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County Conference on Concussions

‘Safer Sports’ at heart of seminar


Parents, trainers, coaches, athletic directors and more gathered to learn about concussions.


When will you be back? That’s the question on everyone’s minds when an athlete is sidelined by injury. Most of the time that timeline goes according to plan no matter what the injury, but there can be hiccups along the way. One common type of injury, however, can impact an athlete not just on the field of play, but in life, as well.

Concussions, a type of traumatic brain injury (TBI), are unlike sprains and tears and breaks and bumps and bruises — they aren’t as easily identifiable, you can’t see them and you don’t know what’s going on inside someone’s head, both literally and figuratively.

The panelists:
Safer Sports Conference on Concussions

Epidemiology, Scope of the Problem and Neuroimaging

Dr. Steven Flanagan

Director of NYU Langone Concussion Program

Neurological and Medical Aspects of Concussions

Dr. Barry Jordan

Assistant Medical Director, Burke Rehabilitation Hospital

The Role of the Athletic Trainer in Concussion Management

Dave Byrnes

Certified Athletic Trainer at Yorktown High School and president of Section 1 Athletic Trainers Society

Strategies for a Successful Return to School: The Medical-School Partnership

Gerard Gioia, Ph.D.

Chief of Pediatric Neuropsychology, Children’s National Health System, Washington, D.C.

Proper Baseline and Post Injury Assessment and Task Force Initiative Update

Marc Herceg, Ph.D.

Commissioner of Community Mental Health, Westchester County

And in today’s society, they are also increasingly under the microscope.
The goal Westchester County Executive Rob Astorino had in mind in sponsoring the Safer Sports Conference on Concussions seminar and creating the Westchester County Concussion Task Force is to educate — not scare, he said — the masses about the positive things being done to help athletes before and after they receive such an injury.

Prior to each panelist giving his presentation, Astorino spoke briefly about his intentions “to best use our resources in the country to make our community safer.” He noted that when a child scrapes a knee or twists an ankle parents know what to do. Not so with traumatic brain injuries such as concussions.

“But when there’s a head injury, we don’t always know what to do,” he said. “We want to make sure that everyone who participates in sports, whether it’s the athlete, and certainly the parent and the teacher and the athletic trainer and the coach, etc., everyone involved knows what to do and knows how to handle these types of injuries.”

The task force, formed in July, is putting together a model program to offer county high schools for post-injury management. Dr. Neil Roth, a Scarsdale resident and orthopedic surgeon who added a concussion component to his private practice, is a member of the task force.

According to literature given to all attendees of the Aug. 20 conference at the Westchester County Center’s Little Theater, Astorino wanted four main points to come across:

• How to recognize the signs and symptoms of sports concussions;

• The importance of proper sideline, baseline and post-injury assessment;

• How to navigate specific treatment options; and

• How to get back on the field and in the classroom in good health.

But some aren’t having it. During the Q&A session with the panelists, all experts in the growing field of concussion study, one audience member asked in a no-longer-packed Little Theater why football was not being banned in its current form in favor of flag football. “What would be lost? All the beauty of the sport and the sportsmanship and the game plan would all be there. Why not just move away from tackle?” she asked.

Westchester County Department of Community Mental Health commissioner and task force leader Mark Herceg, Ph.D., replied, “The question becomes, at what point do we stop kids from playing sports, period?” adding, “I shutter when I see on social media that people say there’s a concussion epidemic. There’s no epidemic, it’s not out of control. We know more about it so we’re reporting more and diagnosing more.”

Gerard Gioia, Ph.D., who is chief of pediatric neuropsychology at Children’s National Health Systems in Washington, D.C., has authored concussion literature for the Centers for Disease Control and Prevention (CDC) and is on the advisory board for USA Football, which has implemented a Heads Up program to teach proper tackling and blocking to lower the chances of injury from the youth level up, said, “We actually found in youth football it reduced all injuries by about 70 percent when you compare programs that went through this new training method for coaching kids to programs that didn’t use this, and concussions by 30 percent. Now that’s still only 30 percent and we’ve got to do better than that, so the question now is how can we continue to improve that?”

There is constant research on the topic of concussions, a field that is expanding and leading toward better care and prevention. Regarding football, Gioia said, “Rather than take it away entirely, what we do is manage it. Having said that, everybody has a choice… We are also trying to understand that maybe there is an appropriate age that we start all of these sports. We need to start to analyze that. Maybe the head and neck can’t take the kinds of things at certain ages that it can at other ages. It really puts the onus on each sport to examine what they’re doing much more closely.”

