High School Sports Concussions

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On the eve of the start of the high school football season in Arizona, new regulations are being implemented limiting full contact during football practice. Also, a new video game aimed at educating young people about concussions is being released. Concussion expert Dr. Javier Cardenas of the Barrow Neurological Institute at St. Joseph’s hospital and Dr. Tamara McLeod from A.T. Still University will discuss efforts to cut down on concussions among high school athletes.

Ted Simons: Good evening and welcome to "Arizona Horizon." I'm Ted Simons. Another high school football season starts this week and with it an increased chance that some of those on the playing field will suffer concussions. New efforts were announced today to try to slow down the rate of concussions among high school athletes. The new regulations were put in place by the Arizona interscholastic association. And a new video game aimed at educating kids about concussions is being launched by the Arizona cardinals. Joining me now is Dr. Javier Cardenas, a nationally known concussion expert from the Barrow neurological institute at St. Joseph's hospital. We also welcome Tamara McLeod, a professor in the athletic training program at A.T. still university in mesa.

Ted Simons: Good to have you both here. Thank you for joining us.

Dr. Tamara McLeod: Thank you.

Dr. Javier Cardenas: Thank you.

Ted Simons: What is a concussion?

Dr. Javier Cardenas: A mild traumatic brain injury. As mild traumatic brain injuries, you can have alteration of consciousness. You don't have to lose consciousness to have a concussion. It is a dysfunction of brain physiology. There aren't any changes to the structure, but the function really is the problem. The symptoms, headaches, dizziness, and there are sleep problems, as well as trouble with academics.

Ted Simons: Trouble with concussions. Is it the one-time big hit? Is it a succession of smaller hits? How do you know when you're getting in trouble here?

Dr. Tamara McLeod: Sure, I think that after the first one you definitely need to be concerned. We don't really know currently if it is one large hit or a magnitude of smaller number of repeated blows over time that is going to cause the problem. But once an athlete has been diagnosed with a concussion, we need to take the proper steps to make sure that the concussion is managed and they can return to sports and school safely.

Ted Simons: How do you diagnose a concussion?

Dr. Tamara McLeod: The clinical presentation, signs and symptoms that the athlete reports. Educating parents, athletes, coaches is so important.

Ted Simons: Have the signs and symptoms changed? On the sideline after a big hit, trainers talking to them, doing all sorts of things. What are they doing and how has that changed?

Dr. Javier Cardenas: They are looking at different areas. Physical, behavioral, and cognitive realm. Physical realm, balance is being tested. Headaches are another one. They're subjective. You are asking them about headaches. Other things they check in terms of cognition, thinking skills, memory, looking at numbers and repeating things.

Ted Simons: What kind of follow-up? Let's say that you get hit, go to the sidelines, you can count to ten, balance. You wake up tomorrow, you have a headache, hard to get out of bed. Not sure what is going on. Are there follow-up examinations?

Dr. Tamara McLeod: There should be. That is the key to proper management. A lot of symptoms may not present immediately. Sometimes we see personality changes; Sadness, irritability, a lot of things that parents might notice in their children's personality 3, 4 or 5 days after the injury. So if there's any sign or symptom of a concussion, the athlete should be seen by a qualified medical provider.

Ted Simons: Does that change between kids, adults, three, four, five days, could it be weeks, months?

Dr. Tamara McLeod: It could be. There are some cases where concussion symptoms might last over a month. And that's where we really need to start thinking about managing the student as a student in the classroom and so we need to have increased awareness among teachers, as well as health care providers.

Ted Simons: We talked a lot about concussions. CTE, define CTE and tell us what it stands for but what are we talking about here and how serious is this?

Dr. Javier Cardenas: Chronic traumatic encephalopathy is a disorder we've actually known about for a while. The definitions are there. There are usually three changes. One a change in personality. A second, abnormal movements. And the third is what is considered a Parkinsonism any which they have Parkinson-like features and decline in their function.

Ted Simons: Can it be as simple as I'm forgetting where I'm leaving the keys? I don't have any idea what I had for dinner last night. Everything else is fine, memory is shot. Could it be that simple?

Dr. Javier Cardenas: In many cases it could be, especially the early stages of the disorder. So, the evaluation process is critical. Many people when they start having problems, they look back at their history, one time I fell off my bike and hit my head. It is unlikely that that single event caused that problem, as opposed to repeated trauma to the brain.

Ted Simons: Is this something that -- let's say you've played sports, retired, raised your family, later in life, these symptoms, can they pop up out of nowhere? Is it a steady climb? Or do we know?

Dr. Tamara McLeod: I'm not sure that we necessarily know. Studies about CTE, case series, retrospective in nature. We haven't been able to look forward in time and follow someone from a high school or a collegiate career through their professional career and on through retirement. There are centers that are starting to look at that. We don't have the answers yet.

Ted Simons: Question marks still out there.

Dr. Tamara McLeod: Most definitely.

Ted Simons: You hear about athletes. And these terrible stories of these people, gave their lives to football and 40's, 50's, they're just losing it all. Yet most of these athletes don't seem to be suffering from CTE. How do we know?

Dr. Javier Cardenas: Clearly a number of factors. In addition to the trauma to the brain, there are genetic factors, environmental factors. There are a number of issues. Right now, we have point A, which is trauma to the brain, concussion. And we have point B, CTE, and there is a lot in between that we don't understand.

