Concussion protocols inconsistent at southern Illinois high schools

When you hear the word “concussion,” it’s easy to picture six-foot-tall juggernauts blasting across stadium fields, sending their opposition rag-dolling to the cheers of thousands of spectators. Previous coverage can have the effect of inuring audiences to the morbid realities of brain injuries in professional football, rendering news about the health of a select few millionaire athletes sterile and distant. The concussion reform efforts of years past have lost their novelty, even though new research continues to take place at accelerated rates. What many don’t see in the limelight of media coverage is the concussions in our own backyards, sustained by potentially vulnerable high school and college athletes who don’t have the resources and constant professional medical attention that professional athletes enjoy. 

According to Illinois concussion law, schools are required to have a designated staff member responsible for concussions and programs that safely return students to academic and athletic participation after they receive concussions. Out of 10 Southern Illinois high schools, all have medical professionals present at sporting events throughout the sporting calendar. Eight of the 10 schools have medical professionals observing practices when they can (depending on the risk of injury in the sport). Still, many high schools don’t provide their own medical professionals, instead relying on contracts with local hospitals and colleges to provide athletic trainers and doctors covering their area, which can result in less coverage of potentially dangerous events than if schools had resident professionals. 

 “SIH (Southern Illinois Healthcare) provides the athletic trainers to some high schools, but we’re only there two times a week for school visits, meaning checking injuries and coverage of the games,” said Sarai Yates, coordinator of sports rehabilitation at SIH and a certified athletic trainer at SIH for 20 years. “We’re not at every practice and we’re not at every sport. I think it should be covered more. Obviously, most concussions are gonna happen at practices, not at games because you have kids who maybe don’t play as well, don’t hit as well – or maybe they’re learning to hit – or that’s when they try the new cheerleading pyramid and they drop someone on the head. I truly believe every school in Illinois, high school and junior high, should have an athletic trainer on-site at school during practices and games, but there’s no law. That’s not forced everywhere.”

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Specifically, Illinois concussion law requires high schools to have designated concussion officers to supervise games and practices and create concussion protocols at each school, preferably medically trained. In practice, the law allows schools to contract with medical professionals or even use completely untrained concussion officers if the expense of having medical professionals on staff is prohibitive. 

“Are we really covered here in Southern Illinois? We’re doing the best we can, but no,” Yates said. “Those little schools are not. Murphysboro and Marion are really the only schools in this area that have a full-time athletic trainer on-site at all times. And then there are the schools we cover, and that’s close to every school.”

In the local area, financial resources remain the main issue in getting professional supervision for athletic events.

“It comes down to money and being able to have staff there whereas, you know, the local high schools have one athletic trainer, you know, for all their sports,” said Dr. Scott Schonewolf, SIU’s Director of SIU Sports Medicine Fellowship as well as the Medical Director for the  SIU Center for Family Medicine. “Now, the NCAA and high schools, you know, mandatory you need to be at more of these anywhere where you could have collisions – what we’d call a collision type sport. So it should be there for football, men’s and women’s basketball, soccer, baseball, softball, anywhere we could have that now. But you have your athletic trainer, that is at every practice and everywhere. If you were at the professional level, yes, there might even be a physician there but I don’t know that for sure. They’ll also have ten trainers vs one or two. At the high school, you have one.”

SIU itself sports 12 athletic trainers including assistant and intern athletic trainers  (not including Schonewolf and Dr. Jose Aliling, a fellow in sports medicine at SIU), nearly one for every sport and with two additional interns covering football.

As for the rest of Southern Illinois, the quality of their care really depends on the location, schools size or wealth and whether or not institutions with resources like SIU’s can reach them.

“We try to provide the best care we can. But yeah, the quality of care may be a little bit decreased and it’s just location. If you’re at a big high school with lots of money, you might even have your own, you know, physician that’s contracted with them,” said Schonewolf. “It’s unfortunate, but it’s understandable that schools don’t have athletic trainers at every event. I mean, there are some poor school districts in this state and even, I came from Pennsylvania, where they just don’t have the money or resources. So you use EMS. And we have that, we have had some away teams coming into our local high schools and they don’t [have athletic trainers] and they use our trainer and that is fine. Athletic trainers will help out the best that they can to both teams.”

