Omaha Burke High School sophomore Eric Diaz can only stand around and cheer his teammates on wearing street clothes during a game against Millard South in Omaha on Oct. 3. PHOTO BY MATT MILLER/THE WORLD-HERALD
STUCK ON THE SIDELINES
Inside one concussed player's fight to get back on the field
By Henry J. Cordes / World-Herald staff writer
More than two weeks after Eric Diaz got clobbered in a football game, he finally shook the headaches and dizziness fogging his brain.
In the past, that likely would have been enough to get the Burke High School sophomore back on the field.
But not any more. Like many high schools and colleges, Burke now requires athletes who have suffered concussions to pass a computerized memory test to prove their brains are actually working right again.
After Eric slogged through the battery of tasks requiring him to recall words, letters, symbols and squiggly line doodles, he was in for a surprise. He flunked badly, his results far below what he had scored on the same test before his concussion.
For the disappointed 15-year-old, it meant more time on the sidelines — but also more time for his brain to safely heal.
Of the many ways concussions are proving a game changer in football today, perhaps no development has been more critical than the revolution in how such head trauma is dealt with on the sidelines and beyond.
Coaches today have heightened awareness of the invisible, brain-rattling injuries, how to recognize them, and the danger of allowing players back on the field too soon.
And return-to-play decisions that in the past were frequently left to coaches are now usually made by certified athletic trainers or doctors, often with the aid of new tools offering an objective peek into the workings of the brain.
Gone is some of the guesswork on whether athletes have recovered enough. And gone, too, health advocates say, should be any thought that a coach, player or anyone else should make a return-to-play decision based on anything other than the player's health.
"There has been a culture shift, one that was long overdue,'' said Dr. Brian Hainline, a neurologist who — largely because of concussion concerns — was named last year as the NCAA's first-ever chief medical officer.
Numerous drivers have been behind that shift.
Several high-profile professional players who suffered repeated concussions have been linked to a serious, dementia-causing brain disease, increasing public awareness of the dangers of head trauma in football.
Most states have now passed laws intended to keep concussed youth athletes from playing again too soon. Nebraska and Iowa now have laws that require removal from play of any youth athlete suspected of having a concussion and that require medical clearance before a return to play.
Lori Terryberry-Spohr, the brain injury manager for Madonna Rehabilitation Hospital in Lincoln, said such laws actually take pressure off coaches.
"Coaches didn't know how to handle concussions and were making difficult decisions, often with parents or kids pressing them to get back into the game,'' she said. "Now if the coach even suspects a concussion, it's no longer their decision. It's up to the medical professionals.''
Meanwhile, the use of neurocognitive testing has proliferated throughout pro, college and high school football and is now reaching the youth ranks. Considerably more than 200 of Nebraska's 309 high schools are using the tests, including all of the major schools in the Omaha and Lincoln metro areas.
"I think we've made a lot of progress in a really short period of time,'' said Dr. Dan Tomes of Lincoln, a neurosurgeon who helped form a network of health care facilities that provide free concussion testing to many Nebraska high schools.
Notable progress continues on other fronts, too.
This fall, the governing body for high school sports in Nebraska, in its first mandate directly targeting concussions, required all coaches in the state to be trained on the "three R's'' of sideline concussion management: recognize, remove from play, and refer to a health care provider.
The number of high school coaches taking concussion training online through the organization almost immediately quadrupled, from fewer than 1,200 last school year to about 4,800 so far this year.
But those concerned about concussions say much work remains.
Athletes in rural schools have less access to athletic trainers and the new testing.
And there has been little focus to date on "returning to learn'' — how to guide concussed student-athletes back into the classroom. Youths who have suffered concussions can frequently see their symptoms aggravated by schoolwork, prolonging their recovery.
Some coaches — and even some parents — still dismiss all the worry over concussions. The attitude: I got concussions back when I played, and I'm just fine.
"I still run into schools and coaches who are kicking and screaming over this stuff,'' said Dave Schultz of Nebraska Orthopedic and Sports Medicine in Lincoln.
Meanwhile, many players haven't gotten the message that they should speak up when they don't feel right. A report this year found that only 54 percent of high school players surveyed would always report their concussion symptoms to their coaches, and 53 percent said they would continue to play with a headache that was the result of an injury.
