consent forms aren’t disbursed to parents.

“This is really about just making sure that year after year, time after time, we are continuing to provide education and keep it updated to prevent what can be debilitating effects,” Bartolomeo said.

Similar legislation proposed in the past hasn’t moved forward, she added, due to opposition from some who believe the law would be difficult to enforce and would deter coaches concerned about liability.

“All we’re asking for is education for prevention,” she said.

At a minimum, parents and coaches should be educated on the signs and symptoms of concussions, said state Rep. Diana Urban, D-North Stonington, who co-chairs the committee.

“If I can’t get them to take a whole course, at the very least, we can disseminate information and require that they have it and acknowledge they have it,” she said.

Last year, the legislature passed a provision requiring that youth sports organizers provide parents with information on concussions from the Centers for Disease Control and Prevention. This information is free of charge and is available online, Bartolomeo said.

Coaches of interscholastic or intramural sports are required by law to take an initial course on concussions, and a refresher course every five years. Proposed changes to the law would require coaches to take the refresher course every two years.

Youth sports coaches are not required to take these courses under the current concussion law, but a revision proposed this year would require them to take a refresher course on concussions every two years. Another proposal in this year’s legislation would change the minimum age of participants in a “youth athletic activity” from 7 to 5 years old. The maximum age, 19, would not change. By reducing the age of who is considered a participant in youth athletics, the legislation would apply to more youth sports organizers, coaches and parents, Urban said, thus starting concussion education for children at an earlier age.

At a public hearing on Tuesday, some speakers questioned whether it could be enforced. At least one person felt the bill would prevent some from participating in youth sports.

Theresa Miyashita, speaking on behalf of the Connecticut Athletic Trainer’s Association, said she supported most of the bill but disagreed with a change in the legislation that would extend immunity to the state, municipalities or athletic program operators when educational information about concussions isn’t provided as set out by state law, or if consent forms aren’t collected or disbursed to parents.

“Municipalities and operators cannot be immune” if they fail to comply with the law, said Miyashita, director of the athletic training program at Sacred Heart University.

There is “no way to incentivize or enforce” the law if the parties involved are immune to civil liability, said state Rep. Gail Lavielle, R-Wilton, who is not a member of the Committee on Children but commented on the bill during the public hearing.

“How do you enforce it,” she said. “Give very careful consideration to that.”

Karissa Niehoff, executive director of the Connecticut Association of Schools and the Connecticut Interscholastic Athletic Conference, said she agrees with the legislation’s intent, but took issue with how it might impact children who don’t have parents or guardians who are responsive.

“Not all athletes will be able to get signed consent,” she said.

She recognizes the benefits of organized athletics for children, Bartolomeo said, pointing out that most athletic leagues already require signed consent so it wouldn’t be a burden to sign an additional form relating to concussions. The bill’s intent isn’t to deter children from playing sports, but to educate, she said.

John Cattelan, executive director of the Connecticut Alliance of YMCAs, said there would be an added cost to Y’s across the state to track if each volunteer coach has received the proper training. The legislation would impede the ability for Y’s to recruit volunteer coaches as well, Cattelan stated in testimony submitted to the committee.

There is no added liability for coaches under the proposal, said Steven Hernandez, director of public policy and research for the Committee on Children.

“If a coach acts reasonably to protect the best interest of a child, they are protected by the law,” he said.

Last week, Dr. Anthony Alessi, a neurologist and director of UConn’s NeuroSport Program, spoke to the committee about the impact of concussions on children. He said children are more at risk due to their lack of muscle development. Alessi stressed the importance of education to prevent concussions, especially given the number of youths involved in athletics. Alessi said there are around three million athletes across the country playing youth football. Around one million people play high school football, while 54,000 play college football. There are only about 1,800 people in the National Football League.

State Rep. Noreen Kokoruda, R-Madison, a ranking member of the Committee on Children, said awareness regarding concussions “is fundamental to prevention, and it’s important that children, parents and coaches are well-informed with the risks and ways to avoid concussions.”

A bill raised by the legislature’s Public Health Committee would allow physical therapists to clear student athletes with concussions to participate in team activities. Currently, a student can only be cleared to participate by a physician, physician assistant, advanced practice registered nurse or athletic trainer.

Bartolomeo and Urban both said they were unsure if physical therapists have enough medical background in brain injuries to clear athletes after a concussion. Christopher DiPasquale, a physical therapist from Hebron, submitted testimony Tuesday in favor of the bill. Physical therapists receive extensive training in neurological conditions and manage issues far more complex than those related to concussion protocol, he said. James Leahy, executive director of the Connecticut Physical Therapy Association, made the same case in his testimony.

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NAU researchers receive grant to study concussion reporting

The long-term impact of concussions is widely known but many athletes still fear opening up about head injuries.

NAU interdisciplinary researchers have been awarded a $400,000 grant to study how organizational culture relates to concussion reporting among athletes, coaches and staff.

Research team members Debbie Craigand Monica Lininger, athletic training education professors, and Ann Huffman and Heidi Wayment, psychological science professors, have been awarded the national Mind Matters Challenge grant for their proposal, “Changing the Culture of Concussion Reporting: A Cultural Analysis and Implementation Model.”

“Concussions are unique in the field of athletic injuries because the decision whether to keep playing is less clear,” said Craig, who is director of NAU’s athletic training education program. “Everyone must believe that it is OK to report concussions. This will be a significant cultural shift from the current American football culture. Our goal is to facilitate that shift.”

Wayment said this project is a tremendous opportunity given how rapidly public awareness on head trauma and chronic traumatic encephalopathy, also known as CTE, is increasing.

