WATERLOO, Iowa --- For all the numbers Steve Young and Troy Aikman compiled during their NFL careers, it was their concussion totals of seven and 10 that eventually moved the Hall of Famers from the playing field to the broadcast booth.
Along with the touchdowns and Super Bowl rings, their careers helped concussions surface as a regular conversation topic in athletics.
Finally in 2007, the NFL created a policy prohibiting its players from returning to competition on the same day consciousness was lost. Four years later, state lawmakers and the governing bodies of high school athletics are making sure the same rules apply to the nation's children.
Last summer, information passed down from the National Federation of State High School Associations (NFHS) and the National Athletic Trainers' Association sparked a proactive stance on concussions from coast-to-cost. Iowa's high school boys' and girls' athletic governing bodies went to work creating a formal concussion management protocol in time for the 2010-11 school year.
The essence of Iowa's state law that went into effect on July 1 requiring the removal of concussed student-athletes from competition was written into the protocol.
"It was something that we felt like we needed to do because of the new information that was out nationally regarding concussions and the implications of the young athlete who might have a concussion," Iowa High School Athletic Association assistant executive director Alan Beste said. "We did that a year ago, and then the legislation followed this year."
As the association's sports medicine wellness contact, Beste has been actively monitoring and providing schools with resources on the issue of concussions for the past 22 years.
Iowa is one of 23 states that currently has concussion legislation signed into law. The other 27 states have proposed legislation or bills that are waiting their governors' signatures.
"It started with professional athletes and trickled down into the NCAA and now into the high school ranks," Beste said. "That's not to say we haven't been doing anything for a long time, but the legislation, I think, was a result of the research done at the professional level and then at the collegiate level and high school level with the National Athletic Trainers' Association."
Locally, the legislation has been embraced. Metro schools such as Waterloo West, East, Columbus and Cedar Falls have long-standing relationships with Cedar Valley Medical Specialists, where they subcontract certified athletic trainers who are at the front lines diagnosing concussions and other injuries during high-risk competitions and practices.
The schools also receive assistance from university students in their clinical rotations. Typically, one third-year athletic training student is assigned to a school for the season, along with a rotation of first- or second-year students.
"I was very happy when Iowa signed the concussion bill into law," Waterloo Columbus' licensed athletic trainer Scott Lockard said. "It gets everybody on the same page. ... As athletic trainers, one of our duties is prevention. We're there to make sure that everybody is educated on the issue and return to play decisions and protocol."
Iowa law now dictates that students who have suffered a concussion may not return to competition until full evaluation and written clearance has been received by a licensed health care provider.
"It forces kids to see a doctor," said David Fricke, Waterloo West's licensed athletic trainer. "Before, you'd let the parents know and some parents might take them (to the doctor), some parents wouldn't take them.
"That makes my job a whole lot easier. I don't have any issues with parents or coaches. It's cut and dried - they've got to be cleared."
In an era when school districts are being forced to operate with fewer financial resources, obtaining services from certified athletic trainers can be a challenge. Fricke estimates the price of full coverage at nearly $25,000 annually.
Waterloo Columbus athletics director and head football coach Aundra Meeks estimates his school spends about $20,000 a year on athletic training services. Yet, he's quick to point out the program has been valuable since the early 80s.
"I'd give my salary if somebody said we had to cut that department," Meeks said. "It's that important to us as coaches here to have our athletic trainers on board. It's an invaluable service."
For smaller school districts, it's not as common to see a qualified heath care professional in attendance at sporting events.
Dunkerton's 8-man football program is among the exceptions as it has two medical specialists patrolling its sidelines. The school's superintendent, Jim Stanton, is a certified EMT, while assistant football coach Paul McHone is a physical therapy assistant. McHone was paid a stipend at one time, but when the school entered a budget crunch, he agreed to work for the district on a volunteer basis.
"We're very fortunate," said Dunkerton principal and athletics director Mike Cooper, who estimates most schools in his district have coaches diagnosing concussions.
Three years ago, Wapsie Valley began using funding from its booster club to hire a local physical therapist to work parttime at the school.
