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

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Pediatric Sports Medicine: Essentials for Office Evaluation

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Filtering by Tag: concussion in sports

Six Common Indoor Volleyball Injuries

Working with Olympic level male and female volleyball players has allowed a unique appreciation for common injuries patterns seen in this wonderful yet demanding sport. Since there are six players on the court, I will identify six  frequently seen injuries and will also focus on key prevention tips for players at all ages.


1) Concussions

Most of the concussions I encounter are seen in liberos or defensive specialists, usually from direct impact either from attempted passes of hits at the net or collisions with other players or objects (poles, chairs on courtside) when diving for a ball. I have also seen a fair amount of concussions resulting from mis-matches on the court, namely defensive players trying to return serves or hits from much stronger and older players.

Any new sign of concern (such as dizziness, headache, blurred vision) or behavior change after head trauma should mandate removing the player from all activity and not returning until appropriate clearance from a sports medicine specialist who is familiar with concussion care. 

For more information about dealing with sports-related concussions, click here.

Prevention tips for the volleyball player include calling  for balls before starting a dive, ensuring defensive players are aware of incoming balls during hitting/serving drills, limiting older and stronger players from hitting into younger players, and protecting the boundaries of the court to limit impact with chairs or other objects.

2) Shoulder injuries

Between serving, setting, passing, hitting, blocking and diving, the shoulders receive an amazing array of demands, so it should be no surprise that shoulder injuries are among the most common volleyball-related concerns.

Most shoulder injuries are due to repetitive use and overload stress  leading to common abnormalities. Tightness in the front of the chest leading to a more forward position of the dominant shoulder can reduce normal function of the rotator cuff muscles, leading to pain and decreased hitting and serving accuracy and speed.  Tightness in the back of the shoulder glenohumeral joint can decrease the follow-through phase of hitting or serving and lead to problems with the labrum (soft tissue past between the ball and socket), the inside of the elbow, and even the lower back.

Appropriate stretching exercises combined with strengthening exercises of the scapula (wingbone) can reduce the risk of shoulder overuse injuries. Avoid hitting and serving with signs of fatigue (balls tend to go long with reduced speed) or any form of shoulder pain. Reducing the overall number of hits/serves can help, but more formal hit or serve count recommendations have not been studied at this time.

3) Finger/Hand Injuries

Tend to see finger joint sprains and dislocations mostly with blocking at the net. Rigid wrists with widespread  and relaxed fingers not only allow better ball placement down in the opponents court, but also reduce the chance for acute injuries.

The widespread finger position does place unique stress on the skin web spaces between the fingers that can lead to lacerations or breaks in the skin that are extremely difficult to heal, even with the placement of sutures. Better to prevent these lacerations in the first place by moisturizing the skin between the fingers on a daily basis. 

4) Low Back Pain

Volleyball-related back pain can come either from leaning forward such as with passing or following through on a serve/hit or more with leaning back such as in setting or initiating a serve or hit. Pain that is more with leaning forward could cause issues with the discs between the bones of the lower spine, while pain leaning back could lead to stress injuries of the posterior spine or joints.

It is amazing how much shoulder dysfunction (discussed above) can lead to back problems in volleyball players. If you haven't already, take the time to review post linking shoulder issues to back problems.

Learning how to initiate movements with the gluteal muscles in the buttock area can reduce stress on the lower back, especially with jumping. Single leg gluteal strengthening activities are particularly recommended. Certain technical errors, such as reaching too far for passing or hitting, can also increased forces on the lower back. Setters should attempt to make contact with balls right above their head- reaching too far forward for front sets or backwards on back sets is not the best for long-term back health.

5) Knee Pain

If you are a volleyball player who doesn't have knee pain, then either you are extremely fortunate or perhaps in a bit of denial. 

The repetitive jumping in volleyball often leads to pain in the front of the knee, especially in the patellar tendon connecting the kneecap to the shin bone. Throw in frequent knee contact with the hard wood court surface and you have a recipe for knee problems.

For healthier volleyball knees, pay attention to the following recommendations:

  • Avoid landing on straight knees. Always land and move "softly" with hips, knees and ankles in a bent position.

  • Try to land in good alignment, with the hips and kneecaps lined up with the second toe. Don't let your knees collapse in or rotate.

  • Initiate jumps with the gluteal muscles in the buttock region. This will improve knee and also lower back function.

