Before he became a parent, prior to achieving his credentials as an athletic trainer, Aaron Perreault already recognized the prevalence of head injuries.

He coached junior varsity sports, where the emphasis on skill development didn’t mean the games were played any more slowly or less earnestly. Perreault was privy to the collisions, the sight of a player stumbling to his feet and the how-many-fingers-am-I-holding up test.

Today, as he lugs a laptop loaded with student health data under one arm and a satchel stuffed with school and state regulations over the other, the Perreault of 2012 admittedly cringes at some of the decisions made by the fresh-out-of-college version in 1997.

“Back in my coaching years sometimes they’d go to the doctor, sometimes they didn’t,” Perreault said. “If you didn’t have a headache and were feeling OK, it was, ‘OK, you can play.’ Now we’ve got much stricter guidelines. More precautions. Especially with the NFL and the retired players coming out and making it more public than it ever was.”

As the certified athletic trainer for RSU 10 — covering his alma mater, Dirigo High School in Dixfield, as well as Mountain Valley High School in Rumford and Buckfield Junior-Senior High School — Perreault recently helped rewrite the district’s concussion management standards. The goal was for physicians, athletic trainers, administrators, parents, athletes, even teachers and secretaries, to have a clearer idea of their role in the safety chain.

It’s a process that was conducted throughout the state this past summer and fall as Maine schools scurried to comply with a new law establishing stronger return-to-play guidelines for athletes diagnosed with a head injury.

The law requires all high schools to have a policy in place by Jan. 1 establishing when a student-athlete may return to the playing field or the classroom. It also mandates that the student must be cleared by a medical professional trained in concussion management.

Maine is one of 42 states to have passed laws protecting concussed athletes. All those regulations have been added to the books in the past four years, demonstrating the urgency of the issue.

Of course, in a state where the gaps between urban and rural areas and affluent and financially strapped communities are often magnified, implementation of that law is not a uniform process.

“I think certainly concussion laws are all good,” said Dr. Robert Cantu, a neurosurgeon with the Boston University School of Medicine and Emerson Hospital in Concord, Mass. “Unfortunately the return-to-play guidelines are all different. Some schools have comprehensive education programs for parents, coaches and athletes and some don’t. Some of them have written concussion policies and some don’t.”

Cantu, considered one of the nation’s leading experts in the treatment of concussions, was instrumental in writing the nation’s first return-to-play guidelines. His latest book, “Concussions and Our Kids,” addresses both preventive measures and the many components involved in a full and successful recovery.

Intentional and inadvertent contact are inherent to the games kids play and aren’t going away. There is no equipment scientifically proven to prevent or lessen the severity of concussions, Cantu said.

Rules changes — and Cantu proposes many — often are seen as radical and therefore are difficult to implement. Awareness and early invention, then, become the best weapons in this growing fight.

“The No. 1 message is that no head trauma is good head trauma,” Cantu said. “You can’t take head trauma completely out of sports, but when possible, avoid it.”

Making an ImPACT

More than 80 Maine high schools — approximately half of those that play interscholastic sports — use ImPACT as a primary tool for concussion management.

ImPACT, which stands for Immediate Post-Concussion Assessment and Cognitive Testing, is used both as a means to diagnose the initial injury and to determine when the student has sufficiently recovered and is fit to resume participation in sports.

Schools administer at least one “baseline” test to all incoming athletes. In RSU 10, Perreault typically gives the exam in the fall of every athlete’s freshman year.

Lewiston High School athletes take the test twice, as freshmen and juniors.

“We did that because the brain is changing and developing so much during those years,” said Mary Britt, who was Lewiston’s certified athletic trainer for eight years before leaving in June.

The computerized test takes roughly 30 minutes to complete. It challenges the athlete’s recall, reaction time and critical thinking through various exercises involving words, shapes and colors.

Once those results are entered into a national database, they become the measuring stick when an athlete sustains a concussion.

“If you’re symptom-free for 24 hours, you’re given the test. Sometimes that will make the symptoms come back,” Britt said. “Once the scores come back to where they were before the concussions, we start the return-to-play protocol.”

Cantu’s concern with ImPACT is that schools may embrace the program to comply with the law and accept its results as a sole authority.

“The problem is over-reliance on them. It’s only testing in the cognitive basket of symptoms,” Cantu said. “There’s the sleep basket, the physical basket. Those are not picked up.”

“It’s a tool,” Britt agreed. “It’s not the only thing we use.”

ImPACT isn’t foolproof. Results may vary based on the time of day the test is taken, the ambient noise in the testing environment, or whether or not the subject was engaged in class or exercise immediately before taking the test.

There also is an honor-system component. Some college and professional athletes have admitted to “tanking” the baseline test, intentionally setting a lower baseline score in order to ensure a quicker return to play.

