The question applies to many sports — from hockey to football to girls soccer and cheerleading. The answer is as difficult to nail down as to which came first: the chicken or the egg?
The fact is that more athletes at every level, from high school to the pros, are suffering from concussions than ever before.
What's puzzling players, coaches, trainers, doctors and scientists alike is what exactly has caused this increase.
"Why are there more concussions? Is it because we're doing more to evaluate them and we're diagnosing more? Or is it because kids are bigger, faster and stronger and hitting harder?" asked Beverly High athletic trainer Charla Bouranis, summing up the mystery.
"Personally, I think it's a mix."
Eliminating concussions is next to impossible; in contact sports, injuries of all sorts are inevitable. That makes recognizing head injuries, treating them and ensuring an athlete is fully healed before he or she returns to the field absolutely critical.
That was the aim when Massachusetts passed Senate Bill 2469, commonly known as the Concussion Law, signed by Gov. Deval Patrick on July 19, 2010. The law requires schools to educate parents and athletes about concussions, maintain a recovery policy for both athletics and academics, and calls for reporting concussion statistics to the state's Department of Health.
Understanding head injuries is still an inexact science; the CDC describes a concussion as a traumatic brain injury that comes from a blow to the head. Most occur without a loss of consciousness and simply aren't as plainly obvious as a broken bone or a bad sprain.
Symptoms can include a mild headache, dizziness and a loss of memory and in more serious cases include nausea, vomiting, sensitivity to light and mood swings.
Since symptoms can seem trivial at first, getting the word out about how serious a head injury can be is crucial.
"A lot of times you don't see serious symptoms until the future," said Bouranis, a licensed and certified athletic trainer who graduated from Salem State University. "You try to get across the seriousness of it without scaring people; that's the hardest part."
The law was set to take effect last fall, but schools found themselves unprepared with few guidelines and just a couple of months' notice. The state delayed full implementation; now, after a nearly a year of planning, area schools are abiding by the law this fall.
"As with anything, collecting all the paperwork was a bit of a process," said Beverly High athletic director James Coffey. "But overall I thought it went really well. It was smoother than I thought it would be."
Returning to the field — and the classroom
The law requires parents and athletes to receive information about concussions. Some schools hold a pre-season meeting to meet this requirement, while others use an on-line course provided by the Centers for Disease Control.
Before an athlete can step on the field, schools need to have a form signed by both the parent and the athlete stating that they received the concussion training.
"It caught me by surprise a bit that everything was pre-participation," said long-time Peabody High athletic director Phil Sheridan. "We put together a paper collection day in the summer where we had physicals, permission slips and checking grades all in the same day."
Adding another form for athletic directors to track isn't easy, especially when coaches don't always know what's been turned in and what's missing. Peabody High solved that with an orange card given to every athlete that turned in everything.
"You couldn't practice unless you could give the coach that clearance card. That made it a lot easier," said Sheridan.
To implement the requirements in Beverly, Coffey and Bouranis teamed with schools nurse leader Catch Riccio and BHS school nurse Kim Pappas. The four of them developed the necessary forms and the protocols required to comply with the law.
"We spent a few months getting it all together and it was great teamwork," said Coffey. "The biggest part of the law is it reemphasizes that this is an important topic, a serious topic and the schools need to monitor it."
Studies cited by the CDC note that a person who has had a concussion is more likely to suffer from a second one. Moreover, a second concussion that happens before the brain fully recovers from the first increases the likelihood of long-term problems.
With that in mind, the Massachusetts law requires a student-athlete who has suffered a concussion to complete a graduated return to play program before fully returning to action.
As an example, Peabody has a five-step return to play protocol. Once a concussed athlete is symptom-free for 24 hours, they do 30 minutes of light aerobic activity. If no symptoms return, the process graduates to 30 minutes with sport specific skills, followed by lighter practice is followed and, finally, full participation.
"We had a protocol in place last year that was developed in part by our trainer, the Salem High trainer and the Masconomet trainer based on a larger concussion symposium. We used the experts," said Sheridan.
Some schools use the imPACT test, a neuro-cognitive assessment tool that can be taken on a computer. A healthy student takes the test (which measures brain activity) to establish a baseline or "normal" result. Then if concussed, the student takes the test again to measure how much their brain activity may have slowed or changed.
"You might be asked to pick out which letter is blue or red, or memorize some things. You take it as a freshman to establish a baseline, and post-injury you take it twice. We can compare all three tests," said Bouranis.
In both Peabody and Beverly, all athletes in contact sports take the test.
"It's just another tool in your tool-kit," said Sheridan.
'A great chain of communication'
The law also adds a requirement for a return to academic activity. Students suffering from a concussion may experience loss of memory, light sensitivity and other symptoms that could make completing school work more difficult than under normal circumstances.
"I heard about an incident in another town where a kid failed a quiz and because the teacher wasn't aware of the concussion, (the student was) never allowed to re-take it," said Bouranis. "With this requirement, that never becomes an ordeal."
In Beverly, when a concussion is diagnosed the athletic trainer notifies the coach, the student-athlete's parents, the school nurse and the guidance counselor. The process ensures that everyone is aware of the athlete's condition and can look out for his or her best interests.
"What's changed mostly is the communication. We have a great chain of communication," said Bouranis, who tries to attend various health related conferences and has found just about all of them focusing on head injuries of late.
That underscores the prominent place head injuries have taken in sports culture. The effects of concussions are more visible than ever before. Take, for example, Boston Bruins center Marc Savard, whose career is likely over because of multiple concussions, or Pittsburgh Penguins star Sidney Crosby, who remains sidelines nearly nine months after suffering one.
Masachusetts has tried to be on the cutting edge of recognizing head injuries and protecting student-athletes; the state's concussion law was passed months before the National Football League's "Black Sunday" of 2010, a day with so many head injuries that commissioner Roger Goddell implemented immediate penalties and rules changes to reduce violent blows to the head.
"They're kids," said Sheridan. "You have to take care of them."
When it comes to concussions, knowledge is power. By opening the lines of cummunication and sharing as much information as possible across the school sports specturm, Bay State student-athletes should be better protected from repeat head injuries than ever before.