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Head Games

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New rules governing head injuries changing how coaches, players deal with concussions

By Joel Stevens, Associate Editor

    Turner Talich doesn’t remember the hit, exactly.
    The impact itself is lost in a haze. But he does recall the play it occurred on. He calls it routine, just a part of a full-contact drill he’d done a hundred times in fall camp with the Glenwood football team.

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    But this time the freshman linebacker went in for a tackle and his head slammed into another helmet. This time Talich couldn’t just shake it off.
    He recalls the few moments after the hit vividly.
    “My head was ringing and I couldn’t see for a little bit but it (vision) came back,” Talich said.         “At first I was really light-headed and dizzy. I felt really slow, like my reaction times were slow. I had a hard time walking over to get water and I kind of stumbled.”
    The Rams coaching staff quickly tended to Talich. His parents were summoned and he was taken to Children’s Hospital in Omaha. After a battery of tests doctors confirmed their suspicions: Talich had sustained a concussion, a type of traumatic brain injury caused by a blow to the head that literally shakes the brain inside the skull.
    Talich had no cuts or bruises after his hit. No scar from his concussion. In most concussions there are no visible signs of a brain injury.
    But on the inside, the “scars” of a traumatic brain injury can persist with young athletes.
    And the state of Iowa  is doing something about that.
    Iowa is one off 33 states that have adopted concussion legislation for high school activities. The Iowa legislature took action last April, passing Iowa Code Section 280.13C, or as it’s known, the Brain Injury Policies.  Gov. Terry Branstad signed the bill into law April 7, 2011.
The new law, which went into effect last summer, requires student-athletes in grades 7-12 be removed from a contest immediately – whether in a game or practice – if his or her coach suspects a concussion. The athlete may not participate again until a health care provider trained in the evaluation and management of concussions has evaluated the athlete and given written clearance. The measure applies to both male and female athletes and to all “extracurricular interscholastic activity” which includes dance and cheerleading.
    The Iowa law also requires the districts make a contract with parents concerning brain injuries. Prior to the start of each school year, districts must provide to parents of each student-athlete a concussion and brain injury information sheet for their signature. The sheet must be returned to the student’s school prior to the student’s participation.
That contract worked for Talich. His coaches spotted signs of a possible concussion and procedures had his parents notified and into see a doctor that night.
Talich went home from the hospital the same night with strict doctors orders to rest and avoid visual stimuli such as television and text messaging. It was hard medicine for a 15-year-old to swallow but Talich was symptom-free the next day. He was held out of practices for a week and wasn’t cleared to come back until he supplied a written clearance from his doctor. After a few days of light work, he was back hitting with his teammates.
Glenwood football coach Cory Faust said he’s had three players experience concussions this fall. A fourth was held out for precautionary reasons. The standard rule is a player must sit out with no contact for seven days after being diagnosed with a concussions. After that period the player is evaluated once again and if cleared, Faust has a policy of evaluating the player himself, which includes talking with the player’s parents about his return.
Faust said adjusting to the new guidelines has been a process for him and his coaching staff.
“There has defiantly been a bigger awareness of concussions and head injuries the last few years. Mostly that’s more cautious, I think, than when I was playing,” Faust said. “When I was younger and a player it was pretty common to hear guys say ‘Hey, I just got my bell rung.’ And they’d get right back in the game.
“Now I think you’re a lot more cautious. You see a big hit and you double check and make sure things aren’t more serious than just a big hit.”
Talich, hasn’t had any lingering issues since returning to practice. His mother, on the other hand, wasn’t crazy about him returning to the field.
“She didn’t want me to come back too early and get another one,” Talich said. He’s well aware the odds of sustaining another concussion once you’ve had one go up significantly. Talich thinks about that but that doesn’t stop him from playing.
“It does worry me a little bit. I think waiting like I did and taking those extra-precautions before coming back should help,” he said.

