Sam Dean | The Roanoke Times

Trainer Talena Williams (right) tests Cave Spring High School football player Cody Bushman for a concussion after he was hit in the head during a game earlier this month. The junior returned to class just days later, but his vision was blurry. The doctor ordered more rest.

Sam Dean | The Roanoke Times

Cave Spring High School junior Cody Bushman suffered his first concussion when he was 9 while playing recreational football. He had migraines for a year.

Eric Brady | The Roanoke Times

Eric Brady | The Roanoke Times

Hidden Valley High School junior Jake Hubbard helps from the sidelines during a football game earlier this month. Hubbard received a concussion in August.

Eric Brady | The Roanoke Times

Left: Dr. Brent Johnson checks Hidden Valley High School sophomore Jake Kite before a football game on Oct. 1.

Jake Hubbard, a 6-foot-2-inch, 195-pound middle linebacker, was tackling the ball carrier as the offense ran a sweep when a teammate's thighs slammed into the back of Hubbard's head, knocking him unconscious.

Hubbard doesn't remember the play, regaining consciousness or sprinting off the field and collapsing on the sidelines.

"I have no recollection, but I have watched the film," said Hubbard, a junior at Hidden Valley High School. "Halfway through halftime it was like I randomly woke up. I had no idea where I was."

He had a concussion.

He hasn't played football since, and at 17 years old, his participation in contact sports may be over for good.

Under increasing awareness of sports-related concussions, Hubbard's diagnosis and treatment came at a time of immense change in how these head injuries are treated. On Aug. 29, three days after Hubbard's concussion, the medical journal published by the American Academy of Pediatrics issued new recommendations for treating concussions in young athletes. The recommendations included increasing recovery time and emphasized resting both body and mind.

The recommendations have the medical, sports and academic fields scrambling, with many still in the dark. In the Roanoke region, they have led to an intensive effort to educate football teams and schools midseason about how to best protect their players from complications after a concussion.

The changes also come as government has taken notice. In July, a new Virginia law will require a student-athlete be cleared by a health care provider before returning to play. The law also requires that each local school division set guidelines and policies to educate parents, athletes and coaches about concussions.

Additionally, a federal bill was introduced Sept. 22 that would set minimum state requirements for managing concussions. School systems would have to comply in order to receive federal funds.

The combination of the new Virginia law and the academy of pediatrics report have brought a small group of Carilion Clinic doctors together to spread the word about the changes.

"This has changed everything," said Dr. Thomas Miller, a Carilion Clinic orthopedic surgeon and a sports medicine specialist who also serves as team physician for sports medicine at Virginia Military Institute.

The information is so new that Miller said he knows some doctors, trainers and coaches are unknowingly following outdated information that could harm players.

Led by Miller and Dr. Brent Johnson, the Carilion group also includes neuropsychologist Bill Wellborn and physical medicine and rehab specialist Dr. Trevor Chapmon. The doctors have teamed up with Talena Williams, a Carilion physician assistant and sports trainer who also owns On-Site Sports Medicine Services, a business that supplies trainers to area high schools.

Cognitive rest

The Monday after Hubbard's injury, he was in school struggling to focus.

Doctors now know that Hubbard should have been home resting because the academy of pediatrics recommendations stress cognitive rest including no television, video games, computer use or reading.

"This is about giving the brain time to heal," said Johnson, who is also the Hidden Valley team physician. "It actually makes for a better, faster recovery."

Johnson also suggested limiting texting.

Three weeks after Hubbard's injury, his teammate, sophomore Jake Kite, had a concussion during the team's Friday night game against the Brookville Bees. It happened during the third quarter when Kite, a 5-foot-11-inch, 165-pound safety, collided with the opposition's fullback.

"The guy was pretty big and he hit me pretty hard, and I got pretty dizzy and couldn't stand up," Kite recalled.

Unlike Hubbard, Kite was sent home from school the Monday after his concussion. The same thing happened Tuesday and Wednesday.

"They just wanted me to lay in the dark," Kite said.

While he worried about falling behind in his classes, the school was concerned about giving his brain the proper time to heal.

Kite was likely the first in the region to be given such strict cognitive rest, doctors and educators said.

Hidden Valley Principal Rhonda Stegall acknowledges that there was a significant difference in how each Jake was treated. It wasn't until Miller, Johnson and Williams hosted a Sunday afternoon meeting for athletic trainers and others that she learned about cognitive rest.