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Research done by the National Library of Medicine shows that athletes are more likely to have a concussion during a practice rather than a game. In those findings from 2015 to 2019, 72% of concussions occurred during practices. Another contribution to the high percentage of concussions within practice would be the high amount of practices compared to games. Another interesting statistic is that 48.5% of concussions occurred during preseason training, despite preseason representing only 20.8% of the football season.

Aliling said some schools he’s worked with even have problems providing equipment to keep athletes safe, relying on used safety equipment donated by the community. Oftentimes this equipment is under-investigated, despite the fact that it could provide inadequate protection due to crack and wear.

For smaller schools, like the ones in the area, players are at high risk of having a concussion go completely unnoticed. 

According to the University of Pittsburgh Medical Center and the University of Michigan concussion center, five out of 10 concussions go unreported every year within sports. Two out of 10 high school athletes in contact sports get a concussion within a year. Contact sports are primarily football, wrestling, soccer, and hockey. Basketball, baseball, and softball are additional sports at the high school level that can feature a handful of concussions.

 Jaryd Clark, a former multi-sport athlete at Frankfort Community High School in West Frankfort, has his own concussion story, and it shows just how easy it is for a concussion to go unreported or overlooked. 

During a high school football game in September of 2015, Clark was struck with a friendly fire blindside hit. Playing defensive end, Clark was attempting to tackle the running back when he was involved in a helmet-to-helmet collision with a teammate. Clark has a hard time remembering most of the specifics, but some were too eerie to forget. 

“I was knocked out cold for a second. When I stood up, the sky was green, and the field was blue.” Clark said. 

This happened during a game, yet Clark wasn’t evaluated until after the game. He finished the game after an obvious crushing blow to the head. A blow that left Clark laying on his back and needing assistance to get back to his feet. Still, he remained in the game. During the postgame, it was quickly determined that Clark had indeed suffered a concussion. 

“Bright lights would cause headaches and loud noises as well. I could just tell that it wasn’t normal.” Clark said. 

Clark was forced to sit out of practice for a week and would miss one game as well. He was given some headache medication that helped the pain wear off after four days. Clark returned two weeks after the injury and still didn’t feel 100% healthy. 

“I had a couple more during practice throughout the season for sure, I just wasn’t evaluated for whatever reason. I was having the same symptoms and they didn’t check on me at all. They never really evaluate for hits during practice.” Clark said.  

When no medical professionals are available to observe teams, coaches are the next line of defense against injury. They are expected to know what concussion symptoms are and how to respond when an athlete takes a heavy hit. All 10 southern Illinois schools confirmed that every coach must watch a set of concussion training videos prior to each season, often in meetings with all the other coaches. 

Players are also expected to watch concussion videos prior to the start of their sport’s season. Not all 10 schools could confirm whether their student-athletes had watched concussion prevention and treatment videos prior to the 2022 school year. A major problem, particularly among high school athletes, is that the athletes often don’t know what concussion symptoms are. Even if they are aware that something is off and they’ve taken a large hit, some athletes feel like playing through an injury is more important than their health.

“Even though the kids are educated, they might be educated so much that they know they’re gonna get pulled,” said Yates. “We have a new concussion at Herrin that got reported yesterday, but she got hit on Monday. She didn’t report it until Wednesday. She didn’t report it because she took a blow from a volleyball right before a sectional game. One, she wasn’t sure if she was really concussed, she was embarrassed that she got hit, she wanted to play and so she just went home after the game. The next day she went, ‘oh no big deal, I feel a little better’ but then, by Wednesday, she felt worse, probably because she went to school and tried to focus all day.”

SIU doctors, who cover several of the local highschools and collaborate with SIH, are no strangers to the concept of patients tricking medical practitioners.

“Yes, there are going to be some athletes that won’t tell you,” said Schonewolf. “You know, I think I just read a quote from Bart Scott, a former player here. He kind of scored low on his initial assessment [SIU students complete baseline concussion assessments so that their normal results can be compared to post impact results]. He failed it so he could score better when it was real so he could go back out and play.”

