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Heading off problems

Amid concern about long-term effects, the state is requiring public schools to act to reduce concussions among athletes

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By Chelsea Conaboy
Globe Staff / August 1, 2011

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As football season gets underway, Ivy League athletes will suit up for no more than two full-contact practices each week this year, a change, announced last month, aimed at reducing blows to players’ heads. Under a pending contract agreement, players in the National Football League will return to new rules that limit practicing in pads, too.

Growing concern about the long-term effects of frequent head trauma has begun to change how the game is practiced and played at the highest levels. But for many of those players, the history of injuries began during their early years on the field.

Public middle schools and high schools in Massachusetts will take steps this fall aimed at keeping student-athletes in all sports off the dangerous path toward long-term damage.

Under a law passed by the Legislature last year, everyone involved with school teams - coaches, volunteers, players, parents, and other officials - must be trained annually in how to recognize concussions and get the appropriate care for students who suffer one.

Any student suspected of having a concussion now must be removed from play immediately and cleared by a doctor before returning. The law also calls for students diagnosed with a concussion to have a written plan for gradually returning to both athletics and academics.

The new rules are “a great step in the right direction,’’ said Dr. William Meehan, director of the sports concussion clinic at Children’s Hospital Boston, who sat on the state advisory panel that helped draft the rules.

While advocates agree that the changes are an important starting point, some argue that more needs to be done to keep children’s brains safe from a harm that is invisible but potentially lasting.

What exactly is a concussion? It is not a bruise on the brain. Nor does it involve swelling or bleeding. A concussion can occur when an athlete collides with another player, a goal post, or the ground, causing the brain to rattle or twist in the skull.

That prompts what is referred to as a “metabolic cascade,’’ a series of changes in which the brain’s nerve cells stop functioning as they should and blood flow is slowed. The process is not fully understood, in large part because researchers aren’t able to probe the brains of people who have suffered a concussion. And the effects are not visible on imaging tools, such as CT scans or MRIs.

If a person rests properly - meaning no physical activity beyond walking, and little cognitive activity - the brain can recover in almost all instances, said Dr. Robert Cantu, a Boston University professor of neurosurgery who has been studying concussions and advocating for better prevention among athletes for decades.

But if a concussed athlete keeps playing and suffers further trauma to the head, the situation becomes very different.

“Then the brain may have not only a very prolonged course of recovery, it may incompletely recover and some cells may die,’’ Cantu said.

Researchers have long known that a subsequent blow, following a concussion, can be fatal. But more recent research around the long-term effects of head trauma by Cantu and others at the Boston University Center for the Study of Traumatic Encephalopathy has markedly elevated the level of concern about concussions.

In conjunction with the Bedford VA Medical Center, the Boston researchers have been studying the brains of deceased veterans and retired NFL players for signs of a degenerative disease caused by repeated blows to the head called chronic traumatic encephalopathy. So far, 14 out of 15 deceased players studied have been found to have the disease, which can affect mood, impulse, and memory.

Cantu and other physicians interviewed for this story cautioned that it is not possible to look at a teenager or young adult who has suffered one or multiple concussions and know if those blows will have an impact later in life. They don’t know how much trauma a person can sustain before the degenerative process begins.

“It is absolutely true that there will be a point in time for most people, if they sustain too many concussions for them, when these concussions will have an additive effect,’’ Cantu said. “For each person that’s different.’’

Still, work by Cantu and others at Boston University provided a wakeup call about the dangers of concussions, said Dr. Lauren Smith, medical director for the Massachusetts Department of Public Health, which was responsible for drafting the new state concussion rules.

Some school officials have criticized the rules, saying they create a whole new system of paperwork for districts already short on resources. Smith said her office has tried to make the regulations flexible, by allowing, for example, teams to satisfy the rules’ training requirements by incorporating concussion education into mandatory parent meetings many already hold.