Even with the improvements, people are kidding themselves if they believe that premature return of concussed athletes has completely ended, said Chris Nowinski of the Sports Legacy Institute, a Boston-based nonprofit that has been sounding the alarm on football and concussions.
"As much as we think we've solved the problem, it's not even close,'' Nowinski said.
It's believed about 90 percent of athletes who suffer a single concussion are free of all symptoms — headache, dizziness and fogged memory — and recover normal brain function within about 10 days.
But studies suggest football players have commonly sat out only briefly after a concussion. That put them at an increased risk of repeat concussions, which often lead to impairment lasting weeks or months. In very rare cases, a second concussion before a prior injury has properly healed can lead to catastrophic brain injury, even death.
A University of North Carolina study of high school and college football players in 2000 found that 31 percent of concussed players returned to the field on the same day of their injury, after being held out an average of just 13 minutes. Most players were back within four days.
An NCAA study in 2003 found that 11 of 12 players in the study who suffered second concussions had sat out 10 days or less. The average concussion victim sat out just five days.
A more current federal study, in 2011, suggests improvements in concussion care. It found that only about 5 percent of concussed high school players were back on the field within one to two days — still 5 percent too many, experts say.
Since most who suffer concussions are free of their most severe symptoms within a few days, trainers and health care providers often face pushback from coaches, athletes and parents if they try to hold athletes out longer. It's that pressure that ultimately led to the development of neurocognitive memory tests.
Trainers for the Pittsburgh Steelers in the late 1990s created the first ImPACT test (short for Immediate Post-Concussion Assessment and Cognitive Testing). The tests help detect brain impairments that can persist even after symptoms clear.
Players first take the test before they strap on pads in the fall, establishing a baseline for their normal brain function. Then, if a player does suffer a concussion, subsequent tests once symptoms have cleared can reveal when his brain is truly back to previous performance levels.
Use of such tests did not proliferate within college and high school football nationally until the NFL began mandating their use in 2007.
At the college level, the NCAA doesn't mandate the tests. But like many colleges today, the University of Nebraska-Lincoln requires all of its concussed athletes to pass the test before returning to practice or competition.
Most high schools in the Omaha area began giving baseline tests to football players, wrestlers and soccer players in 2010, and now some middle school and youth league athletes take them, too.
Before the season started, Eric Diaz took a test that recorded memory and response times. He can't start to practice again until his scores get close to the initial test. PHOTO BY MATT MILLER/THE WORLD-HERALD
Across Nebraska, the number of high schools using the test has roughly tripled in the past two years. That spread has been aided by local health care providers that have often covered or helped school districts pay for the baseline testing, which comes to about $2 per athlete.
Even after passing an ImPACT test, players typically go through a five-day gradual return-to-the-field progression before suiting up for another game.
Schultz said it previously was common for a high school player who was concussed at a game Friday to be back at practice the next week and play again the next Friday, never missing a game. Now a concussion is most commonly a two-week injury, and quite often longer.
The tests have their critics. Some studies have questioned whether they too frequently produce inaccurate results. Even the test's producers say the results should not be strictly relied upon when making return-to-play decisions.
Many local doctors and trainers say the tests aren't required to successfully manage a concussion. Still, most also say they're helpful. For one, kids eager to get back on the field are sometimes dismissive of lingering concussion symptoms. But it's pretty hard to fool the test if your brain still isn't right.
"You hear players say 'I'm not going to leave the game unless it's on a stretcher,' '' said Rusty McKune, the sports medicine coordinator at the University of Nebraska Medical Center.
"But that's not an attitude you want to take with your brain. You've only got one.''
Eric Diaz, the sophomore quarterback for Omaha Burke High School's reserve team, scrambled to his left before four opposing defenders corralled and gang-tackled him.
The player who finished off Eric lowered his head and delivered a shot right to Eric's helmet. The sharp crack of the vicious helmet-to-helmet blow — one that probably should have drawn a flag, but didn't — rang out through the stands.
"It was just so loud,'' Lori Battaglia, Eric's mom, later recalled of that September day. "A helmet-to-helmet hit is very frightening.''