  • The best time to stretch the muscles that support knee function is after practice or after a match when the muscles are warm. Focus on hamstrings, quadriceps, hip adductors/abductors and calf muscles.

  • Knee pads help reduce bruises and pounding, especially with repetitive diving drills. 

6) Ankle Sprains

Ankle sprains are the most common acute injury in indoor volleyball, and very few things spark intense debate in the volleyball community more than the question about using ankle braces to prevent these type of injuries. 

The majority of ankle sprains are when the ankle inverts (rolls in) and this most often occurs with play at the net where athletes make contact with another players foot when landing from a jump during hitting or blocking. More chaotic play such as with bad passes or plays out of system can also put ankles at risk.

The theory behind bracing is to reduce abnormal ankle motion, but some fear that depending on bracing might make lower leg supporting muscles weaker and maybe even increase the risk of knee injuries.

Click here to review the debate on ankle braces.

Once an ankle sprain has happened, little doubt that the combination of bracing and appropriate rehabilitation exercises can reduce the risk of future injuries.

Never hesitate to seek the opinion of a sports medicine specialist with any volleyball injury or to learn additional tips to prevent these problems.


Caring for Concussions: Orange Lutheran High School and Dr. Koutures

In the end, it all comes down to relationships.

“As the years have gone by, I’ve learned to appreciate the ability of the athletic trainers to have a relationship with each player,” said Dr. Chris Koutures.

Proud of being one part of the dedicated sports medicine team at Orange Lutheran High School that serves as a model for collaboration and communication.

Practical Recommendations for dealing with a Sports Concussion


Listed below are informative blog posts with practical discussions of common sport-related concussion symptoms and concerns with helpful treatment recommendations.                             Please click on each bullet point below to access the particular article

Concussions do not necessarily require being hit in the head or getting knocked out.  The full definition of a concussion is any fall, blow, or trauma that causes physical, emotion, or mental changes with or without loss of consciousness. 
With formal names like Convergence Insufficiency and Saccadic Dysfunction you might indeed think that this stuff is far too technical to grasp,  but in reality, these issues strike at the very heart of some basic life functions.
Experts Debate: How Many Concussion are Too Many for an Athlete?
In the midst of the usual complexities of recovering from a sports-related concussion, I have found that one simple mantra of "re-start activity in 15-20 minutes blocks" can be an anxiety reducing guideline.
Given that headaches are the most common symptom after concussion and often the last to fully resolve,  I spend a good amount of time with my patients discussing headache triggers, anticipated healing course, and how to reduce intensity and duration

More Dr. Koutures Thoughts on Heading and Helmet Use in Youth Soccer

The United States Soccer Federation decision to not have players under age 12 engage in heading activities and to limit heading exposure in players between age 12 to 13 has fueled many interesting exam room discussions about soccer-related concussions that have led me to develop particular thoughts on the topic, including a very unexpected and somewhat troubling take on the use of of soft helmets.

Many of my ideas have been incorporated in two thoughtful articles written by Lindsey Barton Straus, JD  from Mom'sTEAM.  Highly recommend taking the time to read both, as she very adeptly captures my experience and research with this important topic:

One of the main take-home points that underlies my philosophy and is echoed by several other interviewed authorities emphasized an individualized approach to determining readiness to initiate heading.

While certain categorical age-based decisions are far easier to implement, as we are continually taught in pediatric medicine, the focus should more often be placed on each child's developmental age rather than their chronologic age.

Another maxim in pediatrics- never hesitate to have  a realistic discussion about a difficult topic- in this case, a dialogue between player, coach, family and medical professionals as needed to make the best decision for each athlete.

Having several such realistic discussions about preventing head injuries and making return to play decisions after concussion has also brought a unique, if not cynical insight into a related controversial topic, the use of soft helmets to reduce head injuries in soccer.

From a professional standpoint, I have always been somewhat unconvinced about the true protective value of soft helmets in soccer, and have never mandated that an athlete must wear one in order to continue playing the sport. 

It didn't take long for me to learn that most of my young athletes shared my apprehension about helmet use.

However, their lack of interest wasn't due to their reading of the medical literature, or a more typical adolescent rebellion against parent/coach/medical professional authority. 

Rather, they were afraid to wear them for fear of being a target.

