Pearl River Adds ImPACT, Concussion Management Plan

Pearl River Athletic Trainer Frank Amadio stresses the education of parents, teachers and athletes regarding the dangers involved in suffering any kind of brain injury.

Concussions can cause brain damage and even death and the risk goes up for individuals who take a second blow to the head while already suffering from one.

"I tell the kids I'm not being that health teacher who tells you something to scare you into not doing something. I'm telling the truth. I'm not even sugar coating it. If you go out with a concussion and suffer another concussion, you could die," Pearl River Athletic Trainer Frank Amadio said. "It sounds extreme, but it has happened. It's rare, but it should never happen. It doesn't have to happen. We're here to prevent injuries. Second-impact syndrome is 100 percent preventable when we and athletes and coaches all follow protocols."

The Pearl River School District took further steps to protect its students from head injuries when the board of education adopted a new concussion management policy in compliance with state law Aug. 21. 

"We began assessing athletes sooner than required by the state, but did not have the policy language until late," Pearl River Superintendent of Schools Dr. John Morgano said. "We have everything in place. We were ahead of the curve on this." 

Many of the procedures are not new to Pearl River. They are things that Amadio and other medical personnel were already using to evaluate and treat students with concussions. 

"With the new protocols, which I support, it is five days from your last symptom," Amadio said before the policy was adopted. "Say you are two weeks in and you still have dizziness? You are not cleared. The last day you have any symptoms, add on five days. That's what we do now." 

The policy also includes the creation of a concussion management team that includes Amadio, Pearl River Director of Athletics Todd Santabarbara, a school nurse, a physical education teacher, a coach and the district's chief medical officer. All coaches, including volunteers, must undergo training in dealing with concussions.

The biggest change for Pearl River is the use of the ImPACT testing system with all sports beginning this fall, which is used to help measure the recovery of people who have suffered concussions. 

Part of the problem in dealing with concussions is that doctors and trainers must rely on athletes to self-report many of the symptoms. Blows to the head that knock an athlete unconscious are rare, as few as 10 percent of all concussions. Brain injuries are far more likely have only more subtle symptoms. Amadio listed some other signs of concussion:

• Headache
• Dizziness
• Blurred vision
• Ringing in the ears
• Sensitivity to light
• Memory loss
• Confusion
• Delayed speech
• Numbness in the face
• Tingling
• Nausea and vomiting

"The number one symptom of a concussion is a headache," Amadio said. "That's all you need to have. One symptom. If somebody has a headache after a mechanism of a concussion, which can be a blow to the head or a fall and hitting their head on the ground or a strike to the face.

"Loss of consciousness is clearly a sign of concussion, but those are more severe and not as common as people think. Nausea, in my history, comes with much more severe concussions. Most concussions are, 'I feel a little dizzy and I have a headache."

That brings in the complication. Athletes want to play and they know that a concussion can keep them out of the game for a long time. Even a Grade 1 concussion, a minor one, typically means two weeks before returning to activity.

Athletes may dismiss the symptoms as nothing or hide them so they can participate in their sport.

"An athlete could easily say they don't have any symptoms, but they are throwing up at home," Santabarbara said. "They just want to get back in."

That is where the ImPACT testing system comes in. Pearl River tried it out with boys lacrosse last spring and began preseason testing of all of its fall athletes last week. With ImPACT, athletes are tested before the season to get a baseline measurement of their brain functions. They are tested again after a possible concussion, with the baseline providing a basis for comparison. That comparison is used by the trainer and the athlete’s physician to make an evaluation of the person's recovery. 

"This is why we are so excited about the ImPACT diagnostic program," Amadio said. "You can't see a headache. You can't see dizziness. You can't see what they are feeling. You can only observe their symptoms.

"If they say they have no headache, how do I know? ImPACT is another tool that is going to allow us to read the brain. It is very, very scientific and very helpful in evaluating the true readiness to play."

Pearl River football Head Coach Jeff Michael was excited to hear about having a tool to better evaluate concussions.

"That's awesome," Michael said. "A concussion is bran damage. You don't want anyone out there playing with that. You hear about (former NFL players) in their old age barely functioning or they can't function in their everyday life. You don't want that. You want (student athletes) to go through your program healthy.

"If it is something that they can measure their condition properly, it's a tremendous asset."

Santabarbara and Amadio both compared ImPACT's testing method to a video game. It measures things such as memory, reaction time and concentration. They also pointed out that it is nearly impossible to fool.

"There really is no way," Amadio said. "You can't study for the test. It's like a video game. You can't really fool it."

"It is really a tool to help in our efforts to identify and better manage concussions sustained by student-athletes," Santabarbara said. "We piloted it with the boys lacrosse program this spring because it is a contact and collision sport. That's where we began with the idea in mind that come the fall, we would try and test all of our fall varsity athletes."

