Work with a Canadian brain-injury association, as well as the inspiration of the father of two hockey players who have suffered concussion, has brought a UB faculty member into the forefront of international efforts to establish return-to-play guidelines following concussion in amateur sports.

Those guidelines, painstakingly crafted by Barry Willer, an expert in traumatic brain injury and a professor of psychology in the School of Medicine and Biomedical Sciences, with the assistance of John Leddy, associate professor of clinical orthopaedics and associate director of the university's Sports Medicine Institute, have been adopted by the Canadian Hockey Association (CHA) and the International Ice Hockey Federation. They also were used by the medical committee of the Sydney Olympics.

Willer says that getting the return-to-play guidelines adopted by the CHA was a very significant step forward because "the association governs all amateur hockey in Canada, which makes it the first bona fide sports organization to have adopted guidelines regarding concussion."

Willer, who has been involved with hockey as a player and coach for most of his life, says he agreed to focus his efforts on hockey not only because he loves the sport, but because he felt it would be an effective conduit for introducing return-to-play guidelines in other amateur sports.

"Hockey was born and bred in Canada, so the international sporting community still looks to Canada and the CHA for leadership," he says, noting that the adoption of the guidelines by the International Ice Hockey Federation was the direct result of the CHA action.

Willer points out that the initial impetus for establishing return-to-play guidelines came from the American Academy of Neurology (AAN), but emphasizes that these guidelines, while groundbreaking, do not translate well to the realities of amateur athletics. "Prior to the AAN announcing their guidelines and publishing them in the Journal of Neurology, there were no really authoritative guidelines anywhere. The problem, however, was that the AAN guidelines were basically written for professional sports or other environments where a qualified trainer is on-site and the athletes' histories of concussion are available; in other words, they assume that there is someone on the bench-either a physician or a professional trainer-who can immediately appraise an athlete's condition and determine if he or she can return to play at that time or not."

Willer joined the effort at the urging of Carl Lindros, whose younger son, Brett, had withdrawn from professional hockey after suffering several concussions. Lindros' older son, Philadelphia Flyers star Eric Lindros, also battles with concussion. Carl Lindros had suggested to Willer-both men were involved with the Ontario Brain Injury Association (OBIA)-that the UB professor apply his expertise and influence toward helping establish guidelines of a similar nature in amateur sports.

Willer and his collaborators began by going to the CHA and meeting with the individuals within the association who develop educational programs for trainers.

"What ensued was a debate that centered on the questions, What can we realistically expect from the volunteer trainer/coach on the sideline who is just somebody's mom or dad and who has little or no medical background? What kinds of decisions can we expect him or her to make about a player's condition?" explains Willer.

Out of this discussion evolved the guidelines that were adopted by the CHA, which, according to Willer, have been worded in such a way that they "not only make sense medically, but are presented in a format that enables mom-the-team-trainer to readily understand them-mom, that is, whose occupation may be accounting, not medicine."

Essentially, the guidelines adopted by the CHA involve three basic modifications to the AAN guidelines. In addition to providing wording that better helps inexperienced trainers identify a concussion when it occurs, they recommend that all concussed athletes be asked to see their physician before they return to play. "Also, given the substantial increase in risk for irreversible damage due to repeated concussions, if an athlete has three concussions in the same year, it is recommended that he or she rest away from the sport for the remainder of the playing season," explains Willer.

"These guidelines help make sure nobody goes back to playing sports until they've fully recovered from symptoms of a head injury," notes Leddy, who, as a team physician for intercollegiate athletics at UB, knows firsthand about the dangers of concussive injuries in amateur competition. "I tell the players, when you 'sprain your brain' it's a bigger deal than spraining your knee or ankle. If you play on a bum knee or live with a bum knee, that's one thing. But if you don't come back fully from a brain injury, it's different. You may be left with a significant decline in mental functioning.'"

Despite the apparent simplicity of the modifications made to the AAN guidelines, they required a long series of discussions with the CHA, with final wording changes taking place as late as December of 1999.

Lindros feels Willer's role was crucial to making the project a success. "Due to his scientific expertise and credibility, he (Willer) was able to facilitate the whole process and gain the complete support of Canadian amateur hockey through the CHA. He brought order and cohesion to the effort."

Because the guidelines recommend that players see their physician before returning to play, Willer and Leddy also have been working to provide physicians with educational material about concussion in an effort to help them better assess when it's safe to allow a child to return to playing sports.

"Most family doctors, internists and pediatricians probably don't see enough of these head injuries to really be very comfortable with treating them, and it's not something they're taught about in medical school," notes Leddy. "I think most physicians need more education about how to identify when a concussion has occurred, as well as how to identify and treat symptoms of post-concussive syndrome."

Furthermore, he cautions, "These injuries can be difficult to diagnose, at best. There are a lot of symptoms that mimic other things; also, athletes are prone to minimizing symptoms or downright denying them to the doctor."

Toward the goal of educating physicians, Willer is developing an educational package that includes the return-to-play guidelines, information on symptoms of concussion and assessment procedures for concussed athletes. Through his affiliation with the OBIA, he also is working to organize a medical advisory committee on concussions that, in addition to establishing a consensus on post-concussive symptoms, will sponsor educational conferences for health-care professionals. "In the long run," he says, "the goal is to help physicians be a little more astute at picking up symptoms and a little more aware of the long-term consequences of concussions themselves."

Lindros commends this comprehensive approach to education because he feels it can lead to protection for all children, not just those involved in sports. "These guidelines, and the awareness they help create, apply to everyone, including parents who see their child fall off the swing set and hit their head. They aren't just for sports, but for life in general. What they remind all of us is that the clock doesn't start ticking-a child or an athlete doesn't go back to play-until he or she is symptom-free at rest and with exertion for an appropriate period of time.

"Essentially what we're saying is, 'Let's have greater respect for the body and things we do to the head.' When the body isn't treated with respect, a minor concussion can lead to significant, long-lasting problems."