This is the second installment of a three-part series on concussions. Last week, Courier Publications explored the invisible injury of concussion, what happens to the brain when one occurs, potential risks associated with the injury, and therapies to aid recovery. This week we ask, are children's concussions being properly managed in Knox and Waldo counties?

Our culture values the ability to push through pain, take no sick days, and achieve perfect attendance. Within sports this is even more pronounced. Young athletes tend to brush themselves off and keep going if they can after an injury, especially after a potentially concussion-inducing impact without debilitating symptoms.

Robbie Krul, program manager at The PITCH sports complex in Warren, said about deciding when to "tough out" an injury in sports, "There’s a fine line with injuries: when do you go to the left or to the right? But as far as concussion goes, there’s no fine line."

Because the frontal lobes of the human brain continue to develop until age 25, the Sports Concussion Institute says, "it is vital to manage youth concussions very conservatively to ensure optimal neurological development and outcomes." Not doing so can put young people at risk for second-impact syndrome, or permanent brain damage or death resulting from a second concussion before a previous one has healed.  And according to the Centers for Disease Control, having a concussion makes the brain more sensitive, increasing the risk for another impact to result in concussion.

New studies suggest that a cumulative effect of concussions may affect long-term brain health, and incidents of chronic traumatic encephalopathy, a degenerative brain disease, among deceased long-time football players continue to be reported in the media.

Despite these risks, many doctors argue that pulling children from sports is not the answer. Doing so would cause a greater risk for obesity and heart disease, they say. Instead, risk can be minimized by properly managing concussions when they do occur.

Maine passed a law in 2012 requiring public schools to implement concussion management policies based on a model policy by the Department of Education. These policies stipulate, among other things, that athletic coaches must be trained in concussion management. Students with suspected concussion must be removed from the sport or school activity immediately and must not be permitted to return to play or practice without clearance from a medical provider. Once they are cleared, athletic staff and the school nurses oversee students through a gradual return-to-play protocol that ensures they do not return to the sport with lingering symptoms.

Sports reporter Mark Haskell covered the new policies in December 2012. Just over two years later, Courier Publications interviewed the president of Maine Concussion Management Initiative, school nurses and athletic staff at local public schools about how the policies are going. They say the policies have led to increased reporting, increased awareness among students about the seriousness of concussion, and better management of student concussions. Parent and teacher education, physician training, baseline testing and consistent record-keeping were identified as areas that could be improved.

Parent education

It is ultimately up to the parents whether a student suspected of suffering a concussion is evaluated by a doctor. While the policies stipulate that athletes with suspected concussions are barred from returning to the sport without medical clearance, there is nothing in the policies compelling parents of non-athletes with symptoms to have their children evaluated.

Parents might not get a doctor's evaluation because they do not know their child might have a concussion, because of the expense, because they are not educated about the seriousness of the injury, or because of the policy itself: They may not want their child to be restricted from sports or classroom work and fall behind. If a student is not diagnosed, the injury is not recorded or treated by the school as a concussion.

"Management is all based on diagnosis," said Casey Holmes, athletic trainer at Mount View Middle and High School in Thorndike. "We always have fear students may have sustained a head injury and don't know it, because parents and students are not aware of symptoms."

For parents of athletes, many schools include some education about concussion in preseason meetings with the athletic director, and most send home information about concussions for the parents of athletes to either keep or sign and return, but this information generally is not distributed to parents of non-athletes.

Ellie Weaver, school nurse at Troy Howard Middle School, and Emily Wesson, the nurse at Belfast Area High School, said there are as many non-athletic- as there are athletic-related concussions at the two schools. Wesson said car accidents are the leading cause of non-sports-related concussions at the high school level.

Private schools are not required by the 2012 law to have concussion policies unless they enroll more than 60 percent of their students at public expense, so it is up to parents with children in those schools to educate themselves about the injury. River School High School in Belfast does not have a concussion policy because it does not have a sports program; others contacted did not returned phone calls or emails.