Pearl River was able to try ImPACT for free through a program with Dick's Sporting Goods. It costs $500 to purchase. Some high schools in the Lower Hudson Valley have already been using it. Others, like Nanuet, also addded ImPACT this year, though Nanuet will only be testing its athletes in football, boys and girls soccer and cheerleading. 

Rye Country Day School was among the first in the Lower Hudson Valley to use ImPACT and Rye High School followed in 2009. Athletic Trainer Richard Norman brought the program in at Rye Country Day School. He said that concussions could be even more of a danger in young athletes, whose brains are still developing.

In data compiled by the Brain Injury Association of America, there are between 1.6 and 3.8 million concussions suffered in the United States each year due to sports or recreational activities. 

"To me, the most important thing to understand is that concussions are a part of life and sports," Norman told Patch in 2010. "There are car accidents or somebody can just be fooling around. They are going to happen. It's how you manage them that [is] the real issue."

Long-time Pearl River girls soccer Head Coach Tim Peabody has seen the change in awareness and knowledge of head injuries from his own playing days and through his coaching career.

"I don't think people were less conscientious when I was young. I don't think anybody really understood," Peabody said. "When I was a player, I wanted to be on the field. I didn't know there were long-term implications to it. You can love to play something, but if it's unhealthy because you have some type of injury, the adults need to know better and be able to step in and tell the kids this is not going to work." 

Identifying and Managing Concussions

Amadio takes on much of the responsibility for dealing with injuries among Pearl River's athletes, but he can't be everywhere.

"If I'm on site and I'm in the presence of the injury, I'm looking for signs and symptoms immediately on the field," Amadio said. "From an impact or a fall, I'm observing their behavior. If they are slow to get up, it is obviously a sign that something is not right. 

"But I'm only one person. I can't be everywhere, so I rely on my coaches. They are all certified in coaching classes. They know how to identify the symptoms of a concussion. I rely on them to notify me immediately if there is any blow to the head."

Peabody said he also counts on his team captains to help monitor their teammates. 

"I make sure the team knows if for some reason a kid zones out or maybe is inattentive because she headed a ball and I didn't see it, I make sure the captains know right away they are to stop the kid and come tell me," Peabody said. "With 25 kids, you won't always catch it. I make sure at least three kids know if they are worried, they tell me."

Michael said he also tries to educate the players regarding the importance of being honest about injuries. He doesn't want his players covering up injuries. 

"We call those kids practice heroes," Michael said. "We don't want that. We stress that we need you to last the season. You are no good to us if you put yourself at risk. Why do it to yourself?"

Concussions are graded based on severity. Amadio said that a Grade 1 concussion, which is relatively minor, will typically keep an athlete on the sidelines for two weeks, though it differs on a case-by-case basis.

A Grade 2 concussion usually involves a loss of consciousness. The typical recovery is three-to-six weeks, but can be longer. The new Pearl River policy mandates at least five days of being symptom-free with the student returning to his or her activity on the sixth day, which Amadio said he did even before the district policy came into play.

Amadio said he also takes the athlete's history into account. Anyone who has suffered a concussion is more susceptible having another.

"You take an athlete who has had several concussions and it's totally different," Amadio said. "You are much more cautious. Once you have one, it is easier to have another."

Amadio said that new research indicates that head-on collisions are not as likely to cause a concussion as one that leads to a rotation of the person's head. 

"If it twists your head quickly, there is a much higher rate of concussion," Amadio said. "This is information from conferences and workshops. It's a hot topic now. You have to keep updated and current as the technology gets better and the diagnoses get better."

Part of avoiding concussions is teaching athletes to protect themselves. Using proper technique helps, as does strengthening the neck. Mouthpieces also play a role. 

"Mouthpieces have a huge impact," Amadio said. "It is often overlooked. The mouthpiece's number one job is to reduce shock to the brain, not to protect the teeth. That is a big misconception." 

The definition of a concussion is also often misunderstood. Amadio said it is important to educate athletes and their families. 

"Where I think we can make a huge improvement is educating the parents more," Amadio said. "You have people with all different understandings. I have parents with that old-school mentality. He just got his bell rung. That expression doesn't fly. That is a concussion.

"I had a parent say that if you hit your head, you have a concussion. That's not true."

Concussions Pose A Threat in All Sports

Though sports such as football and hockey are most often associated with concussions, there is a risk of brain injuries in all sports. In fact, according to the Journal of Sports Medicine, girls soccer is second only to football in the number of concussions.

"It is not just the contact and collision sports," Santabarbara said. "With girls soccer, there is evidence of a higher incidence due to them having weaker necks."

Santabarbara pointed to this report on Rock Center with Brian Williams about the high risk of concussions in girls’ sports.

