Pat Forbis instructs an assistant to place his hands on his hips, lift one leg and close his eyes.
For the next 20 seconds, Forbis looks for any sign of wobbling. At first glance, it looks like a field sobriety test. In this case, though, failing the test could mean a person suffered a concussion and needs to see a doctor for further diagnosis and treatment.
While much attention in recent years has been drawn to the impact of concussions on football players, that sport is not alone in causing brain injuries. A study released by the National Academy of Sciences in October included data from the Datalys Center for Sports Injury Research and Prevention that tracked concussions between 2010 and 2012. Among high school sports, women's soccer averaged 6.7 concussions for every 10,000 athletic exposures, meaning games or practice sessions an athlete participated in. That was the third-highest rate behind football and men's lacrosse, which had 11.2 and 6.9 concussions per 10,000 exposures respectively.
Data from the Centers for Disease Control and Prevention show that between 2001 and 2009, 7.7 percent of all visits for soccer-related injuries were for traumatic brain injuries, which include concussions. That's a larger share than the 7.2 percent gridiron football accounted for. Nearly 8 percent of emergency room visits for baseball-related injuries were for concussions, as were 9.7 percent of hockey-related ER trips. The CDC and NAS data both show an increase in the number of concussions reported, though both organizations and Forbis are quick to point out it could come from greater awareness of what a concussion is and how to treat one.
Forbis, Coordinator of Sports Medicine at St. Mary's Health Center, said concussions are an even bigger problem for high school players than they are for college or professional players. For reasons which are still not well-understood, concussion symptoms are more severe and the return-to-play process is slower with high school players. He said this probably is because people are still developing physically at that age.
"Their brain is growing. That brain is different than it is to the person that is above the age of 19 on," he said, adding even at high school age, an impact's effects on an individual athlete will vary.
Eddie Horn, Jefferson City High School's head boys' soccer coach, told KRCG 13 many coaches, including himself, knew very little about concussions until a few years ago.
"My education on how long kids should sit out and the proper protocols to have a player return to competition, I was not familiar with that," he said.
Today, Horn has all of his players take baseline tests at the start of every season to determine their existing mental faculties.
If trainers suspect a player has a concussion, the player takes the test again to compare scores. Those tests helped Jefferson City player Mason Vonderhaar, who had a concussion as a sophomore. He said about four weeks passed before doctors cleared him to play. He said he doesn't think he could have done anything differently.
"You just gotta try and go for the ball, and things can happen," he said.
In soccer, Horn said most concussions result from players either colliding or hitting the ball with their head. Horn said there is no way to prevent the former, but players should try to head the ball at the hairline, where the skull is thickest. He said exercises to strengthen neck and shoulder muscles are a help as well. In addition, Horn said ball quality affects concussion risk. The coverings on inexpensive balls can wear off, allowing the leather to soak up water and make the ball heavier. That can increase the force of impact if the ball hits a player in the head. Horn advocates buying balls whose coverings go down into the seams and replacing them regularly.
The National Academy of Sciences study found head protection does little to prevent concussions, though it can prevent other injuries like skull fractures. Forbis echoed that finding, saying no amount of head protection can prevent a concussion because of the nature of the injury. A concussion happens when the force of an impact causes the brain to slosh around inside a person's skull. Forbis said a person doesn't even have to get hit in the head to have one.
"There is no item, no helmet, no mouthpiece, no add-on to a helmet, that's going to prevent concussions," he said.
He said there is no way eliminate concussions from sports, so the best thing to do is change playing styles to reduce head impacts. This accounts for recent rule changes in football that govern how players should tackle.
If trainers think a concussion has happened, Forbis said a series of tests can determine whether the player should seek medical attention. For example, trainers can start by asking players if they know where they are, what period the game is in, and what day it is. They can ask players to stand on one leg or touch their noses to check coordination. Players can use a smartphone app to answer a series of basic questions on the sidelines. If trainers think something is wrong, a follow-up session can include a computerized test comparing a player's answers to a series of baseline answers compiled at the start of the season. If a doctor ends up diagnosing a concussion, Forbis said players should gradually return to play, starting with basic exercises, then practicing without gear and with gear before finally going back onto the field if a doctor decides it is safe for them to do so.