GMHS Ahead of the Curve in Addressing Youth Concussions
By CHRISTINE KILGORE
February 19, 2012
Youth concussions leave parents and educators with “one opportunity,” Vicki Galliher often says, to manage recovery properly. If not done correctly, recovery from concussions can be prolonged, and the potential for long-term neurological risks may be magnified.
Ms. Galliher, the Athletic Training Coordinator at George Mason High School, is the driving force behind a critical trend in Falls Church City Public Schools: A long-standing but growing appreciation by school officials, educators, and parents for the role that cognitive rest–and individualized, fluid plans for academic accommodations–play in proper concussion recovery.
It’s not only the physical rest and return-to-play decisions that are important. Cognitive rest is critical as well–and this often means time out of school, modified academic schedules, and other changes at home and at school.
“I think we’re now more cognizant of how complicated concussions truly are,” says Dr. Seidah Ashshaheed, principal at Mary Ellen Henderson Middle School. “It is imperative that we do our part as a school by being informed and supportive [with cases of concussion].”
High School Concussions – A Frequent Occurrence
When I began researching the issue of concussions among youth in our community, I learned how frequently concussions occur among FCCPS students.
Examples abound: The high school football player who felt incredibly tired and slept long stretches, and was later determined to have a concussion. The lacrosse player who suffered his second concussion, prompting his parents to steer him to non-contact sports for six months. The hockey player who just felt “out of it” after a game in which he’d taken a hard hit. The middle school soccer player who struggled with headaches and fatigue for weeks after a collision and concussion.
I also saw first-hand, in researching the science of concussions and concussion recovery, how much of the current knowledge of concussions has been acquired just in the last 10 years–and how fast it is evolving. There are many uncertainties, but research has clearly shown that children and adolescents are more susceptible than adults to concussion in the first place, that they are slower to recover, and that they are at higher risk for “second-impact syndrome.”
Studies have shown that once an individual suffers a concussion, he or she is four times more likely to sustain a second one. In addition, a growing body of research is showing that the cumulative effect of multiple concussions increases the risk of neurodegenerative health problems later in life.
I also learned, in trying to unravel my daughter’s health issues and hearing others’ stories, that concussions are under-identified and often arbitrarily treated in the medical community at large, despite an extensive “Heads Up” educational campaign launched by the Centers for Disease Control and Prevention in 2005.
Many physicians don’t appreciate that concussions can result from impacts to the body that jar the head, or from rapid accelerations brought to a sudden stop. Collisions or direct blows to the head are often involved, but aren’t a requirement. Concussions can manifest in many different ways, and symptoms may not occur for days after the injury.
Even when a concussion is suspected, the message from physicians who have not been trained in these brain injuries may be vague–to “take it easy” for a week, for instance.
In reality, recovery should be much more deliberate and measured. The pathophysiology of concussion isn’t completely understood, but most experts agree that concussions cause neurometabolic impairment and significant changes in the balance of neuro-chemicals in the brain. Such changes can effect one’s ability to think and learn, to stay awake and alert, to function well socially and emotionally, and to tolerate noise, light, and motion, among other things.
“The [concussed] brain is in an energy crisis, a metabolic crisis, so treatment must involve conserving the brain’s energy,” says Dr. Joel Brenner, a pediatrician at the Children’s Hospital of the King’s Daughters in Norfolk.
“We treat concussions completely differently than we did 5 years ago,” said Dr. Brenner, who chairs the American Academy of Pediatrics’ Council on Sports Medicine and Fitness and has been working to educate physicians and others about concussion. “We don’t grade concussions anymore, for instance, and we don’t send someone back after a week as a blanket statement . . . There has to be an individualized treatment plan.”
But before treatment can begin, one must identify the concussion, which can be difficult using traditional observation techniques. Even an MRI or other standard imaging technique typically cannot measure the changes in the brain following a concussion.
To provide a better method of identifying a concussion, the medical profession is increasingly turning to “neurocognitive testing,” in which persons suspected of having concussions take tests to measure their cognitive abilities. Ideally, athletes will have been tested before the season begins in order to establish their “baseline” performance, which can be compared against later performance to detect changes in the brain.
Neurocognitive testing, sometimes called neuropsychological testing, has been recommended in several major consensus statements and is widely regarded as the cornerstone of concussion assessment and recovery. According to a recently published survey of high schools that participate in a national injury surveillance system, about 40% used neurocognitive testing in the 2009-10 school year, up from 26% in 2008-09.
ImPACT – The “Gold Standard” of Neurocognitive Testing
George Mason High School’s concussion recovery protocol is based on use of the ImPACT test– a computerized neurocognitive exam with seven modules that measure aspects of cognitive functioning including memory, concentration, reaction time, and processing speed.
