LOGAN, Utah -- For Dale Mildenberger, the issue of chronic concussions in sports can't be solved by better treatment, better equipment or better awareness of the damage a head injury can cause.
Treatment must start at the source of the issue: battling a belief ingrained in the culture of sports that downplaying injuries is not just an expectation, but a requirement.
Too often in sports, terms such as "headaches" and "dings" are used to minimize the seriousness of what amounts to a brain injury in order to rush players back onto the field.
Mildenberger, Utah State University's head athletic trainer, finds that part of sports culture both puzzling and unacceptable.
"It's amazing to me that if a kid breaks a leg, there is no question if he should return (to play). But if he breaks his brain, all of a sudden we want to find ways to put him back in (the game)."
Mildenberger and Utah State's athletic department began baseline testing 11 years ago on every athlete on scholarship with the goal of accurately assessing their past head injuries.
Athletic trainers collaborated with the audiology department and the health, physical education and recreation department to develop a comprehensive system to address all causes and side effects of concussions. This effort created a blueprint for other schools to use to better protect their athletes.
"I see us being poised as one of the premier balance research centers affiliated with sports medicine in the United States," said John Ribera, a professor in the school's communicative disorders and deaf-education department.
About 400 USU athletes undergo tests before their collegiate careers begin to measure cognitive and intellectual capacity, balance and coordination and decision-making abilities.
USU also has designed a system it believes safely returns players to the field, court or track.
After any head injury or concussion, if the symptoms of concussion don't dissipate within 20 minutes, the athletes undergo the Standardized Assessment of Concussion and USU Modified Balance Error Scoring System again to compare the post-injury scores to their original baseline tests.
Even if they pass each test with flying colors, no athlete can return to the field following an injury sooner than five days after they reach the baseline scores of their SAC and Modified BESS tests.
"All the symptoms must resolve before we even consider return to play," Mildenberger said.
This protocol keeps coaches and players out of the decision-making process, putting long-term health ahead of short-term benefit.
"Decisions on whether people return to play are not dictated by score, by game or by depth chart," Mildenberger said. "Just because you run out of linebackers doesn't mean Johnny is OK."
USU also began transferring its concussion protocol to high schools in Logan and around the state in 2004.
Football coach Gary Andersen said Utah State's approach is among the top programs in the nation for building trust among trainers, coaches and players to report and manage head injuries.
"You build a culture of the kids trusting you, the trainers and the system," Andersen said. " That's what keeps them healthy."
Andersen said there is an unquestionable link between football and dealing with pain, but there is also a huge difference between playing "hurt" and playing with a concussion.
"Our message is this: If there's anything to do with the head, then you're not playing hurt," Andersen said. "That's an injury, and you get an injury looked at immediately."