Unhappy with the answers, the questioner made her exit.

The word from the doctors

Dr. Steven Flanagan, director of the NYU Langone Concussion Program, presented data about the instances of concussion, but noted it is “still tough to get good data.” He thinks the numbers from the ’80s of 1.5 million cases per year are an underestimation, especially when compared to 3.8 million today just from sports. “The truth is, I don’t think there are more consussions occurring in this country, it’s just that now that people are much more aware of concussion and the problems that may be associated with it they are much more likely to go to their health care professional, to an emergency department to get care,” he said.

As far as TBI goes, there are more cases when it comes to vehicular accidents, assault and falls. Sports is fourth on the list.

“Luckily though in concussion, most people get better,” Flanagan said. “That’s the good news. As the executive said, we don’t want to scare you. Concussion has a much better prognosis.”

Said Flanagan, “Concussion can occur from any type of contact sport. It’s not just football, even though we hear all this stuff going on in the NFL. We’ve known about concussions in boxing for decades. Punch-drunk syndrome has been described in the 1920s and it’s been around for a while. Boxing is sort of an interesting sport. The whole idea is to give the other guy a concussion.”

One of the big misconceptions about concussions is that you will lose consciousness, though that only happens in about 20 percent of cases. “That’s the exception rather than the rule,” Flanagan said.

There is no test for a concussion and many go undiagnosed or mishandled, which is where the real problems occur.

“Another problem that we deal with as a group of health care providers in treating concussions is that there’s no widely accepted definition that basically is appreciated by everybody,” Flanagan said. “In my field of rehab medicine we use predominantly the definition that comes from the American Congress of Rehab Medicine that basically states… it has to be some type of altered mental state or something that suggests to you that there has been an injury to the brain.”

So what happens to the brain during concussion? “I want you to think of the brain in its natural state,” Flanagan said. “It’s actually pretty soft and has the consistency of warm Jell-O, really pretty soft, and if you have a blow to the body, to the head, the brain is floating in fluid forward and backward, if you can imagine the brain compressing itself, stretching, it may even twist a little bit… and the cells are like telephone wires. They are conducting information throughout the brain and it allows us to do what we do as humans, to think quickly, to pay attention, to solve problems, what have you. If you start cutting those telephone wires the brain’s not going to work so well. It’s like you start cutting the wires of the computer network and you start getting some problems. That’s what’s happening during concussions. In severe cases you actually get some abnormal flow of other cellular components and that nerve cell can actually die.”

There is no actual test to determine whether or not someone had a concussion and the reason CT scans and MRIs are not helpful is they only show what you can see with the naked eye, while the problems lie within microscopic lesions and functionality and physiology. Functional MRI (fMRI) is being used experimentally in concussions because an fMRI detects what parts of the brain are active and then can help determine what the abnormalities are. Then you can later see the brain starting to return to a natural state when healing takes place.

Dr. Barry Jordan, assistant medical director at Burke Rehabilitation Hospital, uses the definition, “An alteration of mental status/neurological function due to mechanical forces affecting the brain.”

Per 100,000 games, a player is more likely to get concussed in football for males and soccer for females. He noted that soccer is more likely from aerial pursuit of the ball, not actually heading the ball.

“It’s important to realize that there’s no concussion-proof helmet that’s out there and the reason why that is is because the primary mechanism of a concussion is the movement of the head,” Jordan said, referring to football. “The head will move regardless if you have a helmet or not.”

Concussions come not necessarily from a blow to the head — though that can certainly do the trick — but from three types of acceleration of the head: rotational, deceleration and impact deceleration. Then the symptoms are physical (headache, incoordination, impaired balance, dizziness/vertigo, nausea/vomiting, blurred vision, fatigue, loss of consciousness), cognitive (disorientation, memory deficits, impaired concentration, decreased attention, feel in a fog, amnesia), behavioral (irritability, inappropriate emotions, sleep disturbance, personality change, sadness/depression, easily distracted).

Knowing prior history for an athlete is essential, according to Jordan, but so is making sure not to miss more serious TBI injuries than concussion because “that can be life-threatening.”

“What you don’t like to see is that after each concussion it takes them longer and longer and each time they have a concussion it takes less of an impact to cause a concussion,” Jordan said. “That pattern is worrisome.”

