Ending the Guessing Game in Concussion Recovery

By Preston Williams
Thursday, April 17, 2008

As Hammond High School athletes headed off to games and practices after school Friday, junior varsity lacrosse player Jake Rotter strolled to an empty computer lab to once again square off against his stiffest adversary: himself.

Rotter sustained a concussion during the JV football season, experienced lingering headaches that prompted him to leave the wrestling team and then endured another concussion playing lacrosse this spring.

In previous years, the school's athletic trainer and Rotter's doctor would have monitored his symptoms -- if there were obvious signs, which is not always the case -- and made a determination about when he could return to action.

Now Howard County and some other Washington area schools can make quantifiable decisions with the ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) program, a tool to help track recovery from concussions.

Howard began using it this school year, and it is free to students, with parental permission.

Here's how it works: Before the season, an athlete takes the computerized ImPACT test, which, in part, measures his memory and reaction time after being shown a series of words, designs, patterns and symbols. It takes about 25 minutes. There is no particular score for which to strive; each athlete's results provide a baseline of information.

"It definitely tests you," Rotter said.

If the athlete experiences a head injury, he retakes the test to see how his results compare with his baseline reading. Is there a lapse in memory? Reaction time? Some other decline in performance?

If his retest results fall markedly short of his baseline numbers, he probably will be deemed not ready to play. The athlete will continue to sit out until his ImPACT scores are close to his pre-concussion results.

The ImPACT test findings remove some of the guesswork about whether an athlete is fit to resume play, and the graphic representation of results makes it easy to explain to athletes and their parents why the athlete might or might not be fully recovered from a head injury.

The program, developed by Mark Lovell at the University of Pittsburgh Medical Center, is used by professional sports teams, colleges and hundreds of high schools in the United States. According to http://www.impacttest.com, the only Washington area school systems to use it are Howard and Fairfax counties, with other individual schools using it, as well.

"There's a real gap in the knowledge of this injury," said Gerry Gioia, director of neuropsychology and director of the Safe Concussion Outcome, Recovery and Education (SCORE) Program at Children's National Medical Center in the District. "What happens is families and kids are getting lots of different messages about whether they can go back to play or not, and many times it's not based on any objective or systematic data."

To learn more about the ImPACT program, and to take the test ourselves, we caught up with Rotter, 16, and Hammond athletic trainer Tim Happel on Friday when Rotter was retaking the test for the second time since sustaining a concussion late last month.

Rotter first got concussed in first grade in a bike accident at Lake Elkhorn. He lost his short-term memory for a few days. A person who sustains a concussion can be more vulnerable to concussion than those who have not sustained such an injury.

"Oh, another butterfly gave you a concussion?" a buddy said to Rotter recently, jokingly suggesting that the middle linebacker-offensive lineman and lacrosse defender, known for his physical playing style, is soft.

When Rotter, who is enrolled in honors courses, is concussed, he suffers from headaches and a lack of concentration. "It feels like you have a haze over you, a fog, kind of," he said, adding that his grade-point average dipped from about a 3.57 to a 2.71 in the fall when he had trouble focusing after his football concussion.

"He's in all really, really intense classes, so concussions have much more effect there than on the field," his mother, Julie, said.

Rotter could tell when he took the first retest April 2 that he was not particularly sharp. He noticed further improvement Friday afternoon, taking it for a second time since his lacrosse concussion. But before clearing him to play, Happel wanted to consult with Gioia, who helped develop the concussion treatment program for Howard schools. (Gioia's children play sports at Mount Hebron High.)

"It seemed like I could remember the shapes a lot easier," Rotter said after his second retest. "I was a lot faster, it felt like. It was a pretty obvious difference."

Mike Williams, coordinator of athletics for Howard schools, said that the county's dozen high schools have tested an average of about 200 athletes each. With the program becoming more established, he expects that number to grow to 400 or more next school year.

"They used to say after two days you could return" from a concussion, Williams said. "Then it went to a week. Now research shows that with high school students, their brains are still developing, and a sustained concussion in a high school student can impact their learning and development for a lifetime. When we saw that, that's what really sold us. It's not a perfect science, but it's the best thing out there."

The cost of the program is $9,000 for the software, about $750 for each of Howard's 12 high schools. But for school systems without certified athletic trainers, administering and interpreting the tests could be a problem. Howard and Fairfax have trainers.

For athletes itching to get back on the field, the ImPACT test can be friend or foe: friend if it raises no red flags, which might result in getting back sooner, or foe if the athlete feels fine -- or is downplaying symptoms, which is common -- but falls short of baseline benchmarks when retaking the test.

Oh, and don't try to lowball your initial ImPACT test. Not only could it be hazardous to your health, it could be embarrassing. Gioia said the test has indicators that expose sandbaggers.

"I feel like [the ImPACT test] is holding me back a little bit," Rotter said, "but I'm also glad it exists. Because if it didn't exist, I'd be back on the field and getting another concussion and be in a worse state."

Varsity Letter is a weekly column about high school sports in the Washington area. E-mail Preston atwilliamsp@washpost.com.

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