The meeting occurred the Sunday after Kite's concussion. So that Monday, Stegall told each of Kite's teachers that he was to be given the time needed to recover and make up any missed work.

Now she's helping to develop a system for cognitive rest at all county schools.

"We're still piecing together on how we are going to approach it," she said. "I think the most important thing that we have to do is educate everyone about the need."

Still, even in Roanoke County the concept of cognitive rest isn't commonplace.

When Cody Bushman had a concussion Oct. 8, three weeks after Kite's, Williams was on the sidelines. All the latest protocols were followed as Bushman was assessed. The next day he went to a sports clinic run by Carilion Clinic Orthopedics, where Johnson, Miller and Williams work. Johnson met with Bushman and recommended that given Bushman's history of head injuries -- this latest was his sixth concussion playing football -- he should end his playing career.

Like with Kite, Johnson told Bushman to lie in the dark, avoiding any brain stimulation.

The message, however, wasn't as clearly explained to Bushman's teachers at Cave Spring High School. Instead, Bushman, a 17-year-old junior, was left to manage the stress of falling behind at school and recovering from his injury on his own.

"Missing one day, you get behind," said Bushman, who hasn't missed a full day of school since the second grade.

The Monday after sustaining the concussion, Bushman went to his morning classes, but struggled to learn. He called his grandmother and left early to go home and nap.

"Moving my head, I still have lag in my vision, my eyes are blurry a little, they don't focus as well," Bushman said that Monday. "That's the physical. It's also mentally hard to focus."

On Tuesday, still complaining of blurred vision, he went to school late specifically to take a Spanish test that he was afraid to skip. Following the doctor's orders to rest at home over the weekend, he hadn't studied.

Returning to play

Dressed in his No. 20 Titans uniform, Kite was on the field for the first defensive play of the Oct. 1 game against Northside High School. On the second play, he took a hit. He jumped up from the ground immediately.

Kite didn't hold back during Hidden Valley's loss to Northside, and his return to the field was preceded by a number of cautionary activities.

The days of someone bouncing back from a concussion to play the second half are over.

"The answer is always no," Miller said. "Players do not return to play the same day."

Even once Kite's headaches subsided, he wasn't cleared to return. Instead there was a gradual process he followed that included five steps laid out in the academy of pediatrics article beginning with no activity and proceeding to full-contact practice.

After several days of rest, Kite successfully made it through each step without experiencing any symptoms. He returned to regular practice the Tuesday before the Northside game, 11 days after the concussion.

A year ago, his recovery would have been more arbitrary, Johnson said.

"Basically, if symptoms had cleared, we would allow them to return to practice right away," Johnson said.

Area athletic trainers and team physicians said they have always erred on the side of caution by not allowing players to return to play while still experiencing symptoms. But they also believe fewer concussions were being identified.

So, while there is a focus on the recovery process after having a concussion, there has also been an increased emphasis on identifying concussions. Miller insists that there is no such thing as just having "your bell rung" and shaking it off. Symptoms like that now are believed to be signs of a concussion.

"The pendulum has swung, and until more data becomes available, we're gong to have to be overly cautious, " Johnson said.

Seeking honesty

Lying is something that health care providers and coaches acknowledge can happen. Johnson said one player this season took pain medications for weeks without telling adults of his symptoms. Now Johnson suggests parents hide over-the-counter painkillers as a way to better monitor an athlete's pain.

Players are eager to return to the field and to school. Kite admitted he contemplated lying, telling the adults that his headaches were gone when they weren't.

"I wanted to play and get back into it, for the team," he said. "And I didn't want to get behind in school."

But he didn't, he said.

"They are a lot more serious about this now. I guess it's a big deal," he said.

Hubbard never lied, but he didn't keep his parents, coaches and health providers entirely informed.

Hubbard's concussion at the beginning of the season wasn't his first. He had another last year during an August scrimmage. It was never diagnosed, but it left him with recurring headaches. He never missed a practice or game.

"It was never really too bad, just the more I hit, the more I'd get headaches," Hubbard recalled. "It wasn't overwhelming pain. It was, like, annoying."

Those headaches, however, have been a clue to his health care team that Hubbard was at risk for more severe concussion-related problems. Those headaches are a reason why he is sitting out the season, and may have to give up football.

Baseline testing

Identifying concussions has come under scrutiny, with experts suggesting too many are undiagnosed. There is no systematic collection of data on concussions among high school and rec league athletes at the local or state levels.

