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Standards for benching high school athletes with head injuries criticized

Photo Credit: TRIBUNE PHOTO: JAIME VALDEZ - PSU linebacker Jake Woolley has suffered four concussions in his three seasons at the school and is working with OHSU neuroscientist Laurie King, who is developing objective balance measurements so coaches and trainers will know when a concussed player can return to action.As she helps attach wristband-size accelerometers around the feet and one wrist of Portland State University linebacker Jake Woolley, Laurie King is aware that Woolley, entering his senior year, has suffered four concussions during his PSU football career. After three of those concussions, he sat out only one week. The fourth, he missed two games, sitting out two weeks.

King is a neuroscientist at Oregon Health & Science University, one of a number of researchers there working to solve the mysteries of an incredibly common and yet little understood malady that mostly strikes young men and women. Her busy season is just beginning — the concussion season.

With high school and college football, soccer and lacrosse teams beginning practice, and wrestling and basketball soon to follow, thousands of Oregon athletes are about to put their bodies into motion. Some of them will get hurt. About one in 10 will suffer a concussion, and of those, many will come back to play too soon.

Researchers such as King are learning that despite the best intentions of most coaches and parents, many of those Oregon athletes are putting themselves at risk for long-term brain damage. Oregon has been ahead of most states, they say, in pushing for concussion control measures. But the more they learn about concussions, the more it becomes clear that the current standards for benching athletes who have suffered concussion-like symptoms are probably inadequate.

“Anyone who is in research thinks that,” King says.

Photo Credit: TRIBUNE PHOTO: JAIME VALDEZ - PSU linebacker Jake Woolley has suffered four concussions in his three seasons at the school and is working with OHSU neuroscientist Laurie King, who is developing objective balance measurements so coaches and trainers will know when a concussed player can return to action.King has data showing that a large percentage of the athletes she sees go back into play before their brains have returned to normal. This includes many who have seen physicians after having suffered a head blow in a game. That spells danger, King says, because an athlete who has suffered a concussion is three times as likely to get a second concussion that season. And that’s where a lot of the long-term neurological damage is done, she says.

“Usually people just look at cognition and send them back if their memory and everything is fine,” King says. “I’m finding in half the people, balance is very impaired past the time they get returned to play.”

That’s why Woolley is turning his head side to side as he walks in a straight line this morning, and reading as he walks. King, who just received a two-year federal grant to continue her work with athletes from PSU, George Fox, Lewis & Clark and Oregon State University, is developing objective criteria so doctors and coaches will know when a concussed athlete has fully healed. Working with PSU athletes she has found that sophisticated instrument-measured balance tests might be a better indication of whether athletes are still impaired than the traditional question and answer sessions to assess memory and cognition.

Physicians have been using balance tests in addition to cognition tests on concussion patients for years, but that has mostly consisted of asking the athlete to walk in a straight line or stand on one foot. King is finding that a concussed athlete can pass the eye test for balance, but still have balance deficits which mean part of their brain hasn’t fully healed. Her accelerometers measure those smaller balance differences.

“They’re not really OK,” King says of athletes who appear healed but fail her tests.

Other researchers are working on different ways of measuring concussive symptoms, from blood markers to eye movement tests. Objective criteria for measuring when an athlete has suffered a concussion and when a concussed athlete is ready to return to playing is critical, because relying on the athletes and coaches does not appear to be sufficient.

PSU’s Woolley has no expectations that he will play professional football. He’s studying kinesiology in hopes of becoming a strength and conditioning coach. “Football doesn’t define me,” he says.

And yet, he’s playing for PSU this year after four concussions in three college seasons.

“You love the game so much it’s hard to stop,” he says.

Photo Credit: TRIBUNE PHOTO: JAMIE VALDEZ - Accelerometers around PSU football player Jake Woolleys ankles and wrist measure minute sways and changes in gate that could signal Woolley is not fully recovered from a concussion.

Athletes often keep mum

A recent study of Washington state high school football and soccer players found that in the 2012 season 11 percent of soccer players and 10 percent of football players reported symptoms that indicated they had suffered concussions. But 69 percent of those athletes said they played while suffering symptoms and 40 percent said their coaches were not aware of their injuries. This despite the fact that high school coaches in Washington, as in Oregon, are required to go through concussion education programs.

That news is no surprise to Terry Favero, a University of Portland biology professor who organized the World Conference on Science and Soccer. Favero recently completed a survey

in which 45 percent of Division 1 soccer players said they

would continue playing with a concussion.

“There’s a disconnect between knowledge and behavior,” Favero says. “Now that people know about concussions we have to figure out a way to change their behaviors and perhaps take the decision-making out of the hands of athletes and coaches.”

Dr. Jim Chesnutt agrees. Chesnutt has been at the forefront of Oregon concussion work for the last 20 years. He’s been advising Portland public high schools for that long, served as a volunteer team physician at Wilson High School, and helped pass legislation mandating a physician’s approval before a concussed Oregon high school athlete can return to play. The legislation also requires all coaches get concussion education, and last year the requirements were extended to nonschool sports.

Photo Credit: TRIBUNE PHOTO: JAMIE VALDEZ - OHSU neuroscientist Laurie Kings research shows that many concussed athletes are not fully healed, even after they pass standard cognition tests.But increasingly, Chesnutt is finding those requirements aren’t enough. Athletes can’t be counted on to report their symptoms. During a game coaches are busy, and focused on the game.

