EDITOR'S NOTE: This is the second of two-day series on football-related concussions at the high school and youth levels.
How quickly can you start and stop a stopwatch?
Can you stand heel-to-toe and maintain your balance?
Most people can do these things and others, like answering simple questions, without difficulty. But when the brain has been rattled to the point of concussion, such tasks are significantly more arduous.
Concussions are being scrutinized more than ever, and Southern Oregon appears to be taking advanced measures when it comes to prevention and treatment at the high school, middle school and Pop Warner levels.
Are the efforts — which include instruction for coaches, trainers and parents on recognizing symptoms and preseason baseline testing of athletes to help diagnose injuries during the season — enough to completely stop concussions? No.
But they might help to ease the concerns of parents whose children do play football, or the concerns of those deciding whether to allow it.
"I don't know if football is getting a bad rap," said Richard Lotz, a nurse practitioner with Southern Oregon Orthopedics who has spearheaded awareness and training for local high schools and youth leagues. "But it is a collision sport. Injuries are part of the game."
The chance of injury can be minimized with proper coaching and safety measures, such as limited contact in practice and "heads-up" tackling drills.
"But ultimately," said Lotz, "it can still be a dangerous game."
When high-profile professional athletes are in the news talking about the toll repeated blows to the head have taken on them — Brett Favre and Tony Dorsett are recent examples — it sends a message.
Whether it's the right message is open for interpretation.
"The trickle down is going to affect some parents who won't let their kids play football, which is sad," said South Medford coach Bill Singler, who played wide receiver at Stanford before beginning a 37-year coaching career.
He has two sons still playing collegiately.
"If kids want to play, they should be given that opportunity," said Singler.
Dr. Timothy Uschold, of Southern Oregon Neurosurgical & Spine Associates, has similar feelings.
"I don't think we should rush to judgment about high school sports based on what we're hearing in the media," he said. "We need to critically evaluate ways to protect kids and find ways for them to play safely."
"I'm a neurosurgeon, and I would let my son play football," said Uschold, who has a 11/2-year-old boy.
Improved measures in recognizing and evaluating concussions make such decisions easier.
Working the sidelines
In the last five years, nearly every state, including Oregon, passed laws to raise awareness to ensure proper treatment for high school athletes.
Lotz is a big part of the safety movement here, overseeing Southern Oregon Orthopedics' volunteer effort to provide care, in concert with school trainers, for North Medford, South Medford, Crater, Phoenix and St. Mary's high schools and the Rogue Valley Pop Warner Football Association. He is a medical consultant for USA Rugby and is the medical provider for Southern Oregon University's rugby teams.
"We're trying to coordinate care to make sure there's continuity between them and ourselves regarding concussions," said Lotz.
Over the years, diagnosis and treatment of concussions has differed between providers, he said. Information gleaned from summit meetings in Zurich, Switzerland, in 2008 and 2012, have since become "the gold standard," said Lotz, when it comes to evaluating and monitoring closed-head injuries and determining safe return-to-play timetables.
Using information from his extensive background in sports medicine, Lotz "morphed" together a standard, battlefield test that is simple to administer for quick evaluation of a player suspected of suffering a head injury.
Prior to the season, he meets with coaches for hourlong concussion presentations.
They then give athletes reaction and equilibrium tests to establish base levels.
For reaction, players start and stop a stopwatch as fast they can, five times. The average time is recorded.
It's similar to a stick-dropping method in hockey, where subjects unclamp then clamp their fingers to catch the falling stick.
For equilibrium, players stand with their dominant foot in front of the other. With hands on hips, they try to maintain their balance for 20 seconds.
The team trainer has a binder with each player's test measurements. If a concussion is suspected, that player's info is pulled and he goes through the tests again. Concussions symptoms can be readily detected.
A difference in stopwatch clicking from, say, .15 seconds to .4 seconds is significant, said Lotz.
If a player loses his balance four times in 20 seconds, it's a clear indication.
"You have an objective test to support that thought," said Lotz.
"A concussed brain doesn't process as quickly," he said. "That's why players who are injured are confused."
If they fail either test, their helmet is taken away and they are removed from play.
Players could cheat the system by dumbing down their numbers if they know what the tests are for, but, said Lotz, "I think all the kids know we're doing this for their own good."
Simple questions make up part of the evaluation.
For high school players, they are: Where are you playing? Which half is it? Who scored first? Did you win your last game?
For kids 13 and under, they are: Where are we playing? Which half is it? What grade are you in? Which school do you attend?
Players are also asked how they feel, and their emotional state is monitored.
The mantra for everyone is, "When in doubt, sit them out," said Lotz, whose medical team also serves as "game-day doctors" for opposing teams that don't have trainers.
