Conflicting reports

From retired professionals, we hear haunting quotes from Kieth Primeau:

"They just don't know the long-term ramifications of head injuries," Primeau said from his home in the Philadelphia area. "I know I'll never be 100 per cent again. I know that time doesn't heal this. In my case, it's inevitable. I don't live in fear of the future, but I recognize the damage I've done to my brain. I force myself to get up every morning, force myself to deal with everyday life. When you can't do that, it means you've succumbed. And I'm not prepared to do that."(cite)

and from Al Toon:

For years after Toon retired because of post-concussion syndrome, he still felt the scary effects: headaches, nausea, dizziness, you name it. He said that for a while he couldn't even sit in an office conference room for a half-hour meeting, because focusing for too long hurt too much. "For a couple of years it was pretty difficult, because there really wasn't very much I could besides own a building and collect a check," Toon said in a telephone interview this week. "To do anything that would require research and mental exercising proved to be very difficult." (cite)

Then you read of 15 year olds with a history of 5 concussions who are sidelined, parents of teens pulling them from competition after 5 concussions, and other college athletes who have the sense to retire before they end up permanently disabled... you even have pleas from kids such as:

...frustration because, even at the highest levels of hockey, they don't seem to understand the severity of head injuries."Unless someone gets severely injured or paralyzed, no one in the NHL's going to get the point," she says. "And that's what frustrates me."

Contrast that with professional athletes such as Ike Hilliard, who appear to be ignoring conventional wisdom and denying concussion symptoms:

The St. Petersburg Times reported that Hilliard was suffering from the lingering effects of a concussion he sustained in Tampa Bay's game vs. Seattle on Oct. 19. According to the report, Hilliard, who underwent spinal fusion surgery as a rookie in 1997, still was suffering from headaches and likely would miss Sunday's game vs. Minnesota and possibly more.(cite)

But Hilliard denies the following quotes refer to concussions

"I've been dealing with something on and off for the last five years, but now it's constant,'' Hilliard told the Times. "Obviously, after the hit, it's something I've got to get control of."

"Everybody is entitled to write what they want to write, but I'm not having any issues with my concussion," said Hilliard. "I'm dealing with issues just like everybody in this locker room. It is just wear and tear from the season.

"Seriously, the quotes are word for word. It says nothing about a concussion. I said I was dealing with some other stuff. It is wear and tear from the season. I did not say the word ‘concussion' at all."

However, the most surprising "non-concussion" diagnosis comes from a player and coach:

(Frank) Gore took a hit Monday night and said he had his neck positioned in the wrong way and strained it. He told reporters yesterday that he was having bad headaches and thought he might have suffered a concussion, but Singletary must have set him straight because later in the day he went back to the media and said he didn't mean that. (cite)

Coash stated:

"Frank Gore is a football player. He does not know what a concussion is," Singletary said. "It may feel like a concussion. I talked to Fergie (trainer Jeff Ferguson) who is one of the finest trainers in the country."

"In all honesty, I don't want to go there. To me, he's going to play." Asked when that determination would be made, Singletary said, "Today. He's gonna play. As far as I know, he's gonna play."

If a player says he has a concussion, and he has been reading and hearing all about concussion testing and management, shouldn't the coach listen?

NHL Update

With new stories focusing on NHL player being hit from behind, as well as being hit in the head, news released at the National Academy of Neuropsychology Conference comes at a good time.

The NHL and the NHL Players Association had yet to release or otherwise present data from their multi-year concussion management program. However, data was presented on October 21st in New York. Incidence statistics:

Seven hundred and fifty-nine National Hockey League players have been diagnosed with concussions since 1997, or an average of about 76 players per season and 31 concussions per 1,000 hockey games.(cite)

Utility of cognitive testing:

Thirty percent of NHL players diagnosed with concussions have normal physical readings but abnormal neuropsychological testing scores

Games missed due to concussion:

While frequency of concussions didn't change much from the 2005-06 season to 2006-07, games missed due to concussion, the number of games players missed because of concussions and related problems jumped 41 percent

Other data presented at the conference, but not included in the ESPN article include history of concussion:

There were no differences on baseline neuropsychological test scores as a function of self-reported history of concussion

Symptom reporting:

30% of a sub-sample of 300 players reported no concussion-related symptoms but had neuropsychological test scores that fell below normal ranges. An additional 11% had normal neutopsychological test scores but reported symptoms related to concussion.

