Chris G. Koutures, MD, FAAP Pediatric and sports medicine specialist

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Comprehensive blend of general pediatric and sport medicine care with an individualized approach that enhances the health and knowledge of patients and their families



Proud physician:
USA Volleyball Mens/Womens National Teams
CS Fullerton Intercollegiate Athletics
Chapman University Dance Department
Orange Lutheran High School

Co-Author of Acclaimed Textbook

Pediatric Sports Medicine: Essentials for Office Evaluation

Orange County Physician Of Excellence, 2015 and 2016


Filtering by Tag: concussion in high school athletes in california

How Much Rest Right After a Concussion?

A 16 year-old running back suffers a direct blow to the head in a Friday night game. He immediately has a headache and dizziness and is removed from the game. He is sent home in the care of his parents after a discussion of particular signs and symptoms that would require emergency evaluation, and follow-up on Monday has been arranged with the his pediatrician.

In the meantime, what should he be able to do over the weekend?

Traditional post-concussion recommendations have focused on strict limitations in both cognitive and physical activity until resolution of concussion-related symptoms. The “cocoon treatment” where absolute avoidance of all stimulation, often carried out in a dark bedroom for several days, was one such initial recommendation.

More recent data suggests that over-aggressive reduction of cognitive and physical stimulation may actually prolong post-concussion recovery. Thomas et al in Pediatrics  found that a strict 5 days of rest resulted in more daily reported symptom scores and slower symptom resolution versus 1-2 days of rest followed by stepwise return to activity. Zemek et al presented a paper at the 2016 Pediatric Academic Societies Meeting reporting that exercise within seven days of injury was associated with nearly half the rate of persistent post-concussive symptoms, or those that last beyond a month.

Striking a balance between overstimulation and understimulation is best done on an individual basis taking into account symptoms and patient preference. Allowing brief (initially 10-15 minute) intervals of activity such as light reading, listening to music, easy walking,  or even texting can reduce feelings of isolation and foster recovery. Patients should focus on one activity at a time (no “multitasking”) and should immediately stop activities that result in worsening of symptoms. Regular medical follow-up evaluation can help determine further at-home activity recommendations and also guide return to learn and ultimate return to sport progression.

Cal AB 2182: Forgets Most Crucial Player in High School Concussion Management

I'm going to applaud the intent of California AB 2182 to help identify and protect high school athletes dealing with concussions.

I'm also going to applaud the sensible decision by legislatures to put the brakes on a state-wide implementation and rather request a smaller pilot program instead.

Now, I'm going to stop clapping and start getting upset.

Here's the crux of AB 2182:                                                                                                            The bill would require a school district, charter school, or private school that offers an athletic program to pay for neurocognitive testing or provide neurocognitive testing, as defined, for pupils who participate in interscholastic athletics in any of 12 designated sports. The bill would require this testing to take place at the beginning of an athletic season before any competitions have taken place, within 72 hours after any head injury and would require that this baseline testing be repeated at intervals not exceeding 24 months for as long as the athlete is enrolled at the school. The testing would be supervised by a licensed heath care provider who is trained in the management of concussions or other head injuries and is acting within the scope of his or her
practice. (emphasis mine)

Anyone associated with high school sports medicine knows full well that a Certified Athletic Trainer is absolutely the most qualified and appropriate health care provider to supervise any form of on-site injury monitoring program such as neurocognitive testing,

It is a embarrassing farce that California is the only US state not to recognize and license Certified Athletic Trainers, so in essence, the same governor that has twice vetoed professional license status now could be asked to support a bill that would potentially create unmitigated disasters without the expertise and contributions of Certified Athletic Trainers.

Who else would be best suited to organize pre-season testing, analyze those results and share with school officials and professional colleagues, deal with athletes who missed or sandbagged the initial testing, arrange for post-injury testing and help confidentially communicate those findings with concerned athletes, coaches, families and fellow medical treating professionals in often emotional and time-sensitive environments?

Anyone else going to line up for this job?

And let's not forget that neurocognitive testing is just one facet of concussion evaluation, and is not the definitive, "pass or fail concussion test" that many have been led to believe.

Appropriate concussion management takes into account many components (including symptoms, balance, vestibular/ocular function, academic performance, mental health) and the ultimate return to both the classroom and the athletic field requires an individualized multi-step process that often requires a team of health care providers.

Let's not also forget that concussions aren't the only issues frequently seen on the high school campus. Every other athletic-related injury requires professional evaluation, management, and coordination to determine severity, need for treatment and rehabilitation, and determine criteria and ability for return to play.

Again, who is the most qualified professional for this job?

You got it, the Certified Athletic Trainer.

Yet estimates show that only 40% of high schools have the most important components of concussion and all injury advocacy and management walking around campus on a daily basis.

So, I'm very frustrated with our California governor and his lawmakers.

Rather than address known, existing crucial deficiencies in providing licensure to Certified Athletic Trainers and funded employment opportunities, the decisions supporting AB 2182 would rather put time and money into testing that likely will not have the necessary foundation for success.

My professional experience has shown that if the allocation decisions were up to me and many of my fellow sports medicine specialty colleagues, we'd take that time and money to fund Certified Athletic Trainers and get our athletes a high return on that investment.

I certainly hope that some, if not all of the pilot schools are institutions that don't have Certified Athletic Trainers so those who analyze the results will get a practical impression of the true struggles raised by this bill.

Now, maybe in a somewhat backwards fashion AB 2182 will actually reveal the importance and expose the lack of Certified Athletic Trainer participation in the daily health and injury identification and monitoring, leading to state-based license recognition and unprecedented levels of placement in high school around the state.

If this happens, wow, then I will really be ready to applaud!