"If I am the only one, or only one of a few that are on the field with a helmet, my opponents will come after me."

After hearing this concern several times over, I must admit that now when asked by a parent about my opinion on helmet use, I reflexively turn to the child and ask them to truthfully tell me their opinion.

Sure enough, I get reminded of the fear of being a target. Definitely makes the parents think a bit differently about helmet use, and given the lack of consistent evidence supporting their use, definitely influences my decision.

This may not be the most scientific way to form a response, and definitely is a sobering reflection on the competitive environment faced by many young players, but it does provide a practical and necessary real-world platform to best address each individual player's needs, concerns, and future expectations.

Curious if others have encountered hesitation to wear soft helmets based on perceived risk of being singled out on the playing field? Does this information change opinion on possible helmet use?






Less Football Practice Contact Time May Mean Less Concussions

In the evolving discussion regarding the impact of limited high school contact football practice time on concussion risk, findings from the University of Wisconsin suggest that less contact practices may indeed result in less football-related concussions.

Photo courtesy:

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The state of Wisconsin was one year ahead of California in mandating contact practice time restrictions. Starting with the 2014 high school fall season, the Wisconsin Interscholastic Athletic Association (WIAA) prohibited contact in practice for the first week and limited full contact to 75 minutes per week for week 2, with 60 maximum minutes per week for week three and beyond. These limits are more restrictive than in California where two 90 minute contact practice sessions are allowed per week during the high school football season, thought the definitions of full contact are similar (game speed drills/situations where full tackles are made at competitive pace and players are taken to the ground).

Licensed Athletic Trainers at several Wisconsin high schools recorded incidence and severity for each sport-related concussion, and compared the two years previous to the rule change (2081 players) with data from the first year of the new limitations (945 players). 

Significant findings included

·        The rate of sport-related concussion sustained in practice was more than twice as high in the two seasons prior to the rule change

·        There was no change in the rate of concussion suffered in games pre and post-rule change

·        There was no difference in the severity of concussion (defined as average days lost from football activity) pre (13 days lost) and post-rule change (14 days lost)

·        Tackling was the primary mechanism of injury in 46% of sport-related concussions

·        Years of football playing experience did not affect the incidence of sport-related concussion in the first year of the new limitations

The authors concluded that limitations on contact during high school football practice may be one effective measure to reduce the incidence of sport-related concussion

How might this relate to California?

This is a well-constructed and much needed initial evaluation on the outcomes of contact practice reductions in high school football, with subsequent years of analysis now being anticipated to see if the above findings hold true over multiple seasons.

The maximum allowed football contact times in Wisconsin are about 42% of the maximal time currently allowed in California, so one may wonder if that increased contact time may make direct extrapolations between the states more difficult. This is where a similar study after the 2015 California high school season is vital to measure the outcomes here in this state.

I was greatly impressed with the finding that there was no change in game-based concussion rate and that the years of previous playing experience not affecting the incidence of new concussion as two potentially landmark outcomes for the future of football safety.  Coherent arguments have been voiced that lack of appropriate contact practice time might increase risk for inexperienced or under-prepared players, especially in game time situations. This was particularly voiced for freshman players with no previous tackle football experience. I eagerly await future studies to see if these outcomes are consistent and robust.

The lack of change in severity (again, measured in days lost) brings up a couple of thoughts. The initial reaction might be a bit of disappointment, in that reduction of cumulative head impacts in practice should perhaps lead to a lower burden of injury with a concussive blow and hopefully a quicker recovery. One may not want to try and read much into using number of days lost as a strong measure of severity, for standard return-to-play protocols often mandate a minimum of 8-10 days off from full activity which could influence the return time possibly more than symptoms and other measures of severity.

One important subject not analyzed in this study was the incidence of non-concussion injury rates before and after the practice contact limits were enacted. Concerns have been issued over under-prepared players not confident in tackling techniques or changes in technique (hitting opponent lower in body, for example) both possibly contributing to less concussions, but more shoulder, elbow, knee, leg and other musculoskeletal injuries. 

Curious if any groups in California are interested or have proposed a similar analysis of our first year with the high school football practice limitations?

15-20 Minute Blocks of Activity: A Guideline for Post-Concussion Recovery

In the midst of the usual complexities of recovering from a sports-related concussion, I have found that one simple mantra of "re-start activity in 15-20 minutes blocks" can be an anxiety reducing guideline..

