How some districts are taking a team-based approach to concussion management to keep students safe.
Concussions are not usually discussed in the same breath as graduation rates, learning initiatives, and teacher evaluations. But increasingly, especially in the aftermath of a $765 million lawsuit settled by the NFL last year with former players, there is a new urgency among scientists to determine the long-term impact of concussions—and among school administrators to address the issue as part of a smart school policy.
Take New York, for example. It is one of 49 states (plus the District of Columbia) that passed youth sports concussion laws in the past five years. At Port Washington School District, on Long Island, every coach carries a card that lists concussion symptoms. And not just the football coach.
"You'd be surprised at the [number] of concussions in noncontact sports," says Stephanie Joannon, director of physical education, health, and athletics in the district. "We had a swimmer who mistimed the wall and got a concussion."
Washington state was the first to pass a law when a 13-year-old middle school student suffered a severe head injury during a football game after returning to play following a concussion that was not properly diagnosed.
What do these laws mandate? Most forbid a return to play on the day of the suspected concussion, require clearance to resume play from a qualified medical professional, and mandate education on the issue for parents and athletes. About half of the laws require training for coaches. Many districts, such as Port Washington, are big on awareness-putting their concussion policy on every school's website and in every student handbook.
Just a few years ago, new brain imaging technology and research shed light on the risk of returning to play after a concussion, and guidelines followed. Unlike, say, a broken arm, a concussion can be hard to diagnose. Usually, there is no loss of consciousness, and symptoms may not be obvious until hours after the incident has occurred. But a jolt to the head can change the way the brain normally works, and mounting evidence points to the need to take this type of traumatic brain injury seriously.
"The more we discover about concussions, the more effort and attention needs to be paid to this issue," says Christopher Nowinski, cofounder of Sports Legacy Institute , a Boston-based nonprofit focused on addressing the sports-concussion crisis. As a former professional wrestler who suffered a concussion himself, he adds, "It's wise for every school to make sure they are on top of this."
District officials need to be aware of the growing body of research and craft a policy that keeps student athletes safe and establishes protocols for how to handle a post-concussion return to school and sports. And to make sure this doesn't become just another policy that collects dust on a shelf, officials need to effectively communicate the policy to coaches, teachers, parents, and students.
Concussions Among Kids
Studies show that youth are more likely than adults to suffer a concussion (they are more vulnerable in part because their neck muscles are less developed), and it takes longer for them to recover. Also, children and teenagers may not be able to articulate symptoms after a blow to the head, making an injury tougher to identify. And because their brains are still developing, it can be that much harder to measure the damage.
It's important for educators and parents to keep in mind that concussions aren't limited to the football field. They also occur among athletes who play soccer, basketball, and other sports (see chart, below). The U.S. National Library of Medicine and the National Institutes of Health report that concussion rates are highest among high school athletes in football, followed by women's soccer, men's soccer, women's basketball, wrestling, baseball, softball, and volleyball.
Research shows that the more concussions a person sustains, the more prone he or she is to experiencing another one. Scientific advances, along with new state laws, triggered a "real sea change" about four years ago, as people began to take the issue of concussion prevention and treatment more seriously, says Mark Lovell, chief scientific officer for Immediate Post-Concussion Assessment and Cognitive Testing. In the 1990s, Lovell invented the computerized evaluation system that is now used in 13,000 schools. Students are given a brief baseline computer test that can be compared to a test completed after a suspected concussion; a concussed student's brain is less efficient and will show visual memory changes, allowing injury confirmation.
"It's not just about putting the athlete back on the field," Lovell says. "It has to do with how is this going to impact classroom performance, and how will the symptoms make it difficult to learn, and what kind of accommodations will they need?"
Despite progress, most concussions are not identified-as many as 90 percent, according to Nowinski. "It's a fight," he says. "I think a segment of the population is becoming very educated, and there are advocates in every community now, but clearly we are not doing enough to [ensure] athletes are safe."
While critics charge that advocating for more stringent rules could discourage young people from being active when there is already an obesity epidemic, Nowinski says it's important to be clear that the message is not anti-sports-it's how to encourage sports to make changes that ensure player safety.
Some schools agree with Nowinski, though others seem to be resisting new regulations and reporting protocols. In Massachusetts, for example, despite a new state law that mandates reporting concussions and head injuries, only a third of schools did so during the 2011-12 school year. Some of Boston's large suburban high schools reported as many as 85 head injuries (out of a student population of 1,500), while others did not submit any incidents.
"The only coaches who are against this are the ones who have not received proper training," says Nowinski.