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Concussions occur mostly in football but it’s not the only sport, by any means, where concussions occur among high school athletes. Studies have shown girl’s lacrosse, girls soccer, boys lacrosse, wrestling and girls basketball also rank high. And loss of consciousness, that universal indicator of a concussion is no longer the standard bearer. Losing consciousness in a concussion is actually fairly rare, occurring in less than 10 percent of sports related head injuries.
The Centers for Disease Control and Prevention estimates there are 135,000 sports-related brain injuries each year among children age 5 to 18. The National Federation of State High School Associations (NFHSA) puts the concussion number at 140,000 annually. While car accidents are the leading cause of traumatic brain injuries, sports are the second leading cause.
    Dr. Mike Kenkel, a Glenwood chiropractor, volunteers as a team trainer at Glenwood’s home football games. He’s a fan of the new rules.
“There is a bit of gray area to the testing but diagnosing a concussion is fairly easy,” Kenkel said. “Usually it’s as easy as looking at a  kid’s eyes and seeing one pupil dilated more than the other or asking him some cognitive questions like where is he and what the score is. Obviously, if it’s severe you know it.”
Kenkel said erring on the side of caution keeps all athletes safer. If an athlete receives a blow to his or her head, portrays any of the signs of possible concussion from dizziness to nausea to a loss of consciousness, then its best to pull the athlete out.
    “The biggest thing is protection of the kids,” Kenkel said. “The new rule is a real positive. There have probably been a lot of kids in the past who have had concussions that went undetected.”
Baseline testing has grown in popularity in recent years to aid doctors in determining brain injuries. The acuities test measures memory, reaction times, and cognitive processing speed before an athlete’s season so doctors will have a test in hand to compare to post-injury. This pre- and post-score on the baselines test often is a primary determining factor how long an athlete sits out and when he can return.  
Dr. Tracy Stromgren, a Glenwood chiropractor board certified in sports medicine, administered baseline testing to all of Glenwood’s football players prior to the start of fall camp.
The test is administered by computer and it tests everything from basic reasoning skills to attention span and working memory to measuring verbal memories, processing speed and reaction time. It actually measures reaction time to 1/100th of a second.
“The main reason we use it is it assists us in an appropriate return to play timeline. We’re trying to get away from post-concussion syndrome or second-impact syndrome, which results from sending a player back too soon.”
Only Stromgren and Glenwood Athletic Director Jeff Bissen see the results. The only time the results are consulted is if that player is re-tested following a concussion.
There’s no tricking the baseline score; players never see their actual scores and comparisons between the original test and the post-concussion test are done by a certified doctor.
If a player sustains a concussions they are tested within 48 hours. Those results are then compared to the baseline test to determine where the player’s cognitive level is as of that moment.
“You can see a fairly significant decline,” Stromgren said. “At times, we have even seen kids with one concussion not being able to every get back to their  original baseline. Which is sad. We’re trying to create coach and parent awareness with this.”
Players can’t be considered for a return to the field until they are symptom free and at their baseline level.
The baseline test has become the standard tool used in clinical management of concussions for athletes. Bissen said Glenwood is one of a handful of schools in the Hawkeye 10 Conference doing baseline testing through of its football players. He said Glenwood will continue their concussion baseline testing this year in all sports except cross country and track and field.
“All professional sports do it, most colleges do it and more and more high schools are doing it,” said Glenwood Athletic Director Jeff Bissen, who helped Stromgrem administer the baseline tests. “It's all a positive and just one more way to try to eliminate injured players playing too soon. Concussions can lead to brain damage if athletes return to play too soon before being cleared by a medical professional and we do not want high school sports to be the reason for those injuries.”

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Contrary to popular belief, concussion severity scales play no role in diagnosis nor treatment of concussions. While the American Academy of Neurology’s 1997 guidelines are generally referred to in determining severity of the concussion according to a Stage I (transient confusion, no loss of consciousness, symptoms resolve in less than 15 minutes) , Stage II (transient confusion, no loss of consciousness, symptoms last more than 15 minutes) and Stage III (any loss of consciousness) levels, that scale is more intended for the patient’s information than any medical practicality.
So when Tallich, the Glenwood freshman, was told his concussion was “moderate” in meant little for his treatment or his recovery.
    Every concussion is different.
    East Mills football coach Andy Irwin recalls an incident with one of his players earlier this fall. The player was in a tackling drill and got up a little wobbly, Irwin said, yet appeared fine when talking to coaches. But when the player, who Irwin described as a smart player who always knew where to line up, suddenly was out of position, he knew something was wrong.
    “It wasn’t a big hit or real hard hit. But I could tell after a few minutes,” said Irwin. “We also have the good fortune of knowing our kids very well because we’re a small school. Some of those signs are easy to look for when the kid comes near you and you can see his eyes are instantly dilated. It’s a very easy thing to notice. And when a kid that always knows where he’s supposed to go, doesn’t, that’s a clear sign.”
    Irwin’s player was immediately pulled from practice and later diagnosed with a concussion. He sat out the Wolverines’ first three games and was just medically cleared last week to return to practice.
“We actually manage (a head injury) beyond that,” Irwin said. “We want to make sure the parents are comfortable with it. With this player I had multiple conversations with the parents to make sure we were fully informed what the doctor was saying. The student was cleared to return to participation but we decided to hold him out another week just to be sure.”
    Irwin, like Faust, played football in college. Irwin was a three-year starting linebacker at Coe College in the late 1990s and Faust a starting cornerback at Central College.
    Both coaches said they were never diagnosed with a concussion as players but both admit, they likely did experience a concussion without even knowing it.
    “It has definitely changed,” Faust said of concussions awareness for coaches and players. “And definitely for the better. It used to be a sign of toughness when you got your bell rung and kept playing. Unfortunately a lot of people used to think that way. It’s definitely not something that should be done.”
Irwin doesn’t think the new rules have changed how he coaches or how his team plays or practices but he said the new rules have done one thing: make him more aware of the risks.
“I think it’s changed more how we handle how we protect an athlete when there is a possible concussion,” Irwin said. “We’re better equipped now to see the signs and we’re more aware of the signs. That’s the biggest change I see.”
Irwin said there is a free on-line concussion management course offered by the IHSAA but the class isn’t mandatory for coaches.
“It’s voluntary right now. I watched just to be aware. I know some states have gone to mandatory concussion management training every year. The information is out there for anybody who wants to use it.”
Lyle Mayberry has been a football official since 1969. While he hasn’t noticed an increase in head injuries in games he’s officiated he has noticed the size and the speed of athletes seemingly increasing every year. So he isn’t surprised the issue of head injuries has become more prevalent. And he thinks proper technique can go far in preventing them.
“Most coaches are good about technique, about teaching kids to not to tackle with their head and not put your head down and not using the helmet as an instrument to deliver a blow,” Mayberry said. “Most coaches are good about that. I don’t know of any coaches in games I’ve done where they aren’t teaching proper technique. That’s not to say a kid might not follow that.”
    Irwin agrees. Coaches have a responsibility to players on and off the field.
“I think the issue that’s always going to come up is that football is a contact sport,” he said. “It’s an aggressive sport. You’re going to have injuries. It’s our job as coaches  to teach proper technique but even with the best and most proper technique you can still have an injury or a concussion. That’s where the concussion management portion comes in. It makes us better coaches.”