One topic in that report is the damage that heading the ball can cause. There has even been some debate about eliminating heading from soccer, though that would fundamentally change the sport.

Peabody said that at least limiting the number of times athletes play the ball with their heads can help.

"From my experience in 27 years doing this, I believe if you and I collide in a game and one of us ends up with a concussion, that can happen in any sport," Peabody said. "The reason why the number is higher in soccer and girls soccer specifically is the number of times the kids head the ball gets to a point where it is too many. There is a cumulative effect. I don't think it's just one time heading the ball."

The concern about a cumulative effect of blows to the head has also been discussed in football. Peabody compared the issue in soccer with pitch counts for pitchers in baseball, which are also meant to protect the athlete from injury.

"The precaution is similar for me in the sense of me limiting the number and intensity of head balls that we do," Peabody said. "If we do it, we do it the right way.

"I made the analogy about pitching only because it gives a relevant (method to prevent injury), but it's in no way a comparison of the injuries. With the head and arm, there is no comparison."

This is another area where the new policy helps. Students may want to return to play and their parents may agree, but the school still has to follow the set procedures. The policy supports the school in the case of parents pushing to have their child return to play. 

The concussion management team will take on the role of implementing the policy and ensuring that its mandates are followed. The policy also calls for the district's chief medical officer to make the final determination, so a doctor must clear all students before they can return to their activities.

Those stipulations help address some criticisms that have been made against New York State's Concussion Management Awareness Act. Dr. Mark Herceg, director of Rehab Psychology and Neuropsychology at Burke Rehabilitation Hospital recently argued that it should mandate the creation of concussion management teams and treatment of all students with concussions by a doctor. Those are not requirements of the law, but they are part of Pearl River's policy.

Second Impact Syndrome

One of the most important facets of protecting athletes from the dangers of head injuries comes back to the point of making sure they never participate in activities while suffering from a concussion. 

A study released in 2011 reported 17 deaths among football players due to second-impact syndrome from 1980 to 2009. The deaths may be rare, but they are also preventable.

The Denver Post ran this report on the 2004 death of Jake Snakenberg, a ninth grader who died after a relatively minor hit due to second-impact syndrome. More recently, 16-year-old Ridge Barden of Homer High School in Phoenix, NY died after collapsing on the field, a victim of second-impact syndrome. 

"We're talking about second-impact syndrome," Amadio said. "The concept is if a concussion is defined as a bruise to the brain, imagine bruising the bruise. The swelling is so rapid and so confined in a small area the space between the brain and the skull. It's a very small space for cerebral spinal fluid. If you bruise a bruise, which is a second impact on that concussion, you run the chance of closing that gap between the brain an the skull and that swelling can cause coma or lead to death." 

The National Football League is currently facing lawsuits from former players accusing the league and medical staffs on their individual teams of misleading them regarding the dangers of concussions. Earlier this summer, lawyers representing approximately 80 former players filed a joint lawsuit. 

"People are becoming more educated," Santabarbara said. "There are a variety of new sources out there to educate people. I don't know if it's a culture shift. It's not like concussions never existed. Now people are recognizing the after-effects."

There have been no incidents of an NFL player dying directly from second-impact syndrome, but according to this report and others, studies of former players who died young showed evidence of brain damage caused by concussions. Such damage has been listed as a potential cause of the suicides by former players Dave Duerson and Junior Seau. Seau's family has agreed to allow his brain to be studied, but those results are not available yet.

Former NFL fullback Merril Hoge, now a television analyst, was cleared to play five days after suffering a concussion in August of 1994 while playing for the Chicago Bears. He suffered a second blow that Oct. 2. He managed to make it to the trainer's room, where he had to be revived after he stopped breathing. When he woke up the next day, he was unable to recognize his wife, his brother or his daughter. Hoge had to re-learn how to read and never played again. 

According to this report in the Pittsburgh Post-Gazette, Garrett Webster was the representative of the Brain Injury Research Institute who contacted Seau's family. Webster's father, NFL Hall of Fame lineman Mike Webster, suffered from dementia, depression and erratic behavior before his death at the age of 50 in 2002.

Though concussions are a danger in all sports, football is still the one with the highest risk.

According to Patrick Huber, project lead for the UPMC Sports Concussion Program up to 3.8 million concussions are recorded every year, with 47 percent occurring in football. Thirty-four percent of football-related concussions happen in practice, 65 percent in games.

USA Football offers a series of videos regarding concussions, ranging from the symptoms to proper treatment and preventative measures. The videos can be found here. 

The research into the diagnosis and treatment of sports concussions is ongoing, but education continues to play a major role. Sometimes that is as simple as a school's athletic trainer making sure athletes realize that they risk brain damage if they try to play with a concussion.