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After Krista Rickards' daughter Sarah suffered a severe concussion on a high school volleyball court in September 2010, the teenager returned to school in a matter of days. Sarah looked just fine. But she quickly became a regular at the school nurse's office, complaining of dizziness and severe headaches triggered by the noise and chaos of the halls and lunchroom, by overhead projections used in classrooms, and by long days and nights of books and homework.

The nurse in her New Jersey high school would let her lie down for a while but eventually dispatched Sarah back to classes. There, the then-sophomore battled problems with memory and concentration before coming home, exhausted and depressed, and trying to get through homework.

By the end of the school year, Rickards had enlisted the help of a neuropsychologist for her daughter. This was new territory for the administrators at Sarah's high school in Cape May Court House, N.J., but Rickards stood firm. Eventually, they negotiated a raft of accommodations that would exempt Sarah from gym class and give her extra time she needed to take tests and complete her assignments.

But by then, Sarah had suffered several more concussions -- in gym class, on the sidelines of volleyball games, in the school stairwell. Sarah was suffering from what neurologists call post-concussion syndrome and eventually had to be home-schooled before graduating last June.
Study: No helmet brand can save football players from concussion risk
After a child has a concussion -- whether under the Friday-night lights or in a jungle-gym accident -- the return-to-play deliberation has gotten plenty of attention. But there's mounting evidence that returning to the rigors of academic activity too soon also can slow healing and exacerbate symptoms. Yet parents, patients and physicians have gotten scant advice on how to manage a child's return to learning after a concussion.

For the first time, a new report in the journal Pediatrics systematically addresses that deliberation. The report underscores that, for a child with mild traumatic brain injury, the noise and chaos of school hallways, the eye strain of classroom instruction and the mental calisthenics of homework and tests can tax the brain at a time when its energies are needed for healing.

It also acknowledges that giving a student's brain healing time is a challenge for many school administrators. They have had little guidance on the matter and are under intense pressure to show improvements in students' test performance, meet the needs of children with long-term disabilities and fulfill an ever-growing list of demands on schools.

"Schools are very structured places, and are really geared toward the average: Everyone gets the same kinds of curriculum," says Rosemarie Scolaro Moser, a neuropsychologist and director of the Sports Concussion Center of New Jersey in Lawrenceville, N.J. "But every concussion is unique, and each student athlete heals at a different rate. So there's no predictability, and that unknown causes a lot of discomfort when you're a school administrator trying to meet goals, deadlines and objectives in a student's progress."

Among most school administrators, the lingering cognitive symptoms of concussion and the requirements of a healing brain remain unfamiliar ground, the authors of the Pediatrics article write. And among the pediatricians who manage children's recovery from concussion, the specifics of educational law and practice can be foreign. Yet both must work together with children and their families to set limits that will allow the brain to heal.

In most cases, that process of recovery will take a week to three weeks, during which a patient's school time might be limited, homework might be curtailed, and frequent breaks might be tolerated. Administrators might allow a concussed student to move between classes ahead of the noise and confusion after the bell, to waive or reschedule tests, and to let a student eat lunch in a quiet place.

The Pediatrics report offers checklists that parents, physicians and schools can use to identify symptoms that are triggered by school-related activities, and to track them as they resolve.

Brooke de Lench, a youth sports expert who founded the group Mom's Team, said new findings about concussion and its aftermath have begun to find their way to physicians and coaches but are still trickling down to parents and school administrators.

"It usually takes a few years," said de Lench, whose film, " The Smartest Team: Making High School Football Safer," is airing this fall on PBS. Patients' families and their doctors are now coming together to help student athletes heal after concussions.

"Now," she said, "the schools really need to get behind this."

That, says Krista Rickards, whose daughter is now a freshman in college, won't be easy, not only because of the competing demands on school administrators, but also because of the nature of concussions.

"As a parent you have to push. I wasn't aggressive, but I was persistent," Rickards said. Once she had clear recomendations from neuropsychologist Moser (authored of "Ahead of the Game: The Parents' Guide to Youth Sports Concussions"), Sarah's school agreed to accommodations, she said.

"It's hard, though, because a concussion is not a seen injury. You can see crutches, you can see a cast, or a wheelchair. You can't see a concussion," she said.
ALSO: Concussions: Even one can change the brain, study finds Football concussions: The smaller hits matter too Study finds concussions common in teens Concussion settlement highlights difficulty of proving brain damage

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Post-concussion return to learning also a tough decision

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After Krista Rickards' daughter Sarah suffered a severe concussion on a high school volleyball court in September 2010, the teenager returned to school in a matter of days. Sarah looked just fine.

