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Monthly Archives: December 2014
After University of Michigan quarterback Shane Morris was waylaid during a play this year, he appeared to suffer a concussion as he stumbled around the field leaning on teammates for support. He proceeded with the next play, then was taken out of the game but put back in later in the quarter. Spectators continued to witness his disorientation, and the announcers commented on why he was still in the game.
Later Coach Brady Hoke and the University’s athletic director, Dave Brandon, came under fire when fans and students demanded resignations for mishandling the sideline situation. A serious miscommunication took place in which the coach and no one on the sideline trained to spot concussions even noticed Morris’ condition for so much as an evaluation. Morris apparently waved help off saying he was OK, but allowing a player–or a coach — to determine a player’s return to the game after a suspected concussive hit is never protocol.
Morris was diagnosed with a probable mild concussion. The university apologized, saying it got the situation very wrong. It’s estimated that 4,000 such concussions are suffered at the college football level.
“As for the incident with QB Shane Morris, that is what happens when trainers and medical folks are not involved. Under the NCAA’s rules this never should have happened,” says Chris Faiella, a Missouri sports and recreation attorney and the author of Unnecessarily Perilous Pastimes. “Unfortunately, the person with the keys to the kingdom is the coach, and coaches get paid for winning.”
Despite what went wrong at Michigan, there are some clear concussion guidelines at every level.
WHAT IS CONCUSSION PROTOCOL?
Generally, the laws around concussion management are a patchwork that varies from state to state. All 50 states have adopted some sort of concussion legislation that applies to school systems, but what it requires varies. “For college sports the NCAA is leader but it has not adopted any legislation, although it has adopted concussion safety guidelines,” says Faiella. Recently the City of Boston adopted an ordinance that imposes similar requirements in all Division 1 high school events involving football and hockey.
The problems with a lack of concussion management are numerous, from the absence of athlete, coach and trainer education to lack of trained personnel. On the high school level, there may or may not be an athletic trainer who is present at sporting events, and there is usually not a physician on the sideline depending on the high school. “Less than 20 percent of high schools in the nation have a true team physician/athletic trainer relationship and while the number of certified trainers is growing at the secondary school level there is still a lot of areas in the country where they don’t have a certified athletic trainer or a physician designated as a team physician on a daily basis,” says Steve Cole, associate athletic director of the College of William & Mary in Virg., who specializes in concussion education and co-developed the SMART (Sideline Management Assessment Response Techniques) Workshop, to train physicians in concussion management.
“When you have a doctor on the sideline, the doctor should make the determination,” says Barry Jordan, MD, MPH, director of the Brain Injury Program & the Memory Evaluation Treatment Service (METS) at Burke Rehabilitation Hospital in White Plains, N.Y., and the Chief Medical Officer of the New York State Athletic Commission and a team physician for U.S.A. Boxing. He is also an Associate Professor of Clinical Neurology at Weill Medical College of Cornell University.
When there is no physician present, then an athletic trainer makes the evaluation for a concussion. “But it should be a team approach. A doctor, athletic trainer and coach should work together and look out for the health and safety of the athletes,” says Jordan.
“Sometimes it’s so obvious you can tell on the sideline they have a concussion. They stumble around, they’re confused, disoriented, thinking it’s January and it’s March or think they are in a different city,” says Jordan. Michigan’s Morris appeared concussed to spectators.
However, just because someone got hit in the head or they stumbled doesn’t necessarily mean they suffered a concussion.
If the diagnosis is not obvious, more detailed testing is required. Jordan says the college level is typically more diligent since there is a team physician and an athletic trainer.
“I think the NFL is doing the best job right now. In addition to the team physicians, the NFL has employed what we call unaffiliated neuro trauma consultants and two physicians are at each game on each sideline whose sole purpose is to look for concussions. And in addition to that there is an athletic trainer in the booth who also looks for concussions.”
Dr. Jordan is one such unaffiliated consultant who spots concussions for the New York Giants. He explains everyone is connected by radio and if a player appears to have taken a suspected concussive hit, they start communicating from the press box down to the sidelines, and the team physician, athletic trainers and consultants get to work sidelining the player for an evaluation.
Cole explains in the commonwealth of Virginia a law has been in effect for about three years that puts parameters in place for concussion management and specifically that you have to provide some education to the student athlete, to the coaches and the parents. “That helps in the recognition side of concussions.”
Players that are suspected of having a concussion should be taken out of play, not returned to the field and then go through a period of rest to give the brain time to heal. “That can be variable but most of the time most concussions will resolve in 7-10 days,” says Jordan.
“The critical part at the collegiate level is that there is clear protocol that the team physician has the final authority of the medical clearance of a student athlete,” says Cole.
RETURN TO PLAY
Before an athlete who has a suspected concussion is cleared for return to play, a licensed health care professional must sign off. In most cases that is a physician, but in some states a licensed physician assistant or nurse practitioner can clear a player.
Players must be asymptomatic and off all medications that treat concussions. For example, you can’t have a player that still gets headaches and is taking pain relievers for those headaches, explains Jordan.
“And really in my opinion, for good concussion symptom management there needs to be frequent follow up,” says Cole.
The risk of serious injury for a player who receives a second concussion while still concussed from a previous concussion could be catastrophic. A concussion that routinely may resolve in 7-10 days could take weeks or months to resolve if a player has another concussion. What’s more, second impact syndrome, which is rare but does occur, includes an exaggerated response to that second concussion which could result in significant neurological trauma including coma, paralysis, long term neurological complications and even death.
