While the national media has intensified its focus on the negative impact of concussions in professional sports, the spotlight has largely passed over Division III athletics. Concussions, however, are an issue at all levels of competition — in October the New York Times reported that five Pop Warner pee wee football players competing in the 120-pound weight limit group suffered concussions — and affect athletes and non-athletes alike.
Medical Director, College Physician and Team Physician Dr. Mark Peluso said that roughly 10 Middlebury student-athletes reported receiving concussions during the 2011-2012 academic year. He believes, however, that the true number of concussions sustained is higher than the given number.
“I expect this number to increase as awareness about concussion leads to increased reporting of a traditionally under-reported condition,” he said.
While other institutions — most notably the National Football League — have come under severe scrutiny either for ignoring the damaging long-term affects of concussions or failing to recognize them, Middlebury understood the severity of concussions at an early stage and has been ahead of the curve with its treatment programs. The College instituted a detailed and comprehensive system of protocols and precautions nearly a decade ago, though awareness of the issue and testing have been an essential element of Middlebury’s sports medicine program for considerably longer.
“It’s one of the things we were doing really well before it became a hot topic,” said Peluso. “We were treating concussions using as much evidence-based or expert-consensus based recommendations years before it became a big issue.”
In an effort to standardize the treatment received by student-athletes in the NESCAC, the Presidents of each college created the Medical Aspect in Sports Committee (MASC). Peluso currently serves as the chairman.
“Based on our preliminary work, we know that all NESCAC schools have the same fundamental approach to concussions,” he said. “There are a few subtle process differences that tend to relate more to the staffing or administrative structure of the different schools.”
When an athlete is suspected of having sustained a concussion or exhibits concussion-like symptoms during a game, he or she immediately goes through a series of what Peluso describes as rudimentary neurocognitive tests. These include recalling the months of the year backwards and repeating groups of numbers in reverse order to test cognitive ability and memory. If the tests are completed successfully and the athletic trainer is confident that the individual is not exhibiting signs of a concussion, he or she is still held out of play for a period of time before re-entering to ensure that symptoms do not develop or worsen. If the trainer feels that the player in question has not satisfactorily responded to the baseline tests or worsens during his or her time on the sideline, the player is immediately pulled from the game and cannot return.
“If we even sniff a concussion we remove [the athlete],” Peluso said. “If you come off [the field] and say ‘I feel foggy, I can’t remember the last play,’ [then] you’re done [playing].”
Peluso is aware that a policy with strict in-game protocols may lead athletes who are wary of being pulled from competition to hesitate to report their symptoms.
“The concern is that [these precautions] might lead to underreporting,” he said. “Someone might not want to report symptoms, and I think that’s going to be a fine line that we’re going to need to continue to manage.”
Bob Ritter, head coach of the football team, shared a similar sentiment, but thus far believes that the system in place has not dissuaded members of his team from discussing their injuries.
“One of the things I was initially concerned about was that we would get an underreporting of concussions, and we haven’t seen that,” he said. “Guys are pretty careful about talking to trainers when they’re having symptoms.”
Return to Play Process
After receiving a concussion student-athletes must complete a 10-step process before they are cleared to return to athletic competition. Before that can be accomplished, however, the immediate objective — once symptoms have subsided — is to gradually re-acclimate the individual to the classroom.
“Forget the playing field — we don’t even worry about that initially,” Peluso said. “[The focus] is getting [the student] back to class. It’s their ability to function in the classroom that tends to be the most impaired.”
In the immediate aftermath of a concussion the individual is observed every four to six hours throughout the day and night by a friend or family member who is asked to monitor symptoms and take the necessary steps if conditions deteriorate. Until symptoms dissipate, the patient is advised to rest his or her brain as completely as possible, thereby avoiding reading, doing class work and limiting use of phones, computers and televisions.
Only when the effects of the concussion have abated entirely is the student-athlete advised to return to class. Here the process is gradual as well. First the student is asked to attend all of his or her classes and to attentively listen, but not to participate. If the student is able to do this without issue, he or she can then begin to participate and begin to work on out of class assignments. Finally, if all prior steps have been successfully completed with no recurring symptoms, the student can return to a full academic schedule in and out of class.
Having satisfied the academic requirements, the student-athlete must still return to baseline neurocognitive function — determined by the ImpACT test — before he or she can begin the process of returning to athletic competition. This begins with an aerobic test to examine how the individual’s brain will respond to elevation in both heart rate and blood pressure.