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Recent attention to long-term brain damage linked to multiple concussions among professional football players has prompted a much closer look at how children and adolescents who participate in sports can be protected from similar consequences.

And with good reason. The young brain is especially susceptible to concussion, and sports-related concussions account for more than half of all emergency room visits by children aged 8 through 13, according to the National Athletic Trainers' Association. A child who suffers a concussion is one and a half times more likely to experience another, and those who have had two concussions have a threefold greater risk of the same injury happening again.

Many parents wonder if it is wise to let their children participate in sports like football and soccer, in which head injuries are most common. Concerns about concussion have been cited as a reason for a decline in enrollment in Pop Warner, the country's largest youth football program.

At the same time, misconceptions among parents and coaches abound about the seriousness of concussions and how best to prevent them, especially for players who often think they are invincible and say they feel fine so they can get back in the game. Studies have found that more than 50 percent of high school athletes and 70 percent of college athletes failed to report concussions they had sustained while playing football.

But first, it is worth noting that almost no sport is free of a concussion hazard, and that participating in sports has "cognitive, physical, emotional and social benefits that outweigh everything," said Steven P. Broglio, the director of the Neurotrauma Research Lab at the University of Michigan and the lead author of the National Athletic Trainers' Association position statement on how best to deal with concussions among young athletes.

For far too long, concussions have been minimized, with youngsters who have sustained one often going back into the game much sooner than they should, sometimes on the very day they are injured. Experts say that even the language commonly used to describe a hit - like "ding" or "bell ringer" - minimizes the seriousness of the injury and should be abandoned.

Perhaps concussions would command greater respect if they were called by their proper medical term: mild traumatic brain injuries. A concussion is caused by a direct or indirect blow to the head. The brain is jostled against an unyielding skull, temporarily disrupting normal neurological and metabolic functions.

Contrary to popular belief, you don't have to lose consciousness to have sustained a concussion. Ninety percent of concussions involve no loss of consciousness or only a brief disruption of mental alertness. You don't even have to hit your head - a whiplash injury can cause one.

Furthermore, the usual five-minute assessment done on the sidelines to check an injured athlete's ability to orient, remember, concentrate and recall words "misses about 40 percent of concussions," Dr. Broglio said in an interview. "A single test is not diagnostic and should not be relied on. Multiple different tests taken together can increase the sensitivity to the mid- to upper 90s."

However, the time allotted to assess an injured athlete on the sidelines is often inadequate to determine whether it is safe for a player to go back in the game, Dr. Broglio said. One of the most dangerous effects of failing to detect a concussion and allowing time for a young athlete to recover fully is second-impact syndrome - rapid, catastrophic swelling of the brain that can cause lifelong impairments, coma and even death - should the athlete have another concussion.

A growing number of parents now weigh the risks of concussion when helping their children decide which sport to pursue. The Institute of Medicine and the National Research Council of the National Academy of Sciences reported in 2012 that tackle football players sustained the most concussions among high-school-age athletes, with 11.2 reported among 10,000 "athletic exposures" - the number of practices and games in which an athlete participates. Lacrosse was the next riskiest, with 6.9 concussions per 10,000 athletic exposures, although one recent study found ice hockey and wrestling to be more hazardous than lacrosse.

Among girls, soccer is associated with the highest risk - 6.7 concussions per 10,000 athletic exposures, according to the academy study. Although many focus on the hazards of heading the ball, a new study of high school soccer players found that contact with another player was by far the most frequent cause of concussions among female and male players.

The study's authors, from the University of Colorado School of Public Health, predicted that "banning heading is unlikely to eliminate athlete-athlete contact or the resultant injuries." They noted that soccer had become a much more physical sport in recent years, resulting in more collisions between players.

Girls' basketball is not far behind, with 5.6 concussions per 10,000 exposures, a rate twice that of boys' basketball.

Gymnastics has seen a sharp rise in concussions in recent years. As the USA Gymnastics organization pointed out last year, "a concussion can be caused by a hit to the body, not just the head. A gymnast could fall, have a whiplash type movement and sustain a concussion even though they didn't hit their head."

The lowest concussion rate is associated with swimming, with only 0.2 such injuries per 10,000 exposures among girls and 0.1 among boys who swim competitively, according to a 2012 study in The American Journal of Sports Medicine.