Having medical personnel on the sideline takes the decision-making away from the coaches, who may be conflicted on whether to send a player back into action for the good of the team. It's a separation of church and state, so to speak, said Lotz.
Coaches appreciate it.
"The system in place now is really good," said Crater coach John Beck.
"I don't want to make the decision on a kid," he said. "I want the trainer and the doctor at the game to say, 'Hey, this guy's out.' Or take his helmet and not let him go back in. I'm glad I'm out of the deal. I'm a coach, not the doctor. It's good to have people at our disposal to do that. We're very fortunate."
To their credit, said Lotz, all the coaches he's worked with this fall are in step with the program. Not once, he said, has a coach lobbied to return a kid to play against the ruling of Lotz or his cohorts.
"The whole point of this is, in the past, people might have rushed to get kids back to playing," said Lotz. "We don't do that. We're obligated to the health and well being of the athlete and not the school or the team."
The week after
When a player has a concussion, a strict course is set in motion.
Parents are notified and given a concussion explanation form and a plan to deal with it. They're told the player can't play again until all forms are completed and an OK is given by a medical provider.
There is a six-day protocol to follow:
Day 0: injury day.
Days 1 and 2: no physical activity.
Days 3 and 4: light physical activity.
Day 5: aggressive physical activity.
Day 6: full contact (controlled).
If at any time the athlete shows concussion symptoms, the process starts over.
"We know a lot about concussions," said Uschold, the neurosurgeon. "At the same time, we know surprisingly little. Everyone seems to respond uniquely to them. Sometimes symptoms dissipate quickly, and sometimes they don't.
"If there are any questions, it's better to remove the child from play. Things that don't result in loss of consciousness or amnesia are still clinically relevant injuries to the brain, so we need to treat them the same way."
During his presentation to coaches, Lotz identifies risks that can lead to concussions.
They include a big difference in the size and speed of players, poor tackling technique, the assumption that "the best helmet" will protect players, head-to-head tackling drills and kickoffs and punts.
The worst scenario is size difference coupled with kickoff and punt returns, when players are running faster at the time of impact.
Greg Reeser, the commissioner of Rogue Valley Pop Warner, said the risk of concussions at the youngest level is miniscule. It's not like the NFL, he said, where "200-pound running backs are running 10-flat and banging into each other. It's weight, or mass, and velocity, and you're going to get injuries.
"As you get smaller and smaller, down to our level, you're looking at greatly reducing mass and speed to the extent that we do not see a problem with concussions."
Which isn't to say Pop Warner dismisses the likelihood of such injuries.
"We've been extremely proactive in mandating concussion training, the same as colleges and high schools," said Reeser.
Of the 800 Pop Warner players in six Rogue Valley associations, said Reeser, he isn't aware of any reports of concussion symptoms.
Tackling instruction is an important deterrent to head and neck injuries.
Heads Up Football is a USA Football program being followed by many prep and youth programs. Tacklers are taught to get a wide, balanced base, bend at the knees, shoot the hips and deliver an ascending hit with head and eyes up, making contact with a shoulder. It has the backing of the NFL and the Centers for Disease Control.
Beck, whose sons play football, is a proponent of the program.
"The kids get tired of doing the heads-up drills," he said, "but it teaches muscle memory. If it keeps one kid safe, it's well worth it."
Another technique is the gator roll, where the tackler goes at or below the waist, wraps up and rolls to bring the ball carrier down.
Beck said a former player of his, Derrick Turituri, now at Arizona, used it recently on a crucial sack against UCLA.
"We rep that every week, a lot," said Beck. "We want to take the danger out of the sport."
Helmets are a protective device, but can be detrimental if used as a battering ram.
"Some people think they're a double-edged sword," said Uschold. "They do have a role in protecting the head, and part of the emphasis is how it's coached and how tackling is taught to avoid using the helmet as an offensive weapon. That's a great next step in protecting kids."
Lotz noted that there are half as many concussions in rugby, which doesn't use helmets, than in football because players don't lead with their heads.
Should your kids play?
It's up to each person to weigh the benefits and risks of playing football.
Those in and around football talk of the camaraderie, working within a team setting, the importance of learning sportsmanship and respect for those guiding the teams.
Others might think the risk is not worth it. They've heard about deaths. They've heard about the effects of repeated blows to the head.
There is passionate debate on both sides.
"I think a lot of it has to do with culture within the community," said Beck. "It'll be interesting to see how it plays out. It's such a popular sport and so many people have played it in the past. It'll be interesting to see if it loses some popularity, but I'm not seeing the numbers dwindling."
Reach sports editor Tim Trower at 541-776-4479, or email firstname.lastname@example.org.