This is interesting data, and I hope that we will see more details in a publication soon.

Sobering realities

The High School football player who sustained two concussions 3 weeks apart has died (cite)

As adults/parents, we know that hiding the symptoms is dangerous, and we cannot rely on young kids to know or report their symptoms. Unfortunately, the burden is on us to monitor symptoms of their kids, even when the sport is not a "collision sport."

New research is suggesting that recovery times be extended to 3-4 weeks following a concussion

...Dr. Lester Mayers in last month's Archives of Neurology. “Nevertheless, given the prevalence of sports head (injuries) and the numbers of young brains at risk, a postconcussion (return-to-play) interval of at least four weeks is imperative.”

The catch phrase: "When in doubt, sit them out."

A Cause for Concern

Coaches and trainers are becoming concerned about concussions in youth athletes. Look at the case of a high school athlete who sustained two concussions this season:

James had been cleared from a head injury earlier this season, but the athletic trainer took extra care after the sophomore took another blow to the head in a junior varsity game.

(The Trainer) noticed James vomiting after the hit -- a typical concussion symptom -- but decided to play it safe and recommend James, the team's starting punter the first four weeks, be taken to the emergency room. From there, he was flown by emergency medical helicopter to the Medical Center,where it was determined Datz had sustained a subdural hematoma, a brain injury in which blood gathers in the brain.

James had surgery immediately -- physicians drilled into his head to drain the pressure off his brain -- and was released from the hospital less than a week later.

He has since returned to school for half-days...

Not every student athletes is as lucky. Take the case of Ryan, a 16-year-old High School football player hospitalized following a brain hemorrhage during a recent game:

Ryan had suffered a recent concussion, but was cleared by a doctor to resume playing... he had undergone a CAT scan before being allowed to return to the field.

The hemorrhage, or bleeding on the brain, occurred about three weeks later during a game... when Ryan tackled an opposing player, then abruptly collapsed. He was rushed to the hospital and was diagnosed with a brain hemorrhage, that required immediate surgery, the statement said.

In a statement... it was "unlikely that Ryne's condition would improve."

Frighteningly, this incident marked at least the third life-threatening injury to a student football player in New Jersey this year.

NFL Week 6

Been busy, but a lot has happened.

Denver WR Brendan Stokley sustained his 10th concussion last week. While you might be thinking "time to retire" he is thinking about not missing the Monday Night game against NE (cite)

Bills QB Trent Edwards sustained a concussion from a helmet-to-helmet hit against the Cardinals in week 6. He is expected to play this week, as the median number of days missed in the NFL following concussion happens to be 6.

NFL Week 4

In the NFL, Cardinals WR Anquan Boldin is recovering after sustaining a horrific concussion that looked more like a severe brain injury at the time, complete with decerebrate posturing. He fractured his sinus membrane, but vows to:

...take a week off, and then I'm going to come back and give them the dirt. I'm going to give it right back to them.' (cite)

Carolina Panthers Tackle Jordan Gross is out following a concussion sustained in Week 4, in which he lay face down on the turf for several moments (cite)

Rams WR Dane Looker sustained a concussion after a blow to the head, and has been held out of practice. (cite)

Word is getting out...

If you have been following the "mainstream media," you might not have seen anything about concussion research, but the NY Times released an article last week announcing that athletes are donating their brains for research on concussion. I took the first step in contacted Chris Nowinski to see if they could use the brains of concussion researchers as controls.

It is good to see that word is getting out. The New Jersey Brain Injury Association recently announced that they provide funds to cover concussion baseline testing at 100 schools (cite).

