REAP: A Game-Changer in Concussion Protocol at Rocky Mountain Hospital for Children

Two women at football stadium

“Concussion” is sure to be a Hollywood blockbuster this Christmas. But to Drs. Brooke Pengel and Karen McAvoy, concussions are real life. The two have been working together since the 2010 inception of Rocky Mountain Hospital for Children’s Center for Concussion – Dr. Pengel on the medical-side and Dr. McAvoy on the psychological end of the condition – to raise awareness of concussion, educate and train parents, schools, coaches and athletes to identify the injury, and ultimately, change the game in concussion protocol.

Authored by Dr. McAvoy, REAP, which stands for Remove/Reduce, Educate, Adjust/Accommodate and Pace, is a 20-page book that serves as the educational foundation for the Center for Concussion. The now nationally recognized model of care stemmed from the 2004 death of Grandview (Colo.) High School football player Jake Snakenberg. Jake, at 15-years old, passed away from Second Impact Syndrome.

Dr. McAvoy was a school psychologist at Grandview at the time of Jake’s death and wrote REAP with four teams in mind for concussion management, specifically, parents, school medical staff, and the school physical and academic teams. It’s a team approach to examine an athlete, weigh in on the decision for them to return to play and make sure a tragedy like Jake’s doesn’t happen again.

We sat down with the concussion experts for Concussion 101 and their thoughts on the upcoming NFL movie, “Concussion.”

What is a concussion?

Dr. Pengel:  A concussion is a traumatic brain injury that occurs from either a blow to the head or a blow to the body. It changes the way the brain functions.

What can be confusing about a concussion, when you define it, is that it doesn’t cause a major amount of structural injury that you can find on a CT scan or MRI. It occurs at the cellular level of the brain and changes the way the cells communicate with each other. This results in fairly dramatic symptoms, both physical and cognitive.

What are the symptoms and signs of a concussion?

Dr. Pengel:  A sign is something one would notice about that athlete – a dazed look, stumbling, confusion, essentially, not acting like him or herself, or on the sports field, not being able to remember or going the wrong direction on the field – fairly dramatic signs.

The physical symptoms are something the athlete feels – headache, sensitivity to light or noise, dizziness, nausea. The cognitive symptoms typically happen later when the athlete is trying to learn in school, but gets confused or can’t remember things. There are also emotional symptoms that go along with concussion, such as irritability, sadness, and simply being out of character.  Sleep/Energy symptoms also can emerge, either difficulty going to sleep or sleeping too much.

Will everyone experience the same symptoms?

Dr. Pengel: We always teach that a concussion can manifest itself in a variety of ways.  Classically, we look for the headache, dizziness, sensitivity to light and noise, but that’s not always how it presents. We really emphasize that a concussion can have a spectrum of symptoms – physical, cognitive or emotional – and the severity can vary in each athlete.

Who is monitoring the athlete and when can they return to play?  

Dr. McAvoy: REAP was written to involve a team approach. Ideally, everyone is monitoring the athlete and weighing in on when he or she can return to play.  For example, the “R” stands for remove and reduce. The parents are asked to remove the athlete from physical activities and reduce texting, video games and computer screens at home. The schools are called on to remove or reduce some of the academic work. And over the course of a couple of weeks, the parents and schools can start to add those things back in again and give their opinion on whether the athlete is symptom-free and ready to return to play.

At the same time, the athlete is also reporting symptoms to the doctor, doing cognitive tests, seeing their athletic trainer, and sometimes visiting a physical therapist.  There are multiple data points to review before the athlete starts on the graduated return to play steps. If they tolerate the graduated return to play steps without symptoms, then we can clear them to play.

That’s the idea, but I can’t say that’s happening everywhere. A lot of youth athletes, when asked, “Do you feel OK?” are eager to say, yes, and then boom, they are sent back to play.

