The countdown is on for every student athlete, coach, athletic trainer, and parent to become knowledgeable about concussions. Although a knock to the head was once jokingly referred to as ‘getting your bell rung,’ the consequences of brain injuries have been proven to be dangerous and, in some cases, deadly.
On Oct. 15, 16-year-old Ryne Doughtery became the fourth high-school student this year to die from a concussion sustained while playing sports. The New Jersey football linebacker succumbed to a brain hemorrhage incurred while tackling another player during a junior-varsity game.
“There have been many deaths in high school and college athletes from concussions,” said Paul Gibbons, athletic director for Monument Mountain Regional High School in Great Barrington.
And they happen across the spectrum of athletics. An 11-year study released in January by the American Journal of Sports Medicine shows concussions in young athletes occur in all sports and affect as many girls as boys — and possibly more.
“When people think of sports-related concussions, they think of football, ice hockey, and lacrosse. But they don’t think about cheerleading, gymnastics, and volleyball, where players can fall and hit their heads,” said Tom Dodge, assistant professor of Athletic Training at Springfield College.
The U.S. Department of Health and Human Services defines a concussion as an injury that changes the way cells normally work in the brain. It can be caused by any blow to the head or the body that causes the brain to move rapidly inside the skull, and concussions can result from a fall, from players colliding with each other, or from a collision with an obstacle such as a soccer ball, hockey stick, or goal post.
But in some cases, they are difficult to identify without neuropsychological testing. Literature from the Brain Injury Assoc. of Massachusetts states that, if an individual is never unconscious and does not exhibit obvious symptoms, a mild brain injury may go undiagnosed. Yet, the person may experience cognitive, emotional, and physical problems, and if the athlete returns to play, they are at risk of suffering second-impact syndrome. That condition can be deadly and occurs when a person experiences a second concussion less than two weeks after the first injury.
As a result of emerging research, physicians and legislators across the nation are doing all they can to protect young athletes. In addition, the Centers for Disease Control and Prevention has created a program titled “Heads Up: Concussion in Youth Sports” to help educate the public.
And in some respects, the joint efforts are working. Dr. Ellen Deibert says it’s easier to treat and manage concussions today because symptoms are recognized and reported earlier than they were in the past.
“My practice has been busy already this year,” said Deibert, a neurologist with Berkshire Brain Injury and Neurological Services, P.C. in Pittsfield. “But it all comes down to education. Laws that were passed in Massachusetts, Oregon, and other states have expedited treatment, and in this case, the law was smart. It normally takes 15 to 17 years to change medical management for a disease, but this has resulted in an increase in public interest.”
The law is especially critical since young players sometimes fail to recognize symptoms or are reluctant to report them. “Athletes constantly try to hide their symptoms,” said Dodge, adding that six Springfield College athletes sustained concussions in recent weeks.
Dodge has a friend whose young son recently suffered a concussion and was prohibited from returning to play by his doctor. But the child was begging and insisted he felt fine, so the man sought Dodge’s opinion.
He warned him about the seriousness of the injury and explained that proper management is critical in preventing further injury, especially since young brains are still developing. But he did acknowledge the emotional distress in the situation. “It’s heartbreaking for a child of any age to have to stop playing, and it’s almost a loss of identity for some kids,” Dodge said.
Rules and Regulations
Several weeks ago, the U.S. Senate held a hearing on detecting and treating concussions in student athletes. They listened to testimony from experts in the field as well as from young athletes who have sustained concussions.
“We see them in children as young as age 7; they begin happening as soon as they start playing organized sports,” said Dr. Anne McKee of Boston University.
Members of the medical panel said problems often arise because athletes don’t want to be benched. And making the matter worse is the fact that athletes are conditioned to play through pain.
“They hide their injuries every day,” Dr. Jeffrey Kutcher of Michigan told the Senate Committee.
The conference also addressed claims by equipment manufacturers that helmets, headbands, and other gear are “concussion-proof.” McKee said advances in the industry have helped to develop better equipment, but even the best helmet cannot control the acceleration and deceleration of the brain within the skull during a forceful blow to the head or body.
Unfortunately, she said, the claims give athletes and their parents a false sense of security. “Athletes report playing much more aggressively when they are wearing this equipment,” McKee reported, as other experts voiced a ‘buyer-beware’ warning.
Deibert concurs. “We see parents who have purchased $700 helmets designed to prevent skull fractures,” she said. “But they won’t prevent a concussion if the impact is severe enough. It’s very important to understand that the brain can still move within the skull if enough force is applied. And athletes don’t have to be hit in the head. The force can be applied to the body.”