Aliling said he’s seen opposing teams attempt to put athletes back out to play after they’ve suffered head injuries that removed them from games or practices.

“When the patient gets concussed, there are several mandatory observable signs that we need to be able to elucidate,” Aliling said. “That patient, when he got hit, remained motionless for more than five seconds. He was staring a blank stare. And then when it came up, he’s very disorganized in terms of his balance, and then he was disoriented.”

This patient in particular also failed neurological tests asking him where he was and what he was doing, even though he reported no pain. The patient, one of the opposing team’s star players, wanted nothing more than to go out and continue to play, despite being clearly injured. Though he was taken out of play at Aliling’s recommendation, the debate still continued in the second half of the game. 

“So I checked him out during halftime, he’s still a little bit disoriented, still kind of like having some neurologic deficit during that time, but he was improving and they were thinking of bringing him back to the second half,” Alilings said. “So I talked again to the other team’s athletic trainer, ‘You know, I’m not biased in any way because I’m currently working for the other team. I’m just here to kind of make sure everybody’s going to be safe and nobody gets injured. I have good intentions. So you know what, even though I’m the opposing team’s physician, I saw what happened in the field. And I think he really does have a concussion.’ So I think they were attempting to bring him back. But I said, ‘there’s no way that you can come back.’”

If the scenario had gone differently, a lack of medical professionals at the site of the game could have forever changed this athlete’s life. The effects of multiple concussions in short succession can range from increased recovery time to catastrophic brain injury or death, yet even a large and obvious injury nearly wasn’t enough to convince this team to keep their star player out of the game. 

“This phenomenon is called the second hit phenomenon, wherein you have a concussion and you’re not completely healed and you pretty much go back to sports and get another concussion,” Aliling said. “The brain has not calibrated to where it was before. So it could cause a catastrophic, catastrophic event, which is kind of weird. It’s kind of like a swelling of the brain where injuries can occur – dysregulation in the blood flow into the brain. It causes cerebral edema and herniation. It could cause lots of disabilities. That’s why we need to do a thorough evaluation of athletes, making sure that when they go back they follow the return to play protocol and when they come back, they’re back to their baseline.”

Though most concussions are mild, suffering a second impact even without obvious concussion symptoms can result in a prolonged recovery time, or worsened injuries. 

“I mean, it [the brain] will usually reset back to normal, but the biggest thing, when you look at advanced – and maybe you were gonna ask this question or not – CTE,  chronic traumatic encephalopathy, whether it’s one big major concussion, or if it’s a lot of small things that the brain might not even realize a small brain injury – small little hits – things build up,” Schonewolf said. 

According to Schonewolf, everyone reacts differently to concussions. Children with developing brains often take longer to recover than adults. According to the University of  Michigan Concussion Center, females take longer to recover than males. Even individuals are subject to great differences in recovery time and symptoms. Individuals that have received concussions before are even more predisposed to them in the future, suffering more symptoms from smaller impacts. Many concussions don’t even come from sports so much as everyday events. 

What all concussions have in common are their bewildering effect on the brain. Concussions cause a flurry of activity in the brain, sending confused signals between the various centers of the brain and producing a mental fog as brain activity slows. Generally fatalities from concussions are caused by exessive blood flow to the brain as a result of this confusion of signals, but over long periods of time concussions begin to have an effect on the structure of the brain itself. This is called Chronic Traumatic Encephalopathy or CTE, something that’s only really detectable by post mortem autopsies of repeat concussion victims. 

“Once you have CTE, it’s permanent. It’s a progressive deterioration in the neurologic status,” Aliling said. “So it affects your cognitive function and executive function, your memory, it alters your behavior. You lose impulse control, it is a form of impulsivity as well so you become impulsive. You have some mood disorders, you lose some cognitive function, especially memory. And then you also have alterations in sleep. So it’s a progressive deterioration. It is actually an accumulation of certain abnormal proteins, tau proteins that kind of developed in the brain. So what they think we’re University of Michigan is doing to kind of get a biomarker to detect tau proteins. Just a way to get it from the blood or from fluids in the body. It’s a technology still in development.” 