The goal is to make concussions a bigger part of the conversation around youth sports “so that kids will be protected wherever they play,’’ Smith said.

Current estimates place the number of concussions that occur each year in high school sports in the United States at around 136,000. When Barry Haley started working as a school athletic trainer 26 years ago, concussions were a common issue but not an urgent one. Athletes shook it off and got back in the game.

“There wasn’t any follow-up to it,’’ said Haley, now athletic director at Concord-Carlisle Regional High School. “There wasn’t an awareness of the long-term effects.’’

That’s changed dramatically, he said, through efforts of researchers and advocates, rule changes in the NFL, and high-profile injuries, like the season-ending concussions of National Hockey League players Sidney Crosby and Marc Savard.

“Kids see that,’’ Meehan said. “Parents see that and say, ‘Hey, wait a minute. Something is different here.’ ’’

Even the maker of the popular Madden NFL video-game series is trying to raise awareness. In the latest edition, to be released this month, players on the virtual field are sidelined when they suffer a concussion.

Student-athletes can have a hard time admitting that something is wrong when the consequence is sitting out from a sport they love. That’s where the rules come in.

They need to know “there’s no such thing as toughing their way through a concussion,’’ said Chris Nowinski, a co-director at the Boston University center and CEO of the Sports Legacy Institute.

Teaching people to recognize slurred speech, confusion, nausea, fatigue, or dizziness as symptoms of a concussion helps, Nowinski said. Athletes should be encouraged to tell someone when they suspect a teammate has suffered a concussion - to look out for each other, but also for the good of the team, as a concussed player’s performance will be impaired, he said.

Nowinski will hold three training sessions for coaches and educators at Boston public schools in early September, and he will focus on more than just concussions. He believes people should be thinking about the total burden of trauma to a child’s brain, including hits that don’t result in a diagnosis.

The research around chronic traumatic encephalopathy supports the idea. Some athletes confirmed to have had the disease never had a confirmed concussion.

Nowinski said he would like to see Pop Warner, which last year instituted new concussion rules, reconsider the age at which children should start full-contact football. And youth soccer should be having a conversation about when to allow athletes to head the ball, he said.

“Every hit to the head counts,’’ he said.

Chelsea Conaboy can be reached at cconaboy@boston.com.

NEW RULES FOR THE SCHOOLS

Students gearing up for fall tryouts will have to add a new piece to their preseason routines this year: concussion training. The Legislature last year passed a law aimed at preventing the progression of concussions in student-athletes, and the Department of Public Health in June issued guidelines that people involved in school sports at public middle schools and high schools must follow to comply. Here are a few highlights of what is required:

■Parents, players, coaches, school nurses, volunteers, and others involved with team sports must participate in a state-approved training program each year aimed at teaching people to recognize the symptoms of concussions and understand the risks of playing without proper rest and recuperation. One way schools can cover this requirement is by including these training materials in parent meetings.

■Before every season, student-athletes must file a history of head injuries to be reviewed by the school nursing staff.

■Students who suffer a head injury or suspected concussion during practice or competition must sit out the rest of the day and be cleared by a doctor before returning to play. The goal, said Dr. Lauren Smith, the public health department’s medical director, is to avoid attempts at sideline diagnosis.

■If students suffer a head injury during the season but not during team activities, their parents must report the incident to the coach or another specified school official.

■Students who are diagnosed with a concussion must have a plan, developed in conjunction with their teachers, parents, coaching staff, and diagnosing physician, for gradually resuming athletic and academic activities.

■Schools must report annual concussion statistics to the state.

GET TRAINED

Under the new rules, just about everyone involved in sports at public middle schools and high schools must go through annual trainings on concussions. The state has approved two online training programs:

The Centers for Disease Control and Prevention has resources for parents, coaches, and schools, including fact sheets, video training sessions, and downloadable posters at www.cdc.gov/features/concussion.

The National Federation of State High School Associations links to its own training course at www.nfhs.org.

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