Dr. Pengel:  That’s true. If I saw a concussion 15 years ago, I would have also asked, “How are you feeling?”  That’s why Dr. McAvoy’s protocol is a complete game-changer. It gives the medical provider sound data that can help their assessment to clear the athlete. That’s what came out of the tragedy of Jake (Snakenberg). It’s not just the doctor’s decision anymore. Thanks to REAP, all of these team members are looking at the athlete and weighing in on the decision to return to play.

What’s the minimum time an athlete should sit out after suffering a concussion?

Dr. McAvoy: We try not to focus on timelines. The protocol for when it’s safe to return to sports is when you are symptom-free from any of those four domains of symptoms: cognitive, sleep, physical or emotional.

Treating a concussion is an individual process; some athletes can be symptom-free in a short amount of time and some won’t be symptom-free until weeks later. It’s dangerous when people say things like, “You have a concussion. You need to sit out for two weeks and then you can go back.” Research shows that 80-90 percent of kids with a concussion will end up resolving or recovering from their concussion within 3-4 weeks. REAP is written with a three week protocol, but we never say, “You have a concussion. You can go back in three weeks”…ever. That’s why it’s so important to have a knowledgeable team working with the students, parents and schools.

Myth Busters: Should you only rest after a concussion?

Dr. McAvoy: That’s evolving. A few years ago, after a concussion, we’d say kids needed to rest physically and cognitively and no one really knew what that meant. But physically, we just shut these kids down completely. No physical activity at all – couch potato’ d them a little bit. And slowly, over the last couple of years, the active rehab idea started coming out of New York – a totally new approach to concussion. It said if they’re not getting better within two to three weeks, start a very small, safe amount of cardio activity.  We started doing that in our clinic and now we’ve moved that up so it’s not necessarily two to three to four weeks, but we’re starting some very safe, light cardio activity within a couple of weeks of concussion.

We have an early exertion program connected with our Center for Concussion called PACER (Progressive Acute Concussion Exertional Program), where physical therapists do motor eye tracking therapy, balance and movement therapy and add in a tad bit of safe cardio activity for our patients. We’ve been doing that for two years now and our recovery rates are really promising.

So, some small amount of the right kind of exercise seems to work better than no exercise. It has not been completely researched and defined yet, but some early exertion is probably the future of concussion. The idea of rest only has gone by the wayside.

Dr. Pengel: I agree. It’s another cutting edge program in our Center for Concussion. And the type of data that we’re gathering is going to change the management of concussion in a very dramatic way.

Athletes gain so much physical well-being from their sport, so if you introduce some sort of physical activity, it’s logical that it’s going to boost their spirits and they’re going to feel a little bit better. If you look at it like this…you have a year-round athlete and you pull them from their sport and they literally cannot do any exercise…I mean, this is how this athlete ticks; it’s part of their personality. So without activity, we find that they still have symptoms, but they also are starting to get depressed and they’re feeling really out of sorts and it’s hard to know if that’s the concussion talking or they’re just out of their routine. So not only is some light physical activity the right thing to do, but subjectively, from the standpoint of the child and athlete going through this, they’re going to feel like the process of healing from a concussion is a lot more tolerable.

What are your thoughts on the movie, “Concussion” and the disease CTE in children?

Dr. Pengel: We’re actually excited to see this movie. I’m an avid football fan.

Dr. McAvoy: Not to mention a Will Smith fan! (Laughs.)

Dr. Pengel: This is what I call the “Fear Factor,” to some degree…we have to be careful what we ask for. We really want recognition of concussion and how important this issue is, but a lot of time the recognition comes in the form of fear…like all of these kids are going to have this brain injury that’s going to cause dementia and suicide and all of these horrible things.

So, the movie is about chronic traumatic encephalopathy, or CTE, a degenerative disease in the brain that has only been diagnosed by autopsy and found in NFL players. The disease is caused by repetitive injury to the head. In boxers, for example, at autopsy, their brains look different than people who have not had cumulative blows to the head. And so, what’s concerning to these researchers, is that we’re taking brains of NFL players and we’re seeing these same types of things. What they have been trying to do, hence the controversy in the movie, is to make the case of cause and effect that because of repetitive blows to the head, these players have developed CTE, which has caused all of these horrible things in their lives – depression, mental illness, suicide and death.  That’s a big leap. There’s a lot more research that needs to be done, and one of the problems is that it cannot be diagnosed in living people.

