Indiana lawmakers, docs aim to improve concussion diagnosis and treatment
Swimming the backstroke with fins at a practice in January, Greenwood High School freshman Matthew Carr contacted the wall sooner than he anticipated, and not with his hand. “I didn’t get my stroke counted and just bonked my head,” says Matthew, 16, who stopped practicing immediately.
“Lights seemed brighter, sounds seemed louder and then I had a constant headache. I was dizzy and felt tingly all over,” he recalls. A trainer referred him to Dr. Michael DaRosa, a sports medicine physician at highly rated Community Health Network in Indianapolis, and DaRosa diagnosed Carr with a concussion. That began a months-long recovery.
In Indiana, coaches are required to remove the athlete from the field of play and the player is not allowed to return to activity until cleared by a health care professional, but lawmakers want more stringent guidelines in place.
In March, the Indiana legislature passed a bill that would require biennial training for youth and high school football coaches on concussion awareness, the first such requirement in the nation, and would call for student athletes who suffer a concussion to wait at least 24 hours in addition to being cleared by a health care provider to play before participating again. The bill is now waiting on Governor Mike Pence’s approval. (Editor’s note: Gov. Pence signed Senate Bill 222 into law March 24, five days after Angie’s List published this story.)
“I think it is in an important initiative to ensure all high school football coaches are well-informed about concussions,” says Dr. David Harsha, a highly rated sports medicine physician with St. Vincent Sports Performance in Indianapolis. “It no longer leaves it to chance that a football coach is aware of the signs, symptoms and initial treatment of concussions.” He adds that the 24-hour wait provision allows time for proper medical assessment of a head injury to determine when it’s right to return to the field.
Pending approval, Harsha hopes to see the law expanded to other sports where players face risk of concussion, such as soccer, wrestling and basketball. DaRosa echoes that and advocated concussion education for all coaches of contact sports, including cheerleading.
The Indiana mandate goes along with the precept that the primary and most effective treatment for concussion remains rest. But for how long and to what extent varies based on a person’s symptoms and remains difficult to pinpoint, say doctors and researchers. So clinicians continue to seek better ways to tailor care to the individual.
“We kind of slowly add physical and cognitive stresses to see if they can handle it,” DaRosa says. That can range from light exercise to schoolwork. “If they can’t handle it, that’s a signal they need to rest more.”
No average concussion recovery
The American College of Sports Medicine says most people with concussions recover in seven to 14 days. But physicians stress that many patients experience symptoms, from balance problems to blurred vision, that persist for much longer and each case differs — often dramatically — from the next. “You should never push through symptoms,” DaRosa says.
After his concussion, Matthew rested for long periods at home. On doctor’s orders, he limited screen time, like watching TV and playing video games, and he and his family monitored his symptoms, including headaches, and paid attention to what he could handle at school without exacerbating them. He took a couple days off from classes and put athletics on the backburner.
His mother, Jodie, and Matthew both say he’s made considerable progress; he’s less irritable — another concussion symptom — and his headaches diminished considerably. Matthew has eased back into swimming by taking laps at a relatively slow pace, and he hoped to return to full activity, beginning as early as March. “I pretty much don’t want to make it worse, and I want to keep my high school swimming and running career at top notch and when I can get back to it I’ll be better than before,” he says.
As in Matthew’s case, trainers and clinicians use tools to measure changes or damage caused by a concussion. That includes a computerized assessment called the ImPACT Test, or Immediate Post-Concussion Assessment and Cognitive Testing, to measure everything from memory problems to slowed reaction time. But researchers continue to seek tests that would provide a clearer picture for concussion treatment.
In January, Brenna McDonald, a neuropsychologist and associate professor at Indiana University School of Medicine in Indianapolis, and another researcher at the school, Dr. Yang Wang, received $300,000 to study how concussions affect blood flow in the brain, one of 16 concussion-related research grants awarded by General Electric Co. and the NFL. McDonald says she hopes their research studying high school athletes will help doctors better assess patients.
“I hope this new study will give us more insight into how brain differences are related to actual symptoms or function differences that kids are experiencing in their life,” she says.
How much rest is enough — or too much?
Most agree, at least in principle, with a concerted push to err on the side of safety. But complicating matters, experts say patients face a raised risk of depression and anxiety when cautious clinicians and parents mandate complete rest and removal of children from school and all other activities for weeks or months. “There’s no evidence to suggest that that kind of total rest works, not on that kind of extreme model,” McDonald says.
Doctors say, for some, symptoms of angst and sadness aren’t avoidable following a concussion and during long concussion recovery periods and may require treatment. McDonald hopes better assessment tools will help all involved strike the proper balance between exercising caution and returning to activities a person enjoys within an appropriate time frame.
“Even though we do an exam and we have an ImPACT Test, we’re not foolproof,” Harsha says. “Certainly, there’s always room for better tools.”
Taking a timeout for safety
Harsha says the No. 1 limitation remains that concussion diagnosis and monitoring rely heavily on individuals themselves, such as young athletes, to give the heads up when something is wrong. “They are more at risk of another concussion if we put them back [into the game] too early and it could be life-threatening,” Harsha says. Though death is exceedingly rare, experts say people with concussions who return to full physical or cognitive activity too early risk further head injury that takes longer to heal.
Multiple concussions can even precipitate a condition called chronic traumatic encephalopathy, a form of dementia for which there is no known cure, that has notably afflicted some retired pro football players — like Hall of Famers Tony Dorsett and Joe DeLamielleure, who have publicly discussed their diagnoses — and boxers, among other athletes.
Harsha says education remains critical. “We try and get the word out and get that done before the fall [sports] seasons,” he says.