Students are most susceptible to brain injury

THE IMAGES ON THE VIDEO are almost too painful to watch.

On Sept. 24, Katie Fellows, a gung-ho forward for BYU women's soccer, positions herself for a header on a long, arcing kick coming across midfield. Lindsey Kasser of the University of Washington sails in at full speed to challenge. Much like the rest of BYU's season, the ball goes Fellows's way and she wins the header.

But Kasser, a moment too late and a few inches too low, connects instead with Fellows's temple. From three camera angles and in slow motion: limp limbs, dropping like dead weight, the Brigham Young University junior is unconscious before she hits the ground.

Concussions are high-profile events for high-profile players. Eric Lindros of the NHL, Steve Young and recently Trent Green of the NFL have all suffered career setbacks or forced retirement, just to name a few. But until recently, the group most susceptible to traumatic brain injuries has been relegated to the bench.

High school students are on the receiving end of at least 68,000 concussions a year, according to the Centers for Disease Control and Prevention. There are likely many more though, because young athletes seldom report the injury. New studies outline dangerous trends in concussions, and professional leagues such as the NFL and NHL are teaming up to promote concussion education.

Fellows's September collision was at least her third since she was a freshman in high school, and the worst that coach Jennifer Rockwood has seen in her nearly 20 years at BYU. It was the worst most anyone had seen. As Fellows hit the ground, players were already yelling for the trainer who was on the field before getting the OK from the referee. Fellows was out cold for three and a half minutes, a frighteningly long time considering most bouts of unconsciousness tied to concussions only last 15-20 seconds.

The same thing that makes Fellows endearing to teammates and coaches, and devastating to opponents, is the same thing that makes her and other young athletes susceptible to brain injuries:

"She goes through people," Rockwood said.

Brain bruise

Remember when your older brother would punch you in the armfi A yellow-brown bruise would form, though if you could dodge the bully for a week, it would fade away. That's the way Dr. Brent Rich explains concussions to high school athletes.

When a football player is hammered, or a soccer player lands on her head, the player's brain smashes against the inside of the skull, essentially leaving a bruise, said Rich, the director of Utah Valley Sports Medicine for the Intermountain Medical Group. The damage can be deadly, though it typically varies from mild to moderate.

"The brain is pretty resilient. Given enough time most people will recover," Rich said.

But remember that your brother would track you down again and again, each time pounding on the bruisefi The pain would get excruciating and it also meant that the spot on your arm would forever be susceptible to easy bruising. When related to concussions, that problem is even more troublesome for youth, whose young brains are still forming and have shown themselves more susceptible to severe and long-lasting damage even after just one concussion.

Those who have had a concussion are four times more likely to have another one, said James Eagar, a trainer at Timpview High School who will be graduating in December from BYU with a degree in sports medicine. Eagar, a boulder of a man who played high school football, has had "three or four" concussions of his own, several in high school.

Football accounts for the most concussions by volume. While specific numbers were unavailable, area trainers say reported concussions range from four to 12 per season, per team. But while football often receives the most attention, a new study shows that girls may be more prone to traumatic head injuries.

Due to appear in the next Journal of Athletic Training, the study from Ohio State University indicates that girls' soccer is second only to football in reported concussions. That is followed by boys' soccer and girls' basketball.

Fellows's concussions started in high school, with one as a freshman and another as a junior. The first was the most severe and happened when she once again led with her head. The nearby goalie, trying to double-punch the ball away instead hammered Fellows.

The hope of trainers and doctors is that as education about concussions increases, even the most purblind athletes will come around to the significance of head trauma.

"When you see someone who's had a significant concussion you wake up to the realities," Eagar said.

Impervious to reality

The problem is that teens seldom understand reality, and teen athletes couple that with a kamikaze mind-set.

"When a kid gets in there with the adrenaline running ... they're going to do what they always do," said Ben Ross, Timpview's athletic trainer of 16 years.

Trainers like Ross have to hold their ground against coaches who don't want to bench a star player, parents looking for scholarships or glory, and players who just want to play, said Rich, who is also a team physician for BYU and UVSC.

Ross and other local athletic trainers have indeed squared off with all three. The players are the trickiest, as they tend to avoid rather than argue with those looking out for their safety. Players have come up with myriad ways to stay in the game if they suspect they have a concussion. From hiding on the bench until the last possible moment to swapping jerseys to memorizing answers to concussion questions that trainers ask, they'll do it all with splitting headaches, blurred vision and a lack of balance.

"The thing that was sad is that the kids would hide it from me," says Donny Bills, Provo High School's trainer.

One method that trainers use to test for concussions is to have series of words that players would repeat forward and backward.

