It was a hot August afternoon and football practice was just getting underway at Cherokee Trail High School in Aurora. Amid the gruff calls of assistant coaches and the smack of colliding shoulder pads came Coach Monte Thelen’s matter-of-fact voice at the end of each play, “Stay up, stay up, stay up!”

Football players at Cherokee Trail High School take part in a “thud” practice as an assistant coach looks on.

It was a half-pads “thud” practice and he wanted players to stay on their feet.

“We’re trying to limit the number of times players hit the ground with each other,” said Thelen. “We didn’t do that 10 years ago. I’m not even certain we did that eight years ago.”

This kind of safeguard is just one of many measures that has been employed over the last several years to help prevent an invisible and potentially life-threatening injury: concussions. In the Cherry Creek school district, where Cherokee Trail is located, the issue resonates with particular intensity because it is where Jake Snakenberg, a Grandview High School freshman, was playing football in 2004 when he took a routine hit and died of “Second Impact Syndrome” the next day.

Along with increasing awareness about concussions in the NFL and at the collegiate level, the 14-year-old’s death helped change the way youth concussions are handled in Colorado, giving rise to the Jake Snakenberg Youth Concussion Act, which took effect Jan 1, 2012.

The death of an athlete may be the most frightening consequence of concussions, but memory problems, concentration problems and other temporary cognitive deficits are more common outcomes. So while coaches and other advocates of good concussion management certainly want to prevent lethal “second hits,” they also want to ensure that concussed students have an efficient recovery so they can function in the classroom.

“It’s not just about return to play. It’s not just about sports,” said Karen McAvoy, director of the four-year-old Center for Concussion at Rocky Mountain Hospital for Children “You cannot return to play until you have 100 percent returned to learn.”

While experts agree that “Jake’s Law” has improved concussion management practices, they say that the state’s school districts and even its doctors do not always approach concussion management in a uniform way.

In Colorado, there is no statewide database on the number of youth concussions, sports-related or otherwise. However, national studies suggest that high school athletes sustain an estimated 136,000-300,000 concussions per year and the numbers have steadily increased. A 2011 study in the American Journal of Sports Medicine found that concussion rates in high school athletics increased by 16 percent annually from the 1997-1998 school year to the 2007-2008 year. The same study found that the most concussions occurred in football, followed by girls soccer.

Concussion resources

Impact of Jake’s Law

Jake’s Law, which applies to students 11-18 in school, club or recreational sports, requires that students suspected of sustaining a concussion be removed immediately from practice or games. In addition, students must be cleared by a doctor or other health care provider before returning to play. Finally, the law requires coaches to take annual trainings on the signs of concussion.

McAvoy said the legislation also helped emphasize the medical side of the concussion equation. Prior to the legislation, families were under no legal obligation to get kids suspected of sustaining concussions during sports checked by a doctor, and some chose not to, she said. With its return-to-play medical clearance provision, the law changed that.

“Through all of this the thread that you see is the culture change,” said McAvoy, who was a school psychologist at Grandview High School when Snakenberg died.

McAvoy said districts like Cherry Creek, Jeffco and Dougco have been at the forefront when it comes to developing effective concussion management programs.

Dr. Danny Mistry, chair of the Concussion Task Force in Grand Junction, said that despite a dramatic increase in awareness because of Snakenberg’s death and his namesake law, youth concussion management practices vary widely around Colorado. Although there are exceptions, he said, the east side of the state is generally ahead of the west side.

“It varies because of resources and education,” said Mistry, who practices at Western Orthopedics and Sports Medicine in Grand Junction, and who is a primary care team physician for Colorado Mesa University and the Colorado Rockies, as well as a team physician for USA Swimming.

In communities where concussion management is lagging, it may be due to both health care providers and the school system.  For example, Mistry said, some doctors may not see many youth athletes and may not be aware of the latest protocol for concussion management. In addition, school districts often can’t afford widespread staff training on concussions.

Like others experts, Mistry and McAvoy emphasize that student concussions must be managed by a team including athletic staff, parents, health care providers and teachers, who can often provide critical feedback about how a concussed student is functioning in the classroom.

Mistry said he hopes the National Institutes of Health or state departments of education will eventually set aside money to educate schools on concussion management.

“We’re in the midst of an epidemic and we have to stem the tide,” he said.

Tools of the trade

Talk to high school coaches and athletic directors around the state and you’ll hear about a variety of tools in place for concussion prevention, identification and management. Often, they’ll note that changes were underway even before Jake’s Law took effect — they saw the direction the pendulum was swinging.