Sports programs outside public schools are not required to have concussion management policies. Neither the Waldo County YMCA's youth soccer program nor the Belfast area peewee football program has a concussion policy. The PITCH and Five Town Football do have concussion policies similar to the school policies.

Krul said the parents he has dealt with at The PITCH are "overall borderline overprotective and that’s a good thing."

Kenneth Jondro, vice president of the Five Town Football youth football program, said parents' over-protectiveness is a problem. He's seen several parents pull their children from the program out of fear of concussions. This is unwarranted, he says, because the program does have a written concussion policy, the coaches are trained in concussion management, and they are always working to improve playing techniques to minimize risk.

Players are taught to tackle shoulder-first, as in rugby, a sport in which players do not wear helmets. He has found it is better at reducing force to the head than the "heads-up" technique advocated by U.S.A. Football.

In any sports program, parents should educate themselves about whether their children's coaches are teaching techniques that minimize risk of head injury. The PITCH introduces heading to its soccer players using softer balls that are thrown rather than kicked, making concussion less likely for young players and helping them learn not to fear the ball. Studies show that players are unlikely to become concussed by heading the ball with proper form.

Chris Bartlett, football coach at Belfast Area High School, said he teaches proper tackling technique and reduces the amount of contact during practice, both of which reduce the chance of concussion.

"All football coaches throughout the state are taking this very seriously, and anytime we get together we talk about it," he said. "I feel we as a group are working toward making the game safe for the players."

Teacher education

When students are recovering from a concussion, it is important that they not push themselves to the point where symptoms return, which can occur from cognitive as well as physical exertion. The model policy states that school personnel should be alert to concussion patients' cognitive and academic issues, including difficulty with concentration, organization, and long- and short-term memory, as well as sensitivity to bright lights and sounds, but there is no specific requirement that teachers be trained in recognizing symptoms or concussion management.

Holmes said teachers at Mount View have been informed of common signs and symptoms of head trauma to help them detect students with concussions in the classroom, but lack of detection and diagnosis is still his biggest concern. Once a student has been diagnosed, Holmes said Mount View teachers do follow the restrictions stipulated by the doctor.

Matt Lash, athletic director at Medomak Valley Middle and High schools, says, “Absolutely teachers need more education. I’m sure they’re aware of [concussion] because it’s in the news, but I’m not sure they’d necessarily know the signs or symptoms.”

Rebecca Miller, Searsport school nurse, said teachers may be reluctant to give students with concussions the extra time they need to complete their work, "but once you have the conversation they get it.”

At Camden Hills Regional High School, Dr. Kendra Bryant of Neuropsychology and Concussion Management Associates of Rockport led a staff training on concussions. School Nurse Janis Hogan said training teachers is still a work in progress.

“We’re trying to get everyone to understand it’s a hidden injury," she said. "It’s not like a broken bone. You’re not hobbling down the hallway.”

One option for students is to set up a 504 plan. Section 504 of the Rehabilitation Act of 1973 prohibits discrimination based upon disability. A 504 plan puts in writing the accommodations a student needs, which the school is then legally obligated to provide.

Physicians: 'Luck of the draw'

Even if a student with suspected concussion is detected by parents, teachers, athletic staff or the school nurse, Weaver pointed out there are steps in the process that the school can’t control.

“Our role is to identify the child, inform the parents, and provide paperwork to take to the doctor," she said. "We can’t diagnose. We have to leave that up to the doctor.”

The model policy requires that a student suspected of having a concussion be evaluated and cleared to return to sports or school activities by a "licensed healthcare provider trained in concussion management,” but does not stipulate how recent that training must be. And physicians do not necessarily have up-to-date training.

Although concussion management is an area that has been changing rapidly over the past decade, medical providers consider themselves trained if they covered concussions in medical school. Moriah Grant, of Waldo County General Hospital’s Orthopedic and Sports Physical Therapy Center, said there are even neurologists who are not trained in the latest concussion management protocols.