“As we know from research in health psychology, just ‘knowing’ that a behavior can negatively impact one’s health is not sufficient for change,” she said. “I am especially excited about our interdisciplinary approach: we will be looking very specifically at multiple factors that impact athletes’ decision-making processes. My colleagues and I each bring a different theoretical perspective to the research, and we are excited to be working together.”

The objective of the project is to investigate the organizational, athletic, individual and interpersonal factors that affect concussion-reporting behavior and develop intervention strategies that increase student-athlete safety and well-being. The research study, funded by the NCAA and the U.S. Department of Defense, will be conducted over two and a half years and involve four different NCAA Division I football programs.

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Simpson College Athletic Trainer Seeking Medical Breakthrough

For as many concussions that have been detected among student-athletes, many more go undiagnosed.

Either the athlete doesn’t disclose their symptoms, or coaches, trainers or parents don’t see them.

WATCH VIDEO HERE. 

But a solution may be on the way.

Allison Klapperich, a Saydel athletic trainer, needs to ask questions and look for symptoms of head trauma.

“Usually they’re pretty honest with me because their heads (are) hurting pretty bad,” she said.

But sometimes, Klapperich said, athletes want to get back in the game so much they don’t reveal everything.

One professor at Simpson College is hoping to be part of a medical breakthrough when it comes to detecting concussions.

Mike Hadden, an athletic trainer and professor of sports science at Simpson, wants to start clinical trials on an instant concussion test.

It takes a drop of the athlete’s blood. If it detects the proteins that release into the bloodstream after a concussion, it will come back positive within a minute, like a pregnancy or blood sugar test.

“Hopefully within two hours of this concussion, find the protein, take their blood, find the protein, study it and see if it can be a valid and reliable bio-marker for a concussion,” Hadden said.

Simpson has applied for grant money to start testing concussed athletes next year.
“Put some blood on here, then mix it with some fluid that will actually react with the protein,” Hadden said.

The Indianola College is just one of dozens of institutions around the country trying to find a way to make diagnosing concussions more clear-cut and conclusive.

“It’s a race. It’s an arms to race to see who can find the concussion sideline tests,” Hadden said.

“That would kind of take the guesswork out of if they’re not showing symptoms. Do they have a concussion or not? We’re going to see it in the next five minutes,” Klapperich said.

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It’s Simple, Hire Athletic Trainers

Legislation that would suspend public school coaches if they allow players to return to a game after suffering a concussion seems to have its heart in the right place, but may be a tad overreaching as we continue to change the sports culture and educate players, coaches and parents about head injuries.

Certainly, we aren’t advocating for a win-at-all-costs mentality that unfortunately sometimes permeates even youth sports, but at the same time, we also don’t think it’s fair to punish coaches who might not have the resources available to properly diagnose a concussion. We’d like to think coaches should get the benefit of the doubt that they aren’t putting our kids in danger of potentially life-altering head injuries.

With that said, concussions — especially in youth sports — are a serious issue that warrant serious discussions and serious consequences if it’s discovered that coaches are endangering children by deliberately letting a concussed athlete play. We’re far more informed about head injuries than ever, and if coaches are letting players get back in the game knowing they’ve suffered head injury, we think the discipline should be quick and harsh. A suspension might not be punishment enough.

If nothing else, the legislation proposed by Del. Mark Chang, an Anne Arundel County Democrat, is a good conversation starter.

Perhaps that conversation should steer more toward making sure every school in Maryland has a certified athletic trainer available who can diagnose concussions, rather than leaving it up to coaches who know Xs and Os, but don’t have the medical training to diagnose a concussion accurately.

Carroll County is fortunate in that each high school has a designated trainer assigned to it. That isn’t necessarily the case elsewhere in the state. Greg Penczek, president of the Maryland Athletic Trainers Association, told The Baltimore Sun that about 61 percent of high schools in Maryland have trainers.

The other option is getting coaches better educated about concussions and testing their knowledge. Currently, coaches must attend training courses on head injuries, but there is no guarantee they are paying attention or retaining the information. Dr. Robert G. Graw, founder of the Crofton-based HeadFirst Sports Injury and Concussion Care Centers, said coaches should have to pass a rigorous test and get certified proving they can recognize symptoms as well as a trainer. We agree that coaches should have to get certified, but that’s not a replacement for having an athletic trainer.

Another benefit to having a trainer is that the coach has a medical professional to point to when, inevitably, a parent insists their son or daughter go back into the game.

Some will say coaches should simply follow the “when in doubt, keep them out,” philosophy, but part of the problem with concussions is the symptoms are often not obvious, the player may not immediately feel the affects, and it doesn’t take a bone-jarring hit to suffer one. This is why the more people you have on the sidelines who know what to look for the better.

It’s important we do everything we can to keep young athletes’ still-developing brains healthy. But before we start punishing coaches, let’s make sure they have as much information and resources available to them to make smart decisions about their players.

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Illinois athletic trainer weighs in on proposed concussion law

Concussions, especially at the high school level, have become a major focus the last few years. New laws have already done more to prevent concussions. Now, more ideas to keep kids safe are making it to the Statehouse.

When athletes take a hit like this, Devin Spears is the first to check them for a concussion.

“Start to stagger, they don’t look right, they may be a half-step slower than everybody else.”

Spears is an athletic trainer. He has seen a lot in his 30 years working with athletes. He says concussions are a whole new ballgame.

“The biggest thing that you can be concerned about with a concussion is some kind of a fracture; a skull fracture which could lead to a brain bleed which is a subdural hematoma. Those the things can kill athletes.”

