Concussions are THE safety issue in sports today. Set up a Google Alert for “concussion” and your inbox will soon fill with articles like my inbox does every day. These articles discuss everything from research, laws, foundations, and new technology to professional sports concussion protocols, injuries to athletes, CTE, and the ongoing and contentious debate about youth tackle football. There are vocal advocacy groups on each side of the fence and they frequently support their points of view with incomplete information at best, and misinformation and frank denial at worst.
We have all watched professional athletes get injured. How many times have you seen a player get hit hard and not move (for at least a few moments), then grab his/her head, and though wobbly and clearly “out of it,” that player is allowed back into the game?
Most recently, in 2018 World Cup play, Nordin Amrabat collided hard with another player. His left shoulder was hit and this wobbled his head. His face clearly impacted the turf and he immediately exhibited the fencing response (concussive convulsion). He was dazed and stayed down for over 10 seconds. He was then helped up and was so wobbly that he braced himself on the trainer. He was “out of it.” Unfortunately, he was then slapped in the face by the trainer and an athlete sprayed water on him (from his water bottle).
To make matters worse, he returned to full play only five days later, wearing a headband that he only wore briefly and then removed.
Watching how these “concussions” or “possible concussions” are managed at the professional level leaves us with more questions than answers. The management of these injuries at even the highest levels of sports is fraught with indecision and poor decision-making. Concussion protocols differ from sport to sport and non-compliance with a sport’s own protocols is a frequent occurrence.The way possible #concussions get managed at the pro level results in more questions than answers, says @DrHorwitz. Click To Tweet
On top of this mismanagement, the reports of these injuries feature sensational headlines and a spiderweb of confusing and inaccurate terminology. So, let’s make sense out of this. Let’s say you are a youth coach with no medical personnel on the sidelines. What do you do?
Policies, Protocols, Pamphlets, and Laws Are Not Enough
Medical papers on concussions discuss protocols for remove from play and return to play. These are important because all kids must be removed from play if a concussion is suspected—“if in doubt, take them out”—and not returned to play until properly examined and given medical clearance. However, a review of the multitude of youth concussion lawsuits and discussions with the attorneys, expert witnesses, and legal professors involved all make one word very clear: Communication.
The Case of Robert Back
I will use the case of Robert Back, a 16-year-old football player from Montana, to illustrate both the medical and legal aspects of proper concussion management.
Robert lived with his father and stepmother, and attended Belt High School, where he was on the football team. The team had an athletic trainer (AT) provided by a local hospital system.
The Montana Concussion Law was signed in 2013, before Robert got hurt. It is named for Dylan Steigers, a 21-year old East Oregon University football player who died in a scrimmage. After an impact, he walked off the field and vomited. An ambulance was called and he died a day later. Like most concussion laws, the Montana law stipulates:
- Educational material must be provided to parents and athletes, and must be signed.
- Coaches must take a concussion course annually (this differs from state to state).
- If a concussion is suspected, the athlete must be removed from play.
- The athlete cannot return without a doctor’s clearance to play note.
The Montana High School Athletic Association and Belt High School concussion policies both followed the Montana State Concussion Law.
Sometime before September 2014, the Back family received the concussion education sheet and the elder Mr. Back signed it. He later stated that he did not read the sheet.
Sept. 5, 2014 (Friday): Robert Back played in an away high school football game and sustained a concussion. He did not report any symptoms to anyone.
Sept. 6-7, 2014 (Saturday-Sunday): Robert experienced nausea and headaches and was brought to the ER that evening by his stepmother. He was diagnosed with a “minor closed head injury.” He was sent home with discharge papers saying he should refrain from playing football until cleared by a physician. His father did not read the discharge papers. Robert continued to be symptomatic on Sunday.
Sept. 8, 2014 (Monday): Robert called his father at work to tell him he did not feel well. He vomited while in the shower. His father called the school and told them Robert would not be in attendance.
Sept. 9, 2014 (Tuesday): Robert went to school but did not go to practice.
Sept. 10, 2014 (Wednesday): Robert’s father took him to see a clinic doctor. The doctor verbally told his father that Robert was not to play football until Sept. 15. The doctor gave him a note saying the same, but the father denied reading it. The doctor stated that each school has its own return to play policy. The Back family said Robert went to school and gave the note to the coach, but the coaches denied receiving the note. It was the family’s understanding that Robert would not play in the upcoming Sept. 12th game.
The AT told the head coach to give Robert an ImPACT test. The coach administered a “pre” test.
Sept. 11, 2014: Robert participated in a non-contact practice, during which he reportedly exhibited confusion and disorientation.