A doctor evaluating a student with suspected concussion might not diagnose, might clear a student too early without verifying his or her symptoms are gone, or might neglect to recommend restrictions to activity.

“There are specific physicians who I have the utmost confidence in their evaluation and treatment protocols and there are others who I am not really confident in,” Holmes said. “There have been times when student athletes have been cleared by physicians and I say ‘No way.’ It’s the luck of the draw.”

Dr. Paul Berkner, president of the Maine Concussion Management Initiative, agrees. “We do think there are not enough physicians who are trained adequately in concussion management across the state,” he said. “The training is readily available through our organization and other organizations, so there’s really no excuse at this point for providers not to get trained.”

Berkner said MCMI has trained 500 providers, athletic trainers, school nurses, nurse practitioners and physicians in best practices for managing concussions.

“I think at some point in the near future," he said, "there will be a national push to get national certification for concussion management so physicians and providers can clearly document what their skills are and what requirements they’ve met to be able to say they were trained in concussion management.”

Some say the situation is improving. Lash said as time goes on, he sees more doctors who are trained, and many now send their own specific recommendations for students with concussions to the school. Miller said one physician was adamant in not clearing the patient even though the parents were pressuring him to let their son return to play.

In the meantime, rather than relying on luck, schools are working to guide physicians in their evaluations by sending forms to fill out for students with suspected concussions. The CDC's Acute Concussion Evaluation Care Plan gives the patient — and the doctors — guidance on what activities to avoid, which symptoms are normal and which require immediate attention, and guidance on rest and nutrition. The plan provides a checklist of suggested classroom restrictions for doctors to fill out, and makes it clear that students should not be cleared to return to sports if they have any symptoms.

“We want to make sure that across all practices they’re using the ACE plan,” said Camden Hills nurse Hogan, “and figure out at what point they should be referred to a specialist.”

Most Knox and Waldo county schools' policies, including those of Camden Hills, further stipulate students must be evaluated by their primary care providers. Hogan said it is more likely for students to be diagnosed properly if they go to their primary doctor rather than to the emergency room.

In some cases the coaches and athletic trainers have more recent concussion training than physicians. The model policy requires the athletic staff and all coaches and volunteer coaches to be trained in identification and management of concussive head injuries before beginning coaching, and every two years thereafter, or whenever the protocols change. Five Town CSD requires its coaches to be retrained every year.

MSAD 40’s policy does not require student to see their primary care physician, but requires that the athletic director grant final approval to begin the return-to-play protocol. The full 2013 Zurich Convention's return-to-play protocol, which most schools follow, is spelled out in its policy.

For schools that have them, athletic trainers, with more more medical training than coaches, provide another level of oversight to managing athletes' concussions. Belfast Area High School and Searsport Middle and High schools do not have athletic trainers, and Medomak Valley Middle and High schools and Oceanside East and West share one.

RSU 3 defines the athletic trainer as a qualified and trained healthcare provider for the purpose of the policy, and does not require the student to see another physician, unless the athletic trainer determines it is necessary.

Holmes, Mount View's athletic trainer, said, “I’m here five days a week and sometimes six. I can follow up every day. You’re not going to get that from a physician.”

Baseline testing

The model policy does not mention testing students to establish a neurocognitive baseline. If administered before a concussion occurs, the ImPACT test, a computerized cognitive test used to measure things like concentration, reaction time and problem solving, can be a valuable tool for comparison with post-impact test results. These results can help doctors determine the neurocognitive status of patients as compared to their baseline and take subjectivity out of return-to-play decisions.

Berkner says baseline testing is valuable for three reasons: “First, it tells athletes that concussions are important, in fact so important that everyone who is playing sports is tested before beginning. Second, it provides us with an individual look at how they’re doing once they’ve been concussed. Third, it gives some really concrete information for parents and athletes if it is abnormal. They can say, ‘Hey, this is something that has directly affected something in my brain and I can measure it.’”