The CDC says nearly 140 people in the United States die from injuries which include traumatic brain injury. In 2009, close to 250,000 children, ages 19 or younger, were treated for concussions.

“When the brain tissue comes into contact with the skull, that’s what causes damage. That’s where you need to have the evaluation techniques or have a certified athletic trainer on hand,” said Spears.

A new state proposal would require trainers to compile monthly reports on the number of students who suffer concussions. It’s something they say they already do.

“We do keep regular records because, when we do get the kids to see the physicians, the physicians want to know what happened, what were the circumstances, what were they like when this occurred?” said Spears.

Athletic directors say they already have procedures in place to make sure their players are safe.

“A student athlete is injured in a game and we feel as though there’s a possibility for concussion, the first thing we will do will give that impact test,” said Dan Roarke.

They say any new law or idea to keep students from getting a serious brain injury should be looked at.

“In my mind is what we’re doing right now, is it going to help? If it helps one kid, it’s worth doing. Is it necessary? Let’s say yes,” said Roarke.

The bill requires an annual report be submitted to the General Assembly. Students who suffer concussions will now also need medical permission to return to class. That law went into effect this month.

All schools must also create plans for dealing with concussions. Other laws include pulling players from practices or games if they show signs or symptoms of a concussion.

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An in depth look at the New Mexico Concussion debacle

When Shawn Nieto felt the hit, he clutched the football tight, making sure not to lose his grip, even as his 16-year-old body fell limply to the ground.

When Erica Nieto saw the hit, she sprinted from her seat in the stands, down near the sidelines and screamed for her son’s attention.

When the trainers at Cleveland High in Rio Rancho, N.M., saw the hit, they ran onto the field to make sure their junior running back was okay.

This much, everyone agrees on. What happened in the seconds, minutes and days that followed the state semifinal playoff game ultimately led both sides to a courtroom. School officials say Shawn was knocked unconscious for 20 to 30 seconds. He suffered a concussion, they said, which meant under state law, he was forced to sit out seven days to recover — which meant he’d miss the following week’s state championship game.

But Shawn says he never lost consciousness and his family insists he didn’t suffer a concussion. So they hired a lawyer and filed a motion in court last month, pleading with a judge to let Shawn play in the title game.

The case highlighted much of the confusion surrounding concussions, particularly as it concerns children and teen-aged football players. In recent years, youth leagues across the country have changed the way they teach football. States have passed laws to ensure high schools monitor player safety better. And the NFL has tweaked its rules and aired public-service announcements to educate a football-crazed nation about head injuries.

Yet, there still remains uncertainty and inconsistency about head injuries in young athletes. Participation numbers continue to drop in many areas, and according to a Harris Poll last year, one in three parents lives in fear that their child will get a concussion and one in four prohibits their kids from playing contact sports because of concussion concerns. The same poll found 87 percent of adults can’t correctly define a concussion, and 37 percent say they’re confused about what a concussion is.

Parents have to sort through conflicting information. Doctors such as Bennet Omalu, the subject of the movie “Concussion” who’s credited with identifying chronic traumatic encephalopathy (CTE) in football players, and Robert Cantu, who co-authored the book “Concussions and Our Kids,” have said children shouldn’t play tackle football until the age 14. Many other concussion experts say the science doesn’t yet support such a drastic conclusion.

And while football families try to sort out the facts, science and the proper precautions, the Nieto family is among those who say concussion hysteria has made the sport’s decision-makers overcautious at times.

“That’s the bogey-man blanket they’re throwing in sports now,” said Peter Nieto, Shawn’s father.

By barring Shawn from competing, the family said the school district violated his constitutional right to due process, his state constitutional right to participate in extracurricular activities and interfered with his educational opportunities.

School district officials in Rio Rancho, meantime, say they were just following the law and protecting the young player’s health and well-being.

When a state judge heard the case last month and was presented with the evidence in an Albuquerque courtroom, he felt he had no choice: Shawn Nieto, who may or may not have suffered a concussion one week earlier, was granted a temporary injunction and allowed to play in the state title game.

Versions of events

Shawn began playing youth football at age 7. His father competed in the sport and his siblings were athletes too. His older sister even wrestled for the school team.

“As a mom, of course you’re concerned about how dangerous this is,” his mother, Erica, said this month in the first interview the family has done, “but I’ve always been an active parent when it comes to this stuff, attending practices, games, events to ensure if there is an injury, I’m there and able to seek medical attention as needed.”

Peter has coached wrestling and junior high football and said he’s gone through specific training related to concussions. “I’m not a professional by any means,” he said, “but I do know what people are concerned with.”

Standing just 5 feet 5, 140 pounds, Shawn took over his team’s starting running back position midway through the season and went on to run for 931 yards and 18 touchdowns. His Cleveland Storm team, a preseason favorite to win state, posted an undefeated record.

The Nietos said the school never gave any training related to concussions, but they were given an informational sheet and required to sign a form.

The team breezed through the season, and despite his size, Shawn emerged as a key contributor. In the team’s playoff semifinal game, Shawn says he remembers everything. The Storm led and were charging down the field. Coaches called for an option play, and Shawn took the ball and began to make a cut. He saw an open field.

“I thought I was gonna score,” he said.

But Shawn was yanked down by a horse-collar tackle and before he hit the ground, another player crashed into him, their helmets colliding.

Shawn lay still on the ground. Trainers hovered over him. They say he was unconscious. Shawn says the wind was knocked out of him and was merely catching his breath.

He eventually rose to his feet and when he reached the sidelines, he gave his mother a thumbs up. Team trainers administered a memorization test, and he correctly recalled two of the three words he was told to remember. He said he was distracted watching the game and missed one. He was given a balance test, too, and says he passed.