I had the opportunity to listen to a concussion segment on the ESPN radio/television show Mike and Mike. They featured both Dr. Bennet Omalu, the subject of the “Concussion” movie, and his mentor Dr. Julian Bailes, on the show, and what was interesting is that Dr. Omalu came right out and said CTE was a major concern for kids. Dr. Bailes respectfully disagreed and said that for the grand majority of kids this was not going to be a concern. So, from a youth standpoint, there is even controversy between those two highly respected researchers about CTE and what it means for our kids.

Yes, it’s concerning repetitive blows to the head can have brain changes that can cause a degenerative brain condition similar to what you see in boxers or someone with Parkinson’s disease or dementia. But when you bring it down to the kids, it doesn’t mean every child playing contact sports or football is going to have CTE. That just isn’t logical.

On the flipside, it’s good that there is a global recognition there could be long-term effects. But there’s a lot missing between linking a child who plays youth football to them dying of suicide when they’re 50 years old. There’s a lot of research that needs to be done in between.

Dr. Omalu also said in a NY Times op-ed piece, “Don’t Let Kids Play Football.” What say you? Is there a medical recommendation for when kids should play contact sports?  

Dr. Pengel: He went out on a limb there, in my opinion. I don’t know if that would be something any of us medical experts would say. I think all sports are evolving to make them safer. In hockey, for example, the contact collision rule was changed a few years ago; in football, there’s been a complete revolution of how the sport is being taught.

So, the experts are not saying there’s an absolute age criteria for when kids can play. On the contrary, we’re saying it’s an individual choice. The family needs to understand the risks of playing contact and collision sports and then make a decision based on their understanding of those risks. In the meantime, there are ways to make sports safer, so that’s what we tend to focus on – how can we make this sport different than it was 10-15 years ago. We don’t really have any evidence that shows us starting at one age compared to the other is any better or safer.

What are some ways we can prevent concussion in youth sports?

Dr. Pengel: Rule changes and paying attention to how kids play can help with prevention. For example, USA Football teaches collision and contact in a graduated fashion for kids embarking on tackle football.  They are teaching the fundamentals and then phasing different levels of contact based on mastery of the fundamentals. They’re not teaching head down, but heads up. It’s called “Heads Up Football,” and that’s one way to teach the sport of football in a safer way. That’s been really helpful and USA Football is doing its own set of research behind that program to see if it’s changing concussion rates.

Officials and coaches also need to have a zero tolerance for unsafe play. Everyone can see at the NFL level the evolution of concussion management and the rules they’ve established to make the game safer. It trickles down to the youth level. So, they’re changing a lot of rules in football to make these high speed collisions less likely.

There’s also some promising protocol in girls’ soccer. There’s an epidemic of concussion in girls’ soccer, where they’re colliding with each other and heading the ball aggressively without, perhaps, proper neck strength. So, researchers are looking at neck strengthening programs from a prevention standpoint in that sport.

Is there a concussion crisis?

Dr. McAvoy: We’ve been dealing with concussions for a long time, just not in the advanced way we are today. There’s an opportunity here and we are definitely using the opportunity to make the entire sport safer, manage these kids better and change the culture in sports and in schools. Concussions have been happening all over the place for decades. We’re changing the culture for kids and that’s not a bad thing.

Dr. Karen McAvoy is a licensed clinical psychologist and the director of the Center for Concussion at the Rocky Mountain Youth Sports Medicine Institute and Dr. Brooke Pengel is a board-certified pediatric sports medicine specialist and medical director of the Youth Sports Medicine program at the Rocky Mountain Youth Sports Medicine Institute, an affiliate of HCA Healthcare’s Rocky Mountain Hospital for Children.

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