Rules Proposed for Gauging Head Injuries

Coaches in youth sports should be more concerned with even mild concussions and learn to administer tests to immediately determine the possible extent of brain injury to their players, researchers reported Wednesday.

“Coaches and players need to understand there is no such thing as a minor concussion,” said Dr. Jay H. Rosenberg, a neurologist with Kaiser Permanente’s San Diego Medical Center and a member of the research team that published the reports Wednesday in the journal of the American Academy of Neurology.

“While you can put ice on an injured knee or pulled muscle, you can’t ‘ice’ the brain,” Rosenberg said.

The articles and proposed guidelines to test injured athletes represent a significant escalation in concern expressed by the medical establishment about one of the most common and undetected kinds of athletic injuries.

Rosenberg and other head injury specialists vowed to mount a campaign to persuade groups such as the California Interscholastic Federation, which regulates school sports, to adopt uniform guidelines on how to spot and assess concussion injuries.

The old standard, which states that unless an athlete loses consciousness he or she has not truly suffered a concussion, is wrong and harmful, the researchers said.

A neurology academy committee chaired by Rosenberg has devised simple memory and exercise tests that coaches can administer on the sidelines. Kaiser Permanente pledged to provide laminated, pocket-size cards to assist coaches and trainers in making evaluations.

CIF commissioners in San Diego and Los Angeles expressed interest in having the academy’s guidelines evaluated by coaches, trainers and physicians. Now, there is no statewide CIF rule on when a player should be removed from a game, with different regions and school districts free to adopt their own standards.

“A study such as this is of great interest to me,” said Barbara Fiege, CIF commissioner for the Los Angeles Unified School District. “It is my intention to provide coaches with as much information as I can. This is a very highlighted area right now.”

The report--which included original research and an analysis of numerous studies of sports-related head injuries--comes amid national concern about injuries to young athletes, including the deaths last fall of high school football players from Coronado High School near San Diego and Reseda High School in the San Fernando Valley.

“Nobody wants to see parents pulling their kids out of organized sports,” said Dr. Kenneth M. Viste Jr., president of the American Academy of Neurology. “We just want to make sure that once players strap on their helmets and play the game, their supervisors have all the necessary tools to provide the best immediate care possible, should the need arise.”

The guidelines have been endorsed by the American Orthopedic Assn., the Brain Injury Assn., National Athletic Trainers Assn., Pop Warner Football, USA Hockey and other groups.

At a news conference in New York, the guidelines were supported by former pro football linebacker Harry Carson and former pro hockey player Brett Lindros, both affected by brain injuries suffered during competition.

“I learned that the brain, unlike a muscle, cannot be rehabbed time and time again,” said Lindros, forced into premature retirement from the New York Islanders.

Carson, who played 13 years with the New York Giants, suffers from the cumulative impact of multiple concussions.

One of the top concerns of the neurology academy committee is that--like Carson--young athletes are at great risk of damage from the cumulative impact of concussions, even if none of the concussions was bad enough to cause unconsciousness.

In addition to the guidelines, the journal Neurology published articles by Rosenberg and Dr. James P. Kelly, director of the brain injury program at the Rehabilitation Institute of Chicago, and by researchers from the Northwestern University School of Medicine, the Rehabilitation Institute of Chicago and the Covenant Medical Center of Waterloo, Iowa.

In their article, Rosenberg and Kelly cite research that 100,000 concussions a year occur in football below the level of professional. Concussion is defined as trauma-induced alteration in mental status that may or may not involve loss of consciousness.

Concussions are divided into three categories. Grade 1 is confusion and disorientation that clears up within 15 minutes; Grade 2 is confusion and disorientation that lasts more than 15 minutes, and Grade 3 is loss of consciousness, regardless of brevity.

The guidelines suggest that for a Grade 1 concussion the athlete should be removed from the game and tested every five minutes until he is symptom-free; for Grade 2 the athlete should be pulled from the game, examined by a doctor within a week and not permitted to play again until he or she has two symptom-free weeks. For Grade 3 the athlete should be taken immediately to an emergency room.

Rosenberg said that until everyone involved with youth sports abandons the “macho mentality” that encourages playing with injuries, athletes will continue to be hurt by “second impact” injuries or cumulative impacts.

“The problem is that too many coaches and athletes view the Grade 1 concussion as just a ‘ding,’ or ‘getting your bell rung,’ a kind of rite of passage or Purple Heart that an athlete has to learn to endure,” Rosenberg said. “That’s just wrong. A brain injury is unlike any other injury to the body.”

Last fall, Reseda High football player Eric Hoggatt, 18, was found dead the morning after a game against Chatsworth High School. His parents have filed a wrongful death lawsuit against the school district, alleging that their son should not have been sent back into the game after complaining of dizziness and tingling in his extremities.

Coronado High player Adrian Taufaasau, 17, never regained consciousness after being tackled by Costa Mesa High School players during a game at Newport Harbor High School. He died two days later.

In both cases, autopsies proved inconclusive in pinpointing the cause of death. Officials from the San Diego County medical examiner’s office suggested that the head and neck injuries that killed Taufaasau may have been incurred during several tackles.

Since the death of Hoggatt, two partnerships have been formed between Los Angeles Unified high schools and medical groups to provide both professional and student trainers to athletic teams.

“It puts a very knowledgeable professional person on site, working not just reactively, but proactively to prevent injuries,” said CIF Commissioner Fiege. “This seems to be the wave of the future.”

Times staff writer Steve Henson in the San Fernando Valley contributed to this report.

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Recommendations to Youth Sports Coaches

Here is an explanation of the three levels, or grades, of concussions and treatment as recommended in the journal of the American Academy of Neurology.

GRADE 1 CONCUSSION

Symptoms

* Transient confusion (inattention, inability to maintain a coherent stream of thought and carry out goal-directed movements).

* No loss of consciousness.

* Concussion symptoms of mental status abnormalities on examination resolve in less than 15 minutes.

Recommended Response

* Remove from contest.

* Examine immediately and at five minute intervals for the development of mental status abnormalities or post-concussive symptoms at rest and with exertion.

* May return to contest if mental status abnormalities on examination resolve in less than 15 minutes.

****

GRADE 2 CONCUSSION

Symptoms

* Transient confusion.

* No loss of consciousness.

* Concussion symptoms or mental status abnormalities (including amnesia) on examination last more than 15 minutes.

Recommended Response

* Remove from contest and disallow return that day.

* Examine on-site frequently for signs of evolving intracranial pathology.

* A trained person should reexamine the athlete the next day.

* Neurologic examination by a physician to clear the athlete for return to play after a full asymptomatic week at rest and with exertion.

****

GRADE 3 CONCUSSION

Symptoms

* Any loss of consciousness, either brief (lasting seconds) or prolonged (lasting minutes).

Recommended Response

* Transport the athlete from the field to the nearest emergency department by ambulance if sill unconscious or if worrisome signs are detected (with cervical spine immobilization, if indicated).

* A thorough neurologic evaluation should be performed, including appropriate neuroimaging procedures.

* Hospital admission is indicated if any signs of pathology are detected, or if the mental status of the athlete remains abnormal.

Sources: American Academy of Neurology; Kaiser Permanente