Every athlete, parent and coach should be familiar with the signs and symptoms of concussion, some of which may show up hours or days after the injury. The athletic trainers' report includes these:

■ Difficulty thinking clearly, concentrating or remembering new information.

■ Headache, blurry vision, queasiness or vomiting, dizziness or balance problems or sensitivity to noise or light.

■ Irritability, moodiness, sadness or nervousness.

■ Excessive sleepiness or difficulty falling asleep or remaining asleep.

Any of these should be reported without delay to a coach, athletic trainer, parent or school nurse. Especially worrisome is a symptom that gets worse with time.

All 50 states and the District of Columbia have laws to protect young athletes suspected of having sustained a head injury. Most important, the laws stipulate that no one with even a slight concussion should return to play the day of injury. The athlete should be evaluated and cleared by a health care provider trained to do so before returning.
This is the first of two columns on concussions in youth sports. Related:
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Concussions Can Occur in All Youth Sports

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Recent attention to long-term brain damage linked to multiple concussions among professional football players has prompted a much closer look at how children and adolescents who participate in sports can be protected from similar consequences. And with good reason.

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Health experts have some bad news for high school football players: There is no particular type or brand of helmet or mouth guard that will keep you relatively safe from a concussion.

The companies that make helmets and mouth guards often claim that their own products can reduce players' risk of a sports-related concussion or lessen the impact of a concussion that does occur. These manufacturers cite "laboratory research" that purports to show one brand is safer than others, and a group of researchers wanted to see if they could verify such claims, according to a summary of a presentation they made Monday at a national meeting of the American Academy of Pediatrics.

The research team, from the University of Wisconsin-Madison and the Medical College of Wisconsin, tracked 1,332 high school football players from 36 schools during the 2012 season. Participating players completed a preseason questionnaire about their injury history and demographic information. Then, as the season progressed, athletic trainers from the schools kept tabs on the incidence and severity of any concussions that occurred.

At the start of the study, 171 of the players - or 13% - told the researchers that they had experienced a sports-related concussion in the previous 12 months. During the 2012 football season, an additional 116 concussions were sustained by 115 players - 8.6% of the student athletes in the study.
Post-concussion return to learning also a tough decision
When the researchers compared the rates of concussions for each type of helmet, they found essentially no difference by brand or by year made. The rate of concussions for players wearing Riddell helmets (the most popular brand in the study) was 9.5%; while the rate for players wearing Schutt helmets was 8.1% and the rate for players wearing Xenith helmets was 6.7%. There was no statistically significant difference in those figures, the team reported.

Nor was there any difference in the severity of concussions, as measured by the number of days players had to sit out (13.5, on average, for those wearing Riddell and Xenith helmets and 13 for players wearing Schutt helmets).

In addition, the concussion rate for helmets made in 2011 or 2012 was 9.3%, which was statistically indistinguishable from the 7.9% rate for helmets made in 2009 and 2010 or the 8.8% rate for helmets that were even older than that.

There was a surprising safety difference when it came to mouth guards. The data showed that the 39% of players who wore "specialized mouth guards" that were "custom fitted by dental professionals or specifically marketed to reduce" the risk of sports-related concussions were actually 90% more likely to experience a concussion than the 61% of players who used generic mouth guards during the 2012 football season.

The researchers noted that their findings were "contrary to manufacturer claims" that specific equipment could protect football players from concussions, which occur approximately 40,000 times per year among high school players in the U.S.

"Caution is advised when recommending specific preventive equipment based on manufacturer claims of reduced risk," they wrote in the abstract that summarized their findings.

Study leader Dr. Margaret Alison Brooks, an assistant professor in the Department of Orthopedics and Rehabilitation at the University of Wisconsin School of Medicine and Public Health, said the report should make players think twice about the assertions made by equipment companies.

"Despite what manufacturers might claim, newer and more expensive equipment may not reduce concussion risk," she said in a statement. "So is it worth the significant extra cost to families and schools?"

She also expressed doubt that any type of equipment could make football perfectly safe for players. Properly fitted helmets can reduce the risk of skull fractures and scalp lacerations, she said, but "because the brain is floating freely inside the skull, I think most experts doubt whether it is possible to ever develop a helmet design that can prevent concussion."

If you're interested in the latest medical research, you like the things I write about. Follow me on Twitter and "like" Los Angeles Times Science & Health on Facebook.
ALSO: Heads-up for dangerous football hits, athletic trainers warn NFL players' brains at work show early signs of concussions' toll Could NFL concussion questions be solved by fly swatters?

