PERMALINK: Tackling a silent epidemic
Tuesday, August 24, 2010
As a sophomore at Austin Prep in Reading, Mass., James Orrigo suffered two concussions in the first half of a varsity lacrosse game.
The first one happened when he was cross-checked by an opposing player and his helmeted head hit the ground. Not knowing he had a concussion, Orrigo says that he stumbled to his feet and returned to play. He registered an assist on a goal later in the half, and when he turned to high-five a teammate he ran into the blunt end of the same opponent's stick.
That blow gave Orrigo concussion No. 2, and left him lying on the field unable to move.
"The kid was standing over me, saying, 'Get up,'" Orrigo said. "So I got mad and tried to grab his leg, and that's when I realized I couldn't move."
Eventually Orrigo was able to crawl to the bench for halftime, where he sat alternately crying and laughing, experiencing little sensation in his hands and slurring his speech. No one suspected what had happened to Orrigo. When halftime was over, the coach shouted at him to go back into the game.
"I said I can barely stand up, there's no way I'm going back in," Orrigo said.
Eventually doctors diagnosed Orrigo with post-concussive syndrome, and for about a year and a half he struggled to get back to normal. He dealt with headaches and depression; was told by school administrators that he might benefit from taking a year off; had trouble speaking, often stuttering and forgetting what he had been saying; and experienced a change in personality. Orrigo's normally sunny disposition clouded over.
Massachusetts lawmakers, following the example of several other states, last month passed legislation aimed at avoiding situations like Orrigo's, regulating return-to-play procedure after a concussion in high school sports. Gov. Deval Patrick signed the bill into law on July 19, and officials are working to implement it in time for the fall season.
Today Orrigo, 19, is back to his sunny ways. He's a sophomore at James Madison University in Harrisonburg, Va., not far from his boyhood home in Alexandria. He says he's glad Massachusetts is taking steps to educate people about concussions, because he realizes that he's fortunate he didn't suffer worse consequences than he did.
"I should've been dead," Orrigo said. "I'm lucky to be alive, because the concussions were so close together. I should've been a vegetable."
The legislation states that no athlete who has suffered a concussion, or is suspected to have suffered a concussion, may return to play in the practice or game in which the injury occurred. The legislation also states that any athlete who has suffered a concussion, or is suspected to have suffered a concussion, must submit written authorization to return to play from a licensed physician, licensed neuropsychologist or certified athletic trainer. Furthermore, the legislation mandates participation in an athletic head injury safety training program and requires all athletes to provide information on any previous head injury history at the start of each season.
Supporters of the bill call it an important step in addressing the concussion issue. But Paul Wetzel, spokesman for the Massachusetts Interscholastic Athletic Association, said "the most significant parts we've been doing for some time." The MIAA has for years had on the books a return-to-play policy, which requires medical clearance after a concussion or a suspected concussion, and a mandatory course for coaches, which includes information on athlete safety. And every student athlete must have had a physical exam within 13 months, Wetzel said, including a medical history, which must be provided by an athlete's parent or guardian. That medical history would include any history of concussion or concussion-like symptoms.
"So on the field and on the team we don't think there'll be much noticeable change," Wetzel said. "We are concerned about the short time to implement the law, because the governor added an emergency preamble, so it takes affect Sept. 1, as we understand it. So the testing and some of these things, that's really a short two-week, three-week period to meet that deadline.
"Contrary to what many people think, August is a very busy month for high school administrators. Now comes a new paperwork project."
Two doctors who support the bill also said they hope the state will take further steps, such as requiring coaches to be certified in athletic concussion management and encouraging further training for doctors in the diagnosis and treatment of concussions.
Dr. Robert Cantu, a clinical professor of neurosurgery at Boston University Medical School, the chief of neurosurgery at Emerson Hospital in Concord, Mass., and a co-director of the BU Center for the Study of Traumatic Encephalopathy, said he was thrilled with the legislation, but added, "there really isn't any teeth in it yet."
"I think the educational efforts at coaches, the educational efforts at parents, and the educational efforts at athletes are all noble and good and a step in the right direction," said Cantu, a renowned concussion expert who has testified before Congress about the concussion crisis in the NFL, and testified multiple times in the run-up to the passing of the Massachusetts legislation. "But over time we'll need to step it up higher, step up the qualifications of the people who are letting [students] go back [to competition]."
