Head Case: Sidelining the Rules on Youth Concussions

A concussion is a traumatic brain injury. It is one of the most serious injuries student athletes can suffer

When a student-athlete is suspected of having a concussion, experts agree, that student should be benched immediately. 

Legislation was written and introduced by Virginia Senator Dr. Ralph Northam — a pediatric neurologist at Children’s Hospital of The King’s Daughters in Norfolk, Va. — in 2010. It requires all school districts to have a written policy stating that students who receive a blow to the head and shows signs of a concussion must be pulled from the sport, including practices, until they have been evaluated and cleared for play by a medical professional.

“This law gives athletes time to recover from a concussion. It especially protects them from second-impact syndrome, which is very dangerous,” says Northam. Second-impact syndrome is getting hit again while still under a concussion. It is a risk not only to the brain, but to the child’s life. Second impact syndrome can make a concussion worse, with the possibility of brain swelling or death.

The law also protects coaches who are being pressured by parents, fans (and the athletes themselves) to put the child back in the game.

The law takes that pressure off of them,” Northam adds.

Virginia follows eight other states that have adopted similar laws, beginning with Washington State a couple of years ago, according to Dr. Peter Gonzalez, a nationally recognized concussions expert and professor at Eastern Virginia Medical School in Norfolk. Gonzalez worked with Norfolk Public City Schools on drafting their policy.

Northam says the law came about because concussions in youth sports are on the rise. Based on 2009-2010 data, the likelihood of suffering a concussion while playing a contact sport is estimated to be as high as 19 percent per year of play. More than 62,000 concussions are sustained each year in high school contact sports.

There are a couple of theories to explain the increase, including that brain injury was not always diagnosed as a concussion in past decades.

Local experts say concussion was once referred to as “having your bell rung” and not considered serious enough to pull a player from a game or practice. Also, the injury was not always noted in medical records and statistics.

Dr. Charles Dillard, a pediatric physical medicine doctor at Children’s Hospital of Richmond, notes recent research has revealed much about concussions: “Even since I have been out of residency, which has been three years, there have been more changes.”

Dillard played high school football at Douglas Freeman High School from 1992-1996. “Back then we were told to shake it off … Now, at the first sign of a concussion, the player is to get out of the game.”

Todd Korbec, head trainer at Warhill High School in Williamsburg, has 10 years’ experience. He agrees that much has changed in the past few years.

The first five years [of my career] you pulled a kid out of the game and waited to see how he felt, then told them to get back in. Looking back, that was not proper science,” he says.

Korbec believes the new law will help players and fans understand his decision to pull a student-athlete from the game and practices if a concussion is suspected.

Another theory that may explain the rise of concussions among student-athletes is the evidence that students are playing harder.

“Because students start playing sports at an earlier age than years before, they are faster and stronger — making them better equipped to hit harder,” Dillard says.

Why are Concussions More Serious in Children?

A concussion is a traumatic brain injury. It is one of the most serious sport-related injuries children and adolescents can suffer. Student-athletes are more likely to develop problems from a concussion than are adults if not treated properly, according to Dr. Joel Brenner, medical director of the sports medicine team at CHKD. Brenner, a member of the American Academy of Pediatrics, has testified before the U.S. Congress on the issue.

There are many injuries from which children can recover quicker and more easily than adults; a concussion is not one of them. For children and adolescents, recovery is a slow process because their brains are still forming.

The developing brain of a child and adolescent is like an egg. When shaken, by the result of a concussion, it can be damaged,” Brenner says.

Brenner notes that the severity of a concussion cannot be determined when it happens. “We only know how severe it was after treatment. It depends on how long it takes someone to recover from it.”

How Does a Concussion Happen?

A concussion can occur in several ways. One is a blow to the head; another is a fall in which the head hits the ground. It can also be an indirect force to the head such as a blow to the chest that causes the head to whip around.

The damage does not only affect memory, it can affect balance, emotional behavior and sleep. It can cause severe headaches and change how a person reacts to stressful situations. It can affect the ability to think and perform simple tasks such as preparing for the school day, Brenner says.

Symptoms usually last seven to 10 days. If the symptoms do not end in that time, a condition known as post-concussion syndrome may apply.

An injured athlete does not need to lose consciousness in order to get a concussion. According to Brenner that only occurs in 10 percent of cases.

There’s also a misconception that helmets prevent concussions. As Brenner points out, helmets are designed to protect the skull, not the brain.

There is also a falsehood that mouth guards protect against concussions, it only protects teeth and other dental parts,” he adds.

Korbec notes student-athletes get concussions off the field many times because of their teenage daring attitude. A concussion off the field may be missed because the blow was not seen by coaches. “I had a swimmer who got a concussion from snowboarding,” he says.

Baseball pitcher Logan Lex, 16, of Hickory High School in Chesapeake, sustained a concussion last July not playing his school sport, but by playing basketball with friends at a local park. “Someone knocked me down and I hit my head on the concrete,” he explains.