The return to play follows the BRAIN acronym of bike, run, agility, in red (as in no contact like a red jersey in football practice) and then no restriction. Jordan said the majority are better in 7-10 days and 90 percent in four weeks. If it takes longer that’s a problem. “Let the symptoms be the guide,” Jordan said.

Both Flanagan and Jordan made presentations at a concussion seminar held in Scarsdale in 2012.

Trainer time

David Byrnes, task force member and Yorktown High School’s certified athletic trainer since 2004, made an analogy saying a parent wouldn’t drop a kid off at a pool without a lifeguard, so why would they drop a kid off at a practice or game without an athletic trainer there?

Athletic trainers are “the glue in the sports medicine team,” Byrnes said, having a key role in assessment, management and being a link between schools, families and medical professionals. Trainers are especially impactful when they get to know an athlete, which helps in the evaluation process.

Byrnes said 65 percent of Section 1 schools have a full-time (40 hours per week) trainer for practices, games and in the training room, while New York State is at 27 percent, the United States 37 percent. He called the numbers “semi-accurate,” but said, “Yes, Section 1 looks great in comparison to New York State and the U.S., but 65 percent is not 100 percent.”

Concussion management begins with baseline testing for athletes in the preseason, continues with on-field assessment and then gets monitored by parents for the next 24-48 hours, which is “critical.” Also critical is the reporting of symptoms by athletes.

Byrnes is big into checklists for his assessments, starting with a Graded Symptom Checklist that features 26 items. The there is a combination of sidelines tests, among them:

• Standardized Assessment of Concussion (SAC): Byrnes called this an “oldie, but a goodie,” quick and reliable and takes 5-6 minutes. It includes four sections — orientation, immediate memory, concentration and delayed recall — that are most accurate with a baseline.

• Sport Concussion Assessment Tool 3 (SCAT3): This is for ages 13 and up, but there is also a Child SCAT3 for 12 and under. It takes about 15-20 minutes.

• Balance Error Scoring System (BESS): This is for balance and takes 5-7 minutes.

• King Devick Test (K-D Test): It takes 2 minutes and athlete reads single digit numbers on flash cards or an iPad.

• Cranial Nerve Testing: Another two minutes, there are 12 parts and it asks the athlete to do things like read scoreboard, stick out his/her tongue, cough, swallow, etc.

• Manual Muscle Testing: If everything is negative, this is cautionary if a violent hit is involved in the potential injury.

Re-evaluations continue and if conditions worsen, further medical care is recommended.

Keynote speaker

Gioia played football when he was younger and then picked up rugby. That taught him a lot about the precautions someone not wearing a helmet will take vs. the risks a player wearing a helmet is willing to take.

“I’m very much a proponent of sports and I think what it does for us all is very, very important,” Gioia said. “But, as we know, and what you’ve heard from our other distinguished speakers, it’s also about balancing that fun, that competition with safety and really knowing what we’re looking for.”

Gioia takes what he calls the Four Corners Approach to Concussion Care (family, medical systems, school, athletic/recreational). For him it’s a community-based approach, “how we really pull together the various worlds that revolve around kids.”

“The whole issue of school and returning to school is critically important to have that team approach,” Gioia said. “The four corners is really important in supporting kids. It’s crucially important that our medical team understand more about the school and how these symptoms can play out in the school, but our school team also understands how this injury can play out medically and that there’s good coordination and communication with the family and the athlete as the centerpiece of that communication. After rehabilitation, again this progressive activity of controlled exertion is really the model you want to start reinforcing after that initial period of restful time. It’s an individualized moderated pattern of activity that we deal with. It’s not about everybody getting the same thing.”

Return to Life (RTL) is at the top of Gioia’s priority list, well ahead of Return to Sports (RTS). “Concussions are not just about returning to sports — they’re about returning to school,” he said. School is a student’s “job,” requiring mental and physical exertion to interact with students and teachers, be in a stressful environment and handle that academic pressure.

From elementary up to high school, a recent study in the Journal of Pediatrics explored the different areas students felt they had the most trouble with in school such as headaches interfering, inability to pay attention, feeling too tired, homework taking longer, difficulty understanding material, difficulty studying for tests and difficulty taking notes. With high school students there were more problems, likely linked to the tougher material they are faced with.

The balance needs to be found between the right amount of activity because both too much and too little will hinder the recovery process. First and foremost is making sure no additional head trauma or second impact is suffered. Nine hours of sleep per night is recommended, which for some students could mean an altered start time for school. The first few days are critical to monitor to see the best course of action for each individual.

“Stress is a high energy activity… at the end of that day you are drained,” Gioia said. “That’s using a lot of physical energy. Concussion is actually an injury that involves an energy deficit as a primary element. When you draw energy away from these overactivities — physical, cognitive, emotional — that’s going to challenge your recovery. The idea here in our recovery is really to balance the recovery with how much exertion. We do that basically by looking at how we respond systematically.”

Gioia uses the PACE model (Progressive Activities of Controlled Exertion) where “instead of rest it’s really managing your activity.” The right type of exertion can put positive chemicals into the brain. Next up is ARM (Active Recovery Management).

“What’s also very important, and I can’t stress this enough with all we hear in the media these days and with all due respect to our media partners that may be here, we tend to hear the more extreme cases, the more catastrophic cases,” Gioia said. “When we think about a concussion oftentimes this dread comes over us, and that dread sometimes — and it’s a serious injury and I don’t want to downplay it at all — but it’s also important to know that you get better and it’s important to really set that positive expectation. Also then what we do is we define what can you handle over the course of your day — what kind of activity and how long can I do it for and how do I then learn to monitor my symptoms and manage my activity so that I don’t increase my symptoms? Again, using your symptoms as a guide for your daytime activity.”

The one difference between RTL and RTS is that in RTL you will return symptomatic, whereas sports you don’t go back unless you are 100 percent asymptomatic. The concussion team within the school is a major resource to ensure proper recovery. For RTL there are six stages:

• Stay home to rest and test out what you can handle;

• Go back to school for a partial day;

• Full day of school with maximum support;

• Full day with moderate support;

• Full day with minimal support;

• Full day with no support.

Gioia lauded the CDC’s Heads Up materials, saying they are “probably one element where Washington has worked OK with your money.” You can visit cdc.gov.headsup and also download an app for iPhone or Droid with important resources that do everything but diagnose concussions.

Questioning ImPACT

Herceg was pleased with the turnout for the conference, which took place during the first week of high school varsity sports. His goal was to take a topic with a large scope and present as much information in what ended up being three hours including the Q&A period. He is enjoying his new role in government in which he gets to “provide accurate information to the public.”

“Concussions are like snowflakes — no two are alike,” Herceg noted.

Knowing that the lone resource many schools are using is ImPACT testing — used at both Scarsdale and Edgemont high schools — is troubling for Herceg. “A computerized test is something that’s not thorough in any nature and I worry and I shudder when people say that for concussions that’s all they do,” Herceg said. “They’ve become the norm and I personally like in my Tweets to put down the indu$try sign with the dollar sign, because that’s really in some respects what it’s become.”

ImPACT measures symptoms (mood, sleep, dizziness, headaches) and verbal/visual memory, processing speed and reaction time. ImPACT is for RTS, not RTL. “It takes about 20 minutes,” Herceg said. “I’m not so sure if a 20-minte test is as comprehensive to measure brain function as well as personality and mood.”

Another issue Herceg takes with a test like ImPACT is that unless the test is given under proper conditions with proper and consistent instruction, it is not as reliable. The test should be given by a trained tester in a room with minimal distractions. Students should be separated, ideally by dividers, and monitored. Groups should be no larger than 15.

Another place the test falls short, according to Herceg, is that ImPACT doesn’t take into account “potential emotional, personality or learning issues” or a person’s state of mind or what medication he or she may be taking. Psychologists should be more involved, he said.

“It’s not just about balance, it’s not just about coordination, it’s not just about how I’m thinking,” Herceg said. “[It’s] the who. The brain is very complex in nature, so to discount that on a test before a brain injury I think is doing some disservice.”

One of the biggest myths, said Herceg, is “There is no single test for concussion, period. It’s misleading when somebody says they passed a concussion test.”

As mental health commissioner and task force leader (westchestergov.com/safecommunities), Herceg will lead the charge to develop a standard protocol to offer local schools for RTS and RTL. Coming soon will be a “surveillance system” for students suffering concussion, a traumatic brain injury.

This is one case where you might be glad Big Brother is watching.

Read more local coverage of your hometown in this week’s issue of The Scarsdale Inquirer. Newsstand copies are available at several locations listed above, or subscribe today for convenient home delivery.


September 11, 2015