The receiver twisted, looking over his shoulder.
‘THWACK.’
An opposing player’s helmet caught him directly under the chin, knocking his head backward to the turf. The whistle blew, immediately stopping the game.
Kerri Downer, then an athletic therapist for the University of Calgary Dinos, recalls the terrifying scene.
Immediately unconscious, the player began to experience seizures.
In a blur of practiced commotion the athletic therapists ran to the field, someone called 911, the ambulance came and rushed him to the hospital. Within 72 hours, the player was symptom free and eventually resumed play.
With a dedicated medical staff and access to top resources, the player was fortunate to make a quick and monitored recovery.
But this may not be the case for every athlete, particularly at the youth level where, despite growing recognition of brain injuries, a patchwork of protocols and a lack of resources can hamper concussion care. For now, the higher the level of play, the better the care.
Return to play protocol
According to Canadian government statistics, football has the second highest sport-related concussion rate in males 15 to 19, after ice hockey. In Alberta, before re-entering the game, athletes must follow a league-specific return-to-play protocol.
Those rules are based on guidelines set at an international conference held every four years. Because of the pandemic, the conference hasn’t been held since 2016, but the guidelines have been used as a major determining factor in how football leagues across Alberta tackle concussions.
Many of these concussions are a result of playing high school, bantam and possibly university football. Concussion care is important because it can create lasting health impacts on young athletes’ lives, both short and long-term.
In Alberta, after a player sustains a suspected concussion playing football, a concussion protocol is followed. The aim of the protocol is to make sure a player doesn’t return to play until properly assessed and treated.
A Canadian government survey says that from 2011 to 2017 there were 665 football concussions in total, about 110 per year, which makes up about six per cent of all football-related injuries.
Compared with the pros, this equals less than half of the equivalent amount. The NFL reported, “During the last five NFL seasons, an average of 247 concussions were reported per year.”
A lack of man-power could create care problems
The international return-to-play protocol acts as a guide for Alberta football leagues in proper management of post-concussion care. Further development of the protocols themselves is left up to the leagues.
From there, variations occur in the finer points of the protocol based on who’s in charge of protocol development. Many leagues look to outside organizations and follow their guidelines.
The University of Calgary is a leader in the field of concussion research, diagnosis and care, so it’s not surprising that they have taken the fundamental guide outlined above and created a detailed protocol.
In addition to her training as an osteopathic manual therapist and nearly 30 years of experience, Bonnie Sutter is the head athletic therapist at U of C.
Sutter says their protocol includes concepts that are based on updated research that has come out since the 2016 statement.
This includes procedures like monitored exercise while an athlete is still symptomatic. “There’s a ton of things that we’re doing that aren’t in that simple six-step return-to-play process,” she say.s
For nearly half of her life, 40-year-old Nicole McLean has been working with athletic therapy and football.
Currently, she is the head athletic therapist with Football Alberta, a provincial sport organization whose members consist of all novice, junior and university organizations that play football in Alberta.
McLean says, “All the coaches would have to take the same education and then the differences will come in. Your minor leagues have less access to physicians and neuropsychologists than the universities do.”
But when it comes to following through on the concussion protocol it’s not just a matter of proper training, it simply boils down to accessibility and resources.
“The protocol says there should be at least 24 hours in between each step that they go through for return-to-play,” she says.
“I mean, in a best-case world then you have each step guided by a physician and at the university that’s usually what happens. At the minor level, it would be more run by the volunteers that work with the team.”
Sutter says that for minor and community leagues, they typically ‘tweak’ the protocols instead of going as in-depth as the universities.
“When you start working with university and professional sport… there’s more human resources and more man-power,” she says.
“If you have a concussion in the community setting, you are not going to have somebody that works with you on a daily basis, who checks up on you, who tweaks some of what you’re doing.”
McLean says, “It’s tough at the minor levels to get access to a physician, like the guideline would like you to see a physician to get diagnosed day one of your injury and then to see a physician again at return-to-play,” she says. “If in that 10 days of your return-to-play, if you can see a doctor once in there you’re probably lucky.”
At football practices, Sutter says they have five athletic therapists on the field at a time, including two certified therapists and a mixture of student therapists. At games, they also have a physician and dentist on hand.