If the athlete does not experience a relapse in the 24 hours following light cardiovascular activity he or she can commence with sport-specific movement. If the individual remains asymptomatic he or she can proceed to non-contact training and weightlifting. This step would permit a wide receiver on the football team to begin individual route running and pass catching. In order to return to full-contact practice, however, he would need to be cleared for full-contact practice by a team physician. This penultimate step allows coaches to assess the athlete’s progress and test his or her game-readiness. Should the individual progress to this point without issue, he or she is finally considered ready for complete participation.
The length of time necessary for a student-athlete to return to the classroom and, subsequently, competitive play after suffering a concussion varies considerably and depends on a number of different factors. Significant factors include the severity of the injury, the number of concussions previously suffered by the individual and whether he or she has a learning disability, to name a few. Typically post-concussion symptoms last two to eight weeks. If after that time the student-athlete continues to experience problems he or she is referred to a neurocognitive specialist. For some athletes who have experienced numerous concussions in the past, the potential risks of continuing playing their sport outweigh the benefits. In some instances the athletes have made the decision on their own, in others Peluso has made the recommendation himself.
“When there have been multiple concussions, return to play may be delayed and in some cases result in a recommendation that the athlete stop playing that sport,” Peluso said. “It is not a pleasant conversation to have with an athlete, but I have had it on several occasions over the past 13 years.”
One such student who felt the risk of sustaining further concussions outweighed the reward of playing is Will Peckham ’14, a former wide receiver on the football team. Peckham suffered a concussion during a preseason practice before the start of his sophomore year. While the immediate symptoms of his concussion were mild, it was his third concussion in just over a year and fourth overall, which delayed his recovery.
“The symptoms from [my fourth concussion] lasted longer than any of my [previous] ones,” said Peckham.
After three weeks of rest he attempted to go through the process of returning to the field for the second time, but stopped when his symptoms returned. Though Peckham was never advised to stop playing football, he decided, given his history with concussions, that stopping was the right thing to do.
“It was a personal decision,” he said. “The marginal benefit of continuing to play wasn’t as great as it used to be.”
While student-athletes who suffer concussions at Middlebury have received great medical support, it can be more difficult to discuss your injury with other athletes who have had concussions. Emma Kitchen ’14.5, a former member of the alpine ski team, sustained a severe head injury, complicated further by significant, sustained post-concussion symptoms when she was involved in a two-bike collision on campus two years go. In addition to the critical, immediate aftermath of the accident — Kitchen was transported to an Intensive Care Unit in Burlington — she faced a long, grueling recovery process away from school with little medical advice other than to rest and an uncertain time frame for her recovery.
“I found that the general experience I had with all of my doctors — and I became obsessed with seeing doctors, I saw 15 or 20 doctors — [was that] no one had any answers,” said Kitchen. “No one knew how long it would be, no one knew what the best [way to] recover was.”
Without any sense of when she could expect to make a full recovery and return to school, Kitchen grew increasingly upset.
“It was a really big frustration that I didn’t have anyone to tell me about how their experience was because people were so quiet about it,” she said.
She finally spoke with a friend who had suffered a number of severe concussions, but had decided to continue skiing despite the significant risk it posed. Hearing his story reassured Kitchen in her own recovery process and ultimately created the idea for Concussions Speak, an online forum where athletes who have suffered concussions can share their stories and receive support.
After missing winter term and all of the 2011 spring semester, Kitchen returned to Middlebury the following fall. On the advice of her neurosurgeon she decided to end her collegiate career as a downhill skier, deciding instead to play for the women’s golf team. Kitchen also applied to MiddCORE, which she saw as a great opportunity to start her initiative, Concussions Speak. Kitchen was awarded MiddCORE’s “Next Big Idea” award for her work with MiddCORE during winter term, which included a feature in Middlebury Magazine.
“[It] was incredible,” she said. “I was able to get so many more contacts and really raise awareness much more so than with any other vehicle.”
Kitchen has since then partnered with two other Middlebury students, Kait Surdoval ’12 and Sierra Sittes ’14, each of who have had multiple concussions with years of post-concussion symptoms.
The group’s mission is to “create a support network and open community for any athlete who has suffered a concussion.”
At this point Kitchen is in contact with approximately 50 people who have suffered concussions or have family or friends who have had concussions. She has found that the two groups of people most likely to reach out to her are parents and high school juniors and seniors.
“A lot of [our] contacts are in their last year’s of high school and trying to figure out how to cope with a concussion and get into university,” Kitchen said. “It’s an extremely stressful time for a lot kids and having a concussion added on to that is terrible.”
Going forward, Kitchen believes that in addition to conducting interviews and providing a forum for people who have suffered concussions, the best way for Concussions Speak to spread its message is through public speaking. She is currently planning a panel discussion for the spring on concussions in athletics, which would involve numerous experts in the field.