After the game, Shawn told his parents he felt fine. He didn’t have a headache and didn’t ask for medicine. He rode a bus three hours back to school, and coaches then allowed him to drive home alone from there.

“If it was that serious, I’d hope they’d notify the parents that there’s some major concern,” Erica said.

Shawn said he was told the next day at school that he was in the concussion protocol and would be unable to play in the state championship game.

Peter drove straight to the school when he heard the news. He talked to coaches, the athletics director and the school’s athletic trainer. The trainer explained Shawn was unresponsive and had been knocked unconscious. The parents say they were never given any paperwork to support the school’s assessment and they never observed any symptoms that Shawn had suffered a head injury in the game.

“We’re not rookies,” Peter said. “We know what a concussion is.”

‘There’s no wiggle room’

While concussions and the degenerative disease CTE has made headlines and been linked to football greats such as Junior Seau and Frank Gifford, researchers are still trying to understand the risks football might pose to young people.

“The younger we go, the less science there is,” said Harry Kerasidis, a neurologist who authored the recent book “Concussionology: Redefining Sports Concussion Management For All Levels,” “and we have kind of extrapolated from studies that were done on older individuals.”

Kerasidis explained that there are two schools of thought: (1) a child’s brain is still developing and any trauma can be especially harmful; (2) children are smaller, slower and perhaps unable to deliver as much force in their collisions as older players. While recent research has found CTE widespread in a former player who was 25 years old at the time of his death, researchers are working to understand definitively the long-term effects of head trauma suffered by young players.

“We really don’t yet have the level of science that we need,” said Gerard Gioia, who heads the division of pediatric neuropsychology at Children’s National Medical Center in Washington and directs the Safe Concussion Outcome Recovery and Education Program. “We don’t know what the difference is between a 7-year-old brain taking a blow or hit versus a 13-year-old versus a 17-year-old. We really need those studies to be done.”

Nieto’s family was eager to learn Shawn’s condition and made a doctor’s appointment for the following day. Shawn met with a doctor and exhibited normal cognitive ability, orientation, memory recall and concentration, according to the family’s court filing.

Backed by the doctor’s recommendation, the Nietos became even more determined for him to play in the state title game and explored their legal options.

“If something looks bad, it doesn’t mean it’s really that bad, you know,” Peter said. “This just happened at an emotional milestone in our son’s life, so we were gonna do whatever we thought we could to get his voice heard, to not lose this opportunity.”

The school district, meantime, was just as adamant that Shawn had been injured and state law required he sit out seven days.

“There’s no wiggle room,” said Bruce Carver, the school district’s athletics director. “If somebody thinks it is [a concussion], we go the safe road and keep him out.”

All 50 states, including the District, have passed laws that address concussion safety in youth sports, but the particulars vary. A concussion might be diagnosed differently in South Carolina than Colorado, and the required recovery might be different in California than Pennsylvania. Arkansas allots money for a program but has no standards in place. Wyoming doesn’t require parents to sign a consent form. Only a handful, such as New Mexico, have a mandatory waiting period before a player can return to action.

While New Mexico’s statute was hailed as one of the toughest when it was signed into law in 2010, opinions vary as to whether a mandatory waiting period is effective. A 2009 study looked at 635 high school- and college-aged concussed football players and found that the waiting period “did not intrinsically influence clinical recovery or reduce the risk of a repeat concussion in the same sports season.”

“This concussion law is just one size fits all,” Erica said of New Mexico’s statute. “It’s expected to fit every situation, and it really does not allow for how to address a conflict — how do you get an independent evaluation? There’s no wiggle room at all and I think there needs to be.”

Still at odds

State district Judge Alan Malott scheduled a hearing for Dec. 4, barely 24 hours before the championship game was schedule to kickoff. Neither the school nor the school district showed up in court, and Malott had at his disposal one key piece of evidence: Shawn’s doctor clearing him to play. Malott granted the injunction.

“The fact that the doctor said he was fine and never was hurt was obviously pretty substantial evidence,” Malott said in a phone interview. “The school didn’t even show up, so I didn’t have the benefit of a coaches’ report or anything like that.”

The morning of the title game, though, Karen Ortiz, the physician who examined Shawn, sent a letter to the school district, rescinding her opinion and saying the family was not forthcoming with the extent of Shawn’s injury.

“Had I understood that there was a loss of consciousness, I would have never provided medical clearance,” Ortiz wrote in a letter first published in the Albuquerque Journal.

A spokesperson for Ortiz’s employer, Lovelace Health System, said the doctor could not comment on the case, citing privacy concerns. Neither the Nieto family nor the judge say they’ve ever seen the letter.

The Cleveland Storm took the field that night and Shawn was in uniform alongside his teammates. But he’d missed the entire week of practice and coaches didn’t use him in the game. Shawn’s lone appearance was for brief a fourth-quarter kickoff. His Storm team posted a 48-35 win to capture the title and cap a 13-0 season. Shawn’s replacement ran for 200 yards and scored a touchdown.

Shawn said watching his teammates win the state championship without him was bittersweet. Many students at his school didn’t understand why his parents took to the courts, and the school hallways this winter have not always pleasant. His wrestling season has since started, though, and he hopes to regain his starting running back job next fall as a senior.

The Nietos remain upset with the letter of the law and the school’s application of it. They’re still confident Shawn never suffered a concussion. School officials overreacted, they say, and Shawn suffered because of it. They plan to write a letter to the local school board suggesting ways the rules could be improved.