He says he “blacked out for a while.” His friends called his mom who rushed him to Chesapeake General Hospital’s emergency room where he began spitting and thrashing his arms, according to his mother, Susan Lex.

Following his initial symptoms, Logan says he had an intense headache for a few days. He was under Brenner’s care for two months before returning to his regular routine.

How Should Concussions be Treated?

Because a concussion is an internal injury, diagnosing one can be challenging.

“It is not like a broken arm, where a doctor can see it is broken and the coaches and trainers see a cast. You cannot wear anything to show you have injured your brain,” says Dillard. “Because it is inside the head, it is harder to flush out,” he adds.

Cognitive rest is important, that is resting the brain. Even watching television can slow recovery. Reading, studying and screen time should be little to none at first and they should gradually return, says Dr. Nathan Zasler, a rehabilitation doctor with Concussion Care Centre in Richmond.

Parents need to be aware of their children’s mood changes and advocate for their children. Do not just rely on the coach to determine if your child can go back in the game or school, Brenner advises.

Once it has been determined a student can return to school, a plan needs to be developed with the parents and school officials. It is best to begin with just a half day, says Brenner. Monitoring should be done throughout the day by the school nurse or athletic trainer.

Cindy Midkiff, an athletic trainer at First Colonial High School in Virginia Beach and co-owner of Virginia Beach Field Hockey League (the largest league in the state), believes parents need to make school personnel aware of the injury especially the teachers and guidance counselors. She feels the new law will give student-athletes the ability to ease back into their school routine safely.

If a student returns to school and develops symptoms such as a headache, he or she should report to the nurse’s office. Sometimes, just taking a 30-minute rest can help. “You don’t want to tough it out,” Brenner emphasizes.

Often parents and teachers are too eager for a child to get back to learning before the brain has healed, Brenner says. Resuming classes and other daily activities too soon can lead to post-concussion syndrome, causing headaches, irritability and other symptoms.

“If a student begins to get headaches and is acting confused then they are not fully recovered and they need to back off school,” Zasler says. “

They need to get as much rest as realistically feasible, if not it could delay their recovery and put them at risk for permanent impairment.”

They should also get reassessed, he adds.

The largest school district in the state, Virginia Beach Public Schools, uses the computerized ImPACT Baseline Testing to determine if an athlete is ready to go back to a sport, says David Rhodes, coordinator of student activities for the district.

Korabec says Williamsburg/James City County Public Schools uses the test as well. Once a student is found to have a concussion, Korabec will not let them back in the game until they complete and pass the test. “I have been working with this for three or four years now, it is a great tool. It validates my position that a student is not ready to go back into the game. It [removes] a gray area. This gives me hard evidence if the student tests poorly,” he says.

Returning to the sport should be slow, starting with basic exercise, such as walking and jogging, then gradually building up to the contact portion of the sport. The student should continue to be monitored for symptoms when they return to the sport, Brenner says.

Athletes Need to Talk About It

It is important for student-athletes to be aware of the injury’s seriousness and be encouraged to report their symptoms.

“I let them know if they have headaches, trouble sleeping or just feel funny, they need to let their parents, coaches and trainers know,” Brenner says.

Many times young athletes feel they are being a bad kid if they complain about symptoms such as a headache following an injury.

So they just blow it off,” Midkiff says.

For middle and high school students, hormones add to the mix of sensitivity, says Dillard. A concussion complicates the already changing teenage body. Plus, students who are taking several advanced placement courses, think missing several days or weeks of studying will really impact their grades so they will not want to take the needed rest, he explains.

Korabec says that during his preseason meeting, “I tell them to be mentally prepared that this could happen and to report it. Luckily, all the news on concussions provided by the NFL has helped. I also give them information on second impact syndrome and [explain] that it could result from a hit that is not that hard.”

To drive the message home, Korabec has all student-athletes watch an ESPN video that profiles a high school player who had a concussion, did not report it and then got second-impact syndrome. “It left him mentally challenged for life,” says Korabec. “This gives them hard evidence.”

While student-athletes, their trainers and coaches need to be aware of concussions, so do parents. Northam points out that the new law will require parents to annually review information (provided by the school division) about the short-term and long-term effects of concussions. Both the student and their parents or guardian must sign a statement acknowledging they received the information.

Not taking head injuries seriously can lead to problems later in life, especially with multiple concussions that are not treated correctly, Zasler says. He points to famed boxer Mohammed Ali, who “got knocked in the head too much” and now has Parkinson’s disease.

Gonzalez adds, “It is a big deal because there is somewhat of an unknown further down the road on how a concussion affects a child.”

About the author

Susan Smigielski Acker

Susan Smigielski Acker is a freelance journalist and editor. Previously, she was a newspaper reporter in Georgia, a feature writer on the U.S. Army Kwajalein Atoll, Marshall Islands, and worked at NASA Langley Research Center. She resides in Newport News, Virginia, with her husband and two daughters.

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