BEYOND THE FIELD
Cole is working on the next measure of concussion management at William & Mary, which is getting the professors in on the act when there is an athlete with a possible concussion. Accommodations may need to be offered to the athlete as far as reading, writing, test taking and other classroom issues due to sensory distractions and loss of focus. Some tasks could be difficult for someone who has suffered a concussion. “It doesn’t do any good if the person bombs the final, bombs the class and at midterm they were doing great. So getting our educators aware of those challenges is the next horizon in concussion management.”
You may not think male athletes and eating disorders go hand in hand. Typically those who excel in sports take exceptional care of their bodies, eat the right foods to fuel their physical activity and train effectively to keep their bodies in top form. You may be surprised then to find that 33-35 percent of athletes report eating disorders. Another surprising statistic is that while 7 million women have an eating disorder in this country, so do one million men.
“What I can tell you is when we look at the male stats it does go across a broad spectrum–anorexia, bulimia nervosa, binge eating disorder and what’s also called eating disorder not otherwise specified (EDNOS), and what that means is, it’s not anorexia, not bulimia, not binge eating disorders, but has characteristics of all three. The ones we typically see predominantly in males is EDNOS and binge eating disorder,” says Jason Arnold, PhD., a psychologist on the inpatient psychiatric and eating disorder program at Walden Behavioral Care with locations around Massachusetts and Connecticut.
Arnold also points out that since eating disorders are viewed as women’s disorders, fewer males report them and/or find other excuses for them as opposed to what they really are.
Some are in denial. “If it’s a women’s disorder what does it say about them as young men,” says Arnold. Is there something wrong with them, does it mean they are girly? Is it a direct assault on their masculinity? Arnold tries to normalize it to eliminate any stigma surrounding being male with an eating disorder. “We do know men have eating disorders; they don’t discriminate.”
With athletes, the numbers are almost double the general population, and a lot of that is going to be due to the pressure that the athletes put on themselves and that coaches may be putting on them, explains Arnold. “What we see is there is a desire to be within a specific weight class, to monitor the fat in the body and to build muscle.”
WHO’S AT RISK FOR EATING DISORDERS?
Arnold says high school athletes are most at risk though athletes can develop an eating disorder at any age. There may be a lot of pressure to succeed, bulk up or play well from both parents, coaches and the athlete themselves. “And one thing we see with eating disorders across the spectrum both male and female, is they have a very rigid perfectionistic quality about their character or temperament, and they think they have to be perfect,” says Arnold.
“I think we know now through research that there are biological and temperamental aspects that put people at risk for developing an eating disorder and that’s true for males and females,” says Jennifer Lombardi, an anorexia survivor and executive director at Eating Recovery Center of California.
Certain biochemistry aspects such as preexisting anxiety or depression, temperament factors such as struggling with self-directedness or knowing who you are, being sensitive to change or conflict, and having a very driven perfectionistic personality raises an athlete’s risk.
RED FLAG BEHAVIORS
“I’ve worked with a number of athletes and typically the warning signs you see is they don’t just do the practice that is required for their sport, they tend to go above and beyond and exercise even to the point of injury or illness, and also oftentimes they are not fueling their bodies properly for the activity they are engaging in,” says Lombardi.
Experts says athletes whose sport requires a weight class such as wrestling and rowing or sports that require weight maintenance, either keeping weight low like gymnasts or jockeys, or high like linebackers, may be more susceptible but all athletes are at risk. Newsweek reported that 40 percent of Cornell University football players surveyed engaged in binging and purging, which is associated with bulimia.
So even when athletes are at the top of their sport and engaged in high levels of coaching and training, you often see someone go outside of those practices and engage in even more exercise for extensive periods of time. They tend to over-train and not fuel or nourish their bodies appropriately.
“If I were a parent or a friend if I notice that somebody’s behavior around food has changed significantly or they are counting calories or weighing or measuring food that would be one potential red flag,” says Lombardi. Another would be a significant change in their exercise routine.
A lot of must do’s instead want to’s surround exercise and working out regardless of weather, injury or illness. There may be a compulsive quality to training and they are willing to sacrifice other things in their life in order to maintain their workout routine and/or their eating patterns.
Eating or exercise that has no flexibility whatsoever based on social events, illness, injury or even time constraints are also signs an athlete may be struggling with an eating disorder.
Has an athlete had undiagnosed anxiety or depression? In terms of their temperament, are they highly harm avoidant meaning they don’t like change or conflict? Are they people pleasing or perfectionistic? “Those are the genetics that load the gun, and when we look at environmental factors, the trip wire behaviors are dieting and intensive exercise, and if that has been introduced for some reason in that person’s life, they are much more at risk to fully develop an eating disorder,” says Lombardi. “Genetics loads the gun and environment pulls the trigger.”
WHAT CAN PARENTS DO?
If parents suspect their athlete may have behavioral changes surrounding food, exercise or overtraining, they should talk to their coaches sooner rather than later, and also get their primary care doctor and a nutritionist involved. Alerting their doctor to a potential problem may provide the necessary intervention as well as asking the help of a dietitian to put the athlete on the right kind of meal plan for his level of activity. Once experts get involved in the name of health, nutrition and proper training, athletes may listen more closely than if it’s perceived as mom or dad nagging to eat better or not workout so much.
Left untreated eating disorders are serious, life threatening illnesses that can cause devastating health, relationship and productivity problems. There’s no difference in success rates between males and females who get help but Arnold says people do have to be ready to get their eating disorder under control. The earlier and more aggressively and seriously you treat an athlete with an eating disorder, the better outcome they will have.