Carver, the school district’s athletics director, said the school and team officials “could’ve done a better job communicating,” but they still support the spirit of the law.

“We feel like we did what’s best for the kid and trying to protect him,” he said.

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Power 5 Conferences Clarify Return to Play Decisions

The NCAA’s major conferences approved a rule Friday requiring that school medical professionals have autonomous and final authority in deciding when an athlete may return to play after a concussion or other injury, a move lauded as a significant health and safety protection.

Although schools are already required to have concussion protocols, the move defines who are the primary medical providers in key decision-making roles and sets a strong wall between medical professionals and coaches, officials said. Schools will be required to ensure that no coach have hiring, retention or dismissal authority over the team doctors or trainers.

“I believe it’s the most important piece of legislation in the history of the NCAA,” said Brian Hainline, the NCAA’s chief medical officer and a neurologist. “It really defines who the primary athletics health care providers are.”

Power Five puts doctors in charge of when players can return to action photo

Stew Milne

A medical staffer checks on Connecticut quarterback Bryant Shirreffs during the game against Houston on Nov. 21. The NCAA’s major conferences approved a rule Friday requiring that school medical professionals have autonomous and final authority in deciding when an athlete returns to play after a concussion or other injury. (AP Photo/Stew Milne)

The rule, approved at the NCAA’s annual convention in San Antonio, was proposed by the Big 12. University of Texas women’s athletic director Chris Plonsky said UT physicians and trainers already control return-to-play issues, and she believes most schools do the same. But she said it was necessary to make it a rule.

“Our students are other people’s children,” Plonsky said. “If I was a parent, I’d want to know who makes that decision. It should be someone with medical authority.”

The rule also means that even if an athlete seeks an outside second opinion, the school’s medical officers still have the final say, Hainline said.

“I think there has been concern expressed there are sometimes influences on the athletic trainer and physician to get them to return to play sooner than they are ready to,” Hainline said. “No one can challenge their authority.”

Southeastern Conference Commissioner Greg Sankey said the conference endorsed medical autonomy in 2014.

“We didn’t need a rule to get there, but it’s healthy to make that clear,” Sankey said.

The rule specifically applies to the NCAA’s autonomy group, comprising the Power Five major football conferences, but other NCAA schools are encouraged to adopt similar guidelines.

In other votes Friday, the autonomy group delayed action on several proposals limiting time demands on athletes, including mandated time off after a season and weekly off days. The group voted to bring those issues back at the 2017 NCAA convention.

“I think we all agree there needs to be a retooling of not only how we count the hours, but also what the expectations on a student-athlete are,” Big 12 Commissioner Bob Bowlsby said. “The life of a Division I student-athlete is not for the faint of heart. They know that when they sign up.”

The group adopted a resolution pledging to come back next year with a proposal that will consider a two-week postseason break, weekly time off and a mandatory eight-hour overnight break from sports requirements.

The delay upset a few student-athlete members of the autonomy group who lobbied for immediate action.

“If we come back a year from now with a comprehensive action plan, that’s ideal. That’s what student-athletes need,” said Ty Darlington, the center on Oklahoma’s football team. “I feel like this should have been done already. … We keep pushing it back. It’s very frustrating for us it wasn’t ready for this convention.”

The autonomy group passed a rule allowing high school baseball players to hire agents when negotiating with professional teams before they enroll in college.

Texas Tech baseball player Anthony Lyons called it an important step for players and their families when deciding whether to turn pro or go to college when “life-changing money” is being offered.

“Right now, there’s a lot of things going under the table you might not know about,” Lyons said.

ORIGINAL ARTICLE

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Athletic Trainer Pens 2 part response to “concussion”

On its opening day, I watched the movie, “Concussion,” and thought as I walked out of the theater that it could change the game of football and the way concussions are viewed by the public. I thought it might also create a more conservative approach in management by medical professionals.

“Concussion” depicts the story of a neuropathologist, Dr. Bennet Omalu, played by Will Smith, and his struggle to warn the National Football League of a brain condition that he discovered in autopsies of former NFL players — Chronic Traumatic Encephalopathy (CTE).

Omalu made his discovery of CTE in 2002 during his autopsy of Mike Webster, the Pittsburgh Steelers’ Hall-of-Fame center who’d fallen on hard times in his retirement. Omalu later discovered CTE in other former NFL players who displayed behaviors usually attributed to older patients with Alzheimer’s disease.

Omalu’s discovery of CTE in former NFL players not only went unheeded by the league and its Mild Traumatic Brain Injury (MTBI) committee, but the NFL went on a full blitz to deny the existence of CTE and to discredit Omalu and his findings. As Omalu’s mentor and boss, Dr. Cyril Wecht (played by Albert Brooks), said: “You’re going to war with a corporation that owns a day of the week. The same day of the week the church used to own.”

Based on my practical experience as a certified athletic trainer, I can see the relevance of this movie regarding brain injuries to athletes and future changes in both the game of football and how the concussed athlete’s care is managed.

The acting in “Concussion” is excellent and captured the reality of the concussion debate now raging in athletics. In addition to Smith, the cast includes Alec Baldwin, playing the role of Dr. Julian Bailes who joins Omalu to raise awareness of CTE and the long-term consequences of concussions on athletes.

(I am privileged to know Dr. Bailes, and though in real life he is more soft-spoken than Baldwin is in the movie, Baldwin does capture the intensity and passion that Bailes exhibits when he speaks of concussions and their consequences.)

