Head Games: An overview of concussions in prep sports
Increased awareness stemming from the discovery of the neurodegenerative disease, CTE, and football-related deaths of former NFL players has produced a wave of new research evaluating the short-term and long-term effects of concussions, sub-concussive hits and traumatic brain injuries.
In July 2017, the Boston University group responsible for a majority of the early research found signs of the neurodegenerative disease in 99% of the brains donated by the families of former NFL players and CTE in 87% of the brains of football players at all levels, including those that had only played football through high school and/or college.
Yet prep athletes are not immune to the injuries suffered by their professional counterparts. In 2017, a University of Michigan study found that nearly 20% of teenagers had been diagnosed with a sports-related concussion and a 2017 study in the American Journal of Public Health found that high school athletes reported nearly 2.7 million concussion injuries between fall 2005 through spring 2016 – a conservative number compared to some studies. The same study found that the rate of concussions among high school football players was much higher than in any other sport.
Dr. Walt Willis, Director of Emergency Department Services at Rush Health Systems, can attest to that information first hand. “The most concussed athletes are football players. That’s half of the concussions seen in youth sports.”
The safety of athletes of all levels of play has led to legislation regarding increased safety measures and the development of a concussion protocol in treating athletes after they have sustained this type of injury.
Mississippi House of Representatives member, Charles Young Jr., speaks about the importance of addressing concussion in the legislature. “I think that it’s past time for us to take note of – and to address it,” he said. “Because there are a lot of people that are having serious repercussions after the fact from it not being addressed in a timely manner.”
In January 2014, Mississippi became the last state to pass legislation concerning concussions in youth sports. House Bill 48, or the Mississippi Youth Concussion Law, defines the concussion protocol for school-sponsored athletic events for MHSAA, MAIS as well as non-members for grades seven through 12. The bill mandates that once there is a suspicion of a head injury, the student-athlete is pulled from play and must be evaluated by a healthcare provider initially and then again before returning to play if a concussion is present.
This law, and similar laws like it, have resulted in a nationwide decline in repeated concussions. It also has had other positive outcomes – namely increased education and better treatment of head injuries when they do occur.
Former Meridian and Biloxi football coach and current Meridian Athletic Director, Chuck Butler, acknowledges that the awareness surrounding head injuries has dramatically increased since House Bill 48 came into law. “As a coach, prior to being made aware, five and six years ago, you just didn’t really think much about it,” he said. “I mean you weren’t educated in it, wouldn’t recognize it if you saw it.”
As a former athletic trainer at Lamar University and now at Northeast Lauderdale, Katherine Craig has seen the increased education on the front lines. According to Craig, “I think with the law, making them see the physician – they’ve been required to sit out until they’ve recovered. And I think it’s also been better because it’s forced people to learn about the concussions and parents become more familiar with it and realize you know just because their child doesn’t show a lot of symptoms doesn’t mean that they’re back to their norm.”
Dr. Willis’ experience also parallels that of Craig. “There seems to be a lot better educated player and parent and coach – we don’t have to struggle now with giving the advice of holding players out and have the challenge of the player or the parent trying to push themselves into playing.”
Yet, for all the good House Bill 48 does, it is limited and exposes shortcomings in what can and can’t be legislated under this current law. One of the biggest concerns is that the law is not all inclusive – it only extends to children in grades seven and above – not regulating children in youth sports.
“I think we should have gone a little bit further and including all phases of the game because, again, concussions aren’t age sensitive, “ Rep. Young Jr. stated. “If you’re four, you can get a violent blow and it can happen. If you’re 40, it can be the same thing.”
Data on concussions in youth sports is limited. A 2017 University of Iowa study estimated that the rate of any injury in youth tackle and flag football was approximately 2.76 injuries per 1000 exposures. Yet clinicians warn that younger children can be more susceptible to concussions.
Per Dr. Willis, “The younger brains are not as concussion adverse as an adult brain, so, it’s a lot – in other words, it’s easier for kids and adolescents to have concussions than adults.”
Craig agrees with Dr. Willis. “We’re just now starting to, you know, be more careful with the older ones,” she says, “but, well the research shows the younger you are, the easier it is to get a concussion and the more detrimental it can be.”
There are no regulations regarding a concussion protocol for young athletes below grades seven under House Bill 48. Coaches are limited to the training that is required by their particular league and then if a child is pulled by a coach for a suspicion of a head injury, there is no mandate the child receive medical attention.
Mike Wilkinson has been an athletic trainer for 40 years and serves as the Chair of the MHSAA Sports Medicine Advisory Committee. Wilkinson points out this limitation with the Youth Concussion Law.