“We have man-power and we have people to work with our team specifically…. When you go to, say, bantam football, that’s not the case.” She says, “They come, they practice, they play, they go away and there’s nobody left really to support them.”
Lower leagues fewer resources
In the Calgary Bantam Football Association, teams have no athletic therapists monitoring for concussions during practices. During games, the league provides one certified athletic therapist per team.
The league also partners with Competitive Edge Sport Therapy for their concussion management and return-to-play protocol, but they are currently making the transition to SHRed Concussion.
With a friendly voice that has a cheerful up-and-down cadence, it’s not surprising that Todd MacKay, head coach of the bantam Mavericks football team, spends his free time volunteering with young athletes.
With the physique of a linebacker and a self-proclaimed slightly-taller-than-average height, MacKay believes in helping kids achieve their full potential.
“I’ve always had a passion for helping kids to achieve what they are capable of … football has always been my favourite vehicle because of how inclusive it is. If you’re a big chubby kid, which is what I was, we’ve got a place for you. If you’re a skinny kid, we’ve got a place for you.”
In regard to how his league handles concussion care, he says, “I think that we’re doing a lot of really good things.”
MacKay says that there is support, but not necessarily medical. In addition to Competitive Edge and SHRed, he says, “You’ve got parents, you’ve got coaches who are interested in making sure that that athlete is healthy … while they may not have as easy access to therapists and facilities, that doesn’t mean that there is a lack of them available for the younger guys.”
MacKay says that one of the differences between varsity (primarily university age) and bantam (players aged 13 to 15) is the level of competition teams are at.
In varsity, “I think they also have significantly more impactful collisions…. They have guys who have more at stake than just whether or not they win a bantam game,” he says.
Sutter says that some athletes are experiencing better care than others because communities may not be as up-to-date on current research.
“They still find people who’ve been told, go home and stay in a dark room until your symptoms go away. So, there’s still that direction that is coming because it’s an ill-informed direction.”
She says that the concept of staying home in a dark room was an inaccurate interpretation of concussion care.
“Rest used to mean no activity whatsoever, no dark room though, and a suggested absence of screen time.” Today, Sutter says this concept has further evolved into resting but with a combination of, “Subsymptom exercises and subsymptom stimulus.”
‘I was so exhausted and I was in so much pain:’ A player’s story
After playing high school football, 18-year-old Jaden Haydu decided to join the Airdrie Irish, a semi-professional men’s team that is a part of the Alberta Football League. This season, he finished playing his rookie year with the Irish in the positions of defensive halfback and quarterback.
But for Haydu, his experience with high school football wasn’t ideal.
He thinks that over his career he has sustained four to five concussions, a mixture of both diagnosed and undiagnosed.
In a high school game, Haydu recalls telling someone about being hit in the head.
“It was right before halftime and I went up to the trainer and I’m like, ‘I got hit really hard in the helmet,’ and it was to the point where you could see their helmet’s face paint right on the top of my helmet.
I went to the trainer and she did this thing where she’s like, ‘remember this sequence in order’ and I got it right, and then I remember going back in the game right after halftime.”
Haydu believes that as a result of multiple concussions, he deals with long-term effects.
“Before I started playing tackle football I could read sentences perfectly. I’d never stutter over my words. I could read perfectly and then ever since I’ve played football it seems like I have a lot of trouble reading, talking in front of people. I always mix up my words…. After every season, sometimes it gets worse, sometimes it stays.”
Haydu says that this is still a problem that he struggles with but he actively tries to focus on his words before speaking.
When asked about high school concussion awareness Haydu says that although it may not be the case for all coaches, “I think they do the minimum.”
“I remember we had to do safe tackling. There was like an hour we did it when they’re supposed to do it for like four hours in total…. I remember them telling us, ‘don’t use your helmet, tackle like this,’ and then we went straight into physical practice.”
In his recent season playing in the Alberta Football League, Haydu says that he didn’t finish a game after getting a suspected concussion. After the game, he was instructed to go see a physician.
But Haydu didn’t go.