The signs of a concussion typically appear within 10 to 20 minutes after impact, said Susan Guyer, associate professor of Exercise Science and Sports Studies at Springfield College. “Knowing that a player has sustained a blow or hit to the head is a warning sign,” she explained. “If a player is confused, feels like they are in a fog, or has a headache, ringing in the ears, or nausea, they are exhibiting signs and symptoms of a concussion. And any indication of this means they must be removed from the game immediately and cannot return to play the same day. The rule is, ‘when in doubt, sit them out.’”
Deibert has been a leader in the field of diagnosing and treating concussions. Her interest in head injuries began in the late ’90s when she ran the brain injury clinic at Washington University. “I felt like head injuries were undertreated and vastly underdiagnosed,” she said.
To that end, she started a concussion clinic at Berkshire Medical Center in 2007 as part of the brain-injury program and implemented the use of a 20-minute computerized neurocognitive assessment test, called ImPACT, for athletes ages 13 and older. The initials stand for Immediate Post-concussion Assessment and Cognitive Training, and the test establishes a baseline to help health care professionals determine when and if an athlete can return to play following a concussion.
Deibert worked with Berkshire Medical Center in a collaboration that resulted in BMC offering the testing to local high-school athletes whose sports put them at high risk for concussions. BMC paid for the testing from 2007 through June 2011. They were tested in short-term memory, attention span, reaction time, and other tasks to demonstrate their cognitive abilities off the field.
Deibert left BMC about a year ago and now runs the concussion clinic via her private Pittsfield practice, but is still a key member of the BMC brain injury program. She says that, although some athletes are taking the test online at home, it was designed to be conducted in a quiet setting under the supervision of a professional.
Gibbons believes so strongly in the ImPACT program that he went to the school committee to educate members about the testing after he learned about it. “They adopted a policy that all athletes in our school [Monument Mountain High] have to take the computerized test.”
It helps, and so does the Massachusetts law, enacted in July 2010, which mandates that any student suspected of sustaining a concussion must be immediately removed from play. But in spite of new rules and regulations, the decision to bench a player “is ultimately a judgment call,” Gibbons says.
Which is complicated by the fact that athletes often consider it “a badge of courage” to play through pain, he said.
In some cases, fellow players report symptoms to a coach when they notice slow reflexes or a peer who is not making sense. “Many times, kids are pinpointed by other players during a football huddle,” Deibert said.
Still, symptoms aren’t always obvious until players return home. And in sports like soccer, where the eye is on the ball, parents or coaches can fail to notice that a player has hit their head. This is the point at which parent education becomes critical.
“If two kids go up for a rebound and hit heads during basketball and one of the children complains to a parent of a headache afterwards, the parent needs to take it seriously,” Gibbons said. “A concussion is bleeding on the brain. Kids may have a macho attitude and say, ‘I hit my head, so what?’ But their brains are still developing, and young children are dependent on adults. So we’re trying to educate parents and let them know that, if their son or daughter exhibits symptoms such as loss of appetite, they need to seek medical attention right away.”
Unfortunately, many coaches, including Gibbons, have encountered parents who played the same sport, got knocked in the head themselves, and don’t think it’s a big deal.
“There may not be any immediate effect. The child may act normally, but later that night or a few days later, their symptoms may become apparent. It’s all a matter of education,” he said, echoing Deibert’s statement.
Healing time can vary, but children take longer to recover than adults, and those with attention deficit disorder, learning disabilities, or a family history of migraines can take even longer than their peers. “Young athletes take longer to heal than adults,” Deibert said. “No one really knows why, but their brains are still developing, even in their teenage years.”
Deibert says parents need to teach their children that their health comes before any sport. “If a child is an under-reporter, it may be because they had a bad experience when they were pulled out of a sport in the past or because someone had a conniption,” she said.
And in some instances, she said, parents are unaware of their children’s dangerous behavior. “Some kids take off their BMX helmets as soon as they leave their neighborhood.”
Guyer noted that concussions today are taken much more seriously than they were several decades ago. “It’s not just a concussion anymore. And it really brings the point home when you hear about a 16-year-old dying,” she said, referring to Doughtery’s tragic death.
“Parents are becoming more and more educated, and data collected over the past 10 years is finally getting out to the public,” she said. “But we will never eliminate concussions, and there is so much more to learn about them and about sub-concussive episodes. We have only looked at the tip of the iceberg.”
Gibbons concurs. “We can’t prevent concussions, although we can reduce their number by teaching proper playing techniques,” he said. “But students and parents need to be aware of the dangerous ramifications of a concussion. The symptoms can be subtle and can involve small changes in attitude, eating habits, or sleep patterns. These are signs that something is going on, and it is more than just a bump on the head.”
However, students have and always will play sports, and Deibert understands that concussions and accidents will continue to occur.
“Life is truly a gamble,” she said. “But people need to do their best to understand and become educated about concussions in young people who play sports.”