From 2001 to 2009, the number of emergency room visits for concussion-type injuries doubled, from 6,500 to 12,360, according to the Brain Injury Association of New Hampshire.
And that’s good news.
“That’s a signal that there is a lot more awareness,” said Steven Wade, executive director of the Brain Injury Association of New Hampshire. “The types of things that people weren’t going to be seen for, more and more, people are seeing a doctor about it.”
Awareness is rising, but concussions remain a mystery, to a certain extent. The injury is still largely a personal one. No one other than the injured individual can explain what they are feeling. No one else can see what’s going on.
More and more, coaches, trainers, parents and athletes themselves are erring on the side of caution. To the medical community, that’s a good thing.
When a football player lies prone on the ground, knocked out, it’s easy to determine he needs help. If an athlete gets up staggering after a hard hit, it’s easy to know that player needs attention. But concussions are frequently much more difficult to identify.
“We can’t see it,” said Laura Decoster, vice-chairwoman of the New Hampshire Advisory Council on Sports-Related Concussion. “That’s what’s so difficult about it.”
Not only that, but sometimes athletes try to minimize the problem.
“If you tell me you don’t have a headache, I can’t see that you do,” Decoster added.
Yet coaches, trainers and the medical community are expressing optimism that concussion awareness is getting to the public, and that athletes are understanding the seriousness of concussions.
The brain injury community has pushed the seriousness of this issue for years. The wars in Iraq and Afghanistan have helped bring attention to it.
“For years, brain injuries were the silent epidemic,” Wade said.
Gov. John Lynch signed legislation last month requiring all school districts to develop concussion management policies. The legislation, Senate Bill 402, requires a student athlete to receive medical clearance before returning to play following head trauma. The bill took effect in August.
Willing to wait
Dr. Adam Cugalj, a physiatrist with the New Hampshire NeuroSpine Institute, remembered a high school football player who was in preseason drills and took a hard hit during morning practice. The athlete stayed in the game and didn’t experience any more hits. During the break between morning and afternoon practice, he reported that he felt a little off. The trainer pulled the athlete out, Cugalj said.
“He was kind of thinking maybe this was an issue for me, and he asked somebody else,” Cugalj said. “The athletic trainer made the right call. They did the neurocognitive testing and he did in fact have a concussion.”
Today, that response is more typical.
“Certainly, there are more athletic trainers and coaches pulling kids out when they are suspecting a concussion,” Cugalj said.
Cugalj said there is still the occasional parent or coach who is stuck in the “old-school mentality” that athletes should “suck it up” and “shake it off,” that it’s just a “ding” or they just got their “bell rung,” but those sentiments are diminishing. Cugalj said the exposure the issue is getting from professionals has had a positive effect on high school and youth sports.
“We need to thank the NFL and the NHL and professional sports in general for that,” said Ron Snow, director of communications for the Brain Injury Association of New Hampshire. “In football in high school, when you got a concussion, you waited a couple plays and then you go back in. That does not happen now. What does happen now is that athletes are evaluated and cleared by a medical professional.”
“It is a brain injury, not just a bump on the head,” Snow added.
But we’re not all the way there.
“I still think that the culture of competitiveness in sports is still such that a lot of people are kind of thinking, ‘I have a little headache, but it’s not that bad. I can still play,’” Cugalj said.
Kids are starting to get the message that concussions can have lasting impacts. Informational posters about concussions hang in locker rooms, Cugalj said.
Studies have suggested people who have suffered multiple concussions may be at greater risk for neurocognitive disorders later in life, Wade said, though he said that research is relatively new. One of the major issues is that people don’t take sufficient time to heal. Symptoms become cumulative and more challenging as people suffer multiple concussions, Wade said.
“A lot of times these are long-term effects,” Wade said. “You don’t see them in the short term.”
What exactly is a concussion?
“You do not need to lose consciousness to get a concussion,” Cugalj said. “But not every blow to the head causes a concussion. Not every athlete who gets up and says his head hurts has a concussion. Those are often tough calls.”
According to the Centers for Disease Control and Prevention, a concussion is a traumatic brain injury “caused by a bump, blow, or jolt to the head that can change the way your brain normally works. Concussions can also occur from a blow to the body that causes the head to move rapidly back and forth. Even ... what seems to be a mild bump or blow to the head can be serious.”
Most concussions occur without a loss of consciousness. The CDC lists a number of symptoms that could indicate a concussion. Some are typical: appearing dazed or stunned or being confused about an assignment or a position. Others might be more difficult to pick up on: a change in personality, mood or behavior.
