Crackin' heads to cut down number of concussions

For decades, nobody worried much when high school football players were “shaken up” or got their “bells rung.” Few knew that the players had probably suffered a concussion. It was just part of the game.

Players, trainers, coaches and parents made up a chain of accountability that could be easily broken at any point, putting teenagers with developing brains at even more risk than their pro or collegiate counterparts.

Players, eager to stay in the game and largely ignorant of the consequences, downplayed or even lied about symptoms. Trainers cleared athletes who displayed signs of a concussion to return to the field in as little as 15 minutes if the symptoms had subsided.

Coaches eager to get athletes who seemed fine back into the action exerted pressures of their own. Most parents were uneducated about the symptoms of concussions and the dangers of returning to play too soon.

Each was acting on the best information available at the time. But with new data on concussions emerging almost weekly, 2010 saw an unprecedented effort across the state to get everyone on the same page. The General Assembly passed legislation requiring medical clearance to return to play, the Virginia Board of Education drafted guidelines on concussions, and local school systems required coaches, athletes and parents to be educated on these traumatic brain injuries.

“The whole mantra is, if in doubt, sit them out,” said Dr. Joel Brenner, director of sports medicine at Children’s Hospital of The King’s Daughters.

The dictum applies to all sports, but it is football, with an estimated 1.1 million players in U.S. high schools alone, where an embedded culture of machismo must be overcome.

Recognizing that no amount of prevention can eliminate concussions entirely, the focus has turned to managing them. Like the sport itself, success requires a team approach.

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PARENTS

One moment they’re cheering from the sidelines; the next, their child is prone on the field. Moms and dads battle fears while seeking answers for the best way to provide support.

Trey Bray, with parents Tom and Theresa Bray, was playing for Great Bridge High in 2008 when he suffered a big hit that knocked him out on the field. He missed four games. (L. Todd Spencer | The Virginian-Pilot)

Bayside High receiver Gene Holloman raced across the middle and leaped for the pass. He got one hand on the ball before a defender lowered his head and shoulder and delivered a blow that sent Holloman crashing to the ground.

The hit fired up the Hermitage High sideline during the team’s Group AAA Division 6 state semifinal win last month but left Bayside’s players and fans cringing as Holloman laid motionless for several seconds.

His mother, Jennifer, missed the hit – another parent had walked in front of her just as it happened – but she didn’t miss the fact that the kid on the ground was wearing No. 2. Her son’s number.

“My first thing: Was he hurt?” she said. “I feared he might have a concussion.”

Holloman eventually walked to the sideline, where trainers and doctors put him through a standard sideline assessment – a short examination that measures orientation, immediate memory, concentration and delayed recall.

She watched cautiously as the trainers cared for her son. With the increased awareness about concussions, she wanted to be sure her son was OK to return to action. “I have heard about the things that can happen in the long run” after head injuries, she said. Her son didn’t have a concussion and was cleared to go back in, but his mother said if she’d seen the hit at the time, she never would have allowed him to return. She saw a replay a few days later on a computer.

“When I saw it … I was flabbergasted because I was like, 'How did he get up from that hit?’ ” she said. “I wouldn’t have let him back in the game because that’s my baby. ”

She added that her husband, who also played football for Bayside, may have had a different opinion, but she said, “His health is more important than any game in the world. ”

She isn’t alone among parents in her feelings about concussions. According to a survey by ESPN The Magazine, awareness and concern about the injury is up among parents. The magazine conducted a survey of 600 people that included 100 parents, along with players, coaches and trainers.

Only trainers voiced greater concern than parents. Yet parents are like everyone else with a role in managing concussion injuries: a little conflicted, somewhat confused and hard-pressed to keep up with the latest information.

Tom Bray can relate. In 2008, his youngest son, Trey, took a devastating hit while playing for Great Bridge High that left him with a concussion. Tom Bray was on the opposite side of the field working the first-down markers when one of his partners said, “You better get over there.”

