IOWA CITY -- There is nothing laissez faire when it comes to concussions and how the University of Iowa sports medicine staff tries to prevent, detect and treat them.
Dr. Andy Peterson, a UI team physician, gave a presentation during a presidential committee on athletes meeting Thursday at Carver-Hawkeye Arena.
Iowa's concussion policy has three major components: the UI athletics sports concussion policy, the sports medicine clinic concussion program, which includes referrals from all over the state, and the sports concussion research program.
Iowa sports medicine clinic sees patients from as far away as five and six hours because the state of Iowa doesn't have many programs focused solely on concussions, Peterson said.
UI student-athletes go through a preseason assessment, including impact testing. It also includes an educational component and a form an athlete must sign to acknowledge they've done their reading on the topic.
Peterson said concussion identification is at the heart of the matter.
"Our athletic trainers and our coaches are charged with the task of identifying a concussed athlete," Peterson said. "It's common for athletes to not realize they're concussed, so we're very aggressive about pulling people from play and evaluating them on the sidelines if we have any questions at all about their ability."
Peterson discussed the use of medications to help athletes recover and return to play.
"That's where some of our difficulties have been over the years, with how medications should be used for controlling symptoms and how people should be returned to play when they're still undergoing therapy and still on medication for their concussion symptoms," Peterson said. In the most recent UI concussion policy, it now requires two of the primary care sports medicine physicians for UI athletes to start medication to control their concussion symptoms.
"That's to make sure there's no ambiguity and we're not going too far out of bounds with anybody," Peterson said.
Peterson said the UI's approach is strictly evidence-based, meaning the treatments are proven and not "the shiny objects in the room."
The UI is engaged in ongoing concussion research, including the Big Ten's joint concussion study with the Ivy League and a youth football concussion study that includes 8,000 athletes in the state of Iowa.
Another study the UI is engaged with is the pupillometer, which measures the pupil's response to different colors and lights. Right now, 95 percent of Iowa's football players and all of its track athletes are enrolled in this. Iowa athletes also are given the BESS Test (Balance Error Scoring System) in the preseason. Peterson said the UI is worried that athletes are simply getting better at taking that test and thus their baseline improves and so it's tougher to detect concussion symptoms.
In regard to preseason concussion testing, can athletes sandbag it? Can they lower the bar for detection?
"I don't know if you've ever tried to intentionally do poorly in something, but it's remarkably hard to make an evenly poor effort," Peterson said. "You don't give an even effort and we're able to detect those the vast majority of the time. If someone has an invalid base on the impact test, we make them re-take it until we get a valid one."
How do physicians identify football players who've been concussed?
"We're dependent on the training staff on the sidelines," Peterson said. "We're dependent on the team physicians on the sidelines. We're dependent on other players and coaches. It happens sometimes, when other players will tell you that one of their teammates isn't right."
The main thing they're looking for? "People performing in a way that you wouldn't expect," Peterson said. "It's not the type of play we [as fans] complain about, but more like people not knowing what their assignments are and not being able to make the types of plays and types of maneuvers they would normally be able to make."
Questions about the score of the game and what half the game is in are asked, but so are specific questions about the play in the game.
"Those are much more sophisticated and should be ingrained in the student-athletes," Peterson said. "We might ask someone what their assignment is on that left sweep that we just ran two plays ago, something like that. Those things tend to be more sensitive in picking up cognitive dysfunction."
Peterson continued on that point and said there's rarely ambiguity.
"I've probably taken care of 100 or 150 concussions on the sidelines over the years, and I can say that I was on the fence once or twice," he said. "The vast majority of the time, it's clear someone has been concussed."
Russ Haynes is a fixture on Iowa's sidelines. He's the associate director of athletic training services and has worked with the Iowa football team since 1987.
"You interact with the student-athletes on a daily basis, so you know their personalities," Haynes said. "You know how they react to things. You know their speech patterns. So, when you're interacting them as their coming off the field, it's fairly obvious right away, knowing them the way we do, that something is going on.