“The biggest single impact on high school sports you could have is to have athletic trainers in all the schools,” Chesnutt says. “You shouldn’t have a program unless you have everything in place to assess the health and safety of your athletes. Ideally that should include a trainer.”

But currently, only about one in four Oregon high schools has a trainer, he adds. Portland public schools have been struggling to find the money to pay for trainers, and this year hopes to have them at least at all night football and soccer games, says Marshall Haskins, athletic director for the Portland Interscholastic League.

A trainer, Chesnutt says, can focus on hits occurring on the field and immediately intervene, whether the athlete says something or not. And in the days to follow, he or she can make sure the athlete has passed all the tests to become symptom free, though Laurie King’s work shows that might not be so easy.

One of Chesnutt’s patients is Sisters resident Jenna Sneva, a competitive skier who suffered from severe migraines before coming to see Chesnutt in 2010. Chesnutt discovered Sneva had never been diagnosed with a concussion, but she had suffered 12 of them, and permanent brain damage.

New research on athlete concussions is constantly changing the diagnosis criteria, according to Chesnutt. Most of the current research was performed on professional athletes, he says, but it may not apply to high schoolers, and certainly not to middle schoolers.

Age, gender make difference

For instance, Chesnutt says that recent research shows that the younger an athlete, the longer the recovery time. And that learning-impaired athletes, such as those with attention deficit disorders, appear to suffer worse cognitive deficits after concussions. Also, stimulants have been found in some studies to help people recover from concussions. And data shows that athletes returning after concussions tend to suffer more knee and ankle injuries.

A recent study using MRIs on high school football players showed critical white matter abnormalities that could portend long-term neurological disorders in the brains of players who had not even suffered concussions.

Photo Credit: TRIBUNE FILE PHOTO - Women soccer players such as the Portland Thorns Christine Sinclair (here in a 2013 match) are more prone to concussions than male soccer players.Girls suffering concussions playing soccer take longer to heal than boys, according to some studies. And a recent study found that the hormone levels present in girl soccer players — where they were in their monthly cycle — affected the severity of their concussive symptoms.

In Chesnutt’s mind, all these studies represent clues, but not answers. As yet nobody has put together a dynamic model of a concussion, he says, that can be applied to all athletes

“It’s like a lot of things in medicine,” Chesnutt says. “The standard practice doesn’t change until you get a preponderance of evidence.”

But it does change incrementally. Chesnutt says in 2007 he was sending football players back into games if they could pass a simple balance test on the sideline. Now he keeps a player with the same symptoms out a week and forces him to miss a game. Chesnutt says based on the latest research he’s starting to wonder if that should be two or three games.

In fact, he cites a study out of Hawaii, where post-concussion testing for football players is more rigorous than here and all schools have trainers. Football players there are held out an average of 23 days after suffering concussions.

“Somebody could argue you’re just looking too closely and so you’re keeping them

out longer,” Chesnutt says of Hawaii’s approach. “But when trained professionals are involved, they actually feel (the football players) are not recovering.”

Coaches must do right thing

Chesnutt, Medical Director of OHSU’s Sports Medicine Program and the OHSU Concussion Program, sees about 4,000 head injuries a year. He says many of the victims take as long as two years for all their symptoms to disappear. He struggles with the question of when it is OK to send a high school athlete back on to the field.

His best guess? About 60 percent of concussed high school athletes can resume playing after one week, he says. About 20 percent need two to three weeks. About 20 percent need one to two months. Chesnutt says there are about 10 percent who will never fully recover and should never play again.

Chesnutt recently gave a talk on concussions at Favero’s soccer and science conference. His sobering takeaway? “People were saying they don’t want to know about concussions,” he says.

Chesnutt is hoping for a study that will show athletes going back into games after concussions are hurting their teams because they are playing worse. He thinks that might get the attention of coaches. Alternatively, a high-profile, expensive lawsuit after a high schooler suffers permanent severe brain injury after going back into play might speed up the process of changing the standards for benching players.

“Everybody’s got to be held accountable,” says Joseph Cammarata, a Washington, D.C., brain injury lawyer representing a professional soccer player who suffered permanent brain damage after being sent back into a game. Coaches are in a difficult position, Cammarata says, but they must reinforce the message to players that their long-term health is more important than playing or winning.

“If, at the end of the day, a kid is clamoring to be put back in and the coach acquiesces to it, then that coach is responsible,” Cammarata says.

Until then, Chesnutt is working a delicate balance between the latest research and athletes who simply want to play.

“I have to tell people almost daily that they can’t play the sport they want, and a couple of times a month that they can’t play contact sports ever again,” Chesnutt says. “My goal is to help them realize the role of preserving their brain.”

Head injury data isn’t tracked in Oregon

It would be nice to know just how many Oregon high school athletes are being removed from games after suffering head injuries, says Jim Chesnutt, medical director of OHSU’s Sports Medicine Program. It also would be helpful to know how long those athletes are sitting out.

That way, Portland athletes and their parents would know if coaches and doctors here were being more or less aggressive than those in other states. Or they could compare one Oregon school with another.

Unfortunately, nobody is collecting and tracking the data that would show which coaches are being cautious enough, according to Chesnutt.

“If you collect data then you have to be responsible for it,” Chesnutt says. “It’s like a lot of things.”

Also, Chesnutt says, one school might have a trainer at games who takes a proactive approach and another school might not. So the data from the school with a trainer might make it appear as if athletes there are taking more hits to the head. Still, it would be valuable.

“The data is hard to get and of questionable accuracy, but it totally makes sense,” Chesnutt says.

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