It’s how you play the game
Wade said high school and youth sports are played at a more intense level today than even 10 years ago. Whether there are more concussions because of that is a difficult question to answer. For that matter, how can officials measure intensity? Regardless, Wade said more people are playing sports than ever before.
“There is definitely an emphasis with coaches to improve techniques,” Snow said.
If coaches, particularly at the youngest ages, are teaching fundamentals on how to tackle and hit opponents, that’s going to have long-term positive consequences. Tacklers should lead with the shoulder and aim for the mid-section, rather than leading with the helmet and aiming for the head. That’s easier said than done.
Some advocate there shouldn’t be any contact in sports until the age of 14 because the brain is most susceptible to trauma while kids are growing. Even elementary school kids are playing more sports at a younger age and for longer periods of time; in many cases young athletes are playing sports year-round, Wade said.
Sports like football and hockey are inherently violent. Contact is a big part of the two sports. Cugalj referenced a successful high school football coach in the northern Midwest. The coach is one of the winningest coaches in the state, but he doesn’t have his players hit at all in practice. The coach figures why risk an injury in practice. The team saves hitting for the games, Cugalj said.
“When the overall exposure to hits goes down, the risk of concussion goes down too,” Cugalj said. The amount of full-pads practice in the NFL and in college football is monitored and limited.
“[Football players] have a sense of invincibility, where they just have to go out and hit somebody,” Cugalj said. “Contact is part of the sport and so the last thing they’re worried about is a potential injury to themselves or another player. ‘I just need to hit this person.’”
Cugalj advocated for shifting mentalities when it comes to the hitting component of contact sports.
“If you take the emphasis off the hit and more onto the sport itself, the instances of injury may decrease,” Cugalj said. “Rather than how hard you hit somebody. Or in hockey, rather than how hard you put somebody into the boards.”
To a certain extent, a hard hit is a part of the game, if that game is hockey or football.
“An interesting point was brought up in a conference: with baseball players, we do pitch counts,” Cugalj said. “Why not hit counts?”
And then there’s the question of equipment: Companies are doing continual research on how to improve helmets. With a price tag of $375, the Riddell 360 football helmet topped the 2012 list in a Virginia Tech study of of which helmets stand the best chance of reducing the risk of a concussion. The Riddell Revolution Speed ($243.99) and the Rawlings Quantum Plus ($250) rounded out the top three in the study. See www.sbes.vt.edu/nid.php. Researchers conducted drop tests with helmets and examined how well helmets managed “impact energy,” according to the website. Officials caution that there is no magic helmet that will eliminate concussions.
During the 1940s and 1950s, football was played with substantially less padding and only leather helmets. Were there fewer concussions in those days or were they just not picked up on? There is no way to know the answer, but the argument could be made that football players were more careful in how they hit each other, because they were wearing less padding, Cugalj said.
“As we make things more protective, are we creating more of a problem?” Cugalj said. In other words, are athletes feeling more invincible when they’re handed a supposedly more protective helmet? It’s not a good idea to run head-first into a brick wall even if you’re wearing the most protective helmet in existence.
“I don’t think I’m advocating for stripping down the padding on athletes,” Cugalj said. “Who knows whether that had any impact? But on this type of injury, plenty of people are questioning how we play the sport.”
Athletes want to play football and coaches certainly don’t want to lose any of their players to concussion injuries, so it’s probably fair to say football isn’t going away, but athletes should expect a re-emphasis on proper tackling technique. They should expect coaches to spend more time going over how to play the game safely, not necessarily while sacrificing the physical nature of the sport. Looking ahead, it’s probably safe to suggest there could be more of an effort to limit athletes’ exposure to hits, perhaps through reducing the number of full contact practice days in football. There is also a movement to have young kids play flag football instead of tackle football. The game isn’t going away, but people are paying closer attention to safety, Decoster said.
Concussions across the sports spectrum
People automatically think of football, hockey and lacrosse when considering concussions since there is so much contact in those sports. Professional football and hockey have seen star athletes miss playing time due to concussions. But those sports are not alone in terms of head injury risk. Cugalj would add cheerleading and girls’ soccer to the list.
Research has suggested women and girls are at greater risk for concussions. The research also suggests they take longer to heal, Wade said. It is possible girls’ neck muscles develop at a slower rate. Decoster wondered if girls were more willing to admit to a coach or trainer they might have a concussion.
