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Advocating for Your Concussed Athlete

January 9, 2019

Advocating for Your Concussed Athlete

Lisa Walker, ATC; Springville High School, Springville, UT

As my school’s athletic trainer, like you, I’m the advocate for the concussed athlete. I'm the one making sure that the athlete's best interests are top of mind whether they’re in the classroom, at home, with a coach or with their peers. I believe successful advocacy requires relationships that are built on a foundation of education, communication and collaboration. It’s not just “a concussion is a concussion.” Each concussion is different and each concussion has to be treated individually.

For me, education is the first step and I educate everyone—the faculty, the counselors, the administration, coaches, parents and students. For example, I make presentations at parent meetings and educate students while administering the ImPACT baseline test.

As important as education is communication. I communicate with the coaches every day about the concussed athlete; if not in person, I call them. I want voice contact, not a text or e-mail, so that I know they understand what the athlete can and can't do. I go directly to the specific coach who is working with the athlete. It’s all about establishing strong relationships and being the athlete’s advocate. You want the coaches to trust you and not see your door as a big, dark hole where the athlete walks in and never comes out. Active communication with coaches allows them to understand the process and be part of the process. We’re all on the same team working to get the athlete back in the game as quickly as possible.

These communication and education efforts apply to parents as well. It’s critical to document treatment instructions. I use a post-concussion symptom scale or score sheet; it's similar to that on the SCAT5, but it's an individual’s page. It has a list of basic symptoms with a score range of zero to six.

Everyday, my athletes are required to complete the score sheet, in pen on paper, so when the parent says, "Why isn't my child playing?" I can say, "Because they are reporting such and such." And when they say, "Well, they didn't tell me that,” I can show them documentation in their child’s handwriting. I know a lot of people who document via computer, but I'm adamant about having information in the athlete’s handwriting. I also document online, but the hard copy stays in their file.

My communications with parents is also individualized; some parents want to hover close, some just want me to handle it. But I talk to all parents when the athlete is turned over to them, and the parent is always contacted prior to the athlete returning to contact or competition. I verify with the parent that they feel their child is fully recovered. Are they sleeping, eating, not asking for medications, and emotionally doing well? Do they have any reason for not wanting their child back to full participation? I believe the parent has to be the first contact and the last contact.

In my home-state of Utah, athletic trainers are licensed healthcare professionals specifically trained in concussion and legally allowed to evaluate, diagnose and return the athlete to learn and to play. If I need assistance, then I get with my collaborating physician, or whatever physician that the parents have selected. Sometimes the parent will take their child to a physician who doesn't know or understand the latest on concussion. I’ll call that physician to update them on the state law and on the latest in concussion treatment. I find that the call is always appreciated. If there is a need to bring in a physician just to manage symptoms, then that absolutely needs to happen. I feel I’m up on concussion as much as anybody, but I wouldn't hesitate to bring in a physician and many times I call and consult with a neuropsychologist.

With return to learn, one of the first things I do is give notice to the teachers, counselor and the administration if the athlete is exhibiting signs and symptoms consistent with concussion. We start making a plan as to how to scale back the classroom stuff, what accommodations they might need, and if it goes on long enough or there's a request, we meet as a concussion management team to make sure that the athlete doesn’t get too far behind. I’m part of the concussion management team because I’m a full-time employee of the school; however even if you’re employed through a third party, you can offer your expertise and benefit the athlete.

Being the one making the call on returning to learn or to play, and I know this sounds cliché, I very literally treat every concussion individually. I look at the age of the athlete, their gender, what sport they are playing, and how long they have been playing it at this level. This helps me determine what I need to do as far as their rehab and supervising their rehab.

I follow the Sport Concussion Assessment Tool (SCAT), which is required by our high school activities concussion policy. I have the biggest decisions to make when we get to step three on SCAT’s graduated return to sport strategies. Because I look at each concussion individually, what I'm going to do at step three for a football player and a cross country runner maybe different due to the type of training they're used to and/or their schedule. You really can’t cookie cutter it; it’s all about individualizing the treatment.

This is where safety comes in. What equipment are they going to use? Do they only get to use their body weight? Do they get to use resistance bands? I don't see anyone putting themself at risk for second impact syndrome with a resistance band. However, with free weights they might be. When they’re at step three or four and can start resistance training, I use resistance bands and body weight exercises; what I call “training in a safe mode.”

As an example, let’s look at a cross country runner’s resistance training. I tend to do things systematically and might start with four directions on the ankle, and then to add resistance bands for the major muscle groups—quadriceps, hamstrings, hips and buttocks region, biceps and triceps. You can also use resistance bands for core strength and add them to pushups, progressively adding resistance and making the task harder.

I also focus on neck strengthening, which is often overlooked unless you're working with football players or possibly a wrestler. Most athletes are likely not paying enough attention to their neck strength. I’m of the school of thought that if you strengthen the neck, you’ll have less occurrence of brain ricochet.

When working with a concussed athlete, you have to train and challenge multiple muscle groups; I don't want them to return to play out of shape. But I have to do it with a safe strategy. And what I do depends on how they were working out before the concussion. If they're a strength or power athlete, they need fewer reps, heavier resistance. If they are an endurance athlete, such as a cross country runner, then I go high reps, low resistance.

Neck Exercise using a TheraBand® CLX™ Band

I don't necessarily tell the athlete when I'm working on improving their balance because I don't want them to just practice in order to pass my tests and get back on the field. I watch how balance naturally comes back; first through the healing process and second through the exercises that they're being asked to do. They're getting stronger and more comfortable with the proprioceptive feedback that occurs.

The only time I specifically address balance is during the initial evaluation, back to the SCAT5, and then again after they've passed through my stages and passed ImPACT. I especially see an advantage of resistance bands and working muscle groups when someone has had a previous injury, especially a lower extremity injury, and they didn't rehab correctly. Likely their proprioception is a little off. Often, I can return them with better proprioceptive function than they had pre-concussion. It's another positive consequence for what we're doing.

Challenging multiple muscle groups using the TheraBand® CLX™ System

I have found it advantageous to use stability disks and exercise balls in the later stages of rehab. It can frustrate the athlete if you bring these tools in too early. I don’t want to overtax their system early on when we're trying to speed up the healing process and want to maintain the level of endurance that they're going to need when they get back to play. But when the athlete is ready to be challenged, using stability disks or exercise balls can allow them to stay with their peers and have something to do rather than sitting in the corner of the room. These exercises take a little bit more mental concentration; you’re not just working on balance. Plus, keeping the athlete active and motivated may also help them deal with the emotional impact of a concussion.

Push up using the TheraBand Stability Disk

As the concussed athlete’s advocate, you’re in the position to make a huge impact on their recovery. Don’t miss the opportunity to do so. It can change their life, and yours.

Bio - Lisa Walker has been an ATC in the secondary school setting since 1993. She has held numerous leadership positions including secretary, treasurer and president of the Utah athletic Trainers' association (UATA) and president of the Rocky Mountain Athletic Trainers' association (RMATA)-D7. During Lisa's leadership as UATA President, licensure and other athletic training legislation were passed in Utah. Lisa is a member of the Rocky Mountain Athletic Trainers' Association Hall of Fame, the Utah Athletic Trainers’ Association Hall of Fame, and the 2015 recipient of the Korey Stringer Institute Lifesaving Education award. She has received numerous other awards at the local, state, district and national level.