Looking to return to homework or other school-based activities?

Start with 15-20 minute blocks.

How much can I spend on my phone?

Start with 15-20 minute blocks.

As we discover that absolute rest and removal from usual duties might be counter-productive to recovery, the counter-concern over returning with too much activity, too quickly, or too soon is valid. 

Enter the 15-20 minute block recommendation.

When to start?

Usually within a few days after a concussion, and I will counsel patients that at a "good part" of the day where headaches or other symptoms are at a lower point, they should select one activity to start in a quiet room without other stimulation (loud music, bright outdoor light, texts on phone, etc). 

While most young people would immediately select their phone, the usual first choice is light reading from a book or magazine rather than a computer screen. 

Set a timer for 15-20 minutes, and once that period passes, stop all activity and take a break.

If successful, try another 15-20 minute block of similar activity again later in the day, and if that goes well, can increase to 20-30 minute blocks the next day.

Don't advise going past the "max" time recommendation. Better to finish "early" without symptoms than to muscle forward, develop a headache, and suffer a setback.

For those trying to decide when to return to school, have found that being able to complete 20-30 minute blocks of work 2-3 times a day is a minimum criteria for considering a partial (likely half-day) return to the classroom.

Once able to do at least 2 blocks of activity per day, can add a block of more "fun" which might include cell phone use, texting, appropriate surfing of internet, music, or even some relatively light video game play.

If unable to get through that initial 15-20 minute block of time due to headache or other symptoms showing up, don't despair.

Take the rest of that day off, and try the next day, again maximizing chances with success by ensuring a quiet distraction-free environment, good food and fluid intake, and hopefully after some restorative sleep.

If a few days of attempting the 15-20 minute activity blocks lead to more failure, then do not hesitate to contact your medical provider for more specific tips and further recommendations.



Tips on Dealing with Post-Concussion Headaches

Given that headaches are the most common symptom after concussion and often the last to fully resolve,  I spend a good amount of time with my patients discussing headache triggers, anticipated healing course, and how to reduce intensity and duration. While this post is not intended to make a formal diagnosis or suggest specific treatments, I do hope to share some insights on post-concussion headaches that will help patients, families, and fellow medical providers.

  • The location of the headache may be exactly at the point of impact, or perhaps on the different side of head, or even involve the entire head.

  • Not uncommon to have all-day headaches right after a concussion. Waking up without a headache should be considered the first sign of improvement. Once that occurs, often headaches will still be daily, but will tend to occur later and later in the day. In the final stages of recovery, the headaches might not be daily, but rather may occur every few days.

  • Look at a throbbing headache as a "pop-off valve" warning sign indicating overload of the healing brain.. While this type of headache might be frequently seen immediately after an injury, the evolution of a throbbing headache later in the recovery can indicate excessive activity, such as too much reading/schoolwork, noise exposure, or screen/media time or even a combination of all those factors at one time.  Reviewing and making adjustments in schedules and environments can turn down the cumulative overload and hopefully the throbbing headaches.

  • Have found that using the 15-20 minute rule can be quite helpful for patients and families in determining if someone can read/text/play video games/watch TV after a concussion? The goal of course is to not trigger a headache or other symptoms. 
    • Pick one activity (let's say reading to start) and try to do it in a relatively quiet environment for 15-20 minutes. If that time limit is reached without a headache, cool- stop, take a break and maybe come back 30-60 minutes later for another 15-20 minute period of reading. If that second attempt also goes well, then can increase the activity period to 20-30 minutes 2-3 times a day. 
    • If headaches come about before the 15 minutes are up, then stop activity, note the time that passed before the headache began, and after the headache has resolved, try the activity again but stop 1-2 minutes before that past headache onset time.

  • If a headache quickly worsens, such as the throbbing headache noted above, an immediate reduction in activity should cause some reduction in intensity. However, in any worsening headache or especially in the case of a "worst headache of my life", one should not hesitate to seek immediate emergency medical evaluation.

While the initial trauma to the head can be a primary cause of post-concussion headache, there can be several other contributors leading to more prolonged and intense symptoms:

  • Commonly see a relative muscle imbalance in the suboccipital region where the skull connects to the cervical spine that can be the basis for one-sided or both sided headaches starting "in the back of the head" or with "neck pain". These types of headaches may be more noticed as the patient starts returning to reading, taking notes, and doing other activities that require holding or turning the head for longer periods of time.

