Two men running at full speed crash their heads into each other.
Their brains, floating in fluid, jostle around, slam into the front of their skull, or, even worse, twist rotationally like a globe shearing the axons around the brain causing the electrical impulses of the nerves to misfire.
The result, if the blow is severe enough, can be a concussion. That word “concussion” has been on the lips of many these days. Doctors and neurosurgeons have learned more about concussions in the last 10 years than ever before. As a result, athletic trainers know more. Football coaches know more. And, encouragingly, so do high school football players.
“It’s a transition in our culture essentially,” said Dr. Andre De Leon, a certified concussion specialist with the Concussion Clinic at Eisenhower Medical Center. “Younger generations now know about concussions. You have one, you’re out at least a week, and that’s just the way it is. There’s no begging to be let back into the game or anything like that. It’s understood. And that’s an important step.”
The days of “he just got his bell rung, he can go back in there and play” are over. In fact, Pittsburgh Steelers quarterback Ben Roethlisberger took himself out of a recent game, concerned he may have a concussion, something that never would have happened even five years ago.
The topic hits the main stream, if it hasn’t already. The movie shows the real life difficulties Dr. Bennet Omalu (played by Will Smith) went through trying to convince the NFL that Chronic Traumatic Encephalopathy was a real thing. The movie also shows how sustaining multiple concussions can alter a person’s personality as it did with Pittsburgh Steelers Hall of Famer Mike Webster, who is focused on in the film, and others including Junior Seau of Chargers fame who committed suicide in 2012.
From the protocol of handling a hard hit on a Friday night to the medical deep dive into CTE, the way concussions are being diagnosed and treated has evolved quickly and dramatically.
That evolution is happening in the Coachella Valley as well.
While high school players aren’t in danger of CTE, they are, of course, susceptible to concussions. And in the last few years, the valley and state has stepped up their game when it comes to concussion prevention and rehabilitation.
The state of California lagged behind on the issue of concussions, but did pass Assembly Bill 2127 on Jan. 1, 2015. It says that if an athlete is deemed to have a concussion, he or she must sit out of all athletic activities for a mandatory seven days. Other states passed similar laws as long ago as 2009.
Many of our high schools partnered with area hospitals long before the assembly bill to be proactive about concussion treatment and management.
Desert Regional Medical Center and Eisenhower Medical Center both team up with valley high schools to conduct Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT). It’s an important first step in the concussion treatment process.
If you haven’t heard of ImPACT, it’s pretty simple. All football players take a 30-minute computer test of their cognitive ability before the season starts. Then, if a concussion or feared concussion occurs, the doctors put them through that test again. They will then have clear data to see if there is an impairment, how severe, and which particular brain function has been weakened the most – memory, balance, vision, etc. Then they can tailor the rehabilitation to the specific problem. Most importantly, it provides a tool, to more clearly know when the player is healthy enough to return to the field.
Desert Regional works with Shadow Hills, Xavier Prep, Cathedral City, Coachella Valley, Indio and Desert Mirage. Eisenhower handles Palm Springs, Palm Desert, Rancho Mirage, Desert Hot Springs, Desert Christian and College of the Desert.
Armed with that knowledge, let’s see what happens when a concussion takes place during a football game on a Friday night here in the valley. We’ll talk to the people who live it: A player, a coach, a sideline trainer and a concussion doctor.
Palm Desert senior Joe Caridi remembers the night of his game as a sophomore against La Quinta vividly. Some parts of the action, though, he needs to see the video tape to remember.
Caridi, currently known to valley football fans as an All-DVL defensive stud, was on the varsity as a sophomore but on this night he was a reserve fullback. On Nov. 8 against arch-rival La Quinta, Caridi subbed in when one of the starting running backs went down with an injury.
“I remember one of the first plays was a reverse option,” Caridi said. “We faked it one way and then (Kyle) Kabeary and I ran an option play toward the sideline. He pitched me the ball and I gained about seven yards and I was focused on running over the cornerback, when the safety came out of nowhere and hit me helmet-to-helmet.”
Caridi laid unconscious on the field.
“I was out for about 50 seconds and then after a while I felt like I had my whereabouts about me and I was walking back toward the sideline with the trainers,” he said. “But later they told me that I wasn’t making any sense, like I was asking the same questions over and over, not remembering that I had already asked it. They just immediately called an ambulance and took me to the hospital. I still don’t really remember anything about the play except getting the ball. I had to watch the video to see what happened.”