“He was out for like two minutes,” Bray said. “But I think the worst part was watching it on the high school highlight shows that night. I mean, it was a vicious hit.”

To the father’s surprise, a doctor at the hospital told the family Trey could return to play the following week.

“Being a dad, I was like, 'The neurosurgeon said he’d be OK to play after a week,’ ” Bray said. “But then reality sunk in, and we ended up waiting four weeks.”

Tom Bray, knowing what he knows now, said listening to the emergency room doctor could have been a huge mistake.

“This was two years ago, and the emergency doctors weren’t even up on concussions,” he said. “If we would have sent him back out there too soon, he could have suffered a serious injury or even died.”

The decision to keep Trey out wasn’t supported by the whole family. Trevor Bray thought his younger brother should be back on the field the next week. Trevor, a former All-Tidewater linebacker, admitted he played with concussions.

“I figured if he could sit up and hold a conversation then why couldn’t he get back out there and play,” said Trevor, who also played at Elizabeth City State University in North Carolina. “ But now I realize and I’m thankful that he didn’t play right away because he could have died. I also realized that it was just stupidity that I played with concussions.”

Trey missed four games.

“That was probably the scariest moment of my life,” said Bray, who plays for Brevard (N.C.) College. “I love the game too much to give it up. But when the doctors told me that if I was to get another serious concussion like I did before I would have to quit, I understood.”

So did his father.

“I’m glad concussions is getting the attention it’s getting,” he said. “Knowing what I know now, I know we did the right thing. We handled it the correct way.”

- Larry Rubama, The Virginian-Pilot

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COACHES

Times have changed since many of these guys played the game with reckless abandon. Now, they are charged with finding a balance – directing the mayhem while preaching safety.

Ocean Lakes High coach Chris Scott said he often tackled headfirst as a player. “I was known for trying to put my helmet on you, or the ball, whenever I could. You can’t coach a kid to play that way anymore.” (L. Todd Spencer | The Virginian-Pilot)

As a three-time Division III All-American, Chris Scott was a headhunter – his helmet his weapon of choice. He used it to dislodge the ball from an opponent, or an opponent from his senses.

Yet eight years removed from his final season, the Ocean Lakes High coach finds himself striving to remove the helmet from his players’ arsenal.

“I never had the talent, but if I had made it in the NFL, I might have never earned a paycheck,” said Scott, who figures weekly fines would have matched any salary. “I was known for trying to put my helmet on you, or the ball, whenever I could. You can’t coach a kid to play that way anymore.”

Recent studies on concussions now have coaches such as Scott, focusing their attention on injuries, not just winning . And if managing head injuries is a team effort, no member of that team is better positioned to protect a player than a coach.

“Coaches and trainers know the players the best,” said Dr. Joel Brenner, CHKD’s director of sports medicine. “If a player is acting differently, not performing the right assignments, forgetful, irritable, disrespectful, confused, those are signs that something’s not right.”

Doctors preach protection; players want to win at all costs. In the middle, coaches confront conflicting roles .

“It’s not a contact sport,” Scott said. “Basketball, soccer, those are contact sports. Football is a collision sport.”

Yet coaches are asked to minimize the damage.

“It’s a thrill-seeker’s sport,” Great Bridge High coach Pete Gale said. “You don’t drive fast cars because they’re safe.”

Added Norcom High coach Larry Archie: “We teach a violent game.”

The difficulties of coaching through this are as nuanced as the language: Headaches are normal, but head injuries are bad; playing in pain is expected, but playing hurt is foolish; helmets are provided for safety but hopefully never used as a weapon.

“There’s a difference between playing hurt and playing injured,” Archie said. “If you’ve got a hangnail, don’t come see me. If it’s your head, that’s different. We’re talking about more than a football game here; we’re talking about a life.”

Coaches say spotting injured players rather than exhorting them to play through pain is a change that has come in the past five years – ever since the NFL’s issues with concussions became more widely known.