  • Headaches often associated with dizziness, blurring of words, or double vision that all may increase with reading, screen work, or note-taking could be a result of disordered vestibular-ocular function affecting the visual and balance centers of the brain. 

  • Altered sleep patterns, commonly with difficulties either initiating or maintaining sleep, can lead to insufficient rest and an increased in headache duration and intensity. One particular trigger in the post-concussion patient is heightened sensitivity to light emitted from screen devices. Good general rules for all of us (not just post-concussion patients) include no screen devices at least one hour before bedtime and not having screen devices in the bedroom.

  • Inadequate food and fluid intake can be a headache trigger for almost anyone, so just imagine how these issues can  be amplified after a concussion. Multiple small meals can be helpful as nausea or diminished appetites are common right after a head injury. Post-concussion dizziness may also be improved with adequate fluid intake, but please do check with your medical provider before increasing or adjusting any type of fluid intake after a concussion.

  • Too much noise or too much light, often in combination with each other or with attempts to concentrate. May need to turn off or reduce background sounds, work individually in a quiet room, or use noise-cancelling devices. Reducing ambient lighting, turning down screen intensity, not sitting near windows with bright exterior light, or using regular or blue-light reducing sunglasses can also be helpful.

There are also over-the-counter and prescription medication, vitamin, and herbal supplements that can assist with headaches after a concussion, and I feel that a discussion of these options is best done in direct consultation with a medical provider who has examined the patient and reviewed all aspects of the medical history.

Please let me know of any other tips for dealing with post-concussion headaches.

New Location: Orange County Return to Learn after Concussion Conference

Designed for classroom educators, administrators, counselors, special education specialists, school nurses, speech/language pathologists, athletic trainers, and other parties who work with student-athletes after concussion.

Featuring renown speaker  Brenda Eagen Brown who will offer practical suggestions based on real-world situations supported by the latest evidence-based research.

I will join other local concussion specialists in a lunch period case-based discussion of return to learn challenges.

Dr. Koutures Quoted on Concussed College Athletes Choosing Early Retirement

Never easy for anyone to have to give up a sport and often the "athlete" sense of identity.

In a thoughtful and well-written article from Inside Higher Ed, Jake New weaves many perspectives on early retirement after concussion.

Highly recommend the read!

New California Football Contact Limits Provide Unique Opportunity to Study Effect on Concussions

According to the findings of a study published in the May 4th online edition of JAMA Pediatrics, practice periods are a major source of concussion for the high school football player

While the actual rate of concussion is higher in game play, just over half of the reported concussions took place during practice times.

The authors suggest that strategies should be implemented to evaluate technique, limit player-to-player contact and overall head impact exposures, and reduce other higher risk practice situations.

While the jury is still out on what constitutes proper technique, the mandates of California Assembly Bill 2127 will afford a vital opportunity to further study the influence of practice time limitations on concussion rates in high school football players.

The bill prohibits high schools from conducting more than 2 full-contact practices per week during the preseason and regular season, and prohibits this full-contact portion of the practice from exceeding 90 minutes in a single day.

To clarify, "full-contact practice" means a practice where drills or live action is conducted that involves collisions at game speed, where players execute tackles and other activity that is typical of an actual tackle football game.

Based on the findings of the above JAMA Pediatrics study, the hypothesis is that these new restrictions should reduce concussion rates in practice simply by limiting exposure time and cumulative risk.

Now, one might ask, why would there possibly not be a reduction in concussion rates?

  • Is there a chance that limited practice times could lead to less comfort with tackling that could result in an actual higher game rate of concussion?
  • Could football programs feel pressure to get in as much contact as possible during the 2 allocated 90 minutes practice periods, possibly leading to more cumulative exposure during that time?

A multi-location review of concussion rates (game and practice) is essential to confirm the effects of California AB 2127. 

In such a study, I would also suggest that concussion rates be broken down by academic grade of player, and even take into account years of experience of tackle football.

I wonder if neophytes (namely incoming freshman) who have never previously played tackle football could be at higher risk from contact practice time limits.  Would the contact time restrictions have less influence on upperclassman who have played tackle football for a longer period of time?

All stakeholders will be eager to see if indeed there is a documented reduction in overall concussion rates, and if such a reduction is seen across all levels of high school football.

