Putting heads first, banning cheerleading's double down

Madison DiGioia loves to fly.

She is 15, strong and trim, and her face lights up when she talks about how she loves to go airborne, to be tossed 15 feet in the air, nearly three times her height, to kick out, twist around twice, and land in the arms of her fellow cheerleaders.

But she was grounded recently.

On Jan. 3, at cheerleading practice at Washington Township High School, Madison took flight, did her kick and double twist, but was caught too low. The back of her head hit the bent knee of one of the girls catching her.

Madison missed five weeks of school, and her concussion took more than two months to heal.

And her story is not unique.

On Tuesday, the national governing bodies of high school sports and cheerleading banned the double twist to a cradle, better known as the double down, because of its role in an increasing number of concussions. The ban becomes effective with the 2012-13 season.

"The number that were coming from double downs was overwhelming and appeared to be increasing," said Jim Lord, executive director of the American Association of Cheerleading Coaches and Administrators.

"The decision was a very hard one to make, because cheerleaders will see this as taking something away from them."

This ban, and the care received by DiGioia, underscore the distance come in recognizing the dangers of concussions and in making efforts to prevent and treat them.

Madison said she remembers nothing of the impact, or of doing the routine again, or of having a 10-minute conversation with her cheerleading coach, who at first couldn't detect anything wrong, only that Madison said her head hurt and asked to sit down.

And then, when Madison tried to get up, she couldn't. She was foggy, and couldn't process where she was. She went to see the athletic trainer, who did an assessment. Many trainers now are well-educated in recognizing concussions. Madison, for example, was given five words to remember: elbow, apple, carpet, saddle, bubble. She was given them again, then asked to repeat them back.

She knew apple and bubble.

A concussion is a brain injury, and Madison was growing more disoriented by the minute.

Madison's mother, Tina Conti, took her straight to the emergency room. And the next day, Madison went to see Robert Franks, a physician who specializes in sports injuries and is director of the Rothman Institute's new concussion program. Madison fell into the bushes on the way into his Sewell office, her mother said.

Franks said medical practitioners in this country, at least in recent years, have become vastly better at both recognizing and treating concussions.

Franks put Madison on complete "brain rest" for two weeks - no computer, no cellphone, no television, no iPod, no homework. Just sleep.

Madison said the pain was intense - "like being stabbed in the back of the head." She went back to see Franks five times in two months.

Both New Jersey and Pennsylvania, along with nearly 40 other states, now have laws that impose strict protocols for athletes who might have suffered concussions. In New Jersey, if a student exhibits any symptoms - headache, drowsiness, disorientation, nausea, blurred vision, poor balance - he is required to stop play immediately and see a physician. The athlete is not allowed to return in any capacity until permission is given by a doctor with a background in concussion management.

Pennsylvania's law, passed this past December, is similar, said Franks.

Many high schools today give athletes a baseline test that measures memory, reasoning, and a variety of cognitive skills. After a concussion, students take the same test, one of many tools in determining whether a student is fully recovered.

Doctors have concluded that the greatest danger is returning to play before a concussion has healed, something that happened all too often in years past in all levels of athletics. Another blow before the brain has recovered can lead to chronic injury or even death.

"We're much more aware now of the long-term consequences," said Franks. "If there's a doubt, you sit the patient out."

Seven years ago, researchers at Ohio State University began gathering data on all forms of injuries to high school athletes, including concussions, from high school trainers nationwide.

Cheerleading ranks 17th out of 20 sports when it comes to overall injuries, but 12th when it comes to concussions, said Lord, the head of the cheerleaders association. And cheerleaders are much more likely to suffer concussions in practice - behind only football players and wrestlers in frequency.

According to Dawn Comstock, the epidemiologist who leads the Ohio State research, cheerleaders sustain a concussion 1.44 times for every 10,000 opportunities in practice. In other words, if 10,000 cheerleaders practice today across America, 1.44 will sustain a concussion.

Comstock was able to break down whether concussions happened after a stunt or a cheer, whether they were caused by contact with the ground or with a teammate.

Lord and his organization combined her data with their knowledge of cheerleading and research to conclude double downs were increasingly a cause of concussion and took the bold and controversial step to stop them.

"I have a really good feeling about reduction in injury going forward because of that decision," he said.

He recently explained the rule change to Georgia cheerleaders and officials. "I heard a few comments from coaches upset about taking those skills away, but I heard from many more that were glad they didn't have the pressure to teach double downs any longer," Lord said. "I also heard from some of the athletes themselves that said to me, 'I hated those!' . . . We've taken the pressure off."

The National Federation of State High School Associations, reviewed the same data and reached the same verdict.

An estimated 96,700 girls do competitive cheerleading. It's the ninth-most popular activity for high school girls, according to the NFHS.

Franks said he was not aware of the rule change, but the physician said he has seen "a large, increasing number" of cheerleaders with concussions.

"They're the population we're really keeping a close eye on because of increasing numbers," he added. "Programs are becoming more aggressive and routines are more complicated and cause injuries and mistakes."

Comstock's research underscored another surprising piece of data: In sports played by girls and boys - soccer, for instance, or basketball - girls are more likely to sustain concussions.

"In gender comparison," she said, "girls have higher rates than boys."

Franks said he has seen this in his practice as well.

And he added two more points to gender disparity.

First, he said, 90 percent of concussions heal within seven to 14 days. But in the other 10 percent - cases such as Madison's, or worse - he has seen more girls than boys.

And second, girls in this 10 percent category also take longer to get better, he said.

"Women are a vulnerable population and we don't know why," Franks said. "And a lot of times have worse symptoms and take longer to get better. We just don't know why yet."

Once Franks gave Madison approval, she returned to cheerleading with even more passion than before.

Her mother was supportive. She trusted Franks' judgment that she could return to action, and she loved seeing her daughter thrive.

Madison was disappointed by news of the ban, and saw it from the perspective of a girl who loves to fly, who is fearless, and who loves to compete. "Those teams that can do double downs won't have that advantage over other teams that cannot," she said.

Her coach, Lauryn Atkinson, knew there had been discussion for years of removing double downs. She understands the decision, but fears it could have a negative impact on her sport.

"I would think," she said, "competitive cheerleaders are going to struggle with the ruling. 'Is this where I want to be now?' " She hopes they continue. "High school cheerleading is wonderful," she said.

Madison's mother, Toni Conti, said of the ban: "I feel mixed emotions. Since they perform on a hard floor, the parent in me feels a sigh of relief. But the cheerleader in me feels that this will hurt the sport, and the cheerleaders who wish to move on to the college level."