Knocking heads in soccer while vying for possession of the ball, as well as physically heading the ball, can cause concussions, particularly at the youth levels. Cheerleaders often run through complicated routines that involve tossing each other into the air. Cugalj said those being tossed aren’t always caught.
Football has the highest rate of concussions, as well as the most athletes playing it. Boys’ ice hockey and girls’ soccer generally fall next in line, Decoster said.
Even supposedly non-contact sports are vulnerable. Athletes playing sports like basketball, wrestling and baseball also suffer their fair share of concussions, Wade said.
Along with more kids playing sports, kids are bigger today, Decoster said, but they aren’t necessarily stronger or more fit. That can create a bad combination that could be leading to more injuries of all kinds in youth sports.
“There definitely is significant risk,” Decoster said of playing sports in general.
Getting past the big hit
When a major collision happens in any sport, it gets athletes’, coaches’ and athletic trainers’ attention. But spotting a concussion isn’t always easy.
“If a kid is unconscious or there’s a big hit and the kid is getting up staggering or he’s clearly shaken up, those are the easy ones,” Cugalj said. “The ones that are often more difficult to pick up on -- and this is really common in youth sports, like hockey and lacrosse -- are injuries that happen behind the play. Something happens in the backfield and a kid hits his head on the turf or the ice.”
A hockey player could be skating behind the play, slip and fall, hitting his head on the ice or the boards. He might have suffered a concussion, but he also might be embarrassed. He might not want to tell the coach what happened, and it’s quite possible the coach never saw the incident since he was following the action, Cugalj said.
Concussions don’t just happen while playing sports, of course. Kids get concussions when they’re just messing around with friends in the yard, Cugalj said.
“In a lot of cases in youth football, the pads are bigger than kids’ shoulders and necks and the weight of the helmet can create almost like a whiplash effect,” Cugalj said. “Not so much when players are colliding with one another.”
Cugalj said poor tackling form in football, which can lead to helmet-to-helmet hits, is more common among the younger ages, although there are plenty of instances, even at the professional level, when a defender leads with his head while tackling, only to suffer a head injury himself.
Even in the case of serious incidents, in some cases the symptoms don’t show up for a while. An athlete experiences a hard hit, feels fine, and tells the coach or trainer as much. Fifteen minutes later or so, the athlete begins developing symptoms. It can be difficult for an athlete to then go back to the coach or trainer to tell them they aren’t feeling well. Athletes are worried about perception, and to a certain extent the reaction can be, “Hey, that wasn’t that hard of a hit. I’m fine,” Cugalj said.
Sometimes it’s easier to act as though nothing is wrong. They can hide or come close to hiding all the outward symptoms, Cugalj said.
“It’s very difficult for kids, even if they might feel horrible, and even if they are almost willing to say they feel horrible,” Decoster said. “It’s a lot easier to say I feel horrible when, ‘Look, my leg is in a cast.’ [When you have a concussion], then you can look fine to everybody else. Only you know you’re not. So it’s up to you.”
A concussion is not something that shows up on an MRI or a CT scan. The healing takes place at a microscopic level, Wade said. Recovering from concussions is simple: rest. Medical professionals, along with coaches and training staff, are reliant on players to be honest about their symptoms. That’s not easy.
“In most cases, they need to take the time to recover and get back to some kind of baseline,” Wade said. “If they do that, there will be a good outcome.”
Concord High School instituted a concussion management program two years ago that involves a baseline neurocognitive test for all athletes. Athletes take the baseline test, which measures cognitive abilities with regard to memory, recall and aptitude. It’s not an IQ test. When an athlete is concussed, they can retake the test and a neuropsychologist can compare the results, Snow said.
“If an athlete gets any type of head injury, we can use this baseline as a guide to test the severity of the injury and to serve as another way of determining when it is safe for an athlete to return to practice or play,” wrote Eric Brown, the football coach at Concord High School, in an e-mail. “The decision making is totally up to the athletic training staff and/or doctors. Any decision about returning to play or practice is totally out of the coaches’ hands.”
Decoster implemented a concussion management program at all three public high schools in the Queen City that includes baseline computerized testing.
Wade sees New Hampshire as a little ahead of the game. The state’s model protocol, designed by the New Hampshire Advisory Council on Sports-Related Concussions, is comprehensive, he said.
“It’s a great tool to guide schools,” Wade said. “I think it’s one of the best in the country.”
The Brain Injury Association of New Hampshire has joined a pilot program with 10 high schools to implement a concussion-management program.