Hopefully, better concussion awareness will help prevent tragedies like the death of an 18-year old high school football player.

Long term implications?

When QB Trent Green suffered a "severe" concussion in 2007, his second in two seasons, there was talk of his retirement. After taking extended time off, he is returning to the starting line-up this weekend, with some columnists offering sage advice (DUCK!)

Similarly, after Flyers forward Simon Gagne missed most of last season with following a concussion, he is returning to action after 7 months off.

With researchers identifying long term risks of depression in athletes who have sustained multiple concussions, a recent article reveals that athletes are lining up to donate their brains to researchers for post-mortem analysis.

While it may take years to make a definitive link, athletes at any level (HS, College, Pros) who are playing contact sports need to take notice and recognize the potential for long-term damage.

NFL: Week 2

Brodney Pool: Cleveland Browns Safety: resumed practice after sitting out with a concussion suffered Aug. 18, his 3rd in 4 years. (ref)

Brandon Jackson: Green Bay RB: listed as probable for week 3 due to a mild concussion (ref)

Gerard Alexander; Detroit Lions Safety: sustained a concussion in week 2 (ref)

Ellis Wyms: Minnesota Vikings DT: suffered a concussion in Week 2(ref)

Let the Games Begin!

I took some time away from the blog this summer, but am ready to resume frequent updates, especially for classes I am teaching this semester. On the day before the NFL season kicks off, let's take a look at those players who experienced concussion in the last season and this pre-season:

Derek Anderson: Cleveland Browns QB: missed two games following a concussion, expected to start Week 1 (ref)

Steve Smith: Carolina Panthers WR: missed practice following a concussion. Should play week 2, following a 1-game suspension (ref)

Matt Schaub: Houston Texans QB: missed 5 games last year due to concussion (ref)

Zach Thomas: Dallas Cowboys LB: missed two games last season following a concussion (ref)

DeShawn Wynn: Green Bay Packers: missed tie in training camp due to concussion (ref)

Let's see what happens...

Brain swishing around?

Mets Outfielder, Ryan Church, has been battling post-concussion symptoms following two concussions sustained this season, and is again back on the disabled list.

Most striking is his description of concussion symptoms:

"I still have the aches, the pains. When I move my head a little bit, I can feel my brain swishing around a little bit. That's what happens when I have migraines."

The NY Daily News quotes Ryan as saying:

"I am exhausted. I am tired," Church said. "With me not feeling 100% I don't feel I can help out the team. I can't keep on going out there and making it worse. We are taking the right steps now to hopefully correct it."

I have not seen research on co-morbidity of concussions and migraines, but this "brain swishing" definitely a unique symptom!

Baseball is definitely a contact sport

Just ask Cardinals catcher Yader Molina, who was involved in a nasty collision at home plate in which he got turned around and took a charge from Eric Bruntlett facing the wrong direction. Interestingly, catchers are particularly susceptible to concussion, even though they are not always aware of the fact they may have concussion symptoms:

"We did a survey of 260 major- and minor-league catchers and asked them a series of questions," Conte said. "When we asked if they had concussions, most said 'no.' When we asked them after they had been hit by a foul tip if they ever got dizzy or ever blacked out or felt nauseated — basically concussion-type symptoms — about 25 percent said 'yes' to that. ...

"But do we have a serious problem with foul tips and concussions with catchers, the answer seems to be 'no.' In the last seven years, we've only had six catchers go on the disabled list with concussions and only two of them were on longer than 15 days."

Molina spend one night in the hospital and appears to be recovering quickly. Luckily, the team is approaching his return with caution:

St. Louis Cardinals catcher Yadier Molina will rejoin the team Tuesday, but it is not yet known how long he will be out due to the concussion he suffered Sunday.

No long term effects?

You might think we have learned a lot about concussion management over the past several years, but sometimes knowledge does not translate into practice.

Case in point: Johan Franzen suffers a subdural hematoma (a collection of blood between the skull and brain) following a hit in a hockey game.

