HEAD GAMES: Concussions are the invisible injury (08/11)

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By Chuck Jones

Athletes used to describe a concussion with funny terms. Getting your bell rung. Having your eggs scrambled. Seeing stars. Being dazed and confused. And even having ants crawling in your head.
But those funny descriptions aren’t that funny anymore.
Concussions have become a lightning-rod topic. Growing awareness and concerns about the rate of concussions have led to more action being taken in an effort to minimize head injuries.
It started when the NFL came under fire after many former players came forward to talk about the culture and dealing with multiple concussions, not to mention the suicides of retirees Junior Seau, Dave Duerson, Andre Waters and Ray Easterling. The NFL began to change its policies in 2009, limiting contact in training camp and practices, and created stricter guidelines for players dealing with head injuries.
Other major sports leagues followed suit in 2011. The NHL stepped up its efforts to reduce concussions, changing rules to prevent blows to the head. Although not as common in baseball, the MLB created a seven-day disabled list just for players with concussions. The NBA and MLS also adopted new ways of dealing with concussions.
The NCAA and Pop Warner, football’s version of Little League, have instituted several rules and practice limitations to prevent head injuries. Leagues have also used stiffer penalties aimed at lessening blows to the head.
The attention produced by professional and college sports on the topic. It has resulted in more awareness at the high school level. Area high schools have been proactive in dealing with the issue and place strict guidelines in place when players can return.
“It has changed dramatically,” said Central Hardin football coach Mark Perry, who played high school football in Ohio before going to the University of Kentucky. “My father coached for roughly 20 years. It was a rarity that you’d be out of a game. It was just you were dizzy or seeing stars. The only way you didn’t go back in is if you were knocked out cold. The awareness is all for the better.”
Dr. Michael Krueger, who specializes in sports medicine, said the trickle-down effort from the major sports leagues and the NCAA has been a good thing to bringing light to concussions.
“I think it’s a chain reaction,” Krueger, of Hardin Orthopedics & Sports Medicine, said. “With the NFL players who have come forward and the suicides, there is more awareness with players and multiple concussions. They’ve made rules and that’s filtered down to colleges and high schools. We’re still learning and we’ll learn more down the road. But it’s more serious than people originally thought.”
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A concussion occurs when the brain rapidly moves inside the skull. The brain floats inside the skull and is surrounded by cerebral spinal fluid, which acts as a shock absorber for minor impacts.
The most common scenario for a concussion to occur is a direct blow to the head or a whiplash effect to the body. The impact accelerates the head, causing the brain to strike the inner skull. When the head decelerates and stops its motion, the brain then hits the opposite side of the inner skull.
Another common scenario is a rotational concussion, in which the head rapidly rotates from one side to another causing shearing and straining of brain tissues. In either case, delicate neural pathways in the brain can become damaged, causing neurological disturbances.
The symptoms of a concussion can be subtle at times and might not be immediately apparent. The most common symptoms are headache, amnesia and confusion. Other symptoms might include slurred speech, ringing in the ear, dizziness and nausea. During some concussions, there may be a loss of consciousness.
“If they’re seeing that he’s having dizziness and having trouble concentrating and he’s having headaches, dizziness and nausea are very big red flags,” said Jimmy Coursey, manager of Hardin Memorial Hospital Therapy & Sports Medicine. “I would go ahead and go to the emergency room — that night.”
Other symptoms which might show up later are: loss of memory; lack of concentration; irritability and other personality changes; sensitivity to light and noise; sleep disturbances; psychological adjustment problems and depression; and disorders of taste and smell.
Krueger said doctors have decreased emphasis on grading concussions by their severity and now focus on case-by-case treatments.
“Every concussion is not the same,” Krueger said. “You can see someone get flattened on the football field and think, ‘Holy crap that person has brain damage.’ And you see someone take a shot to the side and think, ‘He’s fine.’ That’s probably more dangerous and results in a worse prognosis. But each one is different. No concussion is the same.”
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Heightened awareness has brought on new changes. Kentucky’s concussion law, House Bill 281, is a little more than a year old and the protections took effect in the 2012-13 school year.