That swing may have started in 2009, when Washington passed the first in a flurry of state statutes on the issue, the Zackery Lystedt Youth Concussion Bill. Today, the District of Columbia and every state except Mississippi have some sort of youth concussion law.

In Colorado, concussion prevention and education efforts include switching to lower-contact drills, reducing the weekly number of full-contact drills, experimenting with protective equipment such as the “Guardian Caps” that fit over football helmets, giving coaches pocket-sized cards listing concussion symptoms and having players and their parents read and sign concussion information sheets.

The free REAP Project booklet from the Rocky Mountain Hospital for Children is used widely in Colorado. It has also been used in New York and Florida.

Many school districts also use a highly-regarded concussion management protocol written by McAvoy called REAP, which stands for Reduce, Educate, Accommodate, Pace. Contained in a colorful 11-page booklet available for free from Rocky Mountain Hospital for Children, the protocol emphasizes the team approach, the careful monitoring of physical, emotional and cognitive symptoms, and a graduated “return-to-play” that allows student athletes to ramp up physical activity over the course of several days.

As recommended in REAP, districts have increasingly addressed cognitive symptoms of concussions, such as mental fatigue and difficulty concentrating, by making accommodations in the classroom such as reduced note-taking or extra time on tests.

Mark Kanagy, assistant principal of Windsor High School and athletic director in Weld RE-4 School District, said this is true in his district. In some cases, the district has put in place a temporary 504 plan, which are normally used to accommodate students with disabilities, for a concussed student.

Some Colorado districts also use a computer-based test called ImPACT, which measure students’ neurocognitive function at a baseline level as sports seasons begin, and can be administered after a suspected concussion to help determine whether new deficits exist.

While experts caution that ImPACT tests aren’t foolproof, they say they can be one piece of the puzzle in determining whether students are affected by concussion. The test is used at about 100 Colorado middle and high schools, according to company officials.

Paul Cain, athletic director for Mesa County District 51, said his district pays about $1,000 a year to use ImPACT for students in football, soccer, lacrosse, basketball, baseball, softball, diving, and cheerleading, as well as for students in other sports whose parents have requested it.

Kanagy, assistant principal of Windsor High School and athletic director in Weld RE-4 School District, said ImPACT “makes things more quantifiable…It helps take some of the guesswork out of it.”

He said a student might feel fine and have no headaches or other symptoms after a concussion, but if the post-injury ImPACT test doesn’t align with the baseline test, it can indicate something is still wrong.

Still, not everyone thinks ImPACT is an ideal tool. They say that students packed in a computer lab taking the test may not earn reliable baseline scores because they are distracted or deliberately performing poorly. In addition, not all doctors know how to interpret the test.

McAvoy said most school districts never use ImPACT because of its cost. “And that’s okay,” he said. “ImPACT is not necessarily where I would put limited resources.”

Trickle down effect

As standards for concussion education and management among youth athletes have risen, advocates say non-sports concussions in youth are starting to get more notice as well. Those concussions may result from a car accident, a fall or a bicycle crash outside of school, which means school staff don’t always know about them right away, if at all.

The REAP Project booklet is dedicated to Jake Snakenberg, who died of “Second Impact Syndrome” in 2004.

“Our biggest issue is getting non-athletic concussions communicated to our schools,” said Cain. “As a community that’s the next thing we need to work on.”

It’s not unusual for non-athletic concussions to outnumber sports-related ones. During the 2011-12 school year, about 60 percent of 200 student concussions in District 51 were not sports related, said Mistry. At Cherokee Trail High School, there were 25 non-athletic concussions last year compared to 15 sports-related.

“Really it comes down to the responsibility of the parent, the responsibility of the child,” said Steve Carpenter, athletic director at Cherokee Trail.

While some families inform the school nurse about out-of-school head injuries and, in Cherry Creek district staff receive training on recognizing non-athletic concussions, Carpenter said, “Those are tricky ones.”

McAvoy said while Jake’s Law exclusively addresses sports concussions in 11-18 year olds, concussion guidelines she co-wrote for the Colorado Department of Education, also address concussions sustained outside of sports and in students under 11.

Still, since parents aren’t required to seek medical advice for non-athletic concussions, it can be hard for school staff to know how to proceed, she said.

“When does a school feel comfortable releasing them back to recess, physical education and those kinds of things?”