Later that day, the AT reviewed the ImPACT test results and emailed the head coach, stating that Robert “looked OK concussion wise.” The coach interpreted that statement to mean that Robert was cleared to play.
Sept. 12, 2014: Robert was cleared by the coach/trainer to play in that night’s game. He played in the game, and his father was in attendance. Robert “did not sustain any big hits,” yet he collapsed on the sidelines after halftime. An ambulance took him to the hospital, where he had an emergency craniotomy. He is now a quadriplegic who needs 24/7 care.
Sports: A Youth Sports Safety System
When examining the timeline of the Robert Back case, you can see the breakdowns in documentation, communication, and oversight. The goal of a system is to address each of these breakdown points with an actionable tool. Enter TeamSafe
- The parent registers his/her athlete(s) and must report any prior concussions and baseline testing.
- The parent is provided with the most up-to-date concussion education sheet and must attest to reading it and sharing it with their child. The organization now has this documented and no administrative work is required.
- The head coach must create an emergency action plan for his/her team following an easy template that assigns each duty to a coach and/or parent.
- The organization administrator may add any required education courses to a web portal. The course information with a “complete by” date is emailed to the coach and there is an in-app notification as well. The TeamSafe
coach certification course covers brain injury, as well as topics like sudden cardiac arrest, heat injuries, anaphylaxis, asthma, seizures, skin infections, bleeding, broken bones, and more.
- The coach can see a roster of his/her team(s) and if any athlete has a medical issue or prior concussion, or is taking any medications, a medical alert is highlighted.
- If there is a suspected concussion (impact plus one sign/symptom), all signs and symptoms can be quickly toggled and the coach can tap “remove from play.” An immediate text and email is sent to all stakeholders. This notification states that the athlete was removed from play and must be carefully observed for the next 72 hours. “What to do next” information is provided as well, and is reviewed below. A concussion report is generated and placed in the athlete’s profile, with the date, time, person who removed the athlete, and documented signs/symptoms.
- The athlete’s roster entry is highlighted in bright yellow with the words REMOVED FROM PLAY.
- It is then the parent’s responsibility to bring their child to the doctor to get examined. When the doctor provides a note, an image of the note can be taken and uploaded into the system. Another immediate text/email is generated, which states that the athlete has seen the doctor and lists the date on the note. If there is no “return” note, the notification states that the athlete must return to the doctor for follow-up. The athlete’s roster entry is changed with this information. The concussion report is updated with the doctor’s note and return date. The platform even has a suggested doctor’s note template based on all 50 states’ (and the District of Columbia’s) high school concussion return notes. This note simplifies the process for the parent, administrators, and doctor.
- The administrator can follow each step of this protocol from the web portal and view the note to confirm the date and authenticity of the note. (Yes, authenticity is a big issue in youth sports.)
- Once the administrator verifies that all the information is valid, he/she provides the final “clearance.” The athlete roster is once again updated to note the clearance date, and this is not removed until the date of the clearance. Another notification stating that the administrator has cleared the athlete is sent.
Many attorneys were consulted during the development of TeamSafe
The purpose of any risk management policy is to provide a consistent and effective approach to addressing risk, and make all attempts to avoid harm, protect the organization, and protect the athletes.
Risk assessment questions to consider carefully are:
- What could go wrong?
- What is the likelihood that each identified risk will occur?
- What can reasonably be done to reduce the severity, likelihood, or impact of these risks?
- If something goes wrong, how do you respond?
- What is the effect on the organization if a loss occurs (financial, reputation, future viability, etc.)?
Emergency Signs and Symptoms
Know how to identify a problem. These signs and symptoms require immediate medical attention.
- One pupil larger than the other.
- Drowsiness or inability to wake up.
- A headache that gets worse and does not go away.
- Slurred speech.
- Weakness, numbness, or decreased coordination in arms and legs.
- Neck pain or tenderness.
- Repeated vomiting or nausea.
- Convulsions or seizures (shaking or twitching).
- Change in behavior.
- Increased confusion, restlessness, agitation, irritability, or combativeness.
- Unable to recognize people or places.
- Less responsiveness than usual.
- Will not stop crying and cannot be consoled.
- Loss of consciousness (passed out/knocked out). Even a brief (~1 second) loss is an emergency.
Return to Play Guidelines
After a possible concussion, the return to play decision should be made very carefully and with the help of a “return team” that includes the athlete, parents, coaches, administrators, and medical professionals. The consensus statement on concussion in sport—from the 5th international conference on concussion in sport—has the most recent guidelines for sports concussion management and explains the return process.