At least in the nine schools Decoster’s company covers, and the 10 pilot schools working with the Brain Injury Association, parents and athletes are getting plenty of information on concussion risks, signs and symptoms. Parents and athletes are required to sign that they’ve reviewed the CDC’s flyer, which provides basic information on signs and symptoms, Decoster said.
When a kid gets hit and says his head hurts, if he says he can play, the coach has to make a decision whether to put the athlete back in. Medical professionals and trainers would say it’s a good idea to give it some time. But how much time?
“You don’t automatically have to bench a kid ... who’s got a headache after a collision,” Cugalj said. But erring on the side of caution seems to be the rule of thumb now.
“The brain itself is a mystery,” Wade said. “The science has a long way to go.”
Competition, to a fault
Athletes want to play; sports are fun. They don’t want to let their teammates down, and they want playing time.
“The way sports have developed in this country, obviously, it’s become big business and everyone is always looking at getting an advantage,” Cugalj said. “A lot of parents are looking for that million-dollar Nike contract. Obviously, an extremely low percentage of kids actually make it to the elite level.” But athletes are competing for college scholarships.
“We often forget at the youth level in particular, we’re dealing with student athletes,” Cugalj said. “‘Student’ is the first part of the phrase. ... That missing kid may not be able to play a contact sport because of an injury, but what about the academic performance? What about the ability to get and keep a job?”
If a player sees a teammate clearly exhibiting concussion symptoms, that player has a responsibility to make sure the coach and trainer know. “It’s a collective responsibility,” Cugalj said.
If that mentality can be ingrained at a young age, everyone benefits.
“I think that stigma is slowly coming around, at least in the Northeast,” Snow said. “I can’t speak to places like Texas or Ohio where they live and die football. I think the culture is slowly changing.”
Decoster said it doesn’t help, particularly at youth levels, when star NFL quarterback Peyton Manning admits he purposely tried to do poorly on baseline neurocognitive testing so that if he were to get a concussion he’d be less likely to be held out of play.
“We don’t need that kind of help,” Decoster said.
Decoster runs the Safe Sports Network, which provides sports medicine at several high schools in the state, including Manchester, Bedford and Goffstown high schools. During the past couple of years, Decoster has added the youth level as a target audience — not just for concussions. Decoster was seeing more and more kids entering high school with existing chronic injuries.
“Kids see professional athletes play through the pain, but that’s not appropriate for an 8-year-old,” Decoster said.
A cultural shift
Football fans remember segments on ESPN highlighting big hits with the phrase “jacked up.” Officials say now commentators seem to be more careful in how they highlight vicious hits. The National Hockey League and the National Football League have instituted heavier fines for illegal, dangerous hits.
During the opening night NFL game between the Dallas Cowboys and the New York Giants earlier this month, Wade noticed the camera panned to a banner reading Heads Up Football, which is a major effort by the NFL to prevent concussions in schools.
Recreation and youth leagues are where coaches and parents have the opportunity to help children develop good habits, Wade said.
“People always knew there was some risk to play football, but they didn’t appreciate how serious any brain injury really was,” Decoster said. “People thought dings and bell ringers went right along with ankle sprains as part of the game. But really, you only get one brain and there is no surgery to replace it....”
“The NFL finally stopped denying the risk,” Decoster said. Butt hat wasn’t before the threat of lawsuits became a real possibility. Former players now suffering with the consequences of head trauma are blaming the league.
Decoster began a program last year with the Manchester Flames youth football organization. A grant from the Boston Bruins Foundation will help Decoster expand the program to two more youth leagues.
Chris Nowinski, who started the Sports Legacy Institute, which studies head injuries, played football at Harvard. After his college football career was over, he had a professional wrestling career. After suffering a head injury as a wrestler, he was unable to recover after several weeks. When asked by medical professionals how many concussions he’d had in his life, he said he hadn’t had any. In the office of Dr. Robert Cantu, the question was posed differently. Cantu asked Nolinski how many times he had a headache or felt nauseous or groggy after a game. If that’s what a concussion is, then Nowinski said he had a concussion after every game, Decoster said.
“He just didn’t know it,” Decoster said. “If you don’t feel well, tell somebody and get out. It’s far from being uncool.”
A look to the future
Decoster looks forward to a day when there is an objective test that will identify concussions. She hopes that’s the case within her lifetime. “So far, we’ve been going on our clinical best guess,” she said.
“In the past five years, we’ve come so far in terms of public understanding and knowledge,” Decoster said. “When I say to an athlete, ‘No, you have a concussion. You have to sit out,’ there is so much less argument about it. There is definitely improved awareness.”