Physical therapy resident Pam Dunlap examines Gaige Pavlocak during an evaluation at the UPMC Sports Medicine Center on Pittsburgh's South Side. Gaige, a sophomore football player at Southmoreland High School, suffered a concussion in a preseason practice.
By Chuck Finder Pittsburgh Post-Gazette
Fourteen 10- and 11-year-olds from the Peters Township Indians White team gathered under cover for their final practice last week, chased indoors Thursday by rain and sodden football fields.
The youngsters were practicing plays and more for about an hour before finishing with a routine one-on-one drill on tackling fundamentals. Routine as long as no one got a concussion during the final drill again.
One player from the White team -- the Peters Township Junior Football Association's age-group squads are named after the Washington County school district's colors -- has been sidelined for the season's opening three games because of a concussion.
Another, 10-year-old Nick Young, has missed five consecutive games: Three already this year because of a sprained medial collateral ligament in his left knee, and the final two last season because of a concussion.
Rick Young watched Nick, his son, miss those final two games of 2009 -- amid e-mails from the coach pleading, "Can he play this weekend?" -- and then endure two months of concussion-induced emotional and academic turbulence in the fourth grade. That experience motivated Dr. Young, a podiatrist, to become an at-large board member and safeguard the association's 225 young brains.
Parents, players, organizers and regulators are becoming aware of a widespread problem that doesn't belong solely to NFL Sundays. Concussions happen during youth football and college Saturdays, high school Friday nights, and practices all days, down to tykes of 6.
To bring awareness home to Peters, Dr. Young attended the Duquesne University symposium that attracted national concussion experts in March. He collated data about ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing), the process overseen by UPMC and used by the National Football League, the National Hockey League and others. He drafted the association's policy and steered parents to UPMC Sports Medicine's South Side headquarters, where almost half the Peters kids took the baseline test that could prove beneficial in the event of a brain injury.
Shawn McCall, president and a coach in the Peters association, took his four children to the South Side for the computerized test. That included his 10-year-old son who swims.
"The cost is nominal," Mr. McCall said of the $40 regular and $20 group-discount prices for each test. "How much is your kid's brain worth? Come on.
"No pun intended, it's a no-brainer."
Eighty-seven West Allegheny High Indians, freshmen to seniors, gathered on a grass field for practice Wednesday afternoon while the seventh- and eighth-grade unified team used their stadium next door. One sat in a wheelchair -- star Mike Caputo, recovering from a fractured, dislocated ankle. Others were absent due to neck, shoulder and knee injuries.
The team's headaches came early this season. They went, too -- never developing into the symptoms of concussions. They were just headaches.
"Yeah, we've had a couple of dings," said the Indians' longtime coach, Bob Palko, invoking the old-school euphemism. "The normal stuff. Getting used to [contact and new helmets]. We did have some kids miss [practices], but no problems. Precautionary."
This is the coach whose sons -- quarterback Tyler of the NFL Kansas City Chiefs' practice squad, and receiver Luke, an Arizona Cardinals scout -- got concussions playing for him.
"Oh, hell, yeah," Mr. Palko said. He spoke about being vigilant, watching his players closely and detecting when they behave differently after a head injury. His voice fell to nearly a hush. "I'll be honest, I've always been cautious."
His boss for the past 11 years, West Allegheny athletic director Dave McBain, is a certified trainer who spent nearly a quarter-century working sidelines from high schools to volunteering with the Steelers. Mr. McBain sits on sports-medicine committees for WPIAL and Pennsylvania Interscholastic Athletic Association. He has helped guide two policy changes this year.
One highlights and alters the wording in the portion of the state preseason physical forms that ask parents to acknowledge they are aware of concussion risks. Another change allows game officials, if they see signs of a possible head injury, to remove a player from the field and consult with sports medicine personnel on the sideline about the player's potential return.