"I had a collection of blood," Franzen said. "It was not in the brain, but between the skull and the brain. It self absorbed between two and three weeks.

"It was a little bit scary. I couldn't do anything because that would have beendangerous. When it's the head, you get kind of scared. I was glad nothing happened because I played with it for a while, so, it's a good thing nothing happened."

So, he missed 6 whole games in the playoffs, returning in Game 2 of the Stanley Cup finals against Pittsburgh. The General Manager described the situation as being dictated by headaches:

"He had a bunch of headaches. We thought it was normal, but it persisted and got to be abnormal. Game 1 (against Dallas), he got hit real hard, it looked to me by (Steve) Ott, and he complained of headaches the next morning. We did an MRI, and it showed he had a little bit of subdural hematoma. So we needed that blood to dissipate and it did, and then he played when he did."

"It certainly appeared like the original injury happened during the Colorado series, and then he got hit again and then we did the MRI, and that's when the doctor shut him down until the blood was dissipated," Holland said. "We weren't sure when he'd be able to play. We did an MRI after one week, and after two weeks, the blood was gone, and then they wanted one more week.

Luckily, there was no concussion:

"It's important people know he didn't have a concussion, because once you have a concussion, you're concerned about a history. He didn't have a concussion. He just had basically, in layman's terms, a bit of a bruise on the brain. Now that it's over, it's nothing. It's nothing that's going to affect him long term."

A hit severe enough to cause bleeding within the skull, persistent headaches, and removal from athletic competition. However, no concern about what caused the bleeding to occur, or whether or not it will happen again. No long term effects?

I went to a baseball game and a football game broke out?

Interesting article in today's NY Times about Mets'player Ryan Church, who has sustained two concussions this year, the most recent one 8 days ago. It appears he has been "cleared to play" by the trainers/medical staff, even though he is still experiencing symptoms such as dizziness, lethargy and headaches. Church has played since the concussion, going 1-4 as a pinch-hitter, but the manager and GM appear to have no idea how to manage a concussed player (citing CT and MRI results, which are negative in Mild TBI, and relying solely on subjective reports by the concussed player):

Minaya emphasized that a CT scan of Church the night of his injury showed no damage, and that a magnetic resonance imaging test Tuesday was also negative. Minaya and Manager Willie Randolph said the club had relied principally upon Church’s reports to trainers about how he felt before each game, and sometimes during it, in deciding if he was available to play.

“It’s his call,” Randolph said. He added: “He’s been feeling a little bit groggy, and most of what he feels is that uneasiness with his total, you know, mind. It’s kind of weird because he feels like he’s kind of foggy. He says he can hit, he can do that. But in the outfield, he’s unstable out there.” Randolph added: “When you’re talking about head injuries, I’m pretty lame on that. I don’t even know how to respond to, you know, when we can put him out there.”

Before almost every game, he has told reporters of symptoms. At one point he said, “I’m just sick of feeling like this.”

Further, The GM does not understand concussion testing, calling a 30-minute test "time consuming":

The Mets began having players take baseline neuropsychological tests in spring training so that they could be tested against them after an injury; however, Church did not take a test, Minaya said, because of time restrictions.

“My understanding is that it’s a long test,” he said. “If I’m not mistaken, it’s about a half-hour or more.”

Concussion experts commented on the case:

Dr. Mickey Collins: "That’s a situation that could be very dangerous... I haven’t examined this player personally, but if there were a second trauma to a person still experiencing symptoms, the risk could be much higher to a player’s health because he hasn’t healed from the first concussion."

Dr. Robert Cantu: "You’re playing roulette with your patient. You know the chances of him having another concussion are low, but you’re running the risk of exacerbating the symptoms that he does have. Now a person who would be asymptomatic in a week or two can have those symptoms go on for many months."

