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The Six Pillars of Concussion Risk Management: The MomsTEAM Approach

Head injuries in football, as in other contact and collision sports, cannot be completely eliminated, but there ARE steps that can be taken to minimize risk. The Smartest Team

Our high school football concussion documentary, The Smartest Team,TM  focuses on what I call "The Six Pillars"TM of concussion risk management: ​

Pillar One: Comprehensive concussion education

When MomsTEAM, with the help of one of the country's pre-eminent concussion experts, Dr. Robert Cantu, launched its comprehensive concussion safety center in 2001 - becoming, in Dr. Cantu's words, the "pioneer" in youth sports concussion education - the subject was years away from gaining the attention of the national media.

Today, virtually every expert in the field puts concussion education at the top of the list of ways in which football - and all contact and collision sports - can be made safer.

A comprehensive concussion risk management program begins with education. All stakeholders in football - athletes, referees, administrators, parents, coaches, and health care providers - should be educated about:​

  • ways to reduce the risk of concussion and brain/neck/spine injury (Pillar Two)
  • the critical importance of early identification of concussion after one occurs, including the need to create an environment which encourages athletes to report their concussion symptoms and those of their teammates, the need for an athletic trainer or other medical professional on the sideline to conduct an immediate concussion assessment (Pillar Three)
  • conservative treatment and management (physical and cognitive rest) and return to learn (Pillar Four)
  • principles of cautious return to play (Pillar Five ); and
  • factors suggesting that retirement from football and other contact and collision sports is advisable (Pillar Six)

Parents and Players

​While nearly every state in the country now requires that parents and players receive some basic concussion safety information as a condition to participation, much more education than can fit on to an 8 1/2 by 11 sheet of paper is required.

Ideally, all parents and players should attend a comprehensive concussion safety meeting before every football season, where they can be taught:

1. to recognize the signs and symptoms of concussion: 

2. to watch for delayed symptoms. It is not uncommon for concussion symptoms or signs, including behavioral changes, and concentration and memory problems, to only appear hours or even days after a strong blow to the body or head during practice or game action. Delayed symptom onset is especially common among younger athletes; [1]

3. the need to regularly and close monitor athletes during the first 24-48 hours after diagnosed concussion for signs of deteriorating mental condition suggesting a more serious brain injury which requires immediate hospitalization,

4. the benefits of  cognitive and physical rest in the first few days after concussion, including staying home from school, and the importance of a gradual return to school (Pillar Four) and to sports (Pillar Five); and

5. the dangers of continuing to play with concussion symptoms and/or returning to play too soon, before a child or teen's still-developing brain has fully healed (Pillars Four and Five), including increased risk of potential adverse short- and long-term, and even catastrophic health consequences, ranging from:

(a) longer recovery time; to 

(b) persistent symptoms which may linger for weeks or months (e.g,post-concussion syndrome), to

(c) permanent cognitive difficulties (problems with memory and concentration), and emotional problems; to

(d) devastating degenerative neurological disease, such as chronic traumatic encephalopathy.

The precise effects of mild traumatic brain injury such as resulting from concussion and repetitive sub-concussive hits, and the degree they increase the risk of long-term health problems is unknown and will vary tremendously among student-athletes;and

6. the need for parents, coaches, and teammates to create a safe reporting environment which encourages honest reporting by athletes of concussion symptoms (not only theirs, but their teammates).[12-15]

Coaches

The key person in the concussion risk management program outlined in The Smartest Team is the certified athletic trainer (AT), but coaches play an important role as well, especially in the high school or youth football programs without access to an AT (more than 50% at the high school level; athletic trainers are probably few and far between in youth football):

1. Coaches should be trained to teach players heads up tackling and blocking (Pillar Two)

2. Coaches should be trained to watch for and recognize the signs of concussion.​

3. When an athletic trainer, team doctor or other medical professional with concussion education and training is not present on the sideline - which is strongly recommended - a coach should know to immediately remove a player from practice or play and arrange for an immediate evaluation by medical professional, and not allow the athlete to return to play that day, if he or she observes any of the following signs observed after a direct or indirect blow to an athlete's head:

(a) loss of consciousness (however brief);

(b) balance or coordination problems (unsteady gait, athlete stumbles, walks sideways or is labored in their movements);

(c) disorientation or confusion (inability to respond appropriately to so-called "Maddocks" questions);

(d) blank or vacant look;

(e) visible facial injury in combination with any of the above.

4. Coaches should actively, consistently, and repeatedly encourage honest self-reporting of concussion symptoms by athletes and use of a "buddy system" in which athletes are assigned to watch for signs or symptoms of concussion in designated teammates.  Recent studies have shown that coaches' negative attitude about concussion reporting is the biggest barrier to such honest reporting,[12-15]

5. Coaches should always put athlete safety first, above winning. In other words, coaches need to be part of the concussion solution, not part of the concussion problem.

Health care professionals

Primary care physicians (PCPs),  along with certified athletic trainers, treat the vast majority of concussions which do not require specialized care. admit to being unaware of current concussion management guidelines (Pillars Three and​ Four), or find the guidelines too confusing or cumbersome to put into practice.

Increased concussion education of PCPs is needed, especially now that all but a handful of states require that high school athletes suspected of having a concussion receive written approval from a clinician before returning to play (Pillar Five). One of the principal purposes of such laws - not to return athletes to play prematurely before their brains have healed - will be thwarted if clinicians do not know how to diagnose and manage concussion or are unaware of RTP guidelines and allow athletes to return to play sooner than recommended.

Mobile applications

One way for athletes, coaches, parents, officials, support staff and medical personnel to become educated about concussions is by downloading concussion "apps" on their mobile devices. Because of their widespread use, portability and wireless connectivity, mobile phones can serve a unique and valuable function in bridging the significant gap in concussion education.

The key advantages of a mobile phone app as an educational tool are twofold: not only do they give the user the opportunity to download educational materials quickly, but they possess operating systems that support engaging and interactive solutions to learning (2). For an article reviewing the six applications geared for parents and athletes, one of which was created specifically for educating children, click here.

While there is also a need for smartphone apps to organize information on injury demographics, symptom timing, recovery milestones, and medical appointments, and to provide licensed health care professionals diagnostic screening tools, such as the Standard Assessment of Concussion (SAC), [3] Sports Concussion Assessment Tool (SCAT3 [4] and Child-SCAT3 [5]), easily accessible across computing platforms, only four of the eleven applications identified in a 2013 study [2] as being assessment tools state that they are for use by health care professionals. Because use by parents and other non-medical personnel might carry significant legal liability, such applications should only be used as diagnostic screening tools by licensed health care professionals.

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