The problem is that the list would get out. Eagar said while he was working with one team, he would hear them up and down the sidelines or in the gym or in classrooms repeating the words over and over. "Elbow, apple, carpet, saddle, bubble. Elbow, apple, carpet, saddle, bubble. Elbow, apple, carpet, saddle, bubble."

When trainers determine a concussion has been sustained, they take steps based on severity. If a player was knocked out, that's it for the game. If the player wasn't, but trainers deem it serious enough, they still pull the player, even if not everyone agrees.

"If we have somebody that bad, what we will do is take their helmet and stuff away," Ross said.

Those trainers will be getting some help in January, when a group made up of the NFL, NHL, the National Athletic Trainer's Association and the National Academy of Neuropsychology launches a concussion education campaign.

"Often, brain injuries initially go unrecognized," said Chuck Kimmel, president of NATA. "The goal of this program is to educate individuals on the importance of rapid recognition and treatment of concussions to ensure the athlete is ready to return to play."

But when to returnfi

Diagnosis

After her first high school concussion, Fellows was told by a doctor several weeks later that she would have to wait a year to play again.

"I kicked the bleachers. I walked out, I kicked a chair in the hallway and I just started crying because sports were my life," she said.

Another diagnosis determined she could play as soon as the next day, and so she did.

Concussion science is relatively new, says Rich of Utah Valley Sports Medicine. Tests that were used just a few decades ago are now generally ignored. One of the first such tests was based on how long someone had been unconscious. No black out, no concussion.

That, of course, is not the case.

Perhaps of all local trainers, Bills has seen the most serious repercussions of head trauma and a missed diagnosis. Eleven years ago Brad Bohrer sustained two concussion over several weeks. While he didn't hide the problems he was having, he was treated by a doctor for whiplash, not a concussion, after the first incident. The second resulted in permanent damage that left him largely incapacitated to this day.

Understanding the severity of concussions now starts with such things as the Standardized Assessment of Concussion, or SAC.

The test includes a litany of questions on the date alone: Monthfi Date todayfi Day of the weekfi Yearfi What time is itfi

Toss in a balance test, concentration test and others and then add up the score and compare it to their baseline. Even then, there are plenty of wildcards.

"There's not a cookbook, and everybody wants a cookbook," says Rich, who has managed 400-500 concussions.

So is the concussion going to lead to death, as it has several times across the country for young football playersfi Or is it going to wear off in 10 days and you'll be right back in the thick of a corner kickfi CAT scans and MRIs can show some of the damage done and the technology is improving.

But each person reacts differently to a concussion, which makes personal contact and understanding of the student all the more important. That responsibility again comes back to the trainer.

"The problem with taking care of concussions is you have to know the athletes," Rich says.

High schools in Provo, Nebo and Alpine districts all have athletic trainers.

Prevention and treatment

Education can help reduce the number and impact of concussions, but the changing culture of high school sports is negating many of the positive gains.

Athletes are much bigger, and the collisions more earth-rumbling. Consider that 20 years ago, only about two dozen players in the NFL were 300 pounds or heavier. A cursory glance at Utah County high school rosters shows at least a dozen in that category this year, and many more within 20 pounds of that.

It's not just size. More and more, high school athletes specialize in sports. The student who used to play multiple sports is disappearing in favor of those who practice all year for a single season, many in the hopes of a college scholarship. That means they know how to hit harder and jump higher.

Equipment can sometimes overcome force of motion, or at least blunt it.

Helmet makers such as Riddell and Schutt make helmets that they claim reduce concussion frequency by up to a third. But they tend to cost more and schools are on tight budgets. Bills, the Provo trainer, said they try to rotate helmets out regularly but gear that could protect boys from serious brain damage simply isn't available in any kind of quantity.

Soccer players also have head gear available but it's rarely used. Fellows, the BYU player, won't use one though teammate Natalie Nate-Henriksen does because of repeated concussions, said Rockwood, the coach.

Some rules can be put in place to help remove some of the risk. Spearing, i.e. hitting with the head, in football results in a serious on-field penalty. If the yardage is punishing enough, coaches will drill it into players that it can hurt the team's chances of winning.

But all the education, equipment and rules won't stop concussions completely, and so treatment is the next option.

The problem with treatment is that in all but the most serious cases, it's simply a matter of waiting for the brain to heal itself because there isn't much that be done medically. And that doesn't go over so well with coaches and players who have a limited number of games to win or showcase their talents.

It's frustrating for Bills, too. He'd rather see a sprained ankle, or even a broken bone, because that's something he can see and know for sure that it has mended. But until something comes along that more accurately shows if brain trauma has healed, he's more than happy to take the heat for benching a player.

"Some day we might have one die," he said. "That's what scares me."