This is the second of a three-part series on concussions in sports and how athletic organizations are dealing with the aftermath.
The easiest part of dealing with concussions is diagnosing them, coaches and medical professionals say. The symptoms are often obvious, and, when a player is honest, doctors can track recovery well.
Only a small fraction of athletes who suffer a concussion pass out, but most others will become disoriented, get headaches, become nauseous or exhibit any one of dozens of telltale signs.
The hard part is getting everyone to agree on what comes next.
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From the way the severity of a concussion is graded to the length of time a player should sit out after the final symptoms dissipate is what’s unclear, said Andy Grubbs, the assistant director of athletic training at the Hughston Foundation.
“The biggest thing we’re struggling with is getting everyone on the same page,” Grubbs said. “Players, coaches, doctors, parents, they’re all on different timelines.”
For the most part, coaches are far more educated about concussions and their effects than they were just a decade ago, Grubbs said. However, only recently have athletic associations and school districts begun to worry about what to do next.
“Nobody is questioning concussions as serious any more,” Grubbs said. “The debate now is on who should make the call to return to play. Is a trainer enough? A general physician? A neurologist? Or parents? Right now, everyone is trying to find some sort of standard because there just isn’t one out there yet.”
New national guidelines
The National Federation of State High School Athletic Associations, the governing body presiding over state athletic associations, set new guidelines in May. They call for officials to pull an athlete from play if he or she is showing signs of having suffered a concussion. The guidelines also specify an athlete cannot return to a game until cleared by a licensed health-care provider.
It is a step in the right direction, but it lacks detail, according to coaches and medical professionals. What constitutes a licensed health-care provider can range from state to state and can encompass everything from a general physician to a nurse practitioner. The NFHS plan also does not lay out a set of guidelines for those professionals to base their diagnoses or set a standard for safe recovery.
That means that an athlete may get approval to return to play from one doctor while a teammate with the same condition may be held out for a week or more by another doctor. The plan for continued treatment and evaluation also changes from doctor to doctor. And confusion sometimes sets in when multiple doctors examine an athlete because they may be rating the severity of the concussion with one of several widely used grading systems.
To help cut down on the confusion, the Alabama High School Athletic Association took the NFHS’s policy a step further this summer by passing a resolution specifying a medical doctor must clear a player and stipulating all AHSAA coaches take the NFHS’s free online course on concussions.
To date, nearly 3,000 high school coaches in Alabama have taken the course, which is more than any other state, AHSAA media director Ron Ingram said.
New local policy
The Georgia High School Association, like most states, simply has adopted the NFHS’s policy. It also passed this month a resolution encouraging coaches to take the online course.
The Muscogee County School District and the Hughston Foundation have gone even further, creating a comprehensive plan to deal with concussions from diagnosis to treatment.
When the Hughston Foundation began piecing together the new policy for Muscogee County, the plan’s developers wanted to avoid some of the vague language in the NFHS policy or similar ones other counties or states had drawn up.
“We wanted to cut down on any possible confusion between doctors, trainers and coaches,” Grubbs said. “I’ve seen notes from doctors that say a kid’s concussion is a Grade 3. But what’s a Grade 3? Is that on the 1-3 scale some doctors use or is it on the 1-5 scale some doctors use? I’ve seen at least three scales being used, and it just shows the need we had to get everyone working together so that, when you go to one doctor who says it’s a Grade 3, another doctor is going to recognize what kind of Grade 3 it is.”
A version of the new concussion policy already has been printed in the district handbook and sent to coaches. While the final version still is waiting to be approved by a consulting neurologist, little is expected to change, and any new guidelines will be sent out in revised versions.
Muscogee County School District athletic director Gary Gibson said the vision for a new, more specific policy arose with district coaches and trainers about three years ago, when the NFL made changes to its concussion treatment guidelines.
“Once that happened, it really got our attention,” Gibson said. “We started looking around the country for ways to improve our concussion policy with student safety in mind.”
Gibson said he feels more comfortable with where the new policy puts responsibility and with the level of caution involved.
“We didn’t want the parents to feel the pressure of making the decision, and we certainly didn’t want to go on the word of the student-athlete,” Gibson said. “We also didn’t want the coaches to have to make a medical decision. What we wanted were doctors who could all be on the same page about this and a plan that covered all students the same.”
When to return?
Grubbs said the new plan’s details will eliminate much of the wiggle room athletes previously had, which allowed them too often to return to play too early.
“We just weren’t as concerned with the long-term effects of concussions 10 or 15 years ago,” Grubbs said. “You might get knocked out playing football, be dizzy, not remember where you are, yet, 30 minutes later, if you told your coach you felt all right, you would be back on the field. With this plan, there’s no more of that.”
The clock starts when the first symptoms show, such as dizziness, headaches, memory loss or poor vision. From there, doctors determine the severity of the concussion and a 24-hour waiting period begins.
Athletes are then given tests that measure their reaction times and ability to think clearly, which often are changed by a concussion. After 24 hours without symptoms, the athlete may begin light physical activity, such as jogging or bicycling.
Next comes sport-specific activities and no-contact practices and, after approval from a doctor, a return to full-contact play. Assuming symptoms are mild and subside, an athlete might take as many as seven days to return to full participation. If the symptoms reappear at any point, the athlete has another 24-hour waiting period and starts the process over with light physical activity.
A week may seem like forever to a high school football player whose life revolves around Friday nights, but Grubbs said each stage of the policy has been carefully crafted to ensure nobody risks returning to play too early. One concussion makes an athlete more susceptible to another. Neurologists recognize the days immediately following the first concussion as the most likely for a player to get second-impact syndrome from another hit.
Second-impact syndrome happens when another hit magnifies the bruising on the brain. The brain quickly swells, often leading to permanent physical impairments or death.
“Some kids understand how dangerous it can be,” Grubbs said. “But some kids are just too tough or have this Superman mentality about getting hurt.
“We’re trying to make sure that there’s no way someone can get a concussion and return to play too early.
“It’s tough to tell a kid they can’t play for a week, but knowing what I know, I don’t mind having to do it.”