ImPACT, which stands for “Immediate Post Concussion Assessment and Cognitive Testing,” is not the only such system available, but it has fast become the gold standard. It was developed at the University of Pittsburgh Medical Center by psychologists Mark Lovell and Micky Collins and neurologist Joseph Maroon, the Pittsburgh Steelers team neurosurgeon. ImPACT is utilized throughout professional sports and among many colleges and high schools. (While many high schools do not employ neurocognitive testing, let alone have an athletic trainer, the vast majority of those schools that do use neurocognitive testing have chosen ImPACT.)
At GMHS, Galliher uses ImPACT to test possibly-concussed athletes against a baseline established prior to the season. The test takes approximately 20 minutes, with students sitting at a computer reacting to different on-screen tasks. Comparing the before-and-after test results allows Galliher to document the presence or absence of injury and even quantify specific areas of dysfunction. Used in conjunction with symptom reporting and clinical assessment, repeated ImPACT tests also can help guide recovery. (The test can be performed in the absence of baseline results, but its true value cannot be realized since each individual is different).
The George Mason athletic department advises all GM athletes participating in moderate-to-high-risk sports to complete baseline ImPACT pre-season testing. This year, boys tennis has also elected to participate (one of their players sustained a concussion last year during match play). Parents have the option of opting their child out of the baseline testing program, but Coach Galliher says she’s never had a parent refuse.
When Coach Galliher implemented the ImPACT protocol in 2003, George Mason was one of approximately 250 high schools nationwide that were integrating the protocol into their athletic programs. She had sought out the best of training, working at the University of Pittsburgh Medical Center’s Sports Concussion Program with the neuropsychologists who founded the software and testing protocol, as part of her overall ImPACT education and certification.
“The initial reaction [to the ImPACT program] was really positive because we were providing care not available elsewhere,” said Tom Horn, athletic director at George Mason. “And we were removing ambiguities in terms of whose call it is to return a student-athlete to play.”
Many GMHS parents have become believers. “My son’s doctor completely missed the concussion,” said one father. “My son collided with another player in a game last spring and didn’t feel himself afterward. There was no loss of consciousness, no headache, no memory loss, so the doctor felt there was no concussion. But when Coach Galliher readministered the ImPACT test, his performance was so diminished, there was no question he had a concussion. And then we started to see more symptoms a couple days later.”
“Thank goodness she caught it,” the father said. “If we had let him return to play at that time, it could have been very dangerous.”
For Ms. Galliher, the testing protocol also has worked hand-in-hand with symptom monitoring–and with physicians’ instructions, in some cases–in guiding academic planning, managing cognitive exertion, and determining when students can resume a full schedule of school attendance and studying. (In concussion treatment, complete cognitive recovery–the ability to function cognitively without any exacerbation of symptoms–is a prerequisite for reintroducing physical activity. It can take days, weeks, months, or longer for cognitive recovery. Prompt diagnosis and proper management lessen the risk of prolonged recovery. )
Ms. Galliher works with students and families on guiding the recovery process, meeting with students and parents and communicating with teachers and staff about each student’s limitations and progress. Last month at one point, she was working on 14 concussion cases at George Mason and Mary Ellen Henderson Middle School (“MEH”).
For the GM student who sustained a concussion in a hockey game last year, recovery meant several days at home followed by a flexible school schedule (going in late and leaving early) and a study regimen with maximal 10-minute study periods and no computer time (the subconscious mind picks up on the refresh rates of screens). Gradually school and study time increased until symptoms were gone and ImPACT results were back to baseline.
Others have been instructed to be more passive students for awhile, listening to discussions, for instance, but not taking notes or completing worksheets or homework. Some are instructed to retreat to quiet places for breaks, or vary their transit times in order to traverse the halls with fewer students. Many require significant limitations on smart-phone use and texting.
“There’s no standard protocol [in the medical world] for reintroducing cognitive learning as there is for reintroducing physical activity. For me, the whole process [of facilitating cognitive recovery for our students] has evolved…we’ve needed to develop and hone it,” Ms. Galliher said. But with processes in place, “you can feel a palpable sense of relief from teachers and parents,” she said. “Before, you could see how stressed kids were about getting behind on schoolwork, how confused teachers were about giving homework, or not giving homework…no one knew what to do.”
Says one parent of an MEH student who recently sustained a concussion, complaining only of a headache several days later: ”Coach Galliher taught us that the symptoms do not necessarily present as we thought. And it was very important for us to learn that cognitive rest was important to his recovery.” Says another parent of a GM student: “She is relentless and lays down the law” for proper recovery.
