Playing It Smart

Lauren
Manfuso
June 19, 2012
The Neurorehabilitation Concussion Clinic helps young athletes figure out a game plan for recovery after a sports-related concussion.

Aidan FieldingIn October 2008, Ryne Dougherty, a 16-year-old New Jersey teenager and junior linebacker for his high school football team, was in the middle of a game when he suffered a blow to his head -- just three and a half weeks after another on-field tackle left him with a concussion. This time, he was removed from the game and sent to the hospital, where they found bleeding in his brain. He died two days later.

Afterwards, an investigation revealed that shortly after the first concussion -- and not long before he was allowed to return to the field -- Dougherty had failed a test meant to gauge whether he was fit to play. Unfortunately, he is one of many student athletes who've suffered traumatic consequences from returning to the game too soon after a head injury.

Every year, an estimated 1.6 to 3.8 million sports-related concussions occur in the United States, leading the Centers for Disease Control (CDC) to conclude that sports concussions have reached an "epidemic level." In recent years, state and federal lawmakers have taken on the issue, partly in response to attention from media outlets and outcries from parents and advocacy groups. In Maryland, state law mandates that all players must receive written clearance from a licensed health care provider trained in concussion evaluation and management before returning to the field after a concussion -- which is, in reality, a brain injury. As more and more people recognize the potentially dire consequences of concussions -- including long-term brain damage and even death -- the need for careful evaluation and high quality, comprehensive care has also increased.

At Kennedy Krieger, that growing need is being met through the Neurorehabilitation Concussion Clinic, built on the expertise of the Institute's internationally recognized Pediatric Brain Injury Program. Through the clinic, patients have access to an interdisciplinary team of specialists that includes neurologists, a physiatrist, neuropsychologists, and a neurosurgeon who diagnose concussions and evaluate patients for physical, cognitive, and behavioral symptoms. They also work with young athletes and their schools to secure extra academic support necessary during recovery and determine when it's safe to return to the playing field.

"A lot of kids and families view us suspiciously because they're worried that our goal is to keep them out of the game," says clinic neuropsychologist Jennifer Reesman. "Look, we think sports are a great thing for kids. We want them to stay involved. But we also want to make sure they can continue to play the game well into their college years if they want to. We want them to take a longer-term perspective. They may be missing a game here or there, or even an important tournament, but we also want to help them stay in the game longer, overall."

Tackling the Myths About Concussions

In the stories about young athletes who play on through injuries, it's usually the coach or the persistent parent pushing that kid to tough it out. Sometimes, Reesman says, physicians find themselves dealing with entire families of athletes -- which only makes the pressure worse. "The expectation is that sometimes you get injured, but that you're going to play on and be okay," she says. "It's not uncommon for us to hear parents say, 'Well, I had a few concussions in my day as well.'"

But as schools and parents grow increasingly educated about the dangers of sports-related injuries and concussions, many have grown wary of that "buck up" attitude.

Sometimes, however, the person pushing hardest to get a young athlete back on the field isn't a parent or a coach, but the athlete himself. After all, for a kid who eats, sleeps, and breathes football -- or soccer, or basketball, or lacrosse -- their entire way of life, not to mention college scholarships and approval of friends and family, may be on the line. "For these kids, sports really are their lives," Reesman says. "This is a huge part of who they are."

Aidan Fielding is no exception.

An honors student at the prestigious Gonzaga High School in Washington, D.C., Aidan was named co-captain of his freshman soccer team during the 2010-11 school year. But his love of sports isn't limited to the soccer field. Whenever the season ends, Aidan looks for any opportunity to keep on playing and competing. And so, in spring 2011, he joined Gonzaga's rugby team. It wasn't soccer, but it was fun, an excuse to play, and a way to spend time with other athletes.

By any definition, rugby is a rough and tumble sport. But compared to its equally high-contact cousin, football, it flies somewhat under the radar. Yet even football -- considered by some the most dangerous of sports -- requires its players to wear helmets, pads, and face masks. Rugby players, on the other hand, wear no protective gear at all -- not even helmets -- despite the sport's infamously hard hits and tackles.

