There was a time when coaches, parents, event organizers and medical professionals largely ignored mild head injuries, mostly because of a lack of understanding and knowledge about their impact. Head-injury symptoms progress over time, and at the moment of injury, might not appear as serious as, say, a torn ligament in the knee or a severely sprained ankle. Kids used to “get their bell rung” and become dizzy or unsteady, but it generally wasn’t considered a big deal. They would return to competition after a few minutes.
In the last decade, however, the approach to addressing these injuries has changed drastically, largely in part to what has happened to former professional athletes. Repetitive head injuries have been shown to have long-term consequences, sometimes resulting in chronic traumatic encephalopathy (CTE), a neurodegenerative disease known to cause cognitive decline, behavioral abnormalities and, ultimately, dementia. Thirty-four former NFL players were found to have the disease. Jim McMahon has been diagnosed with dementia, and he’s suing the league. Another NFL star, Junior Seau, tragically committed suicide, and his family also is suing the NFL, claiming the former linebacker’s suicide was the result of brain disease caused by violent hits he received during his professional career. These and other stories highlight the long-term effects of concussions. CTE is generally diagnosed post-mortem, although new developments are opening the possibility of diagnosis during life. Some college players, including former Texas safety Nolan Brewster and UCLA middle linebacker Patrick Larimore, have made headlines recently for opting to forgo potentially lucrative NFL careers because of head injuries.
Forty-eight states and the District of Columbia have enacted laws to prevent student-athletes from returning to the field too early after a concussion. A bill is awaiting the governor’s signature in South Carolina, and Mississippi is the remaining holdout. The laws are based on Washington state’s Lystedt Law, named for Zackery Lystedt, who suffered multiple concussions during a junior high school football game that resulted in severe brain trauma. The laws are designed to educate athletes, parents and coaches about the dangers of concussions and ensure athletes with symptoms of concussions are removed from play and cleared by a licensed health-care professional before returning
Concerns about concussions have entered into conversations at all levels of sports events. “It’s a matter of education,” says James Parker, director of sports for the Amateur Athletic Union. “It’s making coaches aware and also educating parents, umpires, officials and judges. A trainer may not see what happens, so everyone should be educated on what to look for. It’s not like all of a sudden people started getting concussions, but now there is more awareness. We just have to keep preaching to parents, athletes and coaches to take the proper precautions.”
AAU has precautions in place and, luckily, has never had a major incident, Parker says. The organization hosts events for 32 different sports involving 600,000 participants from the United States and Puerto Rico. The largest are boys and girls basketball, volleyball, wrestling, and track and field.
Concerns About Heat
Another health concern impacting sports events is the possibility of heat stroke. When planning the World Football Festival, a three-week summer celebration in Austin, Texas, last summer, Event Director Greer Monterastelli created a schedule that kept players off the field during the hottest parts of the day, from noon to 5 p.m. “It’s a challenge to have something for athletes to do during that time and deal with pressure from coaches,” he says. “But for the welfare of participants and liability issues, we’re just not going to be out there in the heat.” World Football Festival includes more than 2,000 athletes and coaches from eight countries and five continents.
AAU requires air-conditioned gyms for events held in the heat of summer and water available on the benches at all times. “Hydration is big in Florida where we are located, and we make sure kids are hydrated before, during and after competition,” says Parker. Coaches sometimes are given extra time between quarters or innings to let athletes rest and allow them enough time to drink plenty of water.
Four states devoted to high school football—Alabama, Texas, Florida and Georgia—have banned back-to-back two-a-day practices to limit risk of heat-related deaths. High schools tend to set the standards for practice schedules. If high schools in an area eliminate two-a-day practices, youth programs are likely to do the same, says Parker. An American Football Coaches Association annual survey showed 51 deaths related to heat stroke between 1995 and 2011, with 40 occurring at the high school level.
Regarding high school soccer, several states have transitioned from playing games in two halves to a four-quarter model, which allows extra breaks for players to cool down and drink water, says Mark Koski, director of sports and events for the National Federation of State High School Associations, the national governing body for high school sports and activities.
“When it comes to scheduling, you have to be very smart,” says Koski, who previously planned sporting events for the New Mexico Activities Association. He suggests no back-to-back games, frequent water breaks and clear ground rules established to keep the competitors on a level playing field.
Ensuring Communication and Safety
Jason Aughey, senior director at the Tampa Bay Sports Commission, says he is seeing additional language added to user agreements, contracts and insurance to make sure sporting events are safe. Most changes are in line with the evolving standards of each league or sponsoring organization. “We are right in the middle between the venues and the event organizers, and we work to ensure communication and that everyone works to create a safe environment,” says Aughey. “Everyone has an inherent understanding that for an event to move forward, everyone must be protected, and communication has to take place.”
The Tampa Bay Sports Commission works to attract all types of sporting events to the area, from NCAA tournaments to the Super Bowl to every type of amateur event. One element of safety is to ensure that the proper number of trainers and medical personnel are on hand for an event to address issues like concussions and heat-related or general injuries, says Aughey. Planners often arrange with local trainers to provide adequate coverage, and trainers work as liaisons to on-site EMTs or ambulance services.
