The conversational spark yesterday was a new poster that hangs in every NFL locker room, with the big, bold headline: "CONCUSSION." The line below says, "A must-read for NFL players . . . Let's take brain injuries out of play." The poster goes on to detail the dangers of hiding concussion symptoms from the team medical staff. It is as bold a step as the NFL has ever taken in trying to change the culture of hiding brain trauma from the doctors.
But after a player reports a concussion, well, what then? The player wants to play. The coach wants to know when. The athletic trainer lives his life in between the two of them - and with concussions, the balancing act can be treacherous for everyone, because there still is so much medicine does not understand about brain trauma.
Into that uncertainty, Burkholder has now stepped with a unique, structured approach to figuring out when it is safe for a player to return. He said he adapted a program devised at the University of Pittsburgh Medical Center, and presented his work at a national conference of athletic trainers this June.
The baseline neurological testing that has been done on athletes for about 15 years is just the start for Burkholder. He has come up with five phases of testing, all of which must be passed by the player before he can return.
"I started doing it last year," he said. "Before that, I never had a systematic rehab approach to concussions. We just let them rest, and when they said they felt better and they passed the [baseline] test, we put them back in. Now, I make them go through these five phases.
"What we've done is put very specific guidelines in on ourselves, to make sure that we're making the best decision possible. It's not an exact science and they all know that . . . but this program takes a lot of the gray area out of it for me. I put them through really big challenges before they have to hit somebody, to see if they can handle it. I feel more confident putting a player back in than I did before."
Burkholder said he did not want to talk about specific players out of respect for their privacy. He has handled dozens of concussions in his time here. Some, like Brian Westbrook's, did not go well; Westbrook suffered a second concussion after missing 19 days following an initial concussion last October. Others have gone better. One concussion reported by the team this summer was to offensive tackle Austin Howard, who is back playing. Howard certainly went through Burkholder's protocol.
"We used to tell them to rest, to go to meetings, just don't do the football stuff," Burkholder said. "Now I know that isn't smart, either. I don't send them to meetings anymore. Their brains need to rest, and you have 'Coach Cleats' in there running that film backward and forward, and it drives them crazy. For years, they'd tell me, 'Rick, I hate being in the meetings,' but I'd tell them, 'Go to meetings - it's your job.'
"But what we're finding out is that, if you sprain your brain, what sense does it make to have you go in there and work and watch film and concentrate? I've totally changed my approach, and Andy's been great about it. He understands."
The first phase involves easy exercise in a quiet room, with no impact. So the player rides a bicycle slowly, raising his heart level to only 30 or 40 percent of its maximum. Then he sits on a table and does leg lifts and some stretching. If he can do that and remain symptom-free for 24 hours, the player moves to the next phase. The 24 hours is required at the end of each step. If a symptom pops up, he repeats the previous step.
In the next phase, the heart rate is raised higher, the bicycle is exchanged for a run or walk on a treadmill, some additional strength training is attempted, and the quiet room is now the team's gym (but when it is relatively empty). The third phase ups the ante further with more work in a normal gym environment, adding in video-game playing and also exercises that involve more head movement.
"On average, it takes 3 or 4 days to get through the first phase, then a day or 2 to get through the second," Burkholder said. "Then, the third phase, when you start moving their head, can be a while. That can mess them up. The fourth phase is more sports-specific stuff: run pass routes, pass sets [for linemen], get their heart rate up, more weightlifting. The fifth phase, we put them into a bit of contact - maybe a drill where they're butting up against each other, but not tackling. Late in the season, I have to hit them myself with [padded] clubs, just to jar them a little bit, just to see how they do."
Burkholder said they have to get through all of that, symptom-free, before he will clear them to play.
"That way, I'm not putting a time frame on it - because we don't know," he said. "We just don't know. The day of telling a coach, 'Oh, he'll be better next week,' is over with."
At the same time, there still is no certainty - and the news gets scarier all the time. The word that 41-year-old former Eagles fullback Kevin Turner has ALS possibly brought on by head trauma is just the latest frightening story in this sport where players so routinely disregard their health in exchange for their paychecks.
"I know who my tough guys are back there, and they're not going to tell me if you mandate too many rules," Burkholder said. "This is the right way - to change the culture, to make the players realize there are some long-term effects that we don't know about yet totally.
"The players are protecting each other, which is great. And they are reporting more." *
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