It was also the sound of Eric Diaz joining the hundreds of thousands of football players annually who suffer concussions.
Josh Nichter, Burke's 37-year-old athletic trainer, saw Diaz writhing on the ground and rushed to attend to him. Having worked football sidelines for nearly two decades, from the University of Nebraska-Lincoln to Florida State to the last four years at Burke, he almost instinctively knew what to do.
Nichter first checked Eric for signs of life-threatening head or neck trauma, then slowly helped him sit up. Eric complained of a headache, dizziness, ringing ears and blurry vision, the familiar calling cards of a concussion.
Moving to the bench, Nichter ran Eric through a sideline concussion assessment, a series of standardized questions and tests that Nichter had long before committed to memory.
"Do you know where you are?'' Nichter asked. "Who are we playing today?''
Eric had those answers. But then Nichter asked, "Do you remember what you had for lunch today?''
Eric stared blankly for about 10 seconds, his mind clearly searching.
"I don't know,'' he finally allowed, adding, "My head hurts.''
Nichter recognized this as retrograde amnesia — the inability to recall the most recent of events. It was another concussion clue.
Then Nichter had Eric follow his penlight with his eyes, moving it from side to side. Nichter noticed that Eric's eyes skipped erratically, suggesting an interruption between the brain and optic nerve — yet another concussion indicator.
Finally, Nichter tested Eric's immediate memory, giving him five simple words to remember. Apple. Cart. Spider. Truck. Bubble.
They ran the test three times. Each time Eric recalled only three.
Nichter had seen enough. He summoned Eric's parents from the stands.
"Your son has a concussion, and it's pretty significant right now,'' Nichter said.
Eric's mom took him to the hospital, where he was kept overnight for observation.
Eric stayed home from school the next day and spent days battling crushing headaches. At one point, he slept for 16 straight hours. As concussions go, this was a pretty severe one.
After two weeks, his symptoms finally cleared. That milestone, however, marked only the beginning of Eric's move back toward the field.
Eric was now ready for an ImPACT test, the cognitive test that would offer a peek into how his brain was functioning.
Eric sat before Nichter in Burke's computer lab to go through the battery that would measure his memory, processing speed, reaction time and impulse control.
During the first part, 12 words flashed on the screen, one at a time. Eric was then questioned repeatedly about which words had come up, with phony ones thrown in.
The computer asked whether "house" was one of the words displayed.
"Yes,'' Eric answered.
"Incorrect,'' said the computer, a response that would become common as Eric worked through the test's six parts.
Later, Eric was given three letters to remember: M, V, N. After performing a counting task to take his mind off the letters, he was asked to recall them.
R, V, W, Eric typed, missing badly.
So it went. Eric's responses were often halting and sluggish, a clear sign his brain wasn't right.
Afterward, Nichter pulled up the results. When Eric had taken his baseline test weeks before, he'd scored above the 50th percentile. This time: the 2nd percentile.
"All it's saying is you need more time to heal,'' Nichter told Eric. "You'll get better.''
Eric scored equally poorly when he retook the test a week later. Nichter encouraged Eric to keep his head up. He'd seen kids and their brains make pretty dramatic rebounds.
That's exactly what happened when Eric took his third post-concussion test a week later, almost a month to the day after his original injury.
Eric was far sharper, quickly clicking through his responses. Up flashed the results. All Eric's scores were either back, or mathematically close, to his baseline. He passed.
"Can I go suit up?'' Eric excitedly blurted.
Not so fast, Nichter said. To get back on the field, Eric needed to go through a five-day return-to-activity progression, beginning with light jogging and ending with a full-blown practice.
If all went well, with no returning symptoms or setbacks — and his doctor signed off, a requirement placed in state law a year ago — he would be back on the field in time for his team's final game.
Unfortunately, Eric never got there.
Just two days into his return progression, he hit his head in gym class, a blow strong enough to bring back most of his concussion symptoms. Eric now needed to wait for his head to clear and then pass another ImPACT test.
Eric's football season was over.
The setback was obviously a huge disappointment. But it also served as a useful reminder: Head trauma is no trifling matter.