Holmes considers the ImPACT program the "gold standard" for concussion management, and said all Mount View High School athletes take the test. "You can be symptom-free and still have a concussion, because memory and cognitive function can be delayed, and reaction time can still not be up to baseline,” he said.

At Belfast Area High School, football coach Chris Bartlett is certified to administer the ImPACT test, and tests all athletes in the fall before the season starts or in the first week before any contact practices. He then tests students participating in winter and spring sports who did not get tested in the fall.

A follow-up ImPACT test may be administered, but its results do not determine whether a student can return to play. Bartlett recommends athletes go to Waldo County General Hospital's concussion center for concussion management, where they are given physical tests as well to determine the best time to begin the return-to-play protocol.

At Camden Hills, ImPACT tests are administered freshman and junior year for athletes, and the tests are sent to Bryant. The school requires results the same as or better than baseline scores to be cleared.

Lash said the cost of their ImPACT contract is very affordable, $500 for 250 tests. He said they are administered to all athletes in Medomak Middle and High schools. However, a student athlete at the school who had a concussion in September 2014 said she was not tested before the season started and her doctor did not have the benefit of a baseline to refer to when managing her recovery.

Lash said some schools are moving away from ImPACT testing. He said more important is ensuring the student gets proper rest and follows the Zurich return-to-play protocol. Ilmi Carter, Oceanside school nurse, said they do not do baseline testing because none of the physicians in the area use the data.

"The ImPACT test is a tool schools can use," Berkner said, "but if they don't have providers to adequately interpret the test, then, no, I don't think it has value."

Concussion tracking

According to Sports Concussion Institute, 53 percent of high school athletes have suffered a concussion prior to playing high school sports, and 36 percent of collegiate athletes have a history of multiple concussions. If future studies do uncover a link between multiple concussions and brain disease, it may prove useful to know the number of concussions students have had over their lifetimes.

The model policy does not say anything about tracking concussions, and each school does this differently. Most schools record concussions into the student’s medical history on Infinite Campus, an online database. Tracking methods range from a list in the nurse's agenda book to a shared spreadsheet.

At Camden Hills, Hogan has created a Google Doc spreadsheet and shares it with counselors and the athletic trainer. There she records the student, the date of the concussion, whether there is an accident report, their physician, whether they’ve been evaluated, whether they’ve been cleared, and how many concussions they’ve had before.

Because schools' tracking efforts are new, a student's prior history of concussion generally has not been recorded. Weaver said five years ago, a concussion would show up in a note in the student's file but there was no ongoing tracking. Camden Hills does track the number of prior concussions a student has had by gathering this information on the school's health assessment form.

It would also be useful to keep records of risk factors for concussion complications.

Berkner said MCMI has been piloting a tracking website with 11 Kennebec County high schools and 11 colleges for about 18 months. The site tracks who has concussion in de-identified format, where they were concussed, medical risk factors, when they return to academics, and when they return to practice. The organization recently received a $320,000 grant to expand this tracking program and study incidents of concussion in Maine.

In summary

The Maine Department of Education does well at providing up-to-date training to school nurses and coaches as scientific knowledge about the injury evolves. Schools are doing well at educating students about the importance of rest in concussion recovery, and should continue this effort.

To improve concussion management in schools, all parents and teachers should be educated about symptoms and management, baseline testing should be offered to all students, information on concussion history should be collected, records should be kept consistently, and policies should be implemented smoothly to keep students as free of additional stress as possible.

Until concussion management policies are required at private schools and in sports programs outside schools, parents should be alert to symptoms and educate themselves about the sports programs' training and concussion policies.

Next week Courier Publications will talk to student athletes who recovered from concussions in 2014 to get their perspectives on school concussion management policies.