When coming up with a plan, experts suggest administrators get input from coaches, athletic directors, athletic trainers, physicians, the school nurse, and parents to consider all perspectives. Starting a concussion management program can actually be done at very little cost. The Centers for Disease Control and Prevention offers a free, online concussion-training course for youth sports coaches (see below). "At a minimum, every administrator, parent, and coach should take the online training courses," says Nowinski, who also advocates in-person, in-depth training sessions.
Training is important to get buy-in from coaches, who can be reluctant to pull a star player from a game when the injury isn't apparent, says Calvin Davis, assistant principal for athletics and activities at Proviso West High School in Hillside, Illinois. "In the old days, they'd tell a player to ‘man up' and get back in," he says, adding that there was some fear initially that the new protocols would mean an end to contact sports. "Once educated, the majority have accepted that we are trying to preserve the long-term health of young athletes." Teachers should also receive training so that they understand restrictions placed on students with concussions, who, for example, might be told to limit studying until the initial trauma is over.
John Pizzi Jr., director of athletics at Riverdale Country School in the Bronx, says getting support for new policies is all in how the appeal is framed. He has provided a range of educational outreach to coaches and parents, who realize that, in the big picture, a couple of days on the sidelines for an injured athlete won't make or break college recruitment chances. "They understand the most important thing is the kids' safety," says Pizzi.
Some schools, such as Riverdale, require students and parents to sign forms acknowledging that they have reviewed the schools' concussion policy.
A number of districts are setting limits around exposure to contact sports to minimize concussion risk. Football players, for example, may not use full pads during most training sessions (in line with a no-tackling rule), or soccer coaches may limit headers in practice.
Nowinski's organization, the Sports Legacy Institute, launched the Hit Count Initiative in 2012 with the goal of developing and promoting guidelines to regulate the amount of brain trauma that a child is allowed to incur in sports."
When it comes to kids and concussions, there is more that we do not know than we know," largely because 99 percent of the research focuses on adults, says Stefan Duma, professor of biomedical engineering and department head at the Virginia Tech-Wake Forest University School of Biomedical Engineering and Sciences.
To prevent concussions, schools need to have the right rules, coaches who are educated, and the best equipment. As engineers, Duma's group has worked to improve equipment and study the impact of prevention. For instance, football helmets have been redesigned to better protect players' heads.
At Riverdale, each football player is fitted by a certified technician for a helmet that the player keeps throughout his years on the team. The school bought five-star-rated $250 helmets for each player, a substantial upgrade from the $70 variety the team had for years. During practice, the team uses guardian caps-padded, netted caps that go over the helmet. Studies have shown that guardian caps can reduce a third of the impact, says Pizzi. Additionally, players at Riverdale use an impact-sensing mouth guard that coaches can monitor to alert them to player trauma.
"We've looked at and taken a part of every good idea out there and put [them] into play, trying to cover all bases," Pizzi says.
All of Riverdale's athletes in grades 7-12 get a baseline concussion ImPACT test, and logs are kept on every student. Port Washington evaluates all high school athletes. Schools pay an annual fee for the evaluations, which ran about $500 total for the Port Washington district in 2011-12 and 2012-13.
Remove and Resume
At the heart of concussion management programs are policies outlining when athletes should be removed from play and when they should be cleared to return.
"The bar for removal from play is far too high," says Nowinski. "Most programs don't train everybody to understand the signs and symptoms and to immediately remove athletes from play, and not enough concussions are diagnosed."
Port Washington has established a six-step protocol that students with concussions must follow before being allowed to resume play. The process is predicated on a doctor's clearance that the patient is symptom-free and ready to return. The school gradually brings the student back into activities, checking with each step that they remain symptom-free. "We don't rush them back," says Joannon. "There have been numerous times where the athletes go through the protocol and do exhibit concussion-like symptoms. We feel confident that with this process the athletes are ready when they go back."
Today, having a concussion program in a school is an imperative, says Danielle Greenman, sports medicine coordinator of the concussion management program for the Charleston County School District in South Carolina. "This is not something anyone can afford to neglect. You are never doing too much. If you are covering the care of your student athletes, you are never going to overdo a policy or management."
5 Websites For More Info
Sample district policy
Prevention and treatment of sports-related concussions
"Know Your Concussion ABCs"
A fact sheet for school nurses
Report on Sports-Related Concussions in Youth
The Institute of Medicine
information in 10 areas from prevention to equipment
Sports Legacy Institute
Free online concussion training course
For youth sports coaches
Centers for Disease Control and Prevention
Caralee Adams writes about education, parenting, and health. she lives in bethesda, md. you can write to her and the editors at firstname.lastname@example.org.