"A lot of times, they'll talk with their teammates and ask, 'What was I supposed to do on that play again?' It's their teammates a lot of times who will say, 'Russ, you need to go check out this guy because he's asking me questions that I know he knows.'
"Coaches are the same way. When players come off the field, they interact with the coaches. They engage them, talk with them. If they're personality has changed, a lot of times they won't engage you because they're in a bit of a fog. They'll just sit there and stare at you. They don't engage you as they normally would. That's usually a fairly clear sign."
Coaches don't want players on the field who can't think.
"I think there's a misconception that coaches want their concussed athletes to stay in the game," Peterson said. "No. They're not good."
Peterson covered the issue of retirement from athletics because of concussions.
"Maybe after their first concussion, they get back to competition fairly quickly and maybe after the second one, that happens, too," he said. "Then, a third one takes longer and then a fourth one takes a couple of months. That's someone I'm going to advise to retire."
Another path to retirement is someone who is concussed on seemingly trivial trauma.
"If they take a ball off the helmet, if they are barely tackled and suffer a concussion, that's someone I'm going to advise retire from sports," Peterson said.
Gender-wise, women get more concussions, Peterson said. "If you correct for the sports, it's about twice the rate," he said, "so women's soccer is about twice men's soccer, women's basketball is about twice men's basketball."
Why? He said there are a few theories. One is there are a couple of genes that have been identified in concussions and those genes are expressed differently in women than men.
Peterson was asked if there was a rank order of sports that had the most concussion rates.
"Guess what are highest concussion risk at the university is," he asked. "Cheerleading. If you look at the national data, football and cheerleading are about equal. Here at the University of Iowa over the last year, we've had about five-fold concussions in cheerleading as we've had in football. There's a dramatically higher risk for whatever reason."
Big Ten faculty representatives will be discussing concussions in the next few weeks. Peterson said concussions and numbers are similarly handled throughout the Big Ten except for Nebraska, which has its Center for Brain, Biology and Behavior located in Memorial Stadium.
Iowa is now partnering with X2 Biosystems on a helmet sensor system. The NFL also is adopting X2 concussion management software next season. It's basically a sticker that is placed behind the ear of an athlete. It's accelerometer based and gives an approximation of the G forces applied to the head.
The baseline G forces that cause concussion are all over the map, Peterson said. "It's difficult to know what to do with the information at this point," he said.
The how-to of this equipment remains up in the air. "I think it's going to become standard rapidly," Peterson said. "I think people will be collecting information and not know what to do with it."
This is part of concussion culture change, which has been enlightened by the NFL and studies -- and lawsuits and tragedies -- dealing with chronic traumatic encephalopathy.
Iowa athletics director Gary Barta played quarterback for North Dakota State in the mid-1980s. He said he was diagnosed with two concussions and suspected he might've had others. "How many fingers are you holding up? Three" Close enough," Barta said.
"Everyone who played football in the generation before our current players has stories just like that," Peterson said.
Who decides when it's safe for an athlete to return to sport? The team physicians have the final say.
In the first couple of weeks after injury, it's all about rest and recovery, Peterson said. There are two acute issues with athletics concussions -- energetics [the amount of energy and cells the brain uses to heal itself] and a global dysfunction problems [which basically keeps you from gaining anything from practice or going to class].
The athletes, who also see their trainers at least once a day for concussion, are told to go home and nap as much as possible.
Running back Damon Bullock suffered a pair of concussions during the 2012 season. He was tackled from behind and his head dipped forward and slammed into a defensive back's knee against Northern Iowa. It took 5 1/2 weeks for his return. He was set for a return two weeks before he actually did.
Part of his recovery was quieting down his life.
"It was really blurry, I can't explain it," Bullock said after returning to play in October 2012. "There was a lot of not remembering stuff. It was two weeks after and I thought I was all right, but still, going to class with migraines and all kinds of crazy stuff like that."
Quiet time really means quiet time."You try to educate the athlete that the game playing [video games], text messaging, constant television, all those things will slow down their process of healing," Haynes said. "You talk to them about slowing down the process and being out of practice longer, they're pretty compliant about doing things the right way because they want to be back in practice and not miss games."