This has coaches filling new roles.

Norcom sidelined junior Justin Sullivan in the fall after he was singing on the sidelines. Ocean Lakes sat Lafonte Thourogood after he admitted being “a little dizzy.” The quarterback had played through a separated shoulder without saying much, so Scott knew something was wrong.

“I told him to see the trainer, and I knew right away that” h e was done for the night, Scott said. “That’s the era we live in.”

The new focus has been an adjustment for coaches. Some of them played without consequences through concussions themselves. Many learned the game one way but now have to teach it another. They balance two strong instincts: one to protect and the other to win.

Given the climate, caution wins out, and coaches utter the “safety first” mantra after a comment that might suggest otherwise .

Salem High coach Robert Jackson saw his team lose nine players to concussions this past season, more than any he’s experienced . He wonders if all of the missed playing time was warranted.

“Some of them, I question to myself,” Jackson said. “But I’m not a doctor. If a player has a headache, it’s treated like a concussion. That’s good if it is a concussion. That’s not good if it’s just a headache and we’re diagnosing it as a concussion. But I always listen to my trainer. Safety first.”

Gale expressed similar thoughts. Aside from one player who was left unconscious by a hit, Gale said he often wondered whether trainer Sharon Ivey was playing it a little too safe. “But that’s her job: to be overly cautious,” Gale said.

He and other local coaches primarily speak well of their trainers and agree a good relationship can minimize one of the more difficult responsibilities of a coach .

“My trainer takes all that out of my hands,” Archie said. “She makes it easy on me.”

Some compared the changes in the game with other advances that were initially resisted but since have been embraced. Like restrictions on two-a-day practices and the focus on hydration.

“When we played, it was ironman football,” Jackson said. “You kept right on going and it didn’t bother you. Back then, it was frowned upon to come out (of a game), a sign of weakness that you couldn’t fight through it. We’ve advanced in diagnosing things.”

As the mind-set has advanced, so have practice habits. Scott said that during technique drills, he stresses different “points of contact” than he used to, encouraging players to get their hands and shoulders on an opponent, rather than their heads.

Gale’s team entered the 2010 season with a reputation as a finesse team, one that needed to get tougher.

The old-school fix was easy: Line up your players in the “Oklahoma” drill – players get a running start and smash into each other until a player winds up on the ground or is driven out of the marked area.

“It’s used to determine the biggest and the baddest,” Gale said. “Some of my assistants still wish we could use it, but I told them, 'No. You just can’t… ’ ”

- Chris Carlson, The Virginian-Pilot

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TRAINERS

Treatment procedures have evolved rapidly in recent years. These professionals stand on the front lines and must stand their ground – sometimes against coaches – to aid players.

Trainer Marti Mansfield, who has worked at Kempsville High for 23 years, has seen concussion awareness grow. “I can’t say that I see more now than in the past. I can say I treat them differently.” (L. Todd Spencer | The Virginian-Pilot)

In her cramped office just off the Kempsville High gymnasium, athletic trainer Marti Mansfield picked up a clipboard and read off a list of injuries she had treated the previous day.

“A couple of knees, an ankle and a bloody nose,” she said. Business as usual for Mansfield, a fixture at Kempsville for 23 years. But if some things about her job haven’t changed much over the years, the attention paid to one particular injury has increased dramatically. These days, in addition to the usual knees, ankles and noses, trainers such as Mansfield are charged with looking after athletes’ brains as well.

When it comes to identifying and managing concussions, trainers are on the front lines. In football, that means the sidelines, where they are the first to evaluate athletes who might have a brain injury.

“There have always been concussions,” Mansfield said. “I can’t say that I see more now than in the past. I can say I treat them differently.”

Concussions can be tricky to recognize on the front end, and it’s now established that there is no one-size-fits-all timetable on how long they take to clear up on the back end.

That’s relatively new information. As recently as a year ago , when an athlete showed signs of a mild concussion, a “15-minute” rule was often applied. If he was symptom-free after 15 minutes, he could return to play.

