In Conversation With…features an interview between a leader or figure involved in public education and a representative of the Kentucky School Advocate.
As football season begins, this issue’s conversation is with Dr. Michael Miller, co-chair of the Kentucky Medical Association’s Committee on Physical Education and Medical Aspects of Sports, which helps advise the Kentucky High School Athletic Association on sports medicine issues. He also is medical director of the sports medicine department for St. Elizabeth Healthcare in northern Kentucky.
Q: Could you sum up the state’s mandate regarding sports-related concussions?
A: House Bill 281 was passed in April 2012. It has four main points. The main one is that if any athlete has signs or symptoms of a concussion, they are to be removed from play and are not to return to play on that day until they have been cleared by a physician and present a written note.
There are other aspects. We developed an elaborate training and education program for coaches and that is now in place. It is a sports safety course, and one module is on concussion management. We also had to provide educational materials for athletes and their parents. And the bill provides for emergency action plans. Each school has to develop emergency action plans for each (sports) venue and they have to review them annually and rehearse them. The plans are not just for concussions but for any kind of emergency – for example, if a player collapses or has a heat-related illness.
Q: And the law applies to practices, as well as to games?
A: Yes. It does apply to practices. The challenge is a lot of times at practice you may or may not have a health-care professional, so that is where the importance comes in having these coaches well-trained.
Q: What is one of the main challenges schools face in adhering to House Bill 281?
A: It’s been a challenge for many, many years – we often don’t have a team physician at athletic events. We would love to see a licensed athletic trainer engaged at every high school in the state, but at this time that is not the reality. One of the single best things we could do to help safety of the student-athletes in this state is to get a licensed athletic trainer heavily engaged at every high school. That would be wonderful.
Q: Do you think there will be changes to the law?
A: As new research comes in and we get more knowledge, we may need to tweak and modify it. Right now a lot of our focus is to help athletic trainers and coaches, to equip them with the knowledge to recognize concussions. Having the responsibility to recognize the concussion and begin the process is very challenging in the heat of battle. I am trying to do whatever I can to educate those guys on the front line.
Q: What are the dangers of not removing a player who may have sustained a concussion?
A: I have to say that as much as we have learned, there is a lot more we don’t know about the long-term effects of concussions. Our concern comes in two flavors. One, we feel that if an athlete sustains a concussion, and they still have symptoms and go back in and get hit again while still symptomatic, we think that is a high-risk situation and they may be more susceptible to having more severe symptoms and symptoms that are more prolonged. We think we will see fewer problems if we are more conservative, if we don’t have these kids go back too early.
The other thing we are concerned about is the cumulative effect of concussions. We unfortunately don’t know how many concussions are too many. There are a lot of variables, but more and more information tells us it is not good for a young athlete to have multiple concussions. The more that are sustained over a sports career, the more concern we have of long-term problems.
Q: Are there other measures that schools need to take when an athlete sustains a concussion?
A: For many years, a lot of the focus on concussions has been on return to play. We should have been focusing equally on return to learn: how to get them back to the classroom. Early on in concussion management, we were focusing on the athlete and not the student. Now there is a lot of push to help teachers and administrators on what to do with these kids when they show up in the classroom. We need to rest them not only physically but modify them cognitively.
Schools are starting to invite concussion specialists and health-care experts to speak to administrative staff and teaching staff. I am being invited mostly to come in and speak to coaches. I don’t know if I have been in front of an audience that was just teachers, counselors and administrators, and you know, that is the point. We need to be doing more of that.
Q: What are some other ways to prevent concussions?
A: Whenever people ask what we can do to prevent these concussions, two topics come up a lot. People want to know ‘What is the best helmet?’ The reality is there probably is not one best helmet. We are trying to spread the word that the best helmet is the one that fits properly and is used properly.
And there is some thought that neck strengthening is helpful in prevention. There is some debate, but I am of the mindset that it certainly couldn’t hurt.
Q: Can you give some examples of strategies being used across the country to prevent concussions?
A: In the Journal of School Health in April 2012, there were some prevention strategies for youth football. These are suggestions; none is mandated in the state of Kentucky. But the ideas give people an idea of where we may be headed. One was no tackling under the age 16. That, as you can imagine, would be tremendously controversial. Another was a zero tolerance policy for hits to the head.
I will tell you that in California, a law was passed that will limit the amount of contact that middle school and high school athletes can have. That is a trend. Across the country, we are continuing to educate coaches about teaching good technique, such as not initiating contact with helmets, training players to keep their heads up. One idea is to use a two-point upright stance in football rather than the typical three-point stance. The three-point stance causes players to lower their heads; when the ball is snapped, heads come up and that is when a lot of contact comes. But none of these are policies in the state of Kentucky.
Some schools are saying we need to reduce practice times and full-practice drills. During practices at the high school I work with, (Boone County’s) Ryle High School, the coaches are proactive, making efforts to limit contact.
Q: Are incidence rates of concussions increasing or decreasing?
A: Even across the country, it is difficult for us to evaluate the incidence rate of concussions because a lot of concussions are still going unrecognized. Some of the NCAA’s data provides evidence that the rate of concussions has been increasing over the past two decades. The challenge is that the rate may just reflect that we have improved awareness through education. There is no question that we are seeing more patients with concussions, and that is probably due at least in part that we are educating the public and parents and athletes better, so we are picking up on these concussions more than in the past.
Q: Are other factors influencing incidence rates?
A: Some who are concerned that we are seeing more concussions would say we have more and more young children in sports, so they would wonder if with more exposure to contact sports, is the opportunity to get a concussion greater? And then there is always the issue: Are the forces on our athletic fields getting greater? Through data from the NFL, for example, we know those players have gotten bigger, faster, stronger, so that would relate to bigger forces on the field, which could result in more head trauma.
Q: Are we looking at concussions differently than in the past?
A: The criteria for what defines a concussion are changing as we learn more. There was a time when people would say that you didn’t have a concussion unless there was a loss of consciousness. We know now that 90 percent of concussions in a sports setting don’t have loss of consciousness. As we learn more and as the definition has changed, we are recognizing that minor head injuries are causing more trouble than we once thought.
Q: Where can schools find educational and training resources?
A: The KHSAA website (www.khsaa.org) has a lot of links, references and literature. There is also the sports safety course we have to update every two years. And the third level happens more independently. For example, our medical facility, St. Elizabeth Healthcare, has an athletic training conference that we give all our athletic trainers every summer and concussions are always a topic.
Q: There also is a sideline tool that coaches and trainers can use?
A: We have a tool to help us make decisions on sidelines about whether someone has suffered a concussion. It is called SCAT 3. SCAT stands for Sports Concussion Assessment Tool. The pocket version is a battery of questions and quick little tests you can do on the sideline to help in your decision making.