The information presented at the conference raised a number of important policy implications, including the neuropsychological assessments and other factors that should be considered for determining how soon after experiencing a concussion a player can return to the playing field, the importance of educating the spectrum of people involved in soccer on the consequences of concussion, the signs and symptoms of concussions, about the guidelines for when to allow players to return to play after a concussion, the need for more athletic trainers in school athletic programs, and when to teach heading to children.
Return to Play After a Concussion
The main goal of return-to-play guidelines is to avoid the serious, and possibly fatal, complications of a second concussion occurring too close on the heels of the first. Dr. Guiskiewicz presented evidence that players who experience one concussion are three or four times more likely to experience additional ones than their teammates who have never had a concussion. This probably relates to their style of playing, according to Dr. Hergenroeder, and points to the need to prevent these players from permanently damaging their brains.
There are a number of return-to-play guidelines used to determine how soon athletes can safely play their sport after they’ve had a concussion. Most of these guidelines recommend safe time-out periods based on the seriousness of the concussion, as determined by the loss of consciousness or amnesia.
For example, concussed players who never lost consciousness or experienced amnesia are allowed to return to the game after fifteen minutes if they have no other symptoms of the concussion at that time. If players experience amnesia following their concussion, however, they are usually not allowed to play again until one week after the concussion, and then, only if they are symptom-free for the entire week.
If players lose consciousness following the concussion, that time-out period is extended to at least two weeks, assuming they have not shown any symptoms during that period. If a player has already had two or more concussions during the same season, the time period away from playing should increase for each concussion.
Several of the speakers pointed out shortcomings to these commonly used return-to-play guidelines, and additional factors that need to be considered. “There are increasingly sensitive measures that we need to use in our batteries of evaluating athletes, in order to be more certain that they are actually safe to go back,” noted Dr. Kelly.
One shortcoming to these guidelines, pointed out by Dr. Echemendia, is that they rely on the loss of consciousness to predict the severity of the concussion. But unless that loss of consciousness occurs for a long period of time— thirty minutes or more—data suggest it doesn’t predict the severity of a concussion in the mild range, Dr. Echemendia said. In addition, as mentioned previously, players are often not evaluated soon enough after a concussion to determine if brief losses of consciousness occurred.
Dr. Echemendia did think, however, that the length of time players experienced amnesia after a concussion was a telling factor in how severe the concussion was, and thus how quickly the player can return to the field. “Do we have a posttraumatic amnesia that exists for a minute or do we have one that is 12 hours long? It is important to take a look at that,” he said.
Another major problem with most current return-to-play criteria is that they rely heavily on athletes’ reporting of symptoms to assess whether they should return to play, according to Dr. Echemendia. But as Dr. Kirkendall pointed out, players will “lie, lie, lie to get back in a game.” Dr. Echemendia concurred and recommended that “When a player is standing in front of you and they look dazed or goofy, and they are telling you that they are absolutely fine, don’t take their word for it.”
Dr. Echemendia gave another reason for not relying on players reporting their symptoms, which is that they may not even be aware of them. He also noted that some concussion symptoms, such as headache, are so common that they are difficult to distinguish from other conditions. He pointed out that nearly one-third of the athletes he studied reported concussion symptoms at the beginning of the study, before experiencing any head injuries on the college playing field. “If we base our return-to-play decisions solely on their reports of symptoms, then we end up in trouble,” he said.
Dr. Guskiewicz called for more objective, quantitative measures of impaired brain functioning that would disqualify a concussed, brain-injured athlete from returning to the playing field. Those measures would include neuropsychological assessments as well as objective measures of posture and balance. As an example of the need for better assessment, he brought up the problem of balance, which is often disturbed in people after a concussion. And yet, most assessments of balance are inadequate and inconsistent. “One person may think that the individual has a gross sway, and another person may think they have a very mild or moderate sway,” he said.
Dr. Guskiewicz developed a balance error scoring system that enables the accurate assessment of balance. This testing system grades athletes on their ability to maintain a position while standing on one foot and other tasks. The tests require only an inexpensive piece of foam and can be done on the sidelines of a playing field.
Dr. Kelly added that there are devices, such as those that can measure abnormal eye movements, which can also aid the objective determination of certain concussion symptoms.
Several speakers addressed the importance of using neuropsychological assessments in return-to-play decisions. These assessments can objectively determine when a number of brain functions return to normal following a head injury, according to Dr. Echemendia. As he said, “return-to-play decisions are very difficult because we are trying to find that one moment when it is safe to return to play for someone who has a condition we can’t see.” Neuropsychological assessments can help “see” if that condition has resolved, he said, particularly if baseline, normal values in these assessments are known for the players. Such baseline data could be collected by testing athletes when they first come on board a team, prior to the start of any games. Neuropsychological assessments can also determine if some of a player’s symptoms, such as headache, are due to the head injury or some other cause, noted Dr. Echemendia.