It was the last play of that season for Caridi. He returned to play, and play well, during his junior and senior seasons. He said he’s thankful for everything the training staff and doctors did for him back then. And he said that in just the two years since that incident, he’s noticed a huge increase in the amount of focus and time high school teams spend on concussions.
“We do that ImPACT test which is like 30 minutes on the computer, and just everything about concussions is much more serious than it was,” he said. “We had a couple guys get concussions this year, luckily not me, but they went through all that testing. And they had to wait a little bit to get back on the field. In previous years you never really know when you’re fully healed and you were risking your health to come back. Now you know more.”
And responses like that are heartening to doctors. Thanks to all the discussion and education about concussions, there is a generation of athletes like Caridi who understand the seriousness of the issue, much moreso than their parents and coaches who grew up in the 1960s, 70s and 80s.
Dr. Syndey Pardino, the sports medicine medical director at Desert Regional Medical Center, said he likes to talk to the players when they do their ImPACT testing.
“Even if you still get a dad saying, ‘When I played we just went back out there, what’s the big deal? I turned out fine.’ We try to enforce that this is to help the athletes, not keep them sidelined,” said Pardino who before coming to the desert worked on the sideline of the New Orleans Saints for the 2010-11 season. “I talk to the kids. ‘Do you know what a concussion is?’ ‘Do you know the symptoms?’ Take the opportunity to educate. And I think it’s working with the current generation.”
Shadow Hills High School head football coach and athletic director Ron Shipley has been heavily invested in football for years. He played in high school, at college (New Mexico) and bounced around in the NFL trying to latch on with the Kansas City Chiefs organization. He even played a year in the World League and four years in Canada. He’s seen it all, and he’s been a part of a lot of collisions.
“Back when I played, man, I can’t tell you how many concussions I probably had and were never diagnosed,” Shipley said. “It was just a different time. You’d never go to the team doctor. Never say anything if you thought they might take you out. Now everybody is so cognizant of concussions, I don’t remember it being that big of an issue to anyone back then.”
Now, of course, Shipley is quite astute when it comes to concussion safety. His team has been doing the ImPACT testing for a couple years now and as a coach he appreciates the process.
In a way, it helps take some of the tough decision-making out of his hands.
“I think you have to be extra safe because of all the information out there,” he said. “If we even think someone might have one, they see our trainer and team doctor and go through the concussion protocol. If they have one they’re automatically out seven to 10 days, do the ImPACT testing to see the severity of it. And then what’s great is when they are back, you know they’re ready to be back. You’re not guessing or assuming.”
Even better than properly handling a concussion is preventing them in the first place. That’s what the “Heads Up” movement, created by the Centers for Disease Control, is all about.
It refers to a change in the way football players are taught to tackle. Instead of lowering and leading with your head to tackle the ball-carrier, the new best practice is to keep your head up and lead with your shoulder, see what you’re hitting.
Changing the way you’ve taught tackling for decades isn’t easy for coaches. And that includes Shipley, who has gone through “Heads Up” certification online.
“It was hard, I’m kind of an old-school guy, and I was one of those guys that resisted at first,” Shipley said. “But we’ve changed the way we tackle, not leading with the head so much, using the body more. I’ve progressed into the current age.”
It’s Friday night. The quarterback is sacked. His head hits the ground hard. He’s getting up slowly. That’s when Heidi Navarro steps into action.
“I generally go out on the field or see them right when they come off,” said Navarro, who has been the athletic trainer for five years at Shadow Hills High School. “If we think they took a hard hit. I’ll administer some sideline testing, testing for balance, memory, eye movement.”
If she deems it to be a concussion or likely to be, she said she does two things immediately. She pulls the player from the game and updates the parents. That’s important. She said she likes to give the parents some instruction on how to care for the player in the evening and the next day. Then, within two days, the player will do their ImPACT testing.
Navarro is a big believer in the value of the ImPACT testing. A player who has been deemed to have a concussion has to sit out the mandatory seven days, of course, and is not allowed back on the field without permission from a neurologist or a concussion specialist.
Navarro said this past season only three or four Shadow Hills players had a concussion, which was a good number. The previous season saw closer to 10.