“You could clear them through the test and feel confident about sending them back,” said Steve Suttmiller, an athletic trainer who oversees high school and middle school athletics for Norfolk public schools.

Recent research has shown that merely being symptom-free does not mean an athlete’s brain has recovered enough to return to play. Brains not fully recovered are more vulnerable to a second concussion, which can lead to permanent injury and even death. The risks are more pronounced in young brains, which are still developing.

In April, the General Assembly passed a bill sponsored by state Sen. Ralph Northam, D-Norfolk, that requires athletes suspected of having concussions to be removed from play and not allowed to return without written clearance from a licensed health care provider.

The law takes effect July 1, but local school systems are already following similar procedures. In August, Norfolk adopted a “graduated return-to-play” protocol . Athletes who are symptom-free following one step can proceed to the next step, until they are cleared to play.

“It could take six days, 10 days, two weeks or two months,” Suttmiller said.

As with other school systems, Norfolk gives athletes a computerized brain exam before the season. It establishes a baseline score that is used to help determine when an athlete can safely play again. A satisfactory score by itself is not enough for an athlete to return, but it provides objective data.

The step-based system and brain exams are an improvement over the old, often arbitrary approach. Mansfield, for example, used to clear athletes to return a week after their last headache. “That’s all I had to go on,” she said.

On the sidelines , trainers still rely on their most basic tools: eyes and ears. Rule No. 1: Watch the game.

Sometimes a potential injury is easy to spot. A player might stagger off the field or go into the wrong huddle. In most cases, it’s not that obvious, and players can be reluctant to volunteer information.

“They tend to hide symptoms,” said Kristin Thompson, athletic training director for Bon Secours Hampton Roads Health System, which provides trainers to Portsmouth and Suffolk schools.

It’s up to the trainer to be proactive and evaluate any players suspected of a possible concussion. The standard test is known as a Sport Concussion Assessment Tool. Symptoms include headache, confusion, nausea and vision and balance problems. “If an athlete shows some of those signs, that’s a red light that things are going to stop,” Suttmiller said.

And if a coach objects? Thompson said trainers are told to stand their ground when dealing with overzealous coaches.

“We still have our battles that we face with coaches, but we just have to emphasize that the athletic trainers are not backing down.” ”

Unlike in 2009 , an athlete with symptoms no longer is re-evaluated 15 minutes later. Once removed from the game, the player will need written clearance to return.

Under regulations proposed by the Virginia Board of Education, that clearance could come from a physician, physician assistant, osteopath, athletic trainer, neuropsychologist or nurse practitioner. The key: They need to be licensed by the state.

As a practical matter in South Hampton Roads, physicians are expected to most often have the final say on returning to play. That will take some of the heat off trainers, but concussions remain a hot-button topic .

“The awareness has increased 10 times,” Suttmiller said. “When I first started out, the ACL tear was the big topic, but this is really the first injury that has a state law, and we certainly want to abide by the law.”

- Ed Miller, The Virginian-Pilot

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PLAYERS

They often feel like they can just shake it off. And many players refuse to worry about getting their bells rung. But that big hit that leaves them woozy isn’t something to ignore, doctors say.

Great Bridge High’s Adriell Mayes suffered a concussion in a playoff game in November. A trainer wouldn’t let him back in despite the player’s insistence. He still wishes he had returned. (L. Todd Spencer | The Virginian-Pilot)

Adriell Mayes tried lying. He tried begging. Then, he tried the phone.

The junior running back was desperate.

Despite knowing he had suffered a head injury , he badly wanted back into Great Bridge High’s playoff game against Phoebus, a 35-6 November loss that ended the Wildcats’ season. Mayes failed to convince trainer Sharon Ivey he was fine, and he couldn’t plead his way back onto the field. His dad, unaware he had been diagnosed with a concussion , had Mayes’ brothers hand the running back a phone, telling him to get on the field.