Can Vision Training Reduce Concussions?

While laudable efforts have been put into recognition, evaluation and treatment of a concussed athlete, those are all secondary prevention things done after the injury has already occurred.

Ideally, anything that can be done in the primary prevention world to stop concussions in the first place would be held in the highest of regard.

Helmets and other types of head gear unfortunately haven't served a sufficient protective role.

Now, there are efforts to look at the potential role of Visual Training to Reduce Concussion Incidence in Football, and pardon the pun, the results are eye-opening.

Over the course of 4 football seasons, researchers at a Division 1 Football institution used light board training,  strobe glasses, and tracking drills during pre-season summer camp and followed with weekly light board training during the season.

Findings indicated an association of a decreased incidence of concussion among football players during the competitive seasons where vision training was performed as part of the preseason training. The authors suggest that better field awareness gained from vision training may assist in preparatory awareness to avoid concussion-causing injuries.

The research team did caution  that this is an exploratory study and asked that future large scale clinical trials be performed to confirm the effects noted in this preliminary report.

What are my thoughts on this study?

  1. I recall a discussion with a colleague regarding apparent increased in both number and complexity of concussed young athletes compared with 5-10 years ago. There is little doubt that increased concussion awareness accounts for higher patients numbers, but what about the complexity?  One offered answer surrounded the extent of visual stimulation required of students today- from tablets to smartphones, from more screen time and power point presentations- visual overload can lead to lower threshold for  head  injury. While this hasn't been strictly proven, the findings of the above study could lend support to more effective visual processing and perhaps less overall eye strain may be protective against concussions.
  2. The study does compare head injury rates in the four years prior to the study and those found in the four years with the visual training intervention. There were coaching changes  and thus possibly differences in contact exposures between the before and after groups. Trying to compare the reported rates of concussion between this institution and other Division 1 school can be difficult- many programs are very guarded with injury rates, especially when it comes to concussion.  All reported concussion numbers (pre/post) seem somewhat low, but again, hard to make an exact statement due to lack of comparison data.
  3. If these results are validated, I have to wonder if teams will invest the time and energy to adopt such a program. Knee injury reduction programs have been  developed with solid supporting evidence, but use by teams lags sorely lags. Concussions are obviously a big deal, so I'd like to think that credible prevention programs would be readily put into place, but part of me has doubts from this past experience.
  4. Agree with the study authors that this is a preliminary study that merits further investigation with more schools and players of different ages.  Not ready to run out and ask schools to invest in the visual training equipment and protocols just yet, but quite eager to see if others can reproduce these results.


I think all of us in the sports medicine world are looking for evidence-based techniques to reduce/prevent concussions. Do the results of the above study seem reasonable to you?  Would your team or group be willing to put in the time investment if such a program proved able to limit concussions?



Are Past Unreported Concussions Often Found in Pre-Season Assessments?

The use of baseline assessments to provide comparison data for future concussions provokes controversy about validity, cost, and time investment. If however, such testing routinely uncovered past unreported or even currently symptomatic concussions, would that influence opinions about the significance of such efforts?

Definitely curious if others have found significant numbers of previously unrecognized concussions in their preseason testing?

I met recently with administrators of a local contact/collision sport league who wanted to discuss their pre-season baseline testing program for concussion monitoring.

They have developed an amazing concussion program, complete with education, pre-season testing, surveillance, and return-to-play protocols.

Coaches or team administrators are required to report all suspected or confirmed concussions to league officials for follow-up monitoring of medical evaluation, treatment, recovery and return progression.

The leagues they supervise are growing, with now over 1000 athletes on multiple teams in several cities.

That means the potential of more pre-season evaluations, and whether the medium is computer or paper based, with or without functional testing such as vestibular or visual testing, we all know that this takes time, effort and tends to have a bunch of logistical issues.

So, not unacceptable to find ways to reduce the early season demands but still provide adequate data to analyze players after a concussion.

With the ability to compare post-injury results to solid age-matched normative data sets for many of the neurocognitive platforms, some have begun to question the utility of the time and expense for routine annual baseline testing.

Others have offered the opinion that every other year evaluations might suffice in the school-aged population and thus reduce some of the testing burden but not lose the value of the data.

These both sounded like workable options for this league to consider, until one eye-popping revelation was shared.