“The changes in recent years have been huge, and most people for a long time didn’t understand the importance of the testing and treating concussions properly,” she said. “I still have parents that want to send their kids back out. Educating these parents is very important. As far as coaches go, in the very beginning there might be a little trouble with them wanting players to return to a game, but nowadays that doesn’t happen. Coaches don’t argue with me much anymore.”
So now it’s Saturday morning. A trainer has diagnosed a player with a possible concussion and sends him to retake the ImPACT test with a concussion specialist, who will then measure the new results against the initial baseline results to confirm whether the player has a concussion and formulate a rehabilitation plan.
Pardino, who started the ImPACT program at Desert Regional Medical Center, said a hidden value of the ImPACT testing is that having the tangible data to show the kids or parents helps them believe a concussion has occurred.
“We started ImPACT testing two years ago and it’s a valuable test in that you can’t really see a concussion on an X-ray or an MRI that you can show someone,” Pardino said. “Being able to show the results and the data to the kids and parents helps them buy in. And that’s an important step.”
Both Pardino and De Leon said they see about 20 to 25 concussions during the course of a high school football season in the desert.
Dr. De Leon said while there are other tools out there, he believes the ImPACT provides the most robust data available, revealing not just whether there is a concussion, but which part of the brain is failing.
“The nice thing with the software is it takes any clinically significant changes and makes it nice and red. So you see exactly what’s not normal. That helps us define what centers have been rocked in the brain essentially,” De Leon said. “We want to shut down the parts of the brain that are disfunctioning while keeping the other parts of the brain moving. In terms of concussion, the first week is still the most important part.
“We shut you down and have you rest for a week. These tests help us figure what part of the brain to then go focusing on. If it’s more vestibular (balance), then we focus on vestibular. If it’s more on vision, then maybe we get you to an optometrist. It’s just a way to help us focus on the center that’s really been the most affected.”
So the doctors use the data to set a course for the player to return to play. This is the most important part of the process. The dreaded “second-impact syndrome” is what everyone is trying to avoid. Extreme brain damage, and even in a few instances death has occurred, when an athlete returns to play and has a second concussion before the first one has healed.
“In about 80 to 90 percent of concussions, the player is safe to return to play after resting for 7 to 10 days,” said Dr. Pedram Navab, a neurologist at Desert Regional. “But that 10 percent may have lingering effects. And second impact is where the brain actually will get struck harder and have even more damage where you actually see swelling. Some people have died. That’s where there’s such an emphasis on not sending someone back too quickly. And that’s where education to teachers and coaches is really vital.”
De Leon described second impact like this: “A concussion changes the way the blood flows to the brain. Now sometimes it’s increased, sometimes it’s decreased. If you get a second impact within a short time after that first concussion, that bloodflow is already abnormal and now it’s even more abnormal. Sometimes, it squeezes down and pushes all the blood to your brain and that’s catastrophic.”
The concussion protocol and testing is popular, but not everyone is a fan.
Some players and parents want a hasty return to action, often believing that time missed due to concussion safety measures may cost the player a chance at a college scholarship. Navarro, Navab and De Leon have all seen athletes try to “sandbag” the ImPACT test. In other words, intentionally do poorly on the initial test when they get their baseline data, so that when they retake the test after a possible concussion it will be easier for them to pass.
“They don’t all understand that this is to help them, not prevent them from playing,” Navarro said. “Plus the computer program has ways of detecting that anyway, so you can’t really fool it.”
De Leon concurred that there is still a faction of people out there that think concussion doctors are the bad guys.
“That’s the old mentality,” De Leon said. “A lot of people think we’re going on witch hunts looking for players with concussions. It’s not like that. Believe me, my job is a lot easier if no one has a concussion.”
THE END OF FOOTBALL?
Taking the conversation to an extreme level, is it possible with the increased discussion of concussions and long-term effects such as CTE, that parents will simply not allow their children to play football in the future?
“I’ve thought about that a little,” Caridi said. “Like sometimes when you see something bad happen you think ‘How in God’s name do people want to have their kids play football?’ But I love it. And I think people will always love it.”
Shipley, who has children of his own who have played football, understands the concern, but like Caridi, he doesn’t see the recent surge in concussion awareness as a deterrent.
“I would think there are some parents out there who are hesitant,” Shipley said. “And obviously people are scared about concussions, but it wouldn’t keep me from playing football and it never has.”
Dr. De Leon summed it up.
“The thing that’s hard for some people to understand is that we’re not trying to kill your sport,” he said. “We’re just trying to keep it safe.”