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Brooke de Lench
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"Back in the Game": A Concussion Book That Stands Out In a Crowded Field

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The authors then move from the an expansive and philosophical discussion of the role of the media in the concussion conversation to the nuts and bolts of concussion education, laying out in a series of well-organized chapters and in step-by-step fashion how concussions are identified, diagnosed, and treated, beginning with a discussion of the use - and misuse - of baseline computerized neurocognitive tests, the need for immediate removal from play when concussion is suspected, what to do in the first few hours after concussion, and the recovery process that follows. I found particularly helpful the way Kutcher and Gerstner divide the recovery from concussion into three phases (acute rest, relative rest, and gradual exertion phases), and use a mnemonic (B.R.A.I.N., which stands for Bike (B), Run (R), Agility (A), "In Red" (I) and No Restrictions (N)) to describe the basic framework for graduated exercise return-to-play protocol most experts recommend.

Subsequent chapters discuss post-concussion syndrome and second-impact, an excellent discussion of the links between concussion, sports, depression (with a particularly useful section on the three different kinds of depression and how to keep them straight when all three are present at the same time) and suicide. I found particularly informative their discussion of how suicide rates in general, and among former National Football League players in particular, can be and have been affected by messaging in the media - a phenomenon called the "suicide contagion" - and how, unfortunately, the media, in its coverage of the suicide of players such as Junior Seau and Dave Duerson, has consistently ignored all seven of the recommendations of the Centers of Disease Control on how to avoid spreading that contagion, including not presenting simplistic explanations for suicide, not engaging in repetitive, ongoing, or excessive reporting of suicide in the news, and not providing sensational coverage of suicide.

While some of this information is new (particularly the sections on depression and suicide), much of it covers ground that has been plowed many times before in other books and websites such as MomsTEAM (and our new SmartTeams concussion site). Yet Kutcher and Gerstner somehow manage to come up with ways to convey the information in fresh new ways and easy to understand terms.

Chapter Seven, entitled "How Athletes Can Help Themselves," returns to a theme introduced at the very beginning of the book - that our sports culture teaches athletes, particularly at the elite level, to play through pain and play with concussion, with sometimes dire consequences - and the need for athletes, parents, and coaches to recognize that athletes are "not destructible, they can get concussed, and they need to be honest when they are hurt," or as the authors advises athletes: "Say something. To Somebody. Please."

As with many concussion books, the authors use the stories of former elite athletes, in this case, two-time Olympic gold medalist and World Cup-winning soccer player Kate (nee Sobrero) Markgraf and pioneering X-Games snowboarder Ellery Hollingsworth, to personalize the message that "if an athlete is hurt, if they do not feel right, if they know something is wrong in their gut ... they should ultimately feel empowered to say something. Giving answers they think their coaches, teammates, or family want to hear doesn't help anybody in the end." The challenge that they, like I, have long recognized is to actually get an athlete of any age to actually think that way.

As MomsTEAM and I hav long been doing, Kutcher and Gerstner stress the need for athletes to become educated about concussions, to be leery of television productions, movies, or other media that have been produced for shock value, to ask themselves about the motivation that person has in getting their message out, to question their sources of information, and to rely on trusted resources for their concussion information (it was an honor for MomsTEAM to be included among those resources in the book's appendix).

The advice Kutcher and Gerstner provide to parents and coaches, much of it from former elite athletes who are now standing on the sports sidelines as parents, is solid and grounded on common sense. Parents, they say correctly, need to recognize that their child's coaches are not like professional or elite coaches, that most are unpaid volunteers, and that many may not know more about concussions than they do. They advise that if parents see something that looks dangerous or not totally right, they need to speak up, perhaps not directly to the coach, but through proper channels, such as the booster club, athletic director, parent representatives, or athletic trainers.

As for coaches, they admit that they have to "walk a fine line between advocating toughness and discipline during play and leading athletes to believe they should play through injury and pain," and that, while concussion awareness has improved, there is still a great deal of resistance to changing the "warrior mentality" common to many contact and collision sports.Like the advice we advance in the concussion education game plan developed under our Mind Matters Challenge grant from the NCAA and Department of Defense, Kutcher and Gerstner take the view that: anything short of athletes being totally responsible and accountable about their brain health is unacceptable; that coaches and the athletic training staff need to communicate from the start of the season the message that there "is no heroism or credit given for playing through a concussion" but that "it's unwise, it's dangerous" and will not be tolerated; and that mandated concussion education of players, coaches, parents, and leagues - a position MomsTEAM has advocated for a decade - would do a lot to make contact sports safer

The penultimate chapter ("Changing the Game: On and Off The Field") provides a useful, if familiar (at least to MomsTEAM followers), summary about protective equipment (helmets and mouth guards), warnings against the use of impact sensors and baseline testing in diagnosing concussions), and short, somewhat perfunctory discussions about innovative training techniques ("heads up", helmetless tackling etc.), strength training, proper hydration, and rules enforcement in reducing concussion risk.