But as Dr. Guskiewicz mentioned, neuropsychological functioning is just one piece of a complex concussion puzzle and other factors, such as balance problems and other symptoms also need to be considered when making return-to-play decisions. “There are many pieces to this puzzle, several of which we don’t even know, and you can’t look at just one piece of it,” he said. He also added “no two concussions are created equal.” Some athletes with concussions may do poorly on neuropsychological tests, but well on balance tests, and others will do just the opposite. “That’s why we need to try to make sure that we are looking at every piece of that puzzle in making these decisions,” he said.
Another factor that both Drs. Guskiewicz and Echemendia called attention to was the importance of a player’s concussion history in deciding when they could safely return to play. “The number, spacing, and severity of previous concussions all need to be taken into account,” said Dr. Echemendia. “One of the greatest issues is not necessarily the number of concussions
you’ve had,” he said, “but how closely spaced they are because it gets to the whole issue of the vulnerability of the brain. If the brain is still vulnerable and you have another concussion, that may lead to a more severe outcome.”
Dr. Echemendia also suggested considering player and team factors such as their style of play and position when making return-to-play decisions. If they tend to “play with their heads” or are in a position that puts them in greater likelihood of experiencing another head injury, then a longer delay before returning them to play may be warranted, he said. Another important factor, he added, is the player’s willingness to return to play. “It is very telling when you have a player who tells you ‘you know doc, I feel scared about going back into the game,’” Dr. Echemendia said. Those players should not usually be returned to the playing field, he said.
Another factor in balancing the risk versus benefit assessment of when players should return to a game, raised by Dr. Echemendia, is the importance of the game and the athletic career aspirations of the player. “Is this an athlete who doesn’t want to go any further than high school in their playing, or is it someone who wants to play at a higher level and just signed a 34 million dollar contract?” he said. “You also need to be aware that the importance of the game might try to pressure you to put that player out on the field too early,” he added.
Another factor to consider is the field conditions, according to Dr. Echemendia. A wet slippery field poses more hazards than a dry one, he pointed out.
Dr. Hergenroeder stressed the importance of having qualified physicians examine athletes who have experienced a concussion before they are allowed to return to playing in a game. As he pointed out, this often does not happen and instead coaches make the decision on when a player can resume playing. “Even well-intentioned coaches are probably not making the right decisions in the interest of the player,” he said.
Dr. Hergenroeder also noted that for many athletes, the sport they play is a major part of their lives and restrictions on their playing can be a hardship for them. To make it easier for these devoted athletes, he suggested that recently concussed players who have no symptoms, but can’t yet return to playing a game, can still work out with their teams during practices and participate in noncontact drills.
“One of the greatest issues is not necessarily the number of concussions you’ve had,” he said, “but how closely spaced they are because it gets to the whole issue of the vulnerability of the brain. If the brain is still vulnerable and you have another concussion, that may lead to a more severe outcome.”
Dr. Brooks presented findings from her study that indicated most of the people involved in high school sports, from the players to the team doctors, were not aware of the seriousness of concussions and how to diagnose or treat them. “We found that most student athletes at the high school level do not have information about concussion,” she said.
Dr. Hergenroeder pointed out that in his experience, the team physicians for many high school and middle school teams tend to be obstetricians, pediatricians, or family practice physicians who have no training in concussion management. “The parents on the sidelines are pleased to know that there is a physician there,” he said, “but this physician may not have the skills for handling some of this.”
Dr. Brooks concurred and noted that when she surveyed family practice physicians within the state of New Jersey, she found that less than half of them felt confident treating concussions. Only a third of them felt confident making return-to-play decisions. And what is perhaps most disconcerting, only ten percent of them received a passing grade on her concussion questionnaire. “We need to educate physicians,” she said.
“Right now family practitioners, internal medicine doctors and pediatricians are the gatekeepers before anybody ever makes it to a specialist like a neurologist or neuropsychologist,” Dr. Brooks said. “If we are seeing that our medical providers do not have the most current upto-date information about what a concussion is or is not, then I think we really have our work cut out for us.”
Although 97 percent of the athletic trainers Dr. Brooks surveyed received a passing grade on her concussion test, 17 percent reported using no objective method to assess concussion consistently, and for deciding when athletes could return to playing a game following a concussion. In addition, 60 percent reported that they had never discussed concussion or return-to-play decisions with their team physicians.
One participant stressed the importance of educating coaches because it often is the coach that is making return-to-play decisions. Only one-third of the student athletes that Dr. Brooks surveyed reported receiving any information about concussions from their coaches. Another participant pointed out that the majority of youths play in amateur leagues with volunteer parent coaches and that these coaches must be educated about concussion as well.
Education of the parents of youth athletes is important, added Dr. Brooks. By notifying them of the symptoms associated with concussions, “parents will look at their kids seeing stars, or vomiting or having a sensitivity to lights or sounds in a different way,” she said.
Dr. Brooks added that officials at youth games should also be educated about the signs and symptoms of concussion, as they are the ones responsible for stopping a game once a player receives a head injury. They are also responsible for ensuring that the rough reckless play likely to cause head injuries does not occur out on the playing field.
