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Changing the way a group of people have thought about a specific topic for decades can seem like an insurmountable task.
But only three years after Texas House Bill 2038 became law, high school football coaches and players have pretty much accepted the major changes regarding the diagnosis and treatment of concussions.
"I butted heads with some coaches the first year (2011), but since then, I think they have realized what has happened with athletes who have suffered a second head trauma," said Toni VanDePutte, who recently retired after 29 years as an athletic trainer in the Ysleta School District in El Paso. She also is a sales rep for Alert Services, Inc., an athletic and first-aid medical supply company.
"I personally don't know a coach who would do something that ultimately would hurt a kid just to win a football game," VanDePutte said.
Because of the reputation Texas has earned for its emphasis on high school football, it wouldn't surprise some to hear stories of how coaches circumvented the concussion law to keep their star quarterback playing in a crucial game. Frankly, though, coaches don't want to risk the legal liability of violating a state law on a hot-button national issue.
Randy Matthews, program director for San Angelo Community Sports Medicine and a longtime licensed athletic trainer, echoed VanDePutte's experience about dealing with coaches and concussions.
"I think most coaches' foremost concern has always been the athletes and their safety," Matthews said. "The coaches I'm aware of have adjusted, and education is the key to that.
"It's about awareness that we have to take care of concussions - especially in school-age athletes. The frontal area is the last part of the brain to develop - even past age 20 in some people - and that's the area we hit with. Injury to that area of the brain could lead to a lack of social development."
Matthews and VanDePutte also said players, who sometimes try to hide injuries so they won't lose their starting position, have become more accepting of the concussion law.
"Early on, some kids saw it as a way to get out of practice, but when they saw they had to get a doctor's clearance to return to practice and play in a game, they realized the seriousness of the situation," VanDePutte said.
"Some players are even reporting it when they think a teammate may have suffered a concussion."
Athletic trainers today walk up and down the sidelines during games, talking and interacting with players while looking for concussion-like symptoms.
"The players' acceptance is gaining momentum," Matthews said. "You're always going to have athletes try to hide injuries. We just have to keep educating them. A concussion affects the brain, and nothing good ever comes from trying to hide that."
If a player shows concussion-like symptoms during a game, a SCAT3 evaluation - which checks the players' speech, memory and balance - can be performed on the sideline.
"If their balance is affected, it will show up. Most kids cannot mask the symptoms of a concussion," Matthews said. "If a medical doctor or trainer evaluates the player and finds no symptoms, they can return to the game. But that doesn't happen very often."
If concussion-like symptoms are present, the player is removed from the game. Neurocognitive testing should be done after the game or the following day. If a medical doctor or trainer determines that a player suffered a concussion, the state-mandated protocol for a return to practice and a game begins. The protocol usually lasts seven days or so, which means most players who suffer a concussion will miss the next game. Only a medical doctor can clear a player to return to action.
Recovery time differs with each athlete, and technical devices such as cellphones and video games should be taken away in the initial stages. Athletes also may need to stay home from school for a few days.
"There's not a good answer why some players require more recovery time, but it has nothing to do with mental toughness," Matthews said. "What we're dealing with is an injury to the brain. Symptoms lasting as little as 15 minutes can require seven days of recovery time."
Matthews said in 2009 - two years before the state law - 41 percent of players with concussion-like symptoms returned to play too soon. He now estimates that percentage to be "in the teens or even lower."
While we're talking football here, the state concussion law became reality after awareness of repeated concussions to Natasha Helmick, a Dallas-area youth soccer player who once played a game with vision in only one eye. After suffering four known concussions in five years, Helmick was forced to give up her athletic scholarship at Texas State University, and she began to struggle academically.
"Moms and dads go to their state legislators and say, 'What can we do about this?' That's what happened in Texas," Matthews said of why concussion protocol changed in 2011. "Plus, you had some high-profile cases with former players suing the NFL over not being educated about concussions."
The Texas State Athletic Trainers' Association assisted with the writing of House Bill 2038.
"We wanted it to be a law we could work with - one that protected all athletes with the same level of care, no matter where they live," said Matthews, who regularly works games on Friday nights.
"The one thing the law did was it took the emotions of Friday night out of the decision making. Whether it's the starting quarterback or a third-team kid, they're all treated the same. The law made it purely a medical decision."