“I was so exhausted and I was in so much pain because I had a big, good 300-pound guy roll on top of me and hit me straight in the head. So I just got home and I just rested and … stayed up for six hours, had all of the lights off and just lay there.”
Haydu says that at every game there is a different athletic therapist.
“Before the next game I went to the trainer and kind of told her what happened last game and got a minor checkup, and she said I looked pretty good.”
The timeframe that athletes recover is dependent on many factors, but in one study it points to potential contributing factors like age and development.
It highlights that the amount of time before a player was able to re-enter the game varied based on the level of competition, with high school athletes having the highest proportion of longest recovery time.
In a statement from the Calgary Catholic School District, they said that they follow all requirements set by the Alberta Schools’ Athletic Association.
Spreading concussion awareness
Kerri Downer, now the head athletic therapist for Mount Royal University, understands the importance of concussion care. Over the years, concussion research and awareness has become a valuable part of athletic training to treat the kind of injury she recalled.
“You’ve got two arms, two legs, but you have one brain and you need to protect your brain.”
Todd Mackay
An important part of concussion recovery is collaboration between coaches, therapists and athletes. This has to do with raising awareness of the effects and symptoms of concussions.
With concussions it’s all about early recognition and early reporting from athletes,” Downer says. “So there’s been a big push on educating athletes around why it is important for them to report symptoms.”
Athletes withhold information or trying to hide concussion-like symptoms can cause further damage, she added.
One of the aspects of diagnosing sport-related concussions is willingness on the part of the athlete.
For 18-year-old Haydu, he says, “One of the things that … needs to be talked about more is players that know they have a concussion and still refuse to tell anybody about it. Which I was part of unfortunately.”
Although Downer says it has happened, she says that athletes trying to withhold concussion information is happening less and less due to the proactive awareness and accessible information.
Part of this awareness is from coaches actively promoting the importance of proper concussion management.
Bantam coach Todd MacKay prioritizes the importance of concussion awareness saying that they spend time talking about it as a team.
“I always tell the kids you’ve got two arms, two legs, but you have one brain and you need to protect your brain…. All of the things that you want to do is dependent on you being healthy,” he says.
Concussion understanding over the years
It wasn’t so long ago that brain injuries were treated less seriously. Keith Yeates is a professor at the U of C and the co-lead of the integrated concussion research program there. Yeates has been involved in concussion research for more than three decades and has seen treatment change a lot over that time.
“Mild TBI or concussion was actually viewed as a benign injury. So, we sort of assumed it wasn’t a problem,” he says.
“I was seeing kids referred to me who had what would be considered concussion or a mild traumatic brain injury who weren’t fine and were clearly having problems.”
In regard to sport-related concussions, Yeates says that although there have been many advances in concussion prevention you won’t ever fully eliminate the risk involved in sports.
He says that a lot has been done to reduce the risk, like having non-tackling football practices, but if a concussion does happen he says the most important thing is early identification.
“There’s lots of data now that suggests that the earlier that it’s identified and treated, the better the outcome,” he says. “It’s no longer seen as a problem we can’t treat, it’s a treatable and preventable problem.”
The will is there but are the resources?
The 6th International Consensus Conference on Concussion in Sport is scheduled to take place in October. This consensus statement will likely bring updates to their return-to-play protocols and how teams understand and treat concussions.
Sutter is expecting the next conference to update procedures that U of C has already implemented into their concussion protocols, like monitored exercise while an athlete is still symptomatic, hand-eye coordination and balance exercises. She also anticipates the addition of a pre-stage to the return-to-play protocol that helps therapists with symptomatic athletes.
A lot of these advancements are due to U of C researchers working in collaboration with the conference itself.
“The difference is the consistency coupled with the follow up and follow through we have with the athletes. We see one another daily which gives us a good understanding of their symptoms and what flares them. Knowing that allows us to tailor concussion care and rehabilitation to the specific athlete.”
Although there are many diligent people helping improve football concussion care, whether or not teams have enough resources to properly care for their athletes is still up for debate.
Correction: The description of the Dinos football player getting concussed has been altered slightly from the original version to better reflect what happened on the field. Also, Kerri Downer’s title has been changed to more accurately reflect her role. We regret the errors.