Though he is only in one full scene and in the background of another, Arliss Howard portrays a riveting character as Dr. Joseph Maroon, the Steelers’ team neurosurgeon, who, in a key scene, portrays the anxiety felt by the NFL’s MTBI committee and its attempts to discredit the findings of CTE in former NFL players. The issue is not with science; rather, it’s with the impact that this revelation may have on the multi-billion-dollar business of professional football.

The Centers for Disease Control and Prevention (CDC) reports that there are at least 300,000 sports-related concussions suffered annually in the United States. “Concussion” highlights the severity of concussions on players and those attempts to keep quiet the potential long-term consequences of concussions while playing football. As a result, “Concussion” should further the ongoing discussion of concussions and also of their management and potential long-term consequences not just on football players, but for all athletes who experience concussions.

As a certified athletic trainer with nearly 40 years of experience in caring for thousands of injured athletes, I assessed and helped manage the recovery of hundreds of concussions suffered by student-athletes for 35 years as a staff member of the Syracuse University Sports Medicine Department.

Additionally, I was a participant in the 2010 NCAA Concussion Management Summit that established guidelines for concussion management in intercollegiate athletics. Moreover, as National Athletic Trainers’ Association (NATA) liaison to the NCAA Football Rules Committee for two terms, I wrote the language for the helmet-contact penalty and defenseless-opponent penalty you now see being called in intercollegiate football. (As NATA liaison, I supported the game disqualification of football players who “target” their opponent with their helmet. I also wrote a passage in the 2008 NCAA Football Rules Book on concussion awareness.)

“Concussion” focuses on CTE and concussions, which are related but separate.

A concussion is a complex physiological process affecting the brain as a result of a hit to the head or the sudden stopping of the rapidly moving head, resulting in impairment of function that usually resolves spontaneously over time. Importantly, one does not have to be knocked unconscious to have a concussion. A concussion is a functional disturbance of the brain, while CTE is a neurodegenerative disease associated with Tau protein, which is normally found in the brain and acts as a lubricant in its function, collecting pathologically in different regions of the brain. It is the Tau protein abnormally collecting in the brain of former NFL players that Smith, playing Omalu, discovers in the movie.

CTE is a result of repeated mild traumatic brain injury as a result of chronic trauma to the head in some people. This chronic trauma is in the form of “subconcussive” blows to the head, whereby the blows to the head may or may not cause athlete-reported concussion symptoms, but nevertheless cause trauma to the brain, with repetitive blows to the head. While CTE is associated with older individuals, former college football players who committed suicide in their 20s were also found to have CTE on autopsy.

Not every athlete or person who is subjected to subconcussive hits to his or her head acquires CTE. Keep in mind that though the focus of concussions and CTE is on football players, any athlete, male or female, playing in sports where contact is present can suffer a concussion.

In “Concussion,” no player was disqualified for a concussion or concussion-like symptoms. Competitive athletics end for every athlete. We must protect the athletes from themselves — that is, from making decisions to continue playing with a potentially disabling condition they later would regret.

Some physicians in “Concussion” expressed regret that they didn’t disqualify a player with repeated concussions after seeing the after affects and Omalu’s CTE findings. My experience at SU was the opposite. I am satisfied that the team physicians did the ethical thing and medically disqualified student-athletes from participation as a result of repeated concussions.

Some of the medically disqualified student-athletes later told me they didn’t like the decisions, or the team physician(s) for that matter, at the time. But all are thankful now because they said — though cognizant that they were affected by their concussions — they were afraid of being stigmatized by their disqualification and of losing their identity as athletes, and would have continued to put themselves at risk had we not stopped them.

But back to “Concussion,” the movie …

Gugu Mbatha-Raw, as Prema Mutiso-Omalu, plays the supportive girlfriend and later spouse of Smith throughout the movie. Her line, spoken to Smith — “If you know, you must speak (the truth of CTE)” — is her best one and captures the essence of the film’s goal: To warn players, medical staffs, the NFL and those millions of fans that concussions, and every-day hits to the head while playing football, are serious matters that could lead to a life-altering condition such as CTE.

There is some Hollywood license taken in “Concussion,” which varied from the book by the same title upon which it is based. But that is the usual case in movies. However, even with these departures from the book, one of the film’s final scenes is both haunting and poignant … and reminds the audience that football players may be today’s version of gladiators, but they are people first.

I give “Concussion” three stars out of four for portraying the reality of concussions and CTE, as well as furthering the conversation of protecting athletes’ long-term well-being. The movie “speaks the truth” to the consequences of concussions on athletes. I believe it will not only change the game of football, but also the way in which concussed athletes are treated in the future.

Education regarding the signs and symptoms of concussion and potential long-term consequences (i.e., Chronic Traumatic Encephalopathy (CTE), among other issues) need to be fully explained to both athletes and parents of minor-aged children engaged in sports, especially contact sports.

Some athletes try to “tough out” their concussions by not reporting them for fear of being removed from participation, or upsetting their coach, teammate or parents.

Unfortunately, there are still some coaches who continue to stigmatize by proclaiming that concussions are simply “part of the game” and that athletes who succumb to them are “soft.” These coaches encourage athletes to hide their injuries, or soldier through them, in order to keep the players on the field. Or because that is what these coaches did as players in more unenlightened times.

This unethical practice must come to an end immediately.

Return-to-play protocols following concussions are where most mismanagement occurs. It is important that the athlete be free from all concussion symptoms, that any neuropsychological tests are at baseline levels, and that the athlete is fully engaged in the classroom before the return-to-play protocol is implemented.

Some concussions are mismanaged because the preceding elements were not in place, or were not properly monitored and documented by medical professionals trained in concussion management, prior to returning the athlete to full participation.