Nationally, it's estimated there are 300,000 sports-related concussions a year. In 2003, researchers reported that, among college players, the rate of brain injury had increased during the previous seven years.

More is known at the collegiate level than among younger athletes because more research and resources have been dedicated to the elite athletes. But research has shown children and adolescents are more likely to sustain a concussion and that they take longer to recover.

Many parents say they don't know when to take their child to a doctor and which doctor to see. Should children go to the emergency department? A pediatrician? A neurologist?

Even local doctors can't answer that question.

"There aren't too many people who are willing to assess these kids," Miller said. "And there aren't too many who are up on the research who are available to assess these kids."

Besides educating parents, schools and coaches, Miller said more needs to be done to inform area doctors.

The Carilion group is also looking to establish baseline testing that athletes would take before the season. The test would be repeated after a concussion to help determine if the athlete has fully recovered. There are several different kinds of testing done at the collegiate level, which are used collectively to establish a baseline, including balance and neurological testing.

Wellborn, the Carilion neuropsychologist, is seeking to identify grant money or other funding to conduct the neurological testing. But it is expensive and likely can't be done for every program at every school. He is interested in trying to do it before the soccer season, another sport whose athletes are prone to concussions.

"Baseline testing is not adequate alone to determine if an athlete can return to play; it is much more complex than that," Wellborn said. "But it is a tool that can help individualize an assessment."

Similarly, Williams said the group is looking at using the Nintendo Wii Fit game to do baseline testing for balance skills. The idea is not unique, and some colleges, including the University of Maryland, have turned to the video game. Proponents claim the Wii is a simple and affordable option that is popular with young athletes.

But skeptics say the game isn't calibrated like a scientific tool and that there are other proven ways to measure balance that would give a better baseline. At Virginia Tech, where football players use expensive electronic balance testing, the team physician said he wouldn't recommend using Wii.

"Wiis aren't accurate and there is no scientific proof," said Dr. Gunnar Brolinson, Tech's football team physician.

Brolinson suggested using a less expensive option called the Balance Error Scoring System. It is a foam pad developed by the University of North Carolina on which athletes stand with one foot and are scored by how many times the opposite foot touches the ground. Brolinson said it has its flaws, but at least it has been scientifically tested.

Sandlots

Even as the Carilion group has concentrated its efforts to educate athletes, parents, trainers and coaches at the high schools, they recognize the youngest athletes are also at risk.

"If this is happening in the high schools, where there are trainers who watch out for the kids, who knows what's going on at the younger levels," Williams said. "It's a problem that needs attention."

Bushman suffered his first concussion when he was 9 playing recreational football. He had migraines for a year.

Nationally, there has been heightened attention given to younger athletes and the potential long-term effects including learning delays, emotional problems and behavioral changes. Researchers in Virginia are looking at the link between brain injury and the juvenile justice system. A similar link has been established among adult inmates.

USA Football, the sport's national governing body on youth and amateur levels, has recently launched an advertising campaign emphasizing concussion awareness among the country's more than 1.14 million high school football players.

It's an educational message that David and Donna Culicerto hope spreads quickly to the middle schools and recreational leagues in the area. Their 12-year-old son, Will, has had two concussions identified. The latest was in September during football practice at Northside Middle School when Will, a quarterback, was tackled from behind.

"I got up and tried to tell coach I was OK," Will said. "Then when I was walking over, they told me my eyes were weird. Coach said I was done for the day."

An ambulance was called. Inside, Will couldn't tell how many fingers were being held in front of him. He didn't know his name.

That night, Will did his homework with his mother's help. The following day he went to school, still experiencing headaches. He was sent home when he couldn't remember his locker combination for his first-period physical education class.

His headaches lasted about three weeks. He didn't have strict cognitive rest, because, at the time, his parents, teachers and doctors didn't know to recommend it.

"It makes all the sense in the world, now that I think about it," Donna Culicerto said. "But we just went by what the doctors were telling us."

Will is now out for the season, and his parents said they will have him re-evaluated before letting him back on the field next season.

Will's latest concussion was worse than the one he had last fall during the final game of the season.

"I was dropping back to pass and I got hit pretty good," he said.

He had an instant headache, but he decided to keep playing without telling an adult. At the end of the game, Will vomited.

David Culicerto said the he's glad the research is being done and that more is known since he was in high school.

That's a point Miller said he wants adults to recognize.

"This isn't how we used to do it," Miller said. "But I think there should be a community expectation that things are going to improve at all levels. I hope we are smarter than we were 20 years ago. "