As recently as five years ago, sports concussions often were taken lightly. Traumatic brain injury? No, you were just “dinged” or “had your bell rung.” But as concern has grown about concussions and brain damage—highlighted by the issues of former NFL linebacker Junior Seau and tight end John Mackey and current hockey star Sidney Crosby—so has the development of concussion management for athletes at all levels.
Cobb County is among the leaders in providing access to free baseline testing for every public high school athlete. The same type of testing is available and reasonably priced for pre- and post-high school athletes.
Taking concussions seriously represents “an amazing transformation” says Dr. Mark Brown, a physician with the Bortolazzo Group who is also affiliated with WellStar’s Cobb and Kennestone Hospitals. Brown is one of the leaders in creating a concussion-management program known as ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing), which was made available to about 10,000 Cobb public high school athletes in 2011. His experience with youth and teen concussions includes serving as team doctor for a four-time high school state football champion team in Florida and 25 years in general and emergency room pediatrics, where he’s seen his share.
An estimated 173,285 sports- and recreation-related traumatic brain injuries (TBIs), including concussions, among children and adolescents younger than 19 are treated each year in U.S. emergency departments, according to the Centers for Disease Control and Prevention (CDC). Bicycling, football, playground activities, basketball and soccer account for the highest numbers.
“In the 1980s, the standard was if a player was not knocked out, and if he looked OK in 15 minutes, he was able to play again,” says Brown. “But in a relatively short period of time, we’ve gotten on top of concussion management. I’m a little biased, but I think Cobb’s [high school] program is as good as any in the country.”
Momentum has grown rapidly, says Dr. David Marshall, medical director of Children’s Healthcare of Atlanta’s sports medicine program. A turning point was a concussion suffered by University of Florida superstar quarterback Tim Tebow in a 2009 game against Kentucky. Heavy media coverage focused on baseline and follow-up ImPACT tests—already in use at Florida for several years—that helped determine when Tebow could play again. “Interest has grown in the last four years since Tebow got hit,” says Marshall. “Back then, you never heard about a player getting a concussion. It was ‘he got his bell rung’ or ‘he got dinged.’”
According to the CDC, a concussion is typically caused “by a bump, blow, or jolt to the head or from a blow to the body that causes the head to move rapidly back and forth.” It can happen in an extreme collision or because of repeated impact. Most do not result in unconsciousness, but failure to respond properly can lead to further injury or death.
Coaches are adjusting to the risks of “cumulative, repetitive trauma,” says Carolyn Lawson, a physical therapist and owner of Neurosport Physical Therapy, which works with athletes at Walton High School and the North Atlanta Soccer Association, among others. Lawson says soccer coaches, for example, are becoming more aware of things like limiting the number of headers in practice.
Brown describes concussions as “a change-in-direction injury.” “The head stops but the brain keeps going,” he explains. “The change of direction is so quick that the brain bounces off the skull. The brain is super sensitive to further injury. It is not whether you have one or five or 10 concussions, but whether you are fully healed before you get hit again.”
What sold Brown on ImPACT testing—he earned his credentials as a consultant from ImPACT Applications, Inc. in 2010—is its success at uncovering athletes who appear recovered, but are not. Typically, recovery from a concussion starts with three to five days of physical and mental rest followed by several days of non-contact progressive exertion tests. When the athlete is symptom-free, he is rechecked by a doctor.
“That’s where ImPACT testing is important,” Brown says, citing research. “When you clear someone based on a physical exam, three-fourths of the time you’ll be right. Of athletes who appear normal, 25 percent still have issues. ImPACT picks up just about every one.”
Marshall calls ImPACT the “gold standard” of concussion management programs and the overwhelming choice of medical professionals in the United States. The company counts 7,400 high schools, 1,000 colleges and universities, 900 clinical centers and 200 professional teams and select military units as users.
ImPACT testing started in the early 1990s when, at the request of Pittsburgh Steelers coach Chuck Noll, team neurosurgeon Dr. Joseph Maroon and concussion researcher Mark Lovell developed a paper and pencil neurocognitive protocol and collected baseline results for the team. Since then the company says more than 140 peer-reviewed and 80 independent studies have validated ImPACT’s model. That model is based on comparing pre- and post-concussion test scores to help determine when symptoms have subsided. The tests measure attention span, working memory, sustained and selective attention time, response variability, non-verbal problem solving and reaction time.
Athletes older than age 10 in contact sports such as football, lacrosse, soccer, basketball, cheerleading and gymnastics are prime candidates for ImPACT baseline testing. But Marshall says ImPACT is valuable even without the baseline test because a database of more than 75,000 “normative data” results indicates how athletes of different ages test when normal. Nevertheless, says Marshall, the ImPACT test “is just one piece of the puzzle. It was never designed to be the sole determinant. It is not a substitute for a physician trained in management of concussions.” Adds Lawson, “ImPACT testing does not prevent concussions. It is a tool, one piece of the management process.”
ImPACT testing has been part of the Cobb County School District’s high schools sports programs since 2011. All Cobb public high schools have access to free baseline ImPACT testing for all athletes in all sports, says Steve Jones, district athletics director. WellStar Health System underwrites the cost at 11 high schools, while Children’s Healthcare of Atlanta provides ImPACT testing as part of their contracts with five high schools (Kell, Lassiter, Pope, Sprayberry and Wheeler) for which they provide athletic trainers. Jones estimates that testing cost for a school year is about $8,000 to $10,000.
“Each athlete should have a baseline test done every two years,” says Jones. “The school makes the determination on which sports should test.” He adds that while schools are not required to use the ImPACT testing, it is a good tool in the local schools’ toolbox for them to deal with kids who have had concussion symptoms.
Cobb’s concussion protocol guidelines require that anyone with concussion symptoms be seen by a doctor and be put on a return-to-play protocol. Brown notes that Cobb’s return-to-play policy dates back to 2011 and was ahead of the curve. Georgia’s statewide Return to Play Act of 2013 became law in April and requires schools and recreational leagues to develop concussion return-to-play policies and educate parents about concussion dangers. “I would say that we are one of the leaders for large counties and school systems in Georgia,” says Jones.
Brown calls Cobb’s efforts an overwhelming success. “Going from no baseline-testing program in 2010 to where we are now is a testimony to the community and school personnel,” says Brown. “I’ve never seen a group of people who care more about what they do.”
When in Doubt
High school coaches can depend on trainers to spot concussions on the sideline. But dads and moms who coach youth teams also need to be aware of symptoms, says Lawson. “If there is any concern, go to a health care professional,” says Lawson. Or, as the saying goes, “When in doubt … sit them out.”
Lawson recommends that athletes older than 10 be baseline tested. Neurosport charges $15 for an ImPACT baseline test; $12 for a follow-up test; and $45 for a return-to-sports protocol, she says. Marshall also advises a pre-season physical four to six weeks prior to start of the season for athletes 10 years and older, and suggests that ImPACT baseline testing should be included.
But fear of a concussion shouldn’t keep a young athlete from playing, says Brown. “A concussion is not the biggest danger,” he explains. “Be aware of the risks and get proper care, but for heavens’ sake don’t look at sports as a dangerous thing. The No. 1 threat to health is not concussions, but obesity. The positive parts of sports are much greater than the negative.”