“The head of the Brain Injury Association of the United States is coming to Middlebury in March,” she explained. “He’s here mostly for neurobiology majors, but I want him to speak to athletes and bring in Dr. Peluso and have one of my doctors from home on Skype [all participate].”
SGA Athletic Trainers Bill
While varsity athletes, and particularly those who compete in contact sports, face a higher risk of suffering concussions, students who participate in club sports — with the exception of crew and rugby — are not covered by the sports medicine department and therefore do not have access to athletic trainers or the trainer’s room. Less than a month ago, however, the Student Government Association (SGA) passed a bill recommending the College create weekly hours when non-varsity athletes can meet with experts in sports medicine and receive treatment for their injuries.
“[A number of different club sports and organizations] were very interested in this bill,” said senior SGA Senator Nathan Arnosti ’13 who sponsored the bill.
In particular, the women’s water polo team, which sustained four concussions as a team last year, is calling on the College to provide more money for greater funding in sports medicine.
“Often, because we don’t have access to the medical trainers and because concussions are difficult to notice right away, our players don’t realize for at least a day that they have a concussion,” said captain Olivia Noble ’13. “What happened with all of the four girls last year was that they woke up the next morning and realized they had difficulty focusing their eyes and had bad headaches, at which point they went to the health center. These weren’t minor incidences, but because there is no protocol in place, they weren’t recognized.”
The captain of the men’s water polo team, Peter DiPrinzio ’13, believes that without regular access to athletic trainers, members of his team could risk developing chronic injuries.
“It is very important that we have access to athletic trainers during some set weekly hours to look at chronic and sports-related injuries,” he said. “Without this access, players risk receiving improper or no care for concussions and long-term injuries. Research shows this can have lasting consequences.”
While water polo players may be at less risk than other athletes, Noble does not believe this should restrict them from having access to trainers.
“Water polo players typically suffer fewer acute and chronic injuries than other sports such as rugby, but we feel we are equally justified in ensuring our own personal safety,” she said.
The College currently employs five athletic trainers to cover the 31 varsity sports teams on campus. While he is not responsible for decisions on hiring athletic trainers or their assignments, Director of Athletics Erin Quinn does not believe that the current group can take on additional responsibilities.
“Our athletic trainers are giving all the coverage they can and couldn’t do more than what they’re doing,” he said. “I know that based on how hard they’re working and what they’re doing.”
Arnosti, who understands that the current group of athletic trainers cannot assume greater responsibility, thinks that there are other potential solutions to the issue that would meet the demands of the interested groups.
“It’s going to be an uphill battle,” he admitted. “Hiring a new trainer outright is probably out of the question. I’ve brought up the possibility of doing a partnership with Porter — hiring a trainer from Porter on an hourly basis for two to four hours a week. A third option that we’re looking into is paying [to] train a nurse or another staff member from Parton [Health Center] to be more aware of athletic injuries, including concussions.”
The Next Steps
While Middlebury has a strong foundation in place to treat varsity athletes who suffer concussions, Quinn and Peluso believe that the College would benefit from a higher degree of coordination between the athletics department, sports medicine and the faculty and staff.
“The next step in concussion management at the College … is [to create a joint effort to raise awareness and coordination around the issue],” Quinn said, citing the NESCAC symposium and residential life meetings as two areas where greater discussion about concussions and how they are treated within the foundation of the College can occur.
In February, Peluso and the MASC will meet to discuss how the NESCAC can improve its coverage of concussions. Peluso cited three main areas of improvement: defining concussions, how to treat them and ensuring that both athletes and non-athletes receive greater academic accommodation when experiencing post-concussion symptoms.
“In my experience, one of the biggest problems I see are students that feel pressured to get back to the class early — athlete or non-athlete,” Peluso said. “Teachers by and large are pretty understanding at Middlebury. There are a few that maybe don’t get it, but it’s the students who feel pressure to get back into the classroom that don’t do as well.”
Peter Kim, the head coach of the women’s soccer team, believes that while concussions receive a lot of reactionary coverage, more work can be done to prevent them from happening.
“We try to take as many steps as we can to eliminate the risk of injury and I think we’ve done a pretty good job of that by adding components to our strength and conditioning program,” Kim said. “We’ll do the same thing for concussions. It’s safe to say that we can do a better job improving neck strength. From what I understand concussions oftentimes come from the whiplash rather than the impact itself. If we can give [players] stronger necks to eliminate that — that’s our next step.”
Finally, the College continues to receive recommendations and input from students and student organizations ranging from Kitchen and Concussions Speak to Arnosti and the SGA and a host of club sports. While Middlebury has been cited by many as “ahead of the curve” in diagnosing and treating concussions, in order to stay ahead it will need to continue to improve and expand its coverage, taking heed not only of the recommendations of its administration, but also of the student body.