Their school is among 83 WPIAL and City League members that require their players to take the ImPACT testing. West Allegheny also pays for UPMC Sports Medicine services that include its own certified trainer, much like the 15 schools that rely on Allegheny General Hospital for staffing.
"What the Steelers do, the colleges do, then the WPIAL does," Mr. McBain said. He noted the recent research that discovered brain disease among late ex-Steelers linemen, starting a trickle of concern, awareness, change. "From Mike Webster to Justin Strzelczyk to Terry Long ... things have a tendency to filter down."
Locally, a hockey player was effectively retired from skating at either defense or forward, forced into the nets to play goaltender because of too many concussive collisions before he finished middle school.
Health-care professionals have noted that lacrosse players, from helmet-clad males to helmet-less females, seem to fall victim to head injuries at increasing rates.
Soccer players miss months of class from concussions so severe they can't endure the light or noise at school.
But football is woven deep into the fabric of Western Pennsylvania. It is the most openly physical game, its glorified, crunching collisions the cause -- not only in games but more so in practices -- for such trauma to brains from ages 6 to 22. Its players -- ranging from youths to ex-Steelers and Tennessee Titans safety Chris Hope -- come to the South Side to see some of the world's foremost experts based here, helping to formulate policy from the NFL to the state-federation ranks.
It has played a role in the grieving of at least two Western Pennsylvania families, whose sons sustained eventually fatal head injuries in high school football practices over the past six years. And concussions among young football players happen routinely, yet garner little attention, from two youth-level players transported from local fields by medical helicopters in the previous two weeks to the Bethel Park 13-year-old who returned a simple punt and won't return to play for a month, minimum.
A concussion, simply put, comes from a sports circumstance that sends the brain's chemicals amok.
Imagine an egg yolk inside an eggshell -- the brain is immersed in liquid while inside a larger encasement, the skull. The impact of a collision, or even something as simple as a block or avoiding one, causes an acceleration, deceleration or rotational motion that moves the brain around the skull with significant force. Scientifically speaking, neurochemicals are released or biomechanics are shorn, and imbalances emerge.
Helmet technology, procedures and awareness have improved exponentially in recent years, experts agree.
Still, the conundrum remains: Is there any stopping the brain's sudden, violent movement inside the skull?
"Put an ice cube or a golf ball in a glass and drive around with it," said Dr. Young. "See how many times it clinks against the side of the glass."
Dr. Young cannot forget this episode last fall in his league's championship game for the youngest local level. Adults with the opposing team asked him to approve their star tailback, whom he said blacked out and fell in the huddle before he threw up. Unconsciousness and nausea are prime indicators for a concussion.
"They wanted me to clear him at halftime," said Dr. Young, still incredulous almost a year later. "Ultimately, the boy sat out the second half. It was a championship game, an important game in their 6- and 7-year-old season. But it was 6 and 7 year olds."
The danger zone seems to be skewing younger and younger.
In the tissue of deceased ex-Steelers Webster, Strzelczyk and Long, among other former NFL players, scientists have discovered a preponderance of the disease chronic traumatic encephalopathy, or CTE, where middle-aged brains exhibited the signs of dementia and damage of people a quarter-century older or more.
Doctors with the Brain Injury Research Institute at West Virginia University announced in June they found the same disease in an active NFL player, one who never missed a pro or college game due to a reported concussion: Cincinnati receiver Chris Henry, who died last fall at age 26.
And scientists at the Boston University-based Center for Study of Traumatic Encephalopathy found two breakthrough youth cases. They discovered early stages of CTE in a University of Pennsylvania football player who committed suicide in April at age 21; results were announced last week.
They also detected traces of it in a high school football player who died at age 18, the youngest case yet.
"It's obscene," Michael "Micky" Collins, assistant director of UPMC's Sports Medicine Concussion Program, said of the number of young players seeking treatment for concussions.
Dr. Patrick DeMeo, the Pirates' medical director and director of sports medicine at AGH, said from his vantage point the main issues with concussions deal with severity: What are the long-term effects, and what determines right-to-play clearance to return, with concerns over the potentially fatal second impact syndrome implicit in the post-concussion approach.
