June 24, 2018
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UMaine on leading edge of diagnosis, treatment of head injuries to student-athletes

By Pete Warner, BDN Staff

WORCESTER, Mass. — A head injury can result not only in the abrupt end to an athletic career, but in long-term health problems.

At the University of Maine, the athletic training staff works closely with its health care providers to make sure a concussion suffered by a student-athlete is diagnosed quickly and treated thoroughly.

The spotlight on head injuries has shone on UMaine this week after men’s hockey star Spencer Abbott suffered a concussion during a March 16 game against Boston University.

Concussions suffered by high-profile athletes at the professional and college levels in recent years have led to widespread educational efforts. Some of those cases also have sparked a re-evaluation of procedures used by athletic trainers to make sure at-risk student-athletes are not placed prematurely back in action.

Paul Culina, the head athletic trainer at UMaine, has significant experience treating head injuries. He has been closely involved in Abbott’s treatment, although he is prohibited by privacy laws from discussing his case specifically.

He took considerable time Friday to explain how he and the team of providers working with the UMaine athletic department handle concussions.

First, there is a written plan, a concussion management protocol, as mandated by the NCAA. Culina drafted UMaine’s version.

“Essentially, what it does is insure that every athlete at the university, regardless of gender or sport, and the sports medicine team — all the athletic trainers, physicians, the providers — follow the same protocol in making return-to-play decisions.”

Culina said UMaine has been on the cutting edge of diagnosing and treating athletes who suffer concussions. That is because he has worked closely with Dr. Mickey Collins, one of the foremost experts on head injuries.

Collins, a native of Hermon, is the director of the sports concussion program at the University of Pittsburgh Medical Center. He and Dr. Mark Lovell created the Immediate Post-Concussion Assessment and Cognitive Test, or ImPACT, a computerized neuropsychological test that helps determine the level of a person’s brain injury.

UMaine’s program begins with an educational component. Each fall, student-athletes undergo baseline testing of their balance and vestibular system.

The test gathers information about academic performance, learning disabilities, medications and history of headaches, depression, anxiety and concussions. The students are encouraged to answer honestly, which is important in the event the information is later used comparatively after a concussion.

When a head injury occurs, the athlete is removed from competition and the concussion management plan is initiated. A trainer or medical professional conducts a comprehensive assessment of the injury and the athlete is monitored closely for the next 24 hours.

“Not every big hit to the head results in a concussion and not every concussion is the result of a big hit to the head,” Culina pointed out.

“If they’ve got signs and symptoms that are consistent with being concussed, they don’t return to the game,” he added.

The injured person is asked whether they have any of the 20-30 most common concussion symptoms, including headache, dizziness, visual impairment, numbness, tingling, anxiousness, depression, sensitivity to light and noise, among others.

Symptoms are compared to the student-athlete’s answers to the health history from the annual questionnaire. A day or two after the injury, the athlete retakes the ImPACT test on a computer.

It measures visual memory and verbal memory, both immediate and delayed, along with reaction time to stimuli and speed of processing information. The numbers are compared to the baseline test and show whether the athlete is suffering impairment as a result of the injury.

“I’m happy to report that the University of Maine was one of the first colleges in the country to administer neuropsychological testing on athletes [during 1999-2000],” Culina said.

He shudders to think that for a long time, people who suffered concussions were often told to sit out for a week or two, then were cleared to return to the playing field without further evaluation.

At UMaine, a student-athlete with a concussion is re-evaluated daily to monitor any changes.

“It’s not a cookbook,” Culina said. “You can’t just stick it in the oven, take it out in two weeks and you’re better. We’re looking at what their symptoms are every single day.”

The athletes must fill out a form each day to rate their symptoms on a scale of 0 to 6, with zero being no symptom at all and 6 being the worst possible. When the total score is down to 0 and the athlete is feeling normal, the process for returning to competition begins.

The return-to-play protocol consists of five days. On the first day with no symptoms and normal scores on balance and neuropsychological testing, the athlete does some light exertion to see if the stresses elicit any concussion symptoms.

If any are present, the exercise is stopped and the process begins anew in 24 hours.

If there are no setbacks, Day 2 means an increase in the intensity of the exercise, which is controlled and closely monitored, Culina said. Again, problems mean a return to the first step.

After another 24 hours of monitoring with no symptoms, the athlete begins sport-specific activities. That could mean some limited practicing with the team.

Assuming all is well on Day 4, the athlete is allowed to go through a full-speed practice with no contact. Continued symptom-free performance leads to the fifth day, which includes full practice with contact.

If the athlete gets through all those tests and does not have any further signs of a concussion, the final OK is given by the team physician.

Culina pointed out that in some cases, athletes who are not competing for their teams (i.e. redshirts) or those who are out of season might be held out longer in an attempt to further expedite the healing process.

“This is an important thing. It’s not an ankle sprain,” Culina said. “I tell the kids, ‘You don’t feel that bad, you want to push through, but you’ve got a career ahead of you.’”

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