Ted Simons: Genetic and environmental factors, do we have any ideas?

Dr. Javier Cardenas: Some, there are some studies looking at other form of traumatic brain injury. Those who have two copies of the -- also seen in Alzheimer's, there is a body of literature that shows that those people do very poorly in traumatic brain injury. It is incomplete data, but suggesting that there are other factors involved in this problem.

Ted Simons: In laymen's terms here, I'm trying to compare dementia, Alzheimer's, CTE. Give us an overview.

Dr. Javier Cardenas: Issue with CTE, specific changes to the brain seen under a microscope, like Alzheimer's, it can't be diagnosed with somebody alive. It has to be diagnosed post-mortem. The changes that we see in CTE, the microscopic changes are changes to the brain as well, that are seen on the gross pathology and microscopic pathology of the brain.

Ted Simons: You can see some of the things early. But CTE, a little guesswork out there.

Dr. Javier Cardenas: There is a lot of guesswork actually. And as we see more and more athletes donating their brains to science, we're starting to get a better understanding, but once again, this middle piece about what takes somebody from this kind of injury to CTE, we still need to research.

Ted Simons: What is an athlete to do? What is a young athlete to do? What's the parent, the coach, the trainer of a young athlete to do?

Dr. Tamara McLeod: Sure. I think the best thing they can do is become educated on what are the signs and symptoms of a concussion. What resources are available to them in the community, qualified health care providers that their child can see. Parents should meet the athletic trainer employed by the high school and have a good relationship there so there is an open line of communication.

Ted Simons: Is there more of that happening now than in the past?

Dr. Tamara McLeod: I think definitely more awareness, and a lot of it are the initiatives that the AIA instituted with the mandate of the educational program.

Ted Simons: AIA, what kind of mandates -- how are they responding to this, first of all, and secondly, are they responding enough?

Dr. Javier Cardenas: In Arizona, we are taking the lead in this particular issue. Across the country, just about every state now has legislation and policy and policy is largely in three parts: Education, removal from play, and return to play procedures. The educational mandate simply in most cases is signing a piece of paper saying I understand that concussion is bad. What we've done is created an educational module in collaboration with the Arizona cardinals and AIA. We launched it August of 2011, and since then we've had over 180,000 kids complete the concussion education. It is a requirement for any high school athlete regardless of the sport that they play before they can step on the field or court.

Ted Simons: It sounds like the cardinals have come up with a video game. We have excerpts of this thing. Have to get a kid's attention here. Video game, a bunch of helmets hitting each other, that is a way to education kids and parents, is it not?

Dr. Tamara McLeod: Sure, there is literature out there showing the types of apps in video games is good in increasing awareness about concussions and taking the educational message into a medium that fits the way athletes learn today.

Dr. Javier Cardenas: This particular video game, a grant provided to us, Barrow, by the fiesta bowl. Fiesta bowl is really those who funded this program, initiative, with respect to the Barrow brain ball, video game for kids eight to twelve.

Ted Simons: Let's get to the bottom line of what parents need to know, again, coaches and trainers. What do they need to know that they may not know now? With all of the question marks, what can they know?

Dr. Tamara McLeod: Just to understand the immediate signs and symptoms to have a conversation with their child about being truthful should they ever have some of those signs and symptoms after participating, and then seek out a qualified medical professional, athletic trainer at the secondary school, the person who is probably most well versed in concussion, that they have immediate access to.

Ted Simons: Coaches and trainers, what do they need to know and is there some resistance?

Dr. Javier Cardenas: Coaches, athletic trainers, parents, teachers should know in the state of Arizona, an incredible wealth of resources. We have a research registry tracking every athlete, and they should be involved in that. All of the athletic trainers have access to impact baseline testing for every single athlete in the state and they have access to professionals, Barrow professionals, neurologists to provide concussion consultation remotely. In terms of resistance, we're not seeing much of it. In fact, the AIA came out with a new policy that was implemented this year that says in practice, you're limiting the amount of contact. And so no more than half of the time during the preseason can be contact practice. No more than a third of the time during the season can be contact practice. This was created in conjunction with the football committee.

Ted Simons: With that in mind, it sounds like it's a maintenance program here to try and limit concussions. Sports like football, sports like hockey, especially, is there any way to take this risk and lower it? Do you change the equipment? Do you change the rules? How do you keep the spirit of the game alive and try to protect kids?

Dr. Tamara McLeod: Sure. You definitely want kids I think participating in sports. The message isn't that sports are bad. There is lot of positive from participating. If we look at football and hockey, ice hockey has made significant rule changes with respect to body checking and increasing the age at which kids can start body checking. And football technique, properly teaching tackling technique and behavioral modifications are an area that continues to be explored.

Ted Simons: Would you want your kid playing football these days?

Dr. Tamara McLeod: Yeah, I think it would be okay. As long as, you know, people on the sidelines who could manage it well.

Dr. Javier Cardenas: My kids like books and instruments. That said, they would be able to make that decision and I would be supportive.

Ted Simons: It is good to have you both here. Thank you so much.

Dr. Javier Cardenas: Thank you.

Dr. Tamara McLeod: Thank you.

Dr. Javier Cardenas:Barrow Neurological Center, St. Joseph's hospital;Dr. Tamara McLeod:A.T. Still University;

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