When kids are involved in contact sports like soccer and football, there’s a common parental fear of injury, and even when youngsters are at home just playing — chasing, roughhousing, jumping on trampolines and the like — worries are constant because, let’s face it, it’s easy to get hurt. And while most injuries are readily apparent, concussions are particularly scary, because it’s often very hard to discern when one has occurred.
According to the American Medical Society for Sports Medicine, up to half of all concussions are not reported —which isn’t surprising given this related statistic: 47 percent of athletes feel no symptoms directly after receiving a concussive blow.
Take the case of Sam Schneider, a high school sophomore in St. Louis. As a striker on his school soccer team, he played a key scoring position that was constantly under attack. In a game against a rival team, he took four hard falls and pushes to the ground. But, he kept playing.
Not once did anyone think Sam had suffered a concussion because nobody on the sidelines saw him take a hit to the head.
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“There was never one giant moment in the game when anyone thought he should be taken off the field,” recalled Sam’s mom, Alison Schneider.
That evening, however, warning bells went off. Sam complained of a headache. Schneider told her son to take an Advil.
“He just looked at me right in the eye, blankly. As if he wasn’t looking at me at all,” she said. “About 45 or 50 seconds later, he said, ‘What did you say?’ ”
The Schneiders made sure to check on Sam throughout the night. And they consulted with a doctor. But Sam’s first visit the next day was with the school’s athletic trainer, who held key information: results of a computer-based test Sam had taken earlier in the fall that had scored a selection of his cognitive abilities.
A baseline test
Clayton is one of at least a dozen St. Louis area schools now using — and in some cases requiring — a baseline concussion assessment test for its athletes. The 25-minute test, typically given to students every two years before the start of the athletic season, scores cognitive, memory, response time and visual recognition skills.
In the days after an injury, retaking the test can confirm a decline in skills and a possible concussion. Later, a school or physician will re-administer the test to see if those skills have recovered to the baseline scores. That can indicate whether the athlete is healed and ready to return to play.
“Before this test, to get back to that level of play — it was always kind of a guessing game,” said Clayton High School athletic director Bob Bone. “This is a little bit more concrete information that we’re using, and it makes us feel better about the decisions we are trying to make.”
Research ramps up
This is an age of growing research about the debilitating effects of untreated or repeat concussions. And with the growth of youth sports, there is greater concern about young athletes. But there is still no standard medical test for a physician to unequivocally “see” a concussion.
Concussions are brain injuries at the cellular level that cause adverse biochemical reactions, but they are not seen by MRIs, CT scans or other X-rays. Rather physicians rely on many evaluations. Those appraisals — along with reported symptoms such as headaches, nausea and fogginess — can lead to a concussion diagnosis.
In today’s ramped-up youth sports scene, despite studies that suggest 5 percent to 10 percent of athletes experience concussions during a specific sports season, it can be easy for a minor concussion to be missed. It is not uncommon for student athletes, parents and even coaches to minimize symptoms because kids want to play.
Bone said baseline and post-injury testing takes the pressure off coaches and parents making sometimes emotional decisions about kids returning to play.
At Clayton High School, the athletic director and physicians — not the coaches — make that call, he said.
“I know with coaches, especially in high-contact sports, the tendency used to be, if the kid gets dinged, as soon as they said they felt OK, they’d try to get them back in,” he said. “Now it’s not that way.”
Last year Clayton High School began contracting with the company ImPACT Applications Inc. to use its testing system. The company is one of about four nationwide that provide the service. The school’s parent-teacher organization paid the $1,000 fee and the program is optional for all athletes, although most opt in.
The test measures certain neuro-cognitive functions associated with memory and reaction speed. It is scored in six areas: verbal memory, visual memory, visual motor speed, reaction time, impulse control and reported symptoms.
In some sections test takers are required to first remember a series of words, images or symbols and to later use a mouse to click on images or words that match what they saw earlier — think the childhood game Perfection or the card game Memory. Another part asks takers to click as fast as they can on numbers descending in order from 50 to zero. One section mixes word memory and image memory problems together.
At least one school in the region has expanded required baseline testing to include middle school students. Mary Institute and St. Louis Country Day School had already required the testing among all of its high schoolers for about seven years. Next fall it will include seventh- and eighth-graders.
“Most of our seventh- and eighth-graders are also playing sports, and they are in contact sports like our upper school kids are,” said MICDS head athletic trainer Stacey Morgan. “It just seemed logical to include them.”
An ImPACT official could not estimate the number of schools using the testing but said use has increased dramatically across the country in the past two years. The company is the first to warn that the testing is not going to prevent concussions, nor revolutionize concussion care. It’s one of many approaches that should be used together.
“This doesn’t identify 100 percent of any concussion,” said Doug Tauchen, director of technical support for ImPACT. “This is just a tool that good, trained physician will use to identify what’ s going on in this individual.”
A physical is essential
Scott Bayes, a primary care sports physician with Blue Tail Medical Group and a certified provider of the test for some high schools in the region, said computer testing pales compared with the value of a full physical examination that includes assessment of balance and other issues.
And he warns that ImPACT tests taken after an injury are only valuable when compared to pre-injury baseline scores, because baseline scores take into account such things as pre-existing learning disabilities or cognitive deficits that could also drive down a score.
Alison Schneider said Sam got the best of care with Clayton High School and an affiliated physician.
The morning after the game, when he visited the school’s trainer, his memory and balance problems were obvious. So his next stop was a visit to a physician. Schneider said Sam’s doctor concluded that even though his head may not have taken a direct hit during the game, his brain probably shifted during the impact of hitting the ground, causing the concussion.
Rest for mind, body
In retrospect, Sam thinks he may have hit his head when he took a spill at the end of the field and landed on a part of the running track surrounding it.
Recovery took about eight weeks. First there were several days of deep mind and body rest: no physical activity, no school, no television, no video games, no loud music or bright lights. Then there were school half-days.
Sam was given a homework pass for about three weeks and a pass on tests for six weeks to let his brain rest and heal. Bone, the athletic director, said Clayton High now considers a gradual re-entry into academics just as important as a careful re-entry into athletics when it comes to proper concussion recovery.
It wasn’t until Sam took the ImPACT test and scored better than his initial baseline test that he was fully cleared for athletics in early January.
“I think definitely the nicest thing was to know there was something numerical to base decisions on,” Alison Schneider said.