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Study: No helmet brand can save football players from concussion risk

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Health experts have some bad news for high school football players: There is no particular type or brand of helmet or mouth guard that will keep you relatively safe from a concussion. The companies that make helmets and mouth guards often claim that their own products can reduce players' risk of a sports-related concussion or lessen the impact of a concussion that does occur.

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The backstory of the Riddell 360 Helmet

Just as the nation's top colleges and NFL teams were taking the field for the 2008 season, the Riddell Revolution Speed helmet was making its debut on football fields across the country. With a host of innovative new features and benefits for athletes, the Revolution Speed would go on to earn the first 5-STAR rating awarded for protective helmet safety from Virginia Tech University.

Immediately following the launch of the Revolution Speed helmet, the Riddell product development team gathered in its Rosemont, Illinois development lab. The team was proud of the engineering feat it had just accomplished, knowing the fruit of its labor would help make the game safer and more enjoyable for thousands of athletes. The Speed helmet was recognized for its advanced design, enhanced side-impact protection and quicker-to-release face mask, but discussion with this group had shifted to solving new challenges and putting their creativity to the test.

"In the case of the Speed, it was joining the Revolution family of helmets, whereas our next innovation was a clean slate and anything goes - in the name of protection," said Ralph Infusino, Product Design Manager for Riddell. The team knew it was no time to get complacent. The bar had just been raised, and the team's next great challenge had already been cast: create a new helmet from the ground-up that would push the envelope on player protection from every conceivable angle.

For Riddell's product development team, these aren't mere words. Call it a way of life, an obsession, a calling. The core team of engineers boasts a century's worth of experience, having dedicated their careers to making helmets more protective and the game of football safer. "In biomechanics we are taught to apply engineering concepts to biological systems - in the case of football helmets, we work to reduce forces of impact to the player's head" said Thad Ide, Senior Vice President, Product Development and Engineering for Riddell. "All of the hours in lab helped us identify the designs and product features that best met our goals."

Joining forces with the company's equally obsessive designers, the engineering team drew inspiration and insight from data collected by Riddell's Head Impact Telemetry (HITS) and Sideline Response System Technology (SRS), an on-field player monitoring system used for years by some of the country's top college football programs.

It's obvious that the game of football is evolving, as are the protective needs of players. Research using HITS/SRS technology by an elite football program like University of North Carolina's revealed that some of the most significant impacts an athlete faces - coming from all directions - on the football field take place on kickoffs, and notable findings like these have gone on to influence the way the game is played at all levels.

Leveraging this same data and years of information gathered from other top programs showed that improving impact response in all directions, including at the front of the head where the majority of impacts are experienced, could help improve athlete protection even further. With previous helmet models paying special attention to addressing side impacts, a crucial design challenge emerged: find new ways to manage energy to the head from frontal impacts. Not only did the data align with this challenge, the team evaluated several helmets that returned to Riddell for reconditioning and research that demonstrated significant wear and tear to the front of the helmet and face mask.

Tapping this data, evaluating used helmets first hand and relying on their knowledge from years around the sport, the 360 was born.

Getting under the hood of the Riddell 360

Designing and engineering a football helmet is not for the faint of heart. It can take years to develop an innovative helmet with advanced features and benefits. For the 360, it was truly a decade in the making.

"At Riddell, our designers are a lot like artists. Our product is never perfect and we're constantly refining it," said Infusino.

While it might sound glamorous, football helmet R&D is often rotten and dirty. Well before a helmet design is completed, countless hours are spent reviewing concepts, testing materials and discussing even the minutest of details that might lead to a performance enhancement. "At Riddell, our designers are a lot like artists. Our product is never perfect and we're constantly refining it," said Infusino.

The lengthy "War Room" lab sessions that drove the development of Riddell's Speed helmet had paid off, and would once again become a requirement given the team's aspirations for the 360. "Our meetings would be set for an hour or two, but in reality, they lasted for many hours and even the full day at times," said Vittorio Bologna, Research and Development Manager for Riddell. "We continued on shouting out concepts and building on each other's ideas to ensure we wouldn't lose the momentum generated by our think tank."

"With the one exception of the chin strap, everything about the 360 is new from the ground up," added Ide. "The components, the shell, the liner system, and the list goes on and on-all of which stem from the vision and careful engineering that went into this helmet." At a time when football is being scrutinized more than ever, coaches and parents demand 360 degrees of protection for their athletes. With that necessity in mind, Ide and his team sought to deliver enhancements from the top down with an aggressive shell design and continued integration of its Patented Side Impact Protection package-highlighted by enhanced mandible extensions and backed by increased energy managing materials.