The law requires coaches, athletic trainers, school physicians and nurses, athletic directors and parent volunteers at all public schools and all MIAA member schools to undergo an educational program, which will be adapted from materials already available free from the Centers for Disease Control and Prevention. The materials include the signs and symptoms of a concussion, questions to ask a treating physician and warnings about the potential long-term consequences of playing with a brain injury.
The latter issue is one of the most important, according to proponents of the law.
"That's one of the problems that we've seen: kids want to play," said Massachusetts state Sen. Steven A. Baddour, the primary sponsor of the bill. "If they don't see blood, don't see a broken bone, they want to shake it off and play. But again, you can't shake off a head injury."
Playing too soon after sustaining a concussion, or a traumatic brain injury (TBI), greatly increases the likelihood of suffering another brain injury and of suffering long-term effects, and puts athletes at risk for second-impact syndrome (SIS). SIS is a relatively rare condition in which the brain swells rapidly, occasionally leading to paralysis or even death.
"It's a very injurious thing to allow anyone with symptoms of a concussion to play," Cantu said.
According to the CDC, each year U.S. emergency departments treat about 135,000 sports- or recreation-related TBIs, including concussions, among children ages 5 to 18. And according to the Brain Injury Association of America, as many as 3.8 million people suffer sports- or recreation-related concussions in the United States each year.
Those numbers may actually be higher, as many concussions go unreported and many concussed athletes are not taken to emergency rooms.
Beth A. Adams, a neurotrauma rehabilitation specialist based in Salem, Mass., says that many concussions initially go undiagnosed because the symptoms are often subtle and because doctors must rely on patients for key information, which patients sometimes withhold.
"I've seen countless people in the emergency room given two Tylenol and told it's a headache, it'll go away," Adams said. "A few days later, it hasn't gotten better. The kid says, 'Gee, I'm taking a lot of stuff and it still hurts,' and he's starting to get depressed."
Adams believes that even well-regarded physicians sometimes miss the signs of concussions because they simply don't have enough experience diagnosing them, and hopes that in the future that deficit will be addressed.
"People need to know what they're seeing, because [concussions] can be mismanaged," Adams said.
"Concussion is often referred to as the silent epidemic," Cantu said. "It's not always easy to look at somebody and see if they've suffered a concussion.
"If you look at someone on the football field and one leg is going the wrong direction, it's pretty obvious that something is wrong. It's not the case with concussions."
The vast majority of concussions occur with no loss of consciousness, and most concussion victims are able to conceal their symptoms, according to Cantu. Therefore it is important not only to inform athletes, coaches and parents of the risks of concussion but also to impress upon them the benefits of reporting and recovering from a concussion early on.
CDC materials aimed at student athletes contain the catchphrase "It's better to miss one game than the whole season." In fact, attempting to do too much -- physically or cognitively -- too soon after suffering a brain injury can worsen symptoms and delay recovery, according to Cantu.
"Coaches more than anyone need to realize that in the long run it doesn't help the athlete or the team to play an athlete with a head injury," Baddour said. "If you sit them out sooner rather than later, they can probably play longer and better and have more fun."
While the legislation may not make a huge impact on the field for the MIAA, Wetzel said the increased publicity of the issue and the broadened educational efforts should have an impact on another important group: parents.
"All the continuing references make parents aware that the idea of telling kids, 'Suck it up, get back in the game. This game is important, go back and play,' is not a great one," Wetzel said.
And though educating the public is important, ultimately it may prove more important to change the mindset when it comes to brain injuries.
"Athletes themselves won't typically remove themselves from the game," Adams said. "There's too much at stake for them."
Orrigo, who can never play contact sports again because of the risk of further brain injury, agrees with that sentiment, but argues that it's something that has to change.
"There's this almost old-school, macho attitude," Orrigo said. "You're doing the sport, you need to suck it up. Who are you kidding? It's just a sport.
"There shouldn't be that much pressure on these kids to suck it up and not be a wimp. Someone could die because of that. If I went back in, I would've been dead for sure. It gives you a different outlook on life."
Jack McCluskey is an editor for ESPN.com
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