Realize, we're talking about a close-knit sport community where kids and families know each other well and administrators have designed a visible program that requires reports of all potential concussions, with penalties in place for failure to report.

You’d think that there wouldn’t be too many concussions that could sneak by so many watchful eyes.

Guess again.

A critical review of the pre-season data found a startling disconnect on many teams between the number of concussions officially reported to the league and the number of concussion the kids report in their baseline testing.

When asked to report either number of concussions or current possible post- concussion symptoms, the players admitted to a frankly startling number of concussions, including dates of injury, that were never officially entered into the league data base.

Now perhaps this shouldn’t have been so surprising to those of us having this conversation.

We always worry about under-reporting at the time of injury, not just by athletes, but also unfortunately by adult coaches and parents all eager to limit or eliminate any missed playing time.

Have also learned another thing when working with kids- when it comes to answering questions about symptoms or past concussions, kids just can’t seem to lie to a computer..

They might repeatedly deny past history or current problems to a medical provider in person, but when asked to report information to a computer, the flood gates tend to open.

I must give big-time credit to these league officials for underscoring the importance of their active, critical review of all baseline testing and not just passively collecting data for potential future use.

Their use of the computerized baseline testing information apparently allowed a better look at the true incidence of concussions, and unfortunately, a more realistic look at sandbagging or failing to report.

Now, I’m not entirely ready to endorse a punitive Orwellian “1984: Big Brother is Watching” approach to concussion management.

I still think trust and transparency between all parties is absolutely essential.

I’m also not totally on board with the absolute need for computer-based platforms for concussion evaluation or record keeping for that matter (often handwritten mediums provide sufficient information).

But if an annual computerized pre-season assessment  provides candid responses that reveal sufficiently high numbers of previously unreported or even worse, incompletely healed concussions, then maybe all that work, all that effort, and all those logistical efforts suddenly seem far more justified.

Very curious if other organizations performing large-scale pre-season baseline neurocognitive evaluations have seen a similar difference between “official” concussion reports and those self-reported on computerized assessments?

Is the above experience an isolated phenomenon, or is it worthy of further collaborative study?

Why University Athletes May Hide Concussion Symptoms

I often encounter athletes who continue to practice or play in a game despite suffering concussion signs and symptoms and since hiding this information is not considered advisable and potentially quite dangerous,  have to admit that my initial response is along the lines of "what were you thinking?"

We as medical professionals have a pretty set initial response to a concussion- any suspicion of concussion, immediately remove from activity.

Pretty certain that athletes may view the initial response to concussion in a different light than us medical types.

As I find myself more often hearing of athletes hiding symptoms, my response still is a "what were you thinking?" but rather than asked in a frustrated or ready for a lecture tone, it is asked more in a sense of wanting to appreciate their mindset.

Is it lack of appreciation for the risks of concussion? How about denial? What about worry about losing a role on the team or not wanting to "bother" anyone?

Thus, it was interesting to see that Delaney and colleagues addressed this issues with their study Why University Athletes Choose Not to Reveal Their Concussion Symptoms During a Practice or Game.

The objectives of this paper were to  better understand why athletes who believe they have suffered a concussion while playing their sport “hide,” or decide not to volunteer, their symptoms to medical staff by identifying:

  • specific reasons why athletes who believed they had suffered a concussion during a game or practice decided not to seek attention from medical staff at that time, how often these reasons occurred, and how important these reasons were in the decision process
  • whether there were individual variables that may have made an athlete more likely to not volunteer his or her symptoms to a therapist/trainer or physician during a game or practice.

Findings of anonymous questionnaires that asked only about "self-diagnosed" concussions revealed that almost 20% of the 469 males and female athlete respondents believed they had suffered a sport-related concussion within the past 12 months. Of great interest was the fact that 78.3% of those athletes reporting a concussion did not seek medical attention either during the practice or game.

Why not?

Main reasons for "keeping quiet" were:

  • “Did not feel the concussion was serious/severe and felt could still continue to play with little danger" 
  • "Had similar symptoms of a concussion in the past and felt that there was little or no danger as had no problems with previous concussions or similar symptoms in the past"
  • "Fear that being diagnosed with a concussion would affect standing with the current team or future teams”
  • “Fear that being diagnosed with a concussion would result in negative of repercussions from the coach or coaching staff”
  • "Felt that would be removed from the game by the medical staff and did not wish this to happen”
  • “Fear that being diagnosed with a concussion would result in missing future games"

So, it appears that common human emotions- denial, minimalization and fear- are playing a big role.