"It's tough for a coach, I believe, as the competition is going on to evaluate and make sure that an athlete is in good shape," Wapsie Valley athletics director and boys' basketball coach Marty McKowen said. "The ability to have a trainer here has really helped us out in being able to evaluate concussions."
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This past winter, McKowen worked alongside his school's trainer in making the tough decision to end the career of one of his senior basketball players who had suffered multiple concussions.
"He had one in football and then one early in basketball and had the third one during our season," McKowen said. "None of them were to the point where he had blacked out all the way, but we had a trainer here doing our test and finally he said, ‘I don't think he should participate anymore.' We called mom and dad in, and the athlete himself made an agreement, and we all said he's done for the season. ...
"It takes a lot of pressure off coaches to have somebody who is trained to do that."
Through conversation with family, McKowen recently heard a chilling example of how serious concussions can be.
"My son coaches in the Kansas City area and a kid in his league last year in football actually died from multiple concussions," McKowen said. "You don't have to look very far out of our area, you can just stay in the Midwest and realize that does happen. The nice thing is there is more information out there now for people to be aware of."
As part of its concussion protocol, Iowa's athletic governing bodies have provided schools with a seven-step process for medical professionals to use when evaluating a student's ability to return to competition.
West's Fricke believes as it becomes more affordable, schools will eventually turn to some of the new technology used by NFL teams such as ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing). ImPACT is a computerized system that tests symptoms such as verbal recognition and memory against a baseline test given in the preseason.
According to the company's website, pretesting 300 athletes with 45 post-injury tests would cost a high school $500 a year.
"I think that's probably going to be the next step," Fricke said. "Some communities have it, some don't. It all depends on how much money some of the communities or the schools have to put into that kind of testing."
While legislation and greater anecdotal evidence about the dangers of concussions has surfaced, Dunkerton's Cooper worries about the hot-button issue's potential to cause paranoia. Prior to becoming an administrator at Dunkerton, Cooper coached Dubuque Wahlert's football team for eight years in the 90s.
"You always want to err on the side of caution, there's no question about that," Cooper said. "I just hope we're not overreacting to every little thing that happens.
"I played football, coached football, and you do get bumped around. You do get bumps, bruises, headaches, and that's part of the game. Football is a short season and you only play nine games. You'd hate for a kid to get in a situation where someone is overreacting to it and he misses two or three games - a third of his season. ... But certainly if somebody's got a concussion you don't want to risk that."
When it comes down to protecting the thousands of prep athletes who compete statewide, Beste is determined to make sure Iowa remains at the forefront of education and awareness. He believes high school sports are becoming less dangerous due to the instruction provided by coaches, along with advances in technology and information available to athletes.
"The awareness to safety issues among everybody - coaches, athletes, parents, school administrators - has really been enhanced over the years," Beste said. "As you can educate and make people more aware, you're simply going to make students safer."
Back in the game
The Iowa High School Athletic Association has adopted the following protocol for a return to participation after an athlete has sustained a concussion:
Asymptomatic at rest, and with exertion (including medical exertion in school) and have written clearance from a physician, physician's assistant, chiropractor, advanced registered nurse practioner, nurse, physical therapist or licensed athletic trainer.
Complete physical and cognitive rest. No exertional activity until asymptomatic. This may include staying home from school or limiting school hours (and studying) for several days. Activities requiring concentration and attention may worsen symptoms and delay recovery.
Return to school full-time.
Low impact, light aerobic exercise. This step should not begin until the student is no longer having concussion symptoms and is cleared by the treating primary health-care provider or concussion specialist for further activity. At this point, the student may begin brisk walking, light jogging, swimming or riding an exercise bike at less than 70 percent maximum performance heart rate. No weight or resistance training.
Basic exercise, such as running in the gym or on the field. No helmet or other equipment.
Non-contact, sport-specific training drills (dribbling, ball-handling, batting, fielding, running drills, etc., in full equipment. Weight-training can begin.
Following medical clearance, full contact practice or training.
Normal competition in a contest.