Athlete’s attitudes towards football are often cultivated by coaches and teammates to inspire loyalty to the team and put  great emphasis on winning. Turning a player’s engagement with the sport and loyalty to the team into a risk to their own health is unthinkable, but nonetheless a problem according to the CDC’s online training pamphlet on concussions. 

The American Journal of Sports Medicine claims as many as 7 in 10 young athletes with a possible concussion report playing with concussion symptoms. Out of those, 4 in 10 said their coaches were unaware that they had a possible concussion.

Yates said that the big concussions are easy to notice, because students immediately display obvious symptoms like losing consciousness or experiencing seizures. The smaller concussions are tricky to notice, and yet dangerous to athletes due to the cumulative effects multiple untreated concussions can have on the brain.

This is why it’s concerning that coaches are sometimes the only group responsible for observing concussions at schools, due to the fact that coaches have many other things to worry about, including managing their teams strategy and keeping team morale up. Although they may be able to recognize some signs of concussions through their familiarity with their players, at the end of the day coaches aren’t able to diagnose concussions. The best they can do is watch for heavy hits in games and, even in that area, coaches are unlikely to match the level of attention that an athletic trainer or doctor with only one job can give to the heavy blows in the game.

Despite it all, Schonewolf said, as the atmosphere of today’s athletic world becomes more aware of the health implications of concussions, athletes are acknowledging the importance of concussion protocol more but also says that it depends on the place. 

At SIU, Shonewolf says that players and coaches understand the risks of concussions well. According to the university’s official concussion protocol documents, every year each SIU student athlete is informed about concussions and required to sign a form saying acknowledging that they were educated. 

High schools are supposed to have a designated employee at the school that oversees concussion management. Seven of the 10 schools couldn’t give a good answer when asked who that employee is. Most of the schools break up the oversight among three or four individuals. These individuals ranged from athletic trainers, athletic directors, school nurses, and head coaches. The remaining schools rely on professionals that are under contract with nearby hospitals, such as the SIH Carbondale Memorial Hospital. 

A major positive for the local schools is the reporting of concussions to the IHSA. All 10 schools said that they report their concussions to the Illinois High School Association, the main body serving high school athletics within the state of Illinois. It oversees everything that pertains to high school athletes including concussions and other injuries, but seldom intervenes to alter high school programs. According to Yates, IHSA monitors the number of concussions reported by high schools, but mostly for research purposes. However, there are firm guidelines for treatment once athletes are confirmed to have concussions. Once an athlete has a concussion, they must follow certain guidelines in order to fully return to their schoolwork and their athletic pursuits. The first is “return to learn” and the second is “return to play”. “ That’s where it can get sort of murky. Each school is allowed to list its own versions of return to learn and return to play. They all have the same ideas, but different wording can lead to different interpretations. Out of 10 southern Illinois schools that were surveyed, none of them had the same definitions of the return process for a concussed athlete. This is because Illinois law requires each school to come up with its own concussion protocol, rather than prescribing one state-wide protocol. While this could potentially result in further inequalities in the treatment quality given to athletes based on the staff and expertise at the school, concussion protocol across the entire country has made great advancements in the last couple of decades overall, and did not vary drastically across most of the local highschools.

“I’ve been here for 20 years, so when I started there were really no concussion protocols for the high schools,” Yates said. “You probably could talk to people my age who would say ‘well back in the day no one had  concussions.’ Well, they probably did,  they just didn’t know they had a concussion. Even when I started, if someone took a blow you didn’t even test them for 15 minutes. You let them sit and get their bearings. You didn’t test them because they weren’t accurate. Now we know that that’s not necessarily true. It’s gone from us being educated – as medical professionals even – at a conservative level to now we’ve got protocols for academics, protocols for return to play, protocols for vestibular and vision issues…It’s gone pretty far in the 20 years that I’ve worked. In the medical world that’s pretty impressive.”

Specifically, advancements have been made in the treatment of concussions, even if detection remains an issue. 

“Where it used to be ‘they need to rest, they need to be checked every hour, don’t let them do anything, put them in a dark room’ to ‘well we need to have them doing some activity just no blows to the head, they need to start walking more they need to increase their heart rate to get some blood supply.’” Yates said.

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