Ahead of the Curve
It is a sign of urgency–a sign of the rapidly increasing attention being paid to concussions in adolescent and teen athletes–that 35 states now have laws addressing student-athlete concussions. (In 7 other states, bills are pending.) Several bills addressing concussion safety and management for student-athletes were introduced in Congress in the past two years, but the states have raced ahead, following the lead of Washington State, which in 2009 passed the Zackery Lystedt Law, named after a teenager who suffered a major brain injury after returning to the football field too early.
Virginia’s law requires student-athletes to leave competition or practice when a concussion is suspected, and bars return-to-play on the same day–and until athletes are evaluated and cleared by “an appropriate licensed health care provider” (a definition that includes licensed athletic trainers). The law also requires school divisions to develop policies and procedures for identifying and handling suspected concussions (including addressing academic needs and cognitive demands). Schools must also annually educate coaches and other school staff that advise student-athletes, as well as the students themselves and their parents or guardians.
The Falls Church City Public Schools approved a policy on “Student-Athlete Concussions During Extracurricular Activities” in June 2011 that establishes a “concussion management team” and addresses issues of concussion education and return-to-play decisions. The policy is based on one of the models developed by the Virginia School Boards Association in the wake of the new state law.
To a large extent, however, the new state law and FCCPS policy codify the approach that Coach Galliher and the George Mason athletic department have taken for years. “Coach Galliher brought this to us much earlier,” said Craig Cheney, president of the GMHS Athletic Boosters Association and a former FCCPS school board president. “She’s brought a whole new level of knowledge to us as parents and to teachers. And fortunately, the advantage of a smaller school system is that we can disseminate knowledge much more easily and quickly.”
Ms. Galliher says most importantly, the law puts teeth into efforts to educate student-athletes and their parents. This year, for the first time, completion of an online certificate course about concussions is an annual requirement for each student’s participation in a school’s athletics programming.
“It’s a common perception that football is the main culprit, but for every concussion I’ve seen in GM football, I’ve seen another one in soccer, cheerleading, volleyball, and other activities,” Galliher noted.
Also for the first time, Ms. Galliher provided the same concussion education programming this past fall for MEH faculty and staff, at Principal Ashshaheed’s request, that she has regularly provided for GM staff. Matt Sowers, an MEH school counselor and head coach of the boys varsity tennis team at GM, said the session was informative and impressed upon him how “imperative” it is for educators to understand how concussions can affect students, and to stay on top of the latest knowledge on brain rest and treatment.
“We were amazed at how long [it can take for] full recovery,” he told the Falls Church Times.
Some of our state lawmakers, in the meantime, are discussing the possibility of introducing additional legislation to protect youth who participate in recreational athletic programs, according to Dr. Brenner, who worked with state officials on implementing Virginia’s concussion law.
“One of the biggest research questions right now is, what are long-term outcomes of these young athletes who have concussions–whether it’s one, two, three, or more?” said Dr. Brenner. “Will the 14-year-old who’s had two concussions, for instance, have any memory or attention problems when they’re 30 or 40? We don’t know this quite yet.”
My own review of the medical literature has shown me that research is indeed quickly moving beyond case reports of professional athletes (autopsy-based reports of chronic traumatic encephalopathy in former NFL players, for instance) to more systematic research on brain changes in athletes–both those who’ve sustained symptomatic concussions, and those who incur repeated thumps to the head or other stresses to the brain.
Ms. Galliher is closely watching such research. “As recently as 3-4 years ago, the school of thought was that if you allowed for sufficient recovery, you wouldn’t be at any greater risk for a subsequent concussion,” she said. “But now, regardless of recovery time, we’re starting to see a potential impact of consecutive concussions–on seizure-like activity, for instance, and on [Alzheimer's-like neurodegenerative] changes.”
It is conceivable, said she and Mr. Horn, that in the future, science may identify particular thresholds that will lead to changes in practice parameters–like limits in the number of headers a soccer player should incur during practices. For now, the goals of promoting safe play, ensuring early detection, and facilitating complete recovery are key for FCCPS.
“You can’t cast your brain like you can a broken leg, but you can minimize stimulation and let it rest….You have one opportunity to manage it correctly,” Ms. Galliher said.
NOTE: Coach Galliher will lead a presentation and discussion of concussions and their impact on February 22nd at 7 p.m. in the GMHS Cafeteria. The program, “The Anatomy of an Adolescent Concussion: It’s Not Child’s Play,” is co-sponsored by the FCCPS Student Health Advisory Board and the George Mason Athletic Boosters.
By Christine Kilgore
February 21, 2012