Perhaps most relevant is the comment of Corey Koskie of the Brewers who sustained a concussion in 2006, experienced prolonged symptoms, and eventually had to retire:

"That’s pretty much the reason I’m here today (retired) — thinking I could play through it... I think he’s nuts. He doesn’t want to get to the point where he’s not going to get better. Tell him to call me. It’s not worth it."

Back from Disney: Roller Coaster mania

Took a vacation with the family to Disney World, and went to Epcot, Magic Kingdom, MGM/Hollywood Studios, and Animal Kingdom.

Rode lots of great high-speed rides, including Space Mountain, Everest, Tower of Terror, and Rock 'n' Roll Roller Coaster. My 8-year-old, Ben, was so excited about Everest and RnR Roller Coaster, that I decided to look their stats up online and also found many YouTube online videos. (Everest, RnR, ToT)

So, it turns out the RnR Coaster is "one of the most powerful coasters in North America" accelerating 0-57 in 2.7 seconds, generating G-forces of 4.5 to 5 depending on where you are seated (stats from here).

A long time ago, I was inteviewed on the dangers of roller coasters (with respect to head trauma, which there appears to be none), but I was naturally interested in the possible dangers of such a fast acceleration. Fortunately, UPenn researchers had answered this question back in 2002:

They acquired G force data from three of the most popular and powerful roller coasters in the country: the "Rock 'n' Roller Coaster" at the Disney-MGM Studios in Orlando, Florida; "Speed -- The Ride" at the Nascar Café, in Las Vegas, Nevada; and "Face-Off" at Kings Island, Ohio. Using this data, they calculated peak head accelerations in three directions, assuming the head did not strike a surface. Even considering the worst-case scenario, the researchers found that the largest forces experienced on roller coasters were far below those that are known to cause injury.

I wish I could prove it was my line, but when I was interviewed by the Boston Globe I said "it is more dangerous to drive to the amusement park than to ride the roller coaster" but they didn't include that in the article. However, someone quoting the UPenn study, concluded:

It does not appear that roller coasters produce high enough forces to mechanically deform and injure the brain...

For healthy people who meet the size requirements for the ride, you are probably safer on the average roller coaster than driving to the amusement park,

Playoff Hockey

Last night's Dallas-San Jose game had a hit frighteningly reminiscent of the hit Eric Lindros took from Scott Stevens.. head down, both players moving fast, attacking player hits the opposing player in the head with his shoulder.

One day later, the video is displayed on "NHLFightClub.com", and the spin from the coach is soberingly realistic:

Michalek hit hard. Michalek had his head down tracking a puck, when Morrow crushed him with a shoulder check. Morrow did not hit Michalek’s head, but there was a whiplash effect that could have caused a concussion by jarring the brain against the inside of the skull.

"Obviously, when Milan got hurt at the end of regulation, we played the overtime without him," Wilson said. "A whole game with a short bench, and our guys just kept going."

When asked if he could update Michalek’s health, Wilson replied: "It’s irrelevant. It’s over, so we have to move on."

Back from a brief break, finals looming

Not much "new" by way of news, but the semester is coming to a close and one colleage tells me of college students attempting to schedule formal neuropsychological evaluations to be completed before the end of the semester to document learning disabilities.

This got me reading, and this article mentions student grades being affected by concussion:

...who is enrolled in honors courses, is concussed, he suffers from headaches and a lack of concentration. "It feels like you have a haze over you, a fog, kind of," he said, adding that his grade-point average dipped from about a 3.57 to a 2.71 in the fall when he had trouble focusing after his football concussion.

"He's in all really, really intense classes, so concussions have much more effect there than on the field," said his mother...

Luckily, the focus on professional athletes denying concussions has raised awareness at the lower, youth, levels (ref), or so says a prominent sports agent:

Steinberg, who helped organize the summit along with the Sports Concussion Institute, is sponsoring a California program that will institute so-called "baseline testing" in 1,400 high schools, where athletes are given a cognitive exam that can be repeated after injuries to measure brain impairment.

or, as David Hovda so aptly stated:

"I don't know what's so mild about mild traumatic brain injury," said David Hovda, director of the UCLA Brain Injury Research Center.