Athlete medical disqualification based on concussion history remains a controversial topic. However, team physicians and athletic trainers, as well as coaches and administrators, have an ethical duty to care for and protect all athletes’ long-term well-beings. The question for team physicians is this: What is the magical number of concussions that an athlete can sustain before he or she should retire from contact sports?

There is literature to suggest that three concussions increase the vulnerability of more concussions with less force, placing athletes at risk for potential long-term consequences such as post-concussive syndrome and CTE. In collaboration with team physicians, we included the stipulation in SU’s Concussion Management Plan that the threshold of three diagnosed, time-loss concussions be consideration for possible medical disqualification.

During my tenure at Syracuse, there were student-athletes in other sports besides football who were medically disqualified because of their concussion histories. This is unpopular with athletes, sometimes with their parents, and too often with coaches. No matter how unpopular the decision is to medically disqualify an athlete, the team physician, in consideration of all facts and recommendations from credentialed medical professionals, has the legal authority to make the final determination regarding an athlete’s medical clearance.

Athletes may also “doctor shop” for someone, anyone, to clear them to resume participation despite a concussion history. Again, a good deal of medical disqualification is based on the vulnerability of sustaining further concussions with milder blows to the head after receiving the third concussion, especially if the concussions occurred at a younger age.

Concussion mismanagement is a liability issue for secondary schools, universities and insurance companies. Litigation on behalf of athletes who have had their concussions mismanaged is growing and will become more prominent in the future. As mentioned in the closing of “Concussion,” the movie I reviewed in the first part of this two-part series, there has been a class-action lawsuit by former NFL players against the NFL as a result of mismanaging their concussions during their times as NFL players.

Regarding the treatment of concussions, particularly for the “concussion” clinics that are growing in number, the goal in care should not be to get the athlete back to participation following a concussion as quickly as possible to satisfy a desire by the athlete — or his or her families … or his or her coaches — to get back to sports. Instead, the goal should be to treat the athlete as a patient who has a medical condition that needs specific care to return to a normally functioning life before returning, if ever, to competitive athletics.

The certified athletic trainer is a credentialed professional who is also a state-regulated medical professional in 48 states and has been educated and trained in concussion evaluation and management. The certified athletic trainer is usually the medical professional implementing the return-to-play protocol as well as making the initial concussion assessment and referral. However, there is a growing concern within the athletic training profession regarding interference on the part of some coaches — many with high salaries, nearly all under intense pressure to win — who have an interest in their players’ continuing to inappropriately participate with injuries, particularly concussions.

Though I never personally experienced such pressure at Syracuse University, I am aware of other athletic trainers who have lost their jobs or have been removed from football coverage by coaches or administrators (i.e., non-credentialed medical people) made unhappy by decisions/suggestions to remove injured athletes from competition. Often, these folks lobbied for “their own guys” caring for the athletes, a movement resulting in major conflicts of interest.

Unfortunately, athletic and university administrators empower certain coaches to control all aspects of their programs, sometimes sports medicine included. This is a bad precedent for the potential well-being of athletes and can reflect poorly on institutions. Such was the case this past summer when the University of Illinois fired its head football coach, Tim Beckham, after it was determined that he’d attempted to unduly influence medical decisions and care.

One suggestion to create the autonomy necessary to make medical decisions based on the long-term well-being of athletes is to have the university sports medicine personnel report to a department outside of athletics. The responsibilities of athletic trainers and team physicians are to ensure the health and welfare of the student-athletes, not team success. Thus, they should be judged on their quality of care and not by the traditional standards of number of active participants, or how fast they get athletes back from injuries, including concussions.

There are some university sports medicine departments that report to the university health service or medical school. However, not all schools have such relationships.

In any of those cases, a sports medicine department could report to a university panel — an athletic medical review board comprised of personnel who have experience in ensuring compliance with laws, national standards and best practices, and are not subject to conflicts of interest with unpopular-yet-necessary medical decisions that protect student-athletes’ long-term well-being.

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Editor’s Note: Much like the movie, “The Express,” there have been accusations leveled by critics who insist that the makers of “Concussion” took periodic liberties with the truth in their film dealing with concussions and CTE in the NFL.

The following is a brief email sent to Timothy Neal from Dr. Joseph Maroon, who was mentioned in Neal’s piece (Part I of this two-part presentation) that was posted in this space at 10 a.m. on Thursday, Dec. 31:

Tim:

Well-written editorial. However, the scene depicted in the movie never occurred and at no time did I “discredit” Omalu or his work. I have spent, like Julian Bailes, my whole career trying to protect athletes — Baseline Impact testing has now been done on 10 million athletes. And it was I who encouraged the NFL to look further into CTE. Regardless, keep up your great work and best wishes for the New Year.

— Joe

Joseph C. Maroon, MD
Professor and Vice Chairman
Department of Neurosurgery
Heindl Scholar in Neuroscience
University of Pittsburgh Medical Center
Team Neurosurgeon, The Pittsburgh Steelers
www.josephmaroon.com

ORIGINAL ARTICLES(2):
http://www.syracuse.com/poliquin/index.ssf/2015/12/concussion_the_movie_may_change_the_way_football_is_played_and_viewed_part_i_of.html

http://www.syracuse.com/poliquin/index.ssf/2016/01/coaches_must_give_way_to_medical_professionals_in_the_area_of_concussions_part_i.html

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U of Indy Athletic Trainer details concussion protocol

“I was going to make a tackle, and I just blacked out,” he said.

This was Bryant’s most recent concussion, and he says he has had about three or four since he started college. Bryant is not the only college athlete who has had to deal with concussions. According to concussiontreatment.com, the Centers for Disease Control estimates that 1.6 million to 3.8 million concussions occur each year, and five to 10 percent of athletes will become concussed in any given sport season.