UPMC Sports Medicine Concussion Program Director Mark Lovell, developer of the ImPACT test, spoke at a Seattle conference in July. The subject: the second impact syndrome that killed a Spokane, Wash., player named Drew Swank last year and is fatal in 50 percent of the known cases. The known part is the problem.
A second concussion in addition to an existing, untreated one can prove life-threatening or life-altering. Often, that first concussion goes unrecognized because the athlete didn't detect the signs or decided not to tell anyone in authority. There have been cases where teammates knew, but didn't tell. There have been cases where adults allowed a player to return too soon.
Eighty people crowded into a room to listen to Dr. Lovell, and each one had a connection to a child either killed or left in a wheelchair by second impact syndrome. Those were families affected in Washington, Idaho, Oregon and California, said Dr. Lovell, whose voice trailed off while speaking of that day.
As for the Spokane school where Drew Swank suffered his fatal, second concussion? Citing lack of participation, it dropped football.
Most of the attention, the awareness, comes from the NFL and the changes it adopted late last season amid national controversy and congressional hearings. Other states, leagues and governing bodies ventured before. More follow still.
States including Washington -- the first in 2009 -- Oklahoma and Massachusetts enacted legislation establishing rules for prevention, on-field diagnoses and return-to-play guidelines involving sports-related concussions. Pennsylvania is considering such legislation. NFL commissioner Roger Goodell recently sent letters to 44 governors urging them to adopt a version of the Zackery Lystedt Law, named for the Washington state middle-schooler left in a wheelchair from a second impact concussion.
In April, the NCAA urged its members to mandate return-to-play policies. This came after it changed some of its concussion-related rules regarding helmet contact, removal of injured players and more.
With the start of football this fall, the National Federation of State High School Associations also introduced a new rule: "Any athlete who exhibits signs, symptoms or behaviors consistent with a concussion ... shall immediately be removed from the contest and shall not return to play until cleared by an appropriate medical health care professional."
The revision comes "because we're very concerned about the youngsters returning to play too soon," said NFHS executive director Bob Gardner, whose group oversees 19,000 high schools and 7.5 million athletes. AGH sports medicine's Dr. Edward Snell said he is rewriting the concussion guidelines for the NFHS, a 10-page document "10 years in the making."
West Allegheny's Mr. McBain said the PIAA has emphasized that if game officials suspect an athlete might have sustained a concussion -- and they now carry cards outlining the signs -- they must consult a certified trainer and other sideline medical personnel, who should be either medical doctors or doctors of osteopathy.
The new requirements are outlined in Part III of the revised statewide physical-exam forms that every public-school athlete must complete to be eligible. Other alterations have been made to those forms, known as the Comprehensive Initial Pre-Participation Physical Exam.
Amid controversy around Philadelphia over a concussed NFL Eagles player returning to play moments after his injurious collision last Sunday, Rep. Tim Briggs, D-Montgomery, Tuesday filed House Bill 2728, The Safety in Youth Sports Act, an attempt to get a form of the Lystedt Law enacted in Pennsylvania. The proposed act is scheduled for a House Education Committee vote Monday.
Mr. Briggs said he is working with the PIAA on the legislation that would require, among other things: inclusion of private schools and club sports currently outside of the PIAA's purview; signatures of athletes' parents on a one-page "information sheet" about concussions; participation of all secondary-education coaches in the 20-minute, NFHS Web seminar about concussions; and proper medical attention for injuries that occur in practices and camps where a trainer or health-care professional isn't present.
"It's not a sprained ankle. It has to be taken very seriously," Mr. Briggs said.
Mr. McCall, the coach and president of the Peters youth association, believes the day is approaching when his group makes it mandatory for every player to first undergo ImPACT testing. Maybe others will follow, he said.
"These are 6-, 7-, 8-, 9-year-old kids. I don't want to affect the rest of their lives."