Aughey says event organizers can rely on the local sports commission or CVB to act as a liaison and help connect the dots with venues on issues such as required insurance and facility use agreements.
Facilities Affect Health Issues
Sports events that use multiple facilities can present a greater challenge to managing medical issues effectively, says AAU’s Parker. “When you’re in one place, it’s easier to manage and a lot cheaper to make sure you have trainers there and an ambulance [on standby],” he says. For example, AAU’s 11th-grade national championship basketball tournament used to be held at 10 different sites but has now been reduced to four to provide more efficiency and safety.
Any venue that has experience hosting big events is familiar with the need for insurance and medical services during an event. “When putting out RFPs, make sure the venues can address the questions,” says Koski. “As event planners, we are not medical professionals, and the venues can help lead us.” Koski adds that events “live and die by the venue.”
State associations that are members of the NFHS may provide helpful resources for event planners, says Koski. These members typically plan 13 to 19 large events, such as state championships, every year.
Monterastelli requires one athletic trainer for each 100 athletes for a live football event (two if it’s a tackle event) and makes sure an ambulance is available. Having sufficient athletic trainers to cover an event relieves coaches of the burden of making decisions about injuries. For larger events, he suggests a centralized medical tent as well as a certified trainer for each court or field. Requirements change according to whether a sport is contact or non-contact. Also, requirements vary if games are happening at 18 locations versus a single multiuse complex with 30 fields, adds Monterastelli. Medical requirements also change in the case of a stay-over camp, when a medical professional is needed to care for participants in the dorms who may get sick, have heat issues or need attention related to a possible concussion.
Event planners also should have either a medical director or a supervising athletic trainer on their team to advise and educate them on medical issues, says Monterastelli.
Importance of Risk Management
Having a well-thought-out medical plan that addresses various aspects of ensuring participants’ health can be useful when negotiating premiums for insurance coverage, says Monterastelli. A good relationship with an insurance provider helps, too. “Event planners are looking at ‘What do I have to do to manage the risk for my event?’” he says. Broad issues of risk management are a key component of event management, he adds.
Dr. Patrick Kersey is medical director of USA Football, the national governing body of youth, high school and amateur football. He says event organizers should have emergency action plans, including access to EMS services and medical personnel, protocols in place and involvement by athletic trainers. If there is a general concern about a concussion, the first protocol would be to remove the player and not allow him to return until someone with experience in concussion management has evaluated him. It would be rare for them to return the same day. Kersey stresses the importance of putting evaluation in the hands of trained medical providers.
In order for athletes to return to competition, they must first be symptom-free, with no headache, dizziness, disorientation or poor balance. A neurologist must evaluate them using on-site tools such as a sports concussion assessment tool (SCAT3). Symptom-free athletes should be returned with progressive physical challenges (starting out easy and slow). In the case of a concussion, the normal time away from play might be anywhere from five to 14 days, which would push recovery well beyond the end of most multiday sporting events.
Kersey says there also is a trend toward testing athletes before a concussion injury to establish a neurocognitive baseline to compare with in future examinations, a standard practice at college and pro levels that he says could become part of a pre-participation medical evaluation.
Knowledge is Power
Thorough knowledge of medical issues can inform good decision-making by sports events planners. The National Federation of State High School Associations has developed a free 20-minute online course for students, coaches and parents called “Concussion in Sports—What You Need to Know.” More than 900,000 people have taken the free online course in the past two years. Greater awareness helps officials and coaches recognize the signs of a possible concussion and take those players out of games. The slogan is “When in doubt, keep them out,” says Koski. “This is a new era, and we now understand the symptoms and the science.” The Centers for Disease Control and Prevention also has an online course and other resources related to concussions.
Research also can shed light. USA Football is in the middle of a two-year study monitoring 10 youth football leagues in six states to examine player health and safety. Preliminary findings cover more than 60,000 individual athlete exposures (or participation in games or practices) involving nearly 2,000 youth football players on more than 100 teams. Fewer than 4 percent of youth players sustained a concussion. Contusions were the most common injuries (35 percent), followed by ligament sprains (15 percent). Fewer than 10 percent of players incurred any injury, and 64 percent of those were minor, and the athletes returned to play the same day.
“It’s not a topic that is being ignored, but I don’t see these types of issues curbing the continued growth in popularity of sports as a whole,” says Aughey. “There is continuing progress in education, but it won’t cut down on overall participation.”
Dr. Kersey adds, “No amount of overscrutinization is a bad thing as we better learn and understand this process,” he adds. “I think we’ll see the concern normalize as the pendulum moves more to the middle.”
Properly addressing the possibility of concussion will settle into a mainstream practice. “It won’t be a situation that will change or alter youth sports in the end, other than increasing education and protocols.” Head injuries get better with proper treatments, he says. “The important thing is awareness of an injury and not allowing kids to participate actively until they have truly recovered. If we do that globally, we will be treating this injury as well as we can.”
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