Graphic by Melvin Mendez

Graphic by Melvin Mendez

Head Athletic Trainer Ned Shannon oversees the health care that student athletes receive at the University of Indianapolis. According to Shannon, a concussion can be defined as a transient impairment of neurological function. In other words, it is a brain injury. Shannon said that while there are many definitions for a concussion, the one aspect that each definition agrees on is that the injury is usually not permanent and is caused by blunt force trauma.

According to Shannon, a concussion can result in a loss of consciousness, but that is rare in sports.

“You have this protective equipment,” Shannon said. “You’ve got things like rules in the game that prevent injury. Then you’ve got things like good coaching that teach you not to hit your head on something. So injuries that don’t result in loss of consciousness are typically what are seen in athletics.”

According to Shannon, every NCAA college is required to have a concussion protocol. Shannon said that at UIndy, if an athlete is injured during  a game or practice, he or she is pulled out of the situation.

A sideline evaluation is done that will give the trainer an idea of how severe the concussion may be.  After it is determined that the athlete does have symptoms of a concussion, the four-stage concussion protocol begins.

According to Shannon, the first stage involves pulling the athlete out of all activity in order to monitor him or her while he or she is symptomatic. Symptoms of a concussion include problems with memory, confusion, drowsiness, dizziness, double or blurred vision,  headaches,  nausea, vomiting, sensitivity to noise or light, balance problems and slowed reaction to stimuli, according to healthline.com.

Once an athlete’s symptoms are documented, he or she must take a neurocognitive test called Immediate Post-Concussion Assessment and Cognitive Testing. When student athletes arrive at UIndy, before they begin training, Shannon said they all are required to take ImPACT. The test asks students questions such as their name and the sport they play, as well as symptom questions such as whether or not the student has a headache.

Shannon said that once the student is concussed, he or she will take a post-ImPACT test to monitor his or her symptoms and improvement. The test usually is taken within a day or so after the concussion occurs, Shannon said. The concussed student also will visit with the team physician from the Methodist Sports Medicine Center. The team physician will conduct his or her own evaluation with the student as well, Shannon said.

During stage one, Shannon said that the concussed athlete may not go to class and will be asked to limit his or her texting, time on the computer and time spent playing video games, as these activities require the brain to work while it is injured. Shannon said a lot of athletes ask how long it will take for them to be well enough to return to practice or competition, but Shannon said there is no set timeline.

“Every concussion is different,”  he said. “We’ve had some athletes come back [in] as few days as seven or eight days, and we’ve had some athletes be out [for] months from typically the same level of concussion. It just depends on how the person heals.”

Stage two begins when the athlete is no longer showing symptoms. He or she can return to class, do homework, text and get back to his or her regular routine. From the athletic perspective, the athlete will take an exertion test. Shannon said this means he or she either will run on the track, get on a treadmill or ride the stationary bicycle for about 10 minutes to increase blood pressure, heart rate and breathing rate. Shannon said this test is necessary because it is possible that symptoms will come back during this process. If the symptoms of a concussion do come back during exercise, Shannon said that simply means the brain is not completely healed yet. Once the athlete is able to take the test without the symptoms returning, he or she can move on to stage three.

During stage three, with the team physician’s approval, the athlete can go back to some level of practice and participate in portions where they will not be hit. Shannon said the student will not be required to wear extra protective gear or be limited in any way at this stage.

Stage four is the final stage, when the athlete can go back to full activity and full competition, with the physician’s approval.

Shannon said that while trainers and coaches watch out for injuries, it is also the responsibility of the athlete to report if something is wrong. According to Shannon, all athletes are required to sign a document stating that they will report to someone in authority if they think they have sustained a concussion because the health risks can be major.

“One of the biggest concerns of parents, athletic trainers and sports physicians is athletes who underreport, meaning they don’t say anything about their concussion, [and] they continue to participate and they get hit again. … Now that seemingly mild concussion, if there is such a thing, becomes a much more significant problem,” Shannon said. “You might end up with more significant symptoms, longer time away from sports, hospitalization—so there’s some very, very serious effects if you withhold that information, and you [get] injure[d] again.”

Shannon said that an athlete will go through the stages even if the injury that caused the concussion did not happen during practice or a competition. For example, if an athlete is concussed by slipping on the ice while walking across campus, he or she still has to go through the four stages. There is not a quota of concussions a student must not hit in order to play sports, but Shannon said that some athletes choose not to participate after receiving a frequent number of concussions.

Bryant said he had to go through all four of the stages after receiving his concussion. And while he said it was a lot of work to get back to playing football, he agrees with the process.

“I think they go about it pretty well,” he said. “And they don’t rush you back too fast. … Some coaches [outside of UIndy] ignore the fact that you have a concussion, and they just let you stay in the game.”

Shannon said that the Greyhound coaches are diligent about following the protocol and put athletes’ health above the game.

“There’s very little pressure,  if any at all, from coaches to athletes to return to play faster. … Our coaches do an outstanding job at participating with the return to play of the athletes safely,” he said.

Bryant said he believes athletes should follow this example and take care of themselves by letting someone know if they are concussed.

“I would just tell them [athletes] to let somebody know,” Bryant said. “Don’t be afraid to make people aware of your situation because you want to stay in the game. You’re not helping yourself, or you’re not helping your team. It’s not that big of a deal to stay out of a game [rather] than risk your health like that.”

ORIGINAL ARTICLE:
http://reflector.uindy.edu/2015/12/16/concussion-protocol-monitors-uindy-athletes/