All are understandable and none aren't surprising.

Not saying that they legitimize hiding symptoms or make it acceptable practice.

But rather they give unique insight into the psyche of university athletes and perhaps open particular in-roads to improving the culture of reporting concussion symptoms.

We need to recognize the fear of being removed, and attempt to address this fear by underscoring importance of early admission and treatment hopefully leading to a less complicated recovery and potentially an appropriately quicker return.

We need to have teams and coaches limit any negative responses to concussion diagnoses and provide essential support to any concussed or any injured athlete for that matter.

We need to acknowledge the competitive drive of our athletes and channel this into a competitive drive to protect their brains by offering such comprehensive diagnostic and management programs that athletes wouldn't think of missing out on getting such essential care.






Studying Role of High School Principals in Return to Learn after Concussion

If there isn't enough frustration and feeling of being overwhelmed after suffering a concussion, the process of returning a student back to academic work can only seem to magnify those concerns.

While return-to-play progression protocols have been established to assist in getting athletes back to sport, similar return-to-learn programs have lagged behind.  The sheer complexity of  meeting particular needs and schedule demands of each student requires an individualized plan created with appropriate understanding of expectations and optimal communication between medical professionals, families and educators.

Often, recommendations include  designating a point person who can advocate for the student and family by communication with fellow educators and monitor of student progress.  This same person might also provide on-going dialogue with outside medical providers. However, finding a person with appropriate knowledge and desire to accept and carry out these roles can be difficult. 

A school-based concussion management and response plan can provide further framework to delineate expectations, potential adjustments, and roles, though the actual implementation and utility of such plans has not received much study.

Given the common findings of frustration and lack of apparent coordination in the return to learn process, I was excited to review the article HIgh School Principals' Resources, Knowledge, and Practices regarding the Returning Student with Concussion  in an effort to gain unique and previously unreported insight into school-based resources and management strategies.

Using a cross-sectional computer-based survey of 465 urban, suburban, and rural public high school principals in the state of Ohio, key findings of this study included:

  • Just over 1/3 of the principals had completed some form of concussion training in the past year, with those who completed such training have higher self-reported concussion knowledge scores and were more likely to have provided or supported concussion training for school faculty who were not directly involved with youth sports
  • When identifying a point person, athletic trainers were most often reported, but about 1/5 of respondents did not know or designate a point person at their school. Schools that identified  more than one point person tended to  have more students, a principal with higher self-reported concussion knowledge, and to have a full or part-time athletic trainer.
  • Athletic trainers were reported as the main agents of communication with medical professionals for concussed student-athletes, while school nurses and counselors assumed this role for concussed students who were not athletes. Principals, assistant principals, and guidance counselors assumed the primary role of communication with parents for all students  (regardless of athlete status).
  •  When asked to respond to a list of short-term classroom adjustments commonly recommended for concussed students, over 90% of principals agreed with all or most of them, with just over 30% requiring a health care provider note to initiate the adjustments.
  • Several principals reported a school response-to-intervention (RTI) team to assess student needs and to develop an intervention plan in terms of academic adjustments and accommodations.
  • About 1/3 of the schools had a written concussion plan, with 75% of those plans addressing academic adjustments and accommodations.

How can we use these findings to better assist our concussed students in their effort to return to the classroom?

  • A principal with concussion knowledge is essential- thus ensure more (and hopefully higher quality) concussion training for principals, which could then translate to more training for school personnel, the identification of point persons to assist concussed students, and better communication between principals and the parents of a concussed athlete.
  • An athletic trainer is essential- thus ensure that every high school campus has a  certified athletic trainer acting as an advocate for concussed students and being on campus for part/all of the academic day (not just for after-school activities) to foster relationships with teachers and help monitor student developments.
  • An intervention team is essential to initiate academic adjustments early after a concussion, preferably without the absolute need of a medical provider note to reduce any obstacles.
  • Providing a concussion management plan that delineates roles and expectations and is shared with all key parties (students, school personnel, families and medical providers) to provide education and on-going assessment of the utility of the plan.

What other recommendations do you have to assist concussed students return to learn? Do these recommendations seem reasonable and practical?



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