For youth athletes, the return process includes Return to Learn (School) and Return to Play (Sport). Each of these is a multi-step process that is best overseen and reviewed by the entire return team. Both sets of protocols have similar instructions:
- Move forward to the next stage only when symptom-free for 24 hours. If symptoms re-appear, go back to the previous stage and make sure symptoms vanish. Contact your physician or seek medical help immediately if symptoms worsen.
Return to Learn Stages
Stage 1: No School
- No television, video games, computer use, phone, texting or loud music.
Stage 2: School Part-Time – Maximum Adjustments
- Half-day attendance with appropriate academic adjustments.
- No homework or testing.
Stage 3: School Part-Time – Moderate Adjustments
- Full-day attendance with appropriate academic adjustments.
- Limited homework (does not cause symptoms to return) and no testing.
Stage 4: School Part-Time – Minor Adjustments
- Full-day attendance with no academic adjustments.
Stage 5: Full-Time School with no special accommodations
Return to Play Stages
- Aim: Symptom-limited activity.
- Activity: Daily activities that do not provoke symptoms.
- Goal: Gradual reintroduction of work/school activities.
- Aim: Light aerobic exercise.
- Activity: Walking or stationary cycling at slow-to-medium pace. No resistance training.
- Goal: Increased heart rate.
- Aim: Sport-specific exercise.
- Activity: Running or skating drills. No head impact activities.
- Goal: Add movement.
- Aim: Non-contact training drills.
- Activity: Harder training drills; e.g., passing drills. May start progressive resistance training.
- Goal: Exercise, coordination/thinking.
- Aim: Full contact practice.
- Activity: Following medical clearance, participate in normal training activities.
- Goal: Restore confidence and assessment of functional skills by coaching staff.
- Aim: Return to sport.
- Activity: Normal game play.
Supervision and Oversight
If you do not have medical staff to supervise the stages, the parent can do it by using the appropriate Concussion Symptom Evaluation form each day of each protocol. As long as the score does not go up after the initial 24- to 48-hour period, the athlete can advance to the next stage.
In the school environment, the athletic director/principal will have oversight, but the medical staff guides the return process and decision. In the league/club world (no medical staff), we provide the administrator with full oversight (validity and meaning of date on the doctor’s notes) and final clearance approval.
Addendum 1: A Note on Baseline Testing
A 2018 paper looking at the validity of baseline testing found a “growing concern about the validity of baseline test results — meaning there’s concern over the degree to which the scores on these baseline tests actually reflect an athlete’s true cognitive ability…These findings suggest that the rates of invalid performance on baseline testing may be alarmingly high.”
Dr. Douglas Comeau, an assistant professor at Boston University School of Medicine, summed it up by saying, “PCPs [primary care providers] need to know that the younger a patient is, the less valid the results may be.”
“There were multiple points of failure through this whole case, but there were so many opportunities to do this right.” ~ Dr. Michael Collins (Director of the sports medicine concussion program at University of Pittsburgh Schools of the Health Sciences.)
This case makes it clear that sports organizations must have well-defined policies and provide education to coaches and parents. Yet, without a system of real-time communication and administrative oversight, even the best policies can fail.Back up well-defined policies with a system of real-time communication and administrative oversight, says @DrHorwitz. Click To Tweet
System-wide failures occurred at many points, but the key areas revolve around both doctor’s notes. If these notes were immediately documented and stored (via a simple picture) and immediately communicated to all stakeholders in real time (via text/email), then it is much more likely this outcome could have been changed.
As this reporter stated, “I sincerely hope this case is talked about every year at the beginning of any sports season, because if no one learns from this case we will surely be back in court again writing the same stories about more paralyzed young men and women who suffered the consequences.”
Addendum 2: Symptoms of Concussion
- Headache and/or head pressure
- Neck pain
- Feeling like going to vomit
- Blurry vision
- Double vision
- Slurred speech
- Radiating pain in arms or legs
- Numbness/tingling in arms or legs
- Sensitivity to light
- Sensitivity to noise
- “I don’t feel right”
- “I can’t think clearly”
- “I feel sluggish, groggy”
- “I feel very tired”
- “I feel nervous”
- “I feel sad”
- Memory loss
Signs of Concussion
- Hard collision
- Loss of consciousness
- Slow to get up
- Balance/unsteady walk
- Falling to the ground
- Holding head
- Dazed or confused
- Blank or vacant look
- Facial cut and/or bruise
- Seizure (fencing response)
- Change in behavior
- Inability to stop crying
- Answers questions slowly
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