“We’ve had some kids who consciously maybe try to do as bad as they can on it. I’ve had students take the post-test after a concussion and go, ‘Wow, I did better than I did the first time.’ If the program picks up they feel the test was invalid, we can go back and retest them,” Perreault said. “The ImPACT test is a tool in addition to all the other stuff we have to use. It’s not the be-all, end-all. It’s all about the physician’s interpretation of the results.”

Clear and present danger

Cantu has interpreted those results for nearly 50 years. As knowledge and common sense have increased, so has the intensity of his crusade.

“I see the ones that don’t recover,” Cantu said. “That includes a number of patients from Maine.”

His book details both the success stories and the tragedies of concussion management.

The ongoing coverage of National Football League retirees and their struggles with the fallout from multiple concussions may have unintentionally conveyed the message that most dangers are long-term. The suicides of Junior Seau and Dave Duerson have been linked to brain damage from repeated head trauma. Former NFL fullbacks Kevin Turner and Steve Smith are battling ALS, or Lou Gehrig’s Disease, and research has shown a correlation between concussions and that terminal neuromuscular disease.

But there are life-altering complications for young athletes and their families in the here-and-now. One is second-impact syndrome. When an athlete sustains a second concussion without fully recovering from the first, the consequences can be fatal.

Cantu also has seen evidence of CTE, or chronic traumatic encephalopathy, in the brains of teenage athletes, It is a degenerative condition consistent with the damage observed in retired pro players.

“We have a huge distance to go. Parents haven’t been given the education yet,” Cantu said. “These things have been mandated at the high school level. We’ve got to recognize that a majority of parents at the youth sports level still haven’t received concussion education. The education is only beginning, and it needs to be greatly expanded.”

In his book, the doctor endorses such strict measures as prohibiting tackling at the Pop Warner and FLY football levels and banning the heading of soccer balls under age 14.

He has removed high school and college athletes from competition for a year or more, counseling others to give up contact sports for life.

Local athletic trainers say that sometimes is the right call.

“I think even with all the education there’s still some of that, ‘I want to get back out there. I feel fine.’ People are a lot more aware of the complications,” Britt said. “I’ve had kids come to me after and say, ‘Wow, I thought I was fine but I really wasn’t.’ Kids have had to stop playing sports completely. I’ve seen them struggle in school after a concussion. The more research they do, the more scary it is.”

“We have one student who has been banned from all sports. We have another student who got cleared and mom and dad stepped up and said they’re done,” Perreault added. “I think it’s coming to a point very soon where we’re going to have guidelines that if you have ‘x’ number of concussions in the fall season, for example, you’re done for a complete 12-month period.”

Knowledge on the increase

Much like the diagnosis and treatment of concussions, the study of concussion data is new and evolving. Statistics show that one in 10 high school athletes will sustain a concussion in a given school year.

The Maine Concussion Management Institute, headquartered at Colby College in Waterville, tracks reported concussions through the schools affiliated with ImPACT. Football, not surprisingly, is the sport in which concussions are most prevalent, followed by girls’ soccer and boys’ soccer.

Girls are more likely to suffer a concussion than boys, a trend that has been attributed to everything from neck strength to the styles of play.

“Girls’ sports I think are far more aggressive. They’re not out of control, but they play at 110 percent and they have no fear of that collision,” Perreault said. “They don’t think, ‘What are the consequences if I run into this person?’ I think girls play harder than boys, all the time.”

There is a chicken-and-egg component, as well.

Are concussions on the rise because today’s athletes are bigger, stronger and faster, or because coaches, athletes, athletic trainers and communities are more cognizant of the risks and more diligent with the diagnosis?

Cantu believes it is both but sees ample room for improvement.

“There was a time when 70 to 80 percent of concussions went unrecognized,” he said. “I believe a majority are still unrecognized.”

The doctor said that only 42 percent of high schools in the United States have a certified athletic trainer at all events.

Most of the 17 high schools in Androscoggin, Oxford and Franklin counties have at least a working relationship with an athletic trainer. As is the case with Perreault, that expertise is often shared among multiple schools.

Every connection between a trainer and athlete is a small victory in the battle to minimize the impact of concussions on young, developing lives.

“With the relationship I have with the kids, you know how they act, you know how they relate. A lot of times you can go on that a lot better than a test,” Perreault said. “If there’s nausea, ocular motor skills are lessened, any issues with memory, we’re sending them to get treatment. Depending on how they do the next 24 to 48 hours, we may send them onto the next level. We have a chain of command there.”

Although pressure from coaches, athletes and parents to get an injured player back into competition may never go away, local athletic trainers say that it has become less of an obstacle.

As laws such as Maine’s new standard hit the books and more case studies become part of the public discussion, experts find that their instincts carry more weight.

The days of head trauma being out of sight, out of mind, thankfully, seem to be numbered.

“It used to be, ‘Oh, you just got your bell rung,'” Britt said. “There is definitely a lot more awareness and more acceptance of a concussion as a real injury.”

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