“And we were very opposed that these little league kids – where you can get really – where you can get some damage – that they don’t have any, they can go back and get a concussion and play the very next play.”
Not having restrictions in place not only potentially inhibits the youth athlete from receiving appropriate treatment for the injury, but exposes them to additional damage.
“And the thing that we’re very concerned about is something called a second impact syndrome,” Dr. Willis said. “The second impact syndrome is a time period or is a malady or injury that occurs if a second blow to the head happens when the brain is still trying to recover from the first concussion.”
Another hole in the prevention and management of head injuries is the lack of athletic trainers on hand to recognize and treat head injuries. Nationally only one third of high schools have full time trainers – the gold standard of care recommended by the National Athletic Trainer’s Association. Per Wilkinson, the state of Mississippi has only 6-8 schools that employ full time trainers – far less than neighboring states such as Alabama and Louisiana.
Chad Acton has been an athletic trainer for 18 years and he currently heads AT services in the Meridian Public School District. “It’s very much needed,” Acton states in reference to the need of schools having an athletic trainer. “I mean because that’s life or death. We’re talking about a kid’s future. I mean this is – I mean it’s fun to play sports, and yes it will pay for your college, but ultimately it’s life or death a lot of times. It’s a split decision and nobody is there to take care of the kid, then, that’s a problem there…You hope that the coaches paid attention and understand, but it’s a lot on a coach not to have somebody full time with them.”
Calvin Hampton is the head coach of the Meridian football team and understands the value of having of an athletic trainer to support his student-athletes. “It’s a huge asset to us,” he said. “We’ve been very fortunate to have an on-campus trainer that helps us with our needs and things because some things, with us being coaches, we’ve been – we take concussion courses. We know about injuries and things like that but we coach. And the trainer’s job is to look at the health of the kid so it’s very valuable to have him on campus and check the kid out.”
Schools that do not have athletic training services are relying on the coaching staff to make snap judgments of injuries, including concussions, for which symptoms can vary between children, are not always initially present and can be difficult to diagnose. Only Hawaii and District of Columbia have mandates requiring athletic trainers at their public schools. However, until the Mississippi legislature financially backs a mandate requiring athletic trainers at every athletic event or school, the need will remain unfulfilled.
Rep. Young Jr. supplies what he feels to be an obvious solution. “I simply think, you know, it’s an easy fix. If there isn’t anything in place that mandates someone with medical expertise be on the field, then I don’t think that we should be allowing those events to take place,” he notes. “Concussions have just gotten to the point that they’re much, much, much too serious now. When we were growing up, maybe we didn’t know. But now we know what was taking place. Now we know and we must do better.”
Another gap in House Bill 48 is that it does not address brain rest and when a child should resume academic studies at full capacity. But Mississippi is not alone in this because as of 2016 only eight states had “return to learn” laws.
“You know we’re asking them in the middle of their school year not to go to school or to study or take their test or if they’re on a weekend where they take their ACT they really shouldn’t take it because they’re, it’s just not fair to them,” Dr. Willis stated. “They’re trying to do well on their schoolwork. It also slows down their recovery time.”
Craig agrees. “Like we’re going to hold them out of practice and gradually progress them back in. Ideally that would be the same for school…I mean we’re not going to prevent concussions in football. It’s just we have to learn how to manage them better.”
Solutions for improving the concussion protocol vary. Everything from good equipment, proper tackling techniques, less contact days, increased legislation and more athletic trainers have been recommended and research on this topic is in its infancy and often inconclusive. In 2014, the NFHS recommended limits on full-contact during practices. States that have regulated full-contact practices, such as Texas, Arizona and Alabama among others have seen a significant decrease in concussion rates during practice. The MHSAA also followed suit, allowing only 90 minutes of full contact during the week.
Ultimately, Acton feels the solution starts with awareness. “The main thing is education. I think we need to really stress to everyone – coaches, administration, everybody – how important this is,” he says. “This ain’t – this is not – just you got your bell rung, you got blasted – whatever you want to call it – this is serious stuff.”
Coaches, administrators, clinicians, parents and legislatures have been supportive of efforts to make the game safer.
“I would hate to have a world without football, but I have no issue with all of the things that they’re doing to prevent concussions because concussions have cut short a lot of, a lot of life,” Butler says. “You know, from great football players that you hate, you know, that you didn’t know about. I mean, no one knew. And, you do know now, and they’re doing everything that they can to make their lives after football be worth living.”