Coaches are required to go through training to be aware of the signs of a concussions. The law requires at least one individual who has completed the safety course to be present at every practice and competition. Schools also need to have emergency plans for dealing with potentially serious injuries.
Under the law, educational materials on how to recognize the symptoms and seek proper medical care for concussion victims will be made available to parents, students and the public.
The Kentucky High School Athletic Association has a six-step protocol which has to be followed before an athlete can return. The steps, in order, are no activity, light aerobic exercise, sport-specific exercise, non-contact training drills, full-contact competition/practice and a return to normal game play. Each step is supposed to last at least 24 hours, according to the KHSAA, meaning the quickest an athlete should return to play following a concussion is six days.
“We’ll continue to learn from research and we’ll continue to lean on the medical people around the state,” KHSAA commissioner Julian Tackett said. “The KMA (Kentucky Medical Association) docs give us an unbelievable amount of support and the Kentucky Athletic Trainers Society does a superb job helping. We’ll continue to work with those partners to try to become better and better at protecting our kids.
“I am pleased with the progress, but we’re not at the finish line.”
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Schools in Hardin County and surrounding counties have benefited from the presence of HMH Sports Medicine, which supplies athletic trainers to each school. The trainers regularly check in with coaches at practices and attend nearly every game.
“A word that comes to mind is priceless,” Elizabeth-town girls’ basketball coach Tim Mudd said. “We’re not doctors. None of us want that title. We have a great relationship with our trainers. They are a huge help and very valuable. And it’s been extremely beneficial to the students.”
Another thing which area schools have started is IMPACT testing. Each student is required before the season to do baseline testing, which is neurocognitive testing under normal conditions before injury.
In the event an athlete sustains a concussion, the athlete is tested again. Post-injury testing composite scores are then compared to the baseline scores acquired earlier before a concussion affected brain function. Therefore, baseline testing only becomes of value if, and when, post-testing is utilized after a concussion injury.
“You take the guess work out of it,” Elizabethtown boys’ basketball coach James Haire said. “They do the testing. It says whether they are ready to play or not ready to play. I don’t want to make that determination. It’s never been my role to diagnosis an injury.”
With the steps in place for athletes, Heather Ruccio, who is one of HMH’s certified physicians assistant specializing in neurosurgery, said she doesn’t give the athlete and the parents a time table on a return.
“I’m concerned about your brain and your future,” Ruccio said. “You’re in high school and I would assume you’re going to go to college. So my goal is to make sure that your brain is healthy before you hit the field again, because it’s different for every kid. You could be back there next week or you could be back there in six months. It depends on if you listen to me, if you do what I ask you to do and restrict your activities … then usually you can make the optimal recovery for yourself.”
Coursey praised the steps area schools have taken to help bring about awareness and protection for the athletes.
“I think our local school systems have taken great strides, E’town and Hardin County for sure, because they have taken things a lot further than they are required to,” Coursey said. “… They have taken extra strides to make sure that their athletes are safe.”
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It’s taken decades to bring about change. What used to be described with funny terms, concussions are a serious issue.
“Back in the 90s, coaches were more hardcore,” said John Hardin football coach Chad Lewis, who played at Central Hardin for his father, Mike. “Maybe that wasn’t the best. They would put you back in after a couple of plays. Now we’re being much more precautious. They are teenagers and we need to be much more precautious.”
Haire agreed.
“Its awareness has grown,” Haire said. “Back in the 70s, people used to say he got his bell rung. Here the last 10 years, everybody knows the symptoms of a concussion. I’m always going to put the player’s safety first.”
Krueger said player safety is the bottom line. He estimated there were more than 20 concussions in football last season, calling it a “fairly significant” number.
“I hate to be cold-hearted, but if it’s someone’s last home game and they’ve had a concussion, I’m not going to risk a patient’s life,” Krueger said. “If they haven’t passed their test, they can’t play. It takes the pressure off.
“I feel differently about NFL players,” he added. “They are getting millions and millions of dollars to entertain us. If it’s a playoff game and they want to play, you’re an adult. If you sign something, that’s fine. But high school players are different. They are children. We have to look out for them and do what’s best for them.”
Nathaniel Bryan contributed to this report. Chuck Jones can be  reached at (270) 505-1759 or cjones@thenewsenterprise.com.