Dr. Kirkendall described the case of a high school soccer player who received two concussions in one game from the same player. Using illegal maneuvers, this player forced her to fall on two separate occasions and both times she hit her head. The concussed player went from being an A student to a struggling student and essentially lost an entire semester of school. The player who fouled her twice was not called for a foul either time or restricted from playing. “Reckless play is fairly common,” he said, “and cautionary objection to this reckless play is fairly rare.”
“We have enough information now to roll out the education component, but it needs to go to all levels— not only the youth coach, but the medical community, the coaching community, and the parents and athletes.”
[Mr. Jon Almquist]
Mr. Jon Almquist, who participated in the workshop, coordinates high school athletic training programs in Fairfax County, Virginia, and chairs the secondary schools athletic training committee of the National Athletic Trainers Association. He noted that “We have enough information now to roll out the education component, but it needs to go to all levels—not only the youth coach, but the medical community, the coaching community, and the parents and athletes.” Education of the athletes on the signs and symptoms of concussion “has potentially saved some lives,” he added, “because they’re looking out for their friends.” Because they have been educated about the symptoms of concussion, they recognize them in their head-injured teammates and have brought them to the attention of the coach or team athletic trainer, he said.
To aid with concussion education, Dr. Brooks suggested partnering with the Brain Injury Association of America, and state athletic associations. She also suggested working with insurance companies so they will give school districts a lower insurance rate for their sports programs if they include an educational program about concussion.
Dr. Brooks also thought it important to meet with school board members and principals before running concussion education programs in the school system. “If it comes down from the top, then potentially the coaches and the athletic trainers will participate in these programs and so will the parents,” she said.
She noted that in the concussion education program she ran in a New Jersey school system, none of the parents have ever pulled their children out of athletic programs because they were scared by the information she presented during her education program.
To help with educating the public about the seriousness of concussions, Alan Bergman of the Brain Injury Association of America suggested the formal medical term for concussion, “mild traumatic brain injury,” be changed. “As a lobbyist, I can tell you working on Capitol Hill last year on the Traumatic Brain Injury Act, we struggled to get one sentence in that legislation about looking at mild traumatic brain injury,” he said. “The response was ‘well, if it is a mild injury, it goes away.’ So nomenclature is a major issue here and it is a barrier to public and professional education.”
Mr. Bergman said that even the term concussion connotes nothing more serious than just a three-day headache or bump on the head to most people, according to a Harris poll his organization ran last year. “Maybe we should just say ‘brain injury,’” he suggested.
He added that the problem with the term “head injury” is that most people assume it doesn’t affect the brain. “Somehow people
believe the skull is an iron vault that protects that organ inside called the brain,” he said. Another participant suggested calling a concussion a “moderate brain injury.” This term would preserve the acronym already used for mild brain injury, he noted, yet distinguish a concussion from a more severe brain injury.
Dr. Guskiewicz suggested recommending that all high schools with sports programs have certified athletic trainers. These sports medicine professionals are not only well versed in the signs and symptoms of concussions, he said, but because they deal with the team athletes on a daily basis, they are often better at evaluating head injuries than a physician.
“They know the personality and intelligence level of the athlete so they can detect when there is something out of sync or just not normal,” he said. Dr. Guskiewicz thought athletic trainers should be part of the team of neuropsychologists, neurologists, and physicians that are responsible for evaluating players’ head injuries.
According to Dr. Guskiewicz, athletic trainers are currently present at 38 percent of all high schools in this country. He noted that there are several states right now that have legislation in the works that require placing certified athletic trainers in every school district. Even then, it is unlikely that many school districts would have funding to support enough trainers to attend every game of every relevant sport for all schools.
Dr. Brooks noted that heading is a valued part of the soccer game and adds an important dimension to play. Although Dr. Echemendia pointed out that there currently is no evidence that heading, when done properly, causes brain injury in adults and late adolescents, there still was debate on when youths should be taught to do this practice.
Dr. Hergenroeder suggested heading should be taught early, such as before the middle school years, when youth soccer players are usually first taught to head the ball. “If you teach them how to head correctly, that gets them out of trying things that they see the pros doing and they don’t know how to do, such as the backward head,” he said.
Dr. Brooks added that the American Youth Soccer Organization recommends not teaching heading to players below age 10. “But if you talk to trainers, coaches, and a lot of people that are working in the area of educating players,” she said, “many claim it is really important to potentially develop the neck musculature and have athletes prepare to take headers prior to age 12, so that once they become 12 or 13, they are not confronted with situations that they don’t potentially know how to deal with.”
But one participant at the workshop questioned whether children younger than 12 have the musculature and skeletal development to lock their heads in place, which is an important element of safe heading technique.
Dr. Brooks also noted that some people have suggested limiting heading in youths to certain areas of the playing field as a way of eliminating head trauma from some of the longer, more directly returned balls.