One of the 360's most impactful features, an enhanced occipital lock, is designed to significantly improve comfort, fit and stability.

"We paid special attention to helmet retention and stability on the athlete's head with the design of the 360," said Chris Kays, Senior Product Manager, Hard Goods for Riddell. "In one of those eureka moments, we made a modification to the liner system that improved the overall fit of the helmet. This advanced player protection and is designed to keep a properly fit helmet on the athlete's head so they can stay in the game."

Recent rule changes at the high school and college level stipulate that if a player's helmet falls off during play, then the player must sit out the ensuing play and be cleared to return to the field. The rule change accentuated the importance of the strides made to advance the occipital lock feature.

Perhaps the most significant differentiator that has helped the Riddell 360 earn its "Gamechanger" nickname is its new flexible face mask attachment system. Again, a key insight from the HITS/SRS data showed that the majority of impacts experienced on the football field were to the front of the head.

"We asked the face mask to contribute to the overall protection package and help the helmet manage frontal impact energy better, so the idea of a flexible face mask and new attachment system emerged and was pursued."

"Our toughest job was figuring out a way to redirect energy away from the front of the athlete's head, but getting there wasn't easy," said Kays. "Just when fatigue set in from the labors of the design and development process, we fielded calls and emails from coaches and parents expressing their appreciation for our technology and urging us to continue to address the need for better head protection for athletes. This reinvigorated our team and helped us cross that goal line."

The team's early direction took them down the path of the chin strap and its attachment points, but the mock ups weren't delivering the results they hoped for. Then one day, the Riddell team and its partners from Biokinetics placed a single face mask on the table. "A face mask's natural reaction is to spread apart during a frontal impact, and its purpose is to protect the face and offer a desired look," said Bologna. "We asked the face mask to contribute to the overall protection package and help the helmet manage frontal impact energy better, so the idea of a flexible face mask and new attachment system emerged and was pursued." Ultimately, the team developed a completely new solution for the 360 that features uniquely placed hinge clips and a face mask that flexes upon impact to achieve the desired energy managing outcome.

Getting to the end zone: testing and on-field trials

When a helmet emerges from concept to mock up to test unit, the work is far from over. For the R&D team, many early mornings and late nights are spent running the helmet through the growing list of standards and performance tests. On the field, the helmet is trialed to ensure it can withstand the punishment of the gridiron. Riddell hand selected and personally delivered helmets resembling the 360 we know today to some of its top college football customers like Northwestern, Michigan State University, Purdue and University of Florida. They received prototypes for use during spring football and into "two-a-days" in the fall, where they monitored the helmets closely before and after practice, reporting back on activity and observations that could inform changes to the helmet before a complete roll out. Back at the Riddell lab in Rosemont and Biokinetics lab in Ottawa, Ontario, testing was underway to evaluate the helmets durability.

"When we solicited feedback from our elite customers during the 360 development process, we heard that it would be hard to outdo the Speed," said Dan Vooletich, Regional Vice President, Riddell Sales. "But now when we introduce the 360 to our customers at all levels and start to tick off the helmet's unique features, the 360 really stands apart as something truly game-changing." 2011 marked the helmet's initial season of use at the elite college and professional level. "Our customers were anxious to receive their Riddell 360's to try out in year one, and the resulting feedback has translated into significant momentum for this head protection platform as several programs are moving to upgrade their helmet technology to 360 in 2012. "

The Riddell 360 pushes the limits of helmet technology with its unique design and differentiating protective features. The industry and football community is taking notice. Following in the footsteps of the same helmet that was used as a jumping off point, the Riddell 360 earned the highest possible 5- STAR rating in the 2012 Virginia Tech Helmet Rating study, a feat that only the Speed helmet had accomplished the year before and maintained in this year's results.

If the evaluation by Virginia Tech and early on-field performance is any judge, the Riddell 360 has many downs of football ahead of it. That is, until Riddell's next game-changing innovation.

For more information, visit http://www.riddell360.com/

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Seeds of Innovation: Bringing a Game Changing Helmet to Market

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The backstory of the Riddell 360 Helmet Just as the nation's top colleges and NFL teams were taking the field for the 2008 season, the Riddell Revolution Speed helmet was making its debut on football fields across the country.