Aidan with Dr. ReesmanFor Aidan, the hardest hit came during a tournament on April 30, 2011, when he endured a tackle that would make even NFL players shudder. The details are sketchy, and Aidan doesn't remember much. Witnesses recalled someone tackling Aidan, and in the melee, he either landed on his head or his head was stepped on -- no one's sure. As the pile of players dispersed, Aidan just lay there, unconscious. Then, he suddenly had a violent seizure.

Paramedics came and stabilized him, but he wasn't fully responsive until hours later, after he'd been airlifted to a nearby pediatric intensive care unit. When he finally did wake up, someone asked if he knew who he was. He told them he was professional tennis player Andy Roddick.

By that evening, however, Aidan was conscious and lucid. But he also had bloodshot eyes and was dizzy and "out of it" -- the result of a significant concussion. Two days later, his doctors sent him home with a referral to Dr. Reesman and neurologist Dr. Lam at the Neurorehabilitation Concussion Clinic.

Watching, Testing, Sleeping, Waiting

One of the trickiest aspects of treating a concussion is the idea that recovery lies not in a medical regimen, but in careful assessment, monitoring, and sometimes doing almost nothing at all. There are the obvious tests, including a medical evaluation to assess the injury and neuropsychological evaluations to assess the patient's cognition, balance, and other motor skills. Routine follow-up is also important for monitoring problems that might not be apparent at first, such as memory deficits, personality changes, or decreased cognition. And, of course, patients must be advised about which activities are and aren't allowed -- and monitored to make sure they don't push themselves too hard. But much of the treatment consists of rest and avoiding the athlete's urge to do too much, too soon.

Sometimes the hardest thing to convince a teenage boy to do is nothing at all. "A lot of our recommendations are genuinely simple, with the goal of avoiding a second injury during recovery," Reesman explains. "We needed Aidan to avoid things that made him feel worse or that might lead to a secondary head injury. That's the last thing we want to happen to these patients."

That means a lot of time spent sleeping and, initially, avoiding anything that requires increased concentration, such as homework or reading, which can slow the brain's healing. Which explains why, in the week after his injury -- and in the days before he first saw Dr. Reesman -- all Aidan seemed to do was sleep. "He just got to the sofa and crashed," recalls his mother, Heidi Fielding, of the day they brought him home from the hospital. "For a week he slept like a baby, which was good, but it was also scary."

While the doctor at the hospital had prepared them for this, Aidan's parents couldn’t help but worry: would Aidan ever be himself again? Visitors who saw him described him as seeming "drunk, or loopy" Heidi says. "We couldn't quite tell sometimes if he was just trying to be goofy or if there was something wrong," she continues. "It's hard with a teenager, because they're knuckleheads anyway."

Meanwhile, Aidan was suffering from serious cabin fever. Not only did he miss his friends and sports, but the idea of scaling back on studying for any amount of time felt completely unnatural to a straight-A student who participated on his school’s debate team. Then there were the headaches and the dizziness. "For at least two weeks I was just sitting around," Aidan recalls. "The more aware I became, the more I worried about the effects it would have on my cognitive and mental abilities. It really scared me."

Back in the Game

The other primary component of concussion care is monitoring the patient until he or she regains their previous abilities and reassuring him or her that day will come. "Before I met with Dr. Reesman, I wasn't always feeling very assured that my head would be all right," Aidan says. "But they really helped me understand what I faced, what the risks were, and what my recovery would be like. And it made me feel so much better to hear them saying that I'd be fine, and I wasn't going to be impaired for the rest of my life."

And, of course, he was relieved to know that there was an end in sight to the constant rest. Eventually, he'd be back on the field. "In the beginning, I had no idea how big a deal this would be and what would happen," he says. "But my doctors knew what they were doing, they knew exactly what was going on. That helped a lot."

Aidan and his mom with Dr. ReesmanGradually, Aidan became himself again. By June he was able to run, though with limits. And after a restful summer, he started his sophomore year in the fall, resuming not only his studying, but soccer as well. But while his grades are as good as ever, his game, he acknowledges, has suffered.

"Mentally it really affected my game," Aidan says. "Before I was hit, I had a lot of confidence as an athlete. Now it's taking me a while to get that confidence back."

Still, he considers himself lucky. For a while, his parents talked about him giving up soccer entirely, and rugby was out of the question from the beginning. "I was never going to give up soccer," he says, "but now I realize how lucky I've been to get back into it."