Hidden Wounds of War

I guess I am in a political mood as of late, as this article caught my eye this morning:

Some 1.6 million Americans have served in Iraq and Afghanistan, more than 31,000 have been wounded in action and many more have sustained non-combat injuries or illness. TBI has been called the "signature injury" of this war, and the improvised explosive device (IED) is the leading cause of fatalities and brain injuries..

These powerful devices inflict severe damage and blast shock waves through the body, including sudden and violent impact to the skull causing damage to brain tissue. The resulting TBI can be fatal, or require immediate hospitalization. But more often the result of exposure is a less obvious concussion.

Despite the high incidence, there is little by way of diagnosis, let alone treatment:

Current estimates are that 10 percent to 20 percent of all U.S. military personnel in Iraq suffer concussion. Army studies show less than half of those exposed to IED blasts receive any evaluation.

In the environment of war, such symptoms can go unnoticed and unreported. Experience from sports and other noncombat injuries has shown that if an injured individual sustains a second concussion before resolving symptoms from a previous injury, a "second impact syndrome" can occur with dire, even life-threatening consequences. Repeated concussions cause cumulative damage and slow recovery.

It's a concussion; take it seriously.

Two articles showed up recently, both related to concussions and kids.

Dr. Michael Stuart writes an excellent primer for parents, and Dr. Gerard Gioia is mentioned in a press release about his "SCORE Program:

The program is one of the first of its kind. Currently, most concussion management programs for youth sports lag behind collegiate and professional sports, despite the serious consequences of brain injury on a developing brain.

"Implementing an effective sports concussion management program is essential to safeguard young participants and reduce long term risks,” writes Dr. Gioia. “Management of this serious injury must consider the various effects in the home, school, social and sports environments.”

Consider these "must-read" resources for someone new to concussions.

Interesting Logic

Pardon the brief political slant, but it appears that returning Vets from Iraq did not receive evaluations to diagnose Mild TBI:

"The fear of discovering a massive war syndrome among American troops returning from Iraq was the cause of Pentagon's postponement of routine brain screening among American soldiers for mild brain injuries.

Col. Kenneth Cox, head of Pentagon's medical assessment division, explained the Department of Defense delayed the conduct of brain screenings to steer clear of another potential Gulf War syndrome discovered among American soldiers in the 1990s."

On the bright side, the DOD has granted significant funds to researchers studying Mild TBI:

The Department of Defense has awarded a consortium of Houston institutions a $33 million grant to investigate mild traumatic brain injury, or concussion, the potential severity of which has long been underappreciated.

The grant, an unusually large amount for the government, targets better understanding and treatment of the injury that afflicts about 1.5 million Americans a year and is considered one of the Iraq war's signature wounds.

Valadka said one emphasis of the research will be to determine if the mild traumatic brain injury suffered in blast explosions is similar to such civilian injuries. If so, the research will have great applicability, he said.

However, the project will not end until 2013, so it willbe a long while before these efforts translate into results.

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Research reveals brain changes from concussion

Dr. Erin Bigler, from BYU, has identified "subtle but significant" brain changes that normally go undetected using traditional imaging techniques. In this article they explain the benefits of using diffusion tensor imaging (DTI to look at what he calls "the microenvironment" of the brain, an analysis not provided by traditional MRIs:

The researchers found differences in the appearance of the corpus callosum, which separates the right and left sides of the brain, in 10 teenagers who had sustained concussions one to six days previously and who suffered symptoms such as headaches. The study compared these to the brain images of 10 uninjured teens.

The study found that the concussion patients with the worst symptoms had the most substantial changes on the DTI images. Because the DTI imaging is still "several steps removed" from looking at actual brain tissue, Bigler explains, it's hard to tell if those changes represent swelling.

This story will likely hit the AP and Reuters in the next few days, and should span a tremendous amount of new research.

What is a Concussion Worth?