Mayes’ last chance, he figured, was to have his dad give Ivey the OK to let him play. He tried to get the 25-year trainer to listen to his father, but she wouldn’t take the phone.

“Honestly, I wasn’t thinking about the concussion,” Mayes said. “I just wanted to play.”

A few minutes earlier, he had run the ball up the middle, where a Phoebus linebacker grabbed his legs from behind, toppling him forward. Then a safety launched himself head first toward Mayes , their helmets colliding.

If the helmet had shifted 6 inches, it might have knocked the ball loose and been hailed as a brilliant play. Instead, it drew the ire of Ivey and Great Bridge coach Pete Gale, who lobbied for a penalty.

That’s how slim the margin can be between typical football collision and an injured player. “I know he didn’t to it on purpose,” Gale said. “But after, he said, 'Come on, he only got his bell rung.’ For us, that’s the end of his night.”

Players and coaches often use phrases like “got his bell rung” or “got dinged” to explain away blows to the head.

“It’s a way to minimize the severity,” said Dr. Joel Brenner, CHKD’s director of sports medicine . “ When I’m evaluating someone and want to know if they have a history, I ask them if they’ve ever had their bell rung or been dinged. It’s the same thing. It was a mild concussion.”

Just don’t try telling that to players, who are willing to stay ignorant to stay on the field. Ocean Lakes High senior center Josh Mann sums up the attitude of many players when it comes to head injuries.

“Obviously, it’s an increasingly prevalent issue in the NFL,” he said. “You’re going to butt heads. It’s the nature of the game. I’ve never had a concussion, at least diagnosed. Everyone gets their bell rung. You shake it off.”

When told doctors might tell him he was shaking off serious issues, Mann shrugged it off.

“It puts a different spin on it,” Mann said. “But it hasn’t affected me to this point. Maybe it’s an issue down the road, but my dad played, and he isn’t having any problems.”

That mind-set is one reason doctors believe the answer to limiting the impact of concussions lies in a team approach, one that includes parents, coaches and trainers.

Players learn to love the game but also to overlook its hazards such as concussions.

“I try not to look at them,” Oscar Smith High running back J.C. Coleman said. “It seems like they’re at an all-time high. (But) it’s going to happen in football.”

“I hear about it,” Norcom High junior Justin Sullivan said. “But I don’t worry about it.”

A recent ESPN the Magazine survey of parents, players, coaches and trainers shows players are the most likely of the groups to ignore the risks. The magazine surveyed more than 300 players, and 54.1 percent said they’d risk a star teammate’s health to win a state title by allowing him to play with a concussion rather than lose because he sat out .

While the headlines and attention have hammered home the dangers of concussions , it’s done little to alter the typical tough-guy mentality that’s part of football’s foundation. Ivey and other trainers have resorted to confiscating the helmets of injured players to keep them from sneaking back onto the field.

When Sullivan suffered a concussion in practice, he tried to avoid seeing the trainer, knowing what would happen if he was checked out. His concussion, though, was clear to coaches and teammates after he started humming Erykah Badu songs on the sideline.

When Greenbrier Christian Academy linebacker Austin Pyeatt suffered a concussion this past season, he tried to stay on the field, waving away replacements , even as voices of teammates sounded like roaring in his head. An official eventually sent a wobbly Pyeatt to the sideline. “I would have played the next play,” Pyeatt said.

Ivey, Great Bridge’s longtime trainer, understands why the players take the risk.

“It’s the competitive nature, the drive of the athlete. But they are going to have other games and other second halves.”

Which makes Mayes’ extensive efforts to stay on the field frighteningly commonplace .

Even though he eventually was diagnosed with a concussion, he still regrets that he couldn’t talk his way back onto the field.

“It started hurting when we got back (to the school) and she said, 'You can thank me now,’ ” Mayes said. “It was the right decision, but I still wish I would have played.”

- Chris Carlson, The Virginian-Pilot