Written by Brandon George
Texas' UIL falls behind on concussion policy
The University Interscholastic League's concussion protocol isn't up to date with stricter national guidelines and features more relaxed recommendations for how soon athletes should return to play after head injuries.
Over the last eight months, the NFL, NCAA and National Federation of State High School Associations have adopted stricter concussion guidelines to deal with a complex, dangerous injury that often produces more questions than answers.
The UIL has improved concussion management and education since 2004, but troubling issues linger for Texas' high school athletes, many of whom start football practice this month:
•Unlike guidelines recently adopted by leading concussion experts, the UIL leaves it open for an athlete to return to play on the same day if the athlete hasn't lost consciousness and concussion symptoms are resolved within 15 minutes.
•Like its heat guidelines, the UIL concussion protocol is merely a set of recommendations and isn't policed.
•Fifty-three percent of public schools in Texas and about 92 percent of private schools don't have a full-time certified athletic trainer on staff. Additionally, 33 percent of public schools in Texas (mostly at the Class A and 2A levels) and 87 percent of private schools don't even have weekly access to a certified athletic trainer.
•UIL athletes must fill out a medical history form each year before competing in athletic activities. The forms feature questions that don't always deliver in determining concussion history. National experts say that about half of all concussions go unreported, and therefore undiagnosed and untreated.
Kevin Guskiewicz, director of the Sports-Related Traumatic Brain Injury Research Center at the University of North Carolina and one of the nation's leading concussion experts, said the UIL's concussion protocol "needs to be more stringent" regarding return to play.
Guskiewicz led a 2003 study that found that 33 percent of college football players who returned to play on the same day they suffered a concussion in a game developed symptoms three hours after the game ended.
"My question back to whoever is making that [UIL] policy is, 'Are you sure that the athletic trainers or the team physicians who are making that decision to return within 15 minutes have the tools in place to really ensure that they have not had a concussion?' " he said.
"If they have had a concussion, there's no question that they should not return to play on the same day. If the issue is, 'Well, they appear to be a little dazed and there is nothing else showing up and we don't believe that they've had a concussion,' they better be sure that they have objective tests to validate that diagnosis or nondiagnosis and that return-to-play decision. You should always err on the side of caution."
Risks of concussions
In 2004, the Dallas-based National Athletic Trainers' Association released its position statement on sports-related concussions. The UIL implemented its concussion protocol for the 2004-05 school year as "suggested guidelines for management of head trauma in sports." UIL policy director Mark Cousins said the UIL adopted its protocol from the Brain Injury Association of America.
"Even though schools have their own material they use and develop it on the local level, as long as it works in conjunction with this protocol, we feel like we've been able to provide our coaches with a consistent way that it should be handled," Cousins said. "It's something that we continue to look at and study the new trends that are coming, but we feel like we're in a pretty good place of making people aware of head injuries."
Athletes can suffer permanent brain damage from repeated concussions, even minor ones, and youths often take more time to recover from a concussion than adults because their brains are still developing. Under second-impact syndrome, a second blow to the head - even a seemingly mild one - before a first has healed can lead to death.
Tamara C. Valovich McLeod, a leading national concussion expert, said that a victim is at risk for future concussions, and that for each one symptoms seem to linger longer and recovery time lengthens. McLeod, an associate professor at A.T. Still University in Arizona, said that if the first concussion is treated appropriately, a second one is easier to treat.
"We're dealing with high school kids who, if you tell someone, you might not be able to play," McLeod said. "I understand the position you're in because playing Friday night is the most important thing to them. But if you don't tell someone, you're going to have prolonged symptoms and you may be out for the season."
Cousins said that Texas schools' lack of athletic trainers often leaves medical decisions in coaches' hands.
Most Class 5A and 4A schools have at least one certified athletic trainer on staff, but 3A and smaller schools often don't. Almost always, a certified athletic trainer is present at a UIL football game, but practices frequently go on without a medical professional on the sidelines.
"So if they don't have an athletic trainer, the coaches are making those decisions sometimes," Cousins said, "and we have to make sure the coaches are educated enough to make the right decision and know the right protocol."
In 2007, the Legislature passed "Will's Bill," which requires every UIL school employee connected to athletics to take an annual safety training program, including head injury treatment. Texas was the first state to pass such a law. The law was named for Will Benson, an Austin high school quarterback who died after a head injury.
"That's something that's been really helpful. It makes them more aware of the information and what's going on," Cousins said of the bill.
UIL protocol criticized
Cedar Hill football coach Joey McGuire took his annual test in late June. McGuire, who has two full-time athletic trainers on staff, said he believes the UIL is doing enough to educate coaches about concussions.
"They are taking more and more steps," McGuire said. "The things that are happening are because there are more studies being done and it's in the public more."
Bucky Taylor has been one of the state's most educated high school athletic trainers with regard to concussions. Taylor, who recently retired after 36 years as Mesquite High School's athletic trainer, said he believes that more than half of UIL schools don't follow the concussions protocol.
"With TAKS and this and that and No Child Left Behind and all this other stuff they have to deal with, some of this stuff just doesn't get read or told to them," Taylor said.
He also said that the protocol doesn't have "any teeth to it."
"If I'm a coach at X-Y-Z High School and I put a kid back in a game, who is going to stop me and who is going to punish me?" Taylor said. "The policing of rules is a big deal. The UIL really has no police authority."
Several area districts, including Mesquite and Dallas, have developed their own concussion management policies. Athletic trainers use a variety of cognitive testing tools to diagnose a concussion.
McLeod said every athletic trainer should use a SCAT2 card, a tool developed in 2008 by a group of international experts meeting in Zurich, Switzerland. The card, which can be downloaded from the Internet at no charge, standardizes treatment and follows the most up-to-date recommendations, known as the Zurich Consensus.
An estimated 130,000 high school athletes in the U.S. annually suffer concussions.
Andrew Ahfeld suffered one his junior year playing on the defensive line for Frisco Centennial. Ahfeld, who graduated in May, recalled getting "nailed" on a helmet-to-helmet hit.
"You couldn't really get your legs underneath you," Ahfeld said.
Athletic trainers gave him three words - banana, paper and pencil. Twenty minutes later, when asked, Ahfeld couldn't recall the words. The trainers took away his pads and helmet. He was sidelined for two weeks.
In his senior year, Ahfeld "saw stars" after some collisions, something that he said he never mentioned to athletic trainers.
"Everyone gets that," Ahfeld said.
Travoy McCarver, a wide receiver at Fort Worth Paschal, was knocked out during a game last year. Forced to miss nine days, including a game, the senior chafed while others practiced and played.
After sitting out practices, McCarver would return to the school and run or do drills without the athletic trainers' knowledge.
"I was mad that I couldn't practice," he said.
A concussion history
Concussions account for nearly one in 10 sports injuries, according to the Centers for Disease Control and Prevention.
But the number is probably much greater.
A 2004 study in the Clinical Journal of Sports Medicine found that only 47 percent of all concussions in high school football were being reported.
Reasons for underreporting can vary from an unawareness of what a concussion is to ignoring the issue so that playing time isn't lost.
"The problem with that is if 50 percent of the athletes are not reporting concussions, they may continue to play and then they could get hit again," McLeod said, "and get in a situation with second-impact syndrome, and it could be a catastrophic event."
Before UIL students can participate in sports each year, the students and their parents or guardians must complete a physical evaluation of medical history form.
The form's questions are designed to determine if the student has developed any condition that would make it hazardous to play sports.
According to the Zurich Consensus, "A structured concussion history should include specific questions as to previous symptoms of a concussion, not just the perceived number of past concussions."
Texas' form is vague, asking "Have you ever had a head injury or concussion?"; "Have you ever been knocked out, become unconscious, or lost your memory?"; and "If yes, how many times?" The form also asks "When was the last concussion?" and "How severe was each one?"
"With those types of questions, you miss a lot of concussion history," McLeod said.
Most students and parents view a concussion as being knocked out and are likely to answer "no" if the child has never lost consciousness. Less than 10 percent of athletes who suffer concussions lose consciousness.
In 2008, McLeod surveyed about 500 Virginia high school athletes, asking them a series of questions - both specific and broad - to determine their concussion history. She found that 8.5 percent reported having suffered a concussion and 3.8 percent reported having been "knocked out" while playing sports, but 25 percent said they had been "dinged" or had their "bell rung" and 55 percent said they had suffered concussion symptoms, such as headaches, vomiting or memory loss, after a head injury.
Generally, the colloquial terms "dinged" and "bell rung" should not be used to describe a concussion, McLeod said, because they diminish the injury's seriousness. But the terms can be useful in fishing for an athlete's concussion history.
Through her research, McLeod helped make the concussion history questions on Arizona's medical history forms more wide-ranging. Texas' form is evaluated annually by a UIL committee.
"We wanted to see how they responded depending on how we phrased the question," McLeod said. "We saw that it really makes the difference in how you ask the question."
The overriding theme of concussion management, Taylor said, is to err on the side of caution and take a team effort to identify and treat the injury.
"We make decisions so these youngsters can live long, productive lives and they don't have dementia when they're 45 or shaking when they're 45," Taylor said. "I like the motto of, 'When in doubt, keep them out.' After all, these are kids' lives we're talking about."
Staff writer Mark Dent contributed to this report.