On Wednesday (March 12th) Buffalo defenseman Nathan Paetsch was knocked unconscious by a "cheap shot" elbow (see the video here). The offending player, Georges Laraque, was suspended for 3 games, while Paetsch remains out "indefinitely".

Interestingly, if you watch a hit Paetsch took only two days ago in a game against the Rangers, you can see that he was clearly concussed as he lay motionless on the ice. In fact, in this ESPN article referring to his condition in the Pittsburgh game, they say:

"Paetsch was already sore, playing with a stiff neck after he was checked heavily into the boards by New York Rangers' Sean Avery during Buffalo's 3-2 shootout loss on Monday."

Not to suggest that Paetsch could have avoided the elbow, but it is possible that he not only shouldn't have been on the ice, but the fact that it appears to have been his 2nd concussion in 3 days may have contributed to the severity.

Recovery times

Conventional wisdom states that athletes tend to recover in 7-10 days, with some requiring up to 30 days, and only a select few experience lingering symptoms akin to "post concussion syndrome".

Let's see how concussed athletes in the recent limelight fared:

Some players are out for their season:

Tiffany Roulhac (NCAA-W-Basketball) - out for the season following 2nd concussion.

Mark MacDonald (NCAA-M-Basketball) - Missed 10 games so far (2 months+)

Simon Gagne (Professional Ice Hockey) - Out for the season after suffering 3rd concussion.

Some players miss extended playing time:

Taylor Procyshen (Minor League Ice Hockey) - Missed 21 games (approx. 2 months)

Tracey Kelusky (National Lacrosse League) - Missed 8 games (Approx 2 months).

Other Players miss only a few games:

Tyler Morris (NCAA-M-Basketball) - Misses 2 games (approx 1 week), now practicing.

Chris Higgins (NCAA-M-Ice Hockey) - Missed one game

And some players don't even leave the game in which they sustained the concussion:

Kate Lance (High School Girl's Basketball) - Returned to the same game after falling face-first during overtime, but returned to hit the game-winning shot, then was examined by doctors to determine if she suffered a concussion and, possibly, a broken nose.

Concussions and then some!

Looking at concussion-related news articles for months and months has revealed that concussions do not always happen in isolation, often with other secondary injuries, some of which could be expected:

Concussion and shoulder separation (Hockey):

"Smyth suffered a concussion and a minor shoulder separation after Kings defenseman Jack Johnson checked him into the padded glass partition near the Colorado bench. The Avalanche said Smyth won't return to the ice until he shows no lingering signs of the concussion.

Concussion and spinal contusion (Hockey):

"Lupul returned to the lineup Feb. 9 after missing 14 games with a concussion and spinal contusion."

Concussion and broken nose (Hockey):

"Bergeron was leveled from behind by Flyers' defenseman Randy Jones and went head first into the boards. He suffered a serious concussion and broken nose and has been absent from the Bruins lineup since late October."

Concussion and brain tumor? (Rugby):

"Wallaby fullback Julian Huxley discovered he had a brain tumor after undergoing medical scans following a concussion in a weekend Super 14 match. Huxley was cleared in preliminary scans after he was carried from the field after having convulsions following a head knock in win over Queensland on Saturday night."

It's not very often that neuroradiological studies are positive, so this would definitely be a case of a concussion being a good thing!

Athletic Trainers vs. Trainers

Athletic trainers affiliated with the National Athletic Training Association (NATA) are distancing themselves from Brian McNamee, who has admitted to injecting Roger Clemens with HGH:

The guy who works with boxers is referred to as a trainer, and though he trains boxers, per se, he's a far cry from an athletic trainer who is focused on injury management and injury prevention. We have medical backgrounds and training. And we know the limits of what we can do. We can evaluate and treat an injury, but we never give injections, and we do not prescribe medicine."

Sheridan, 38, first heard the word trainer while watching the 1976 movie Rocky as a youngster. "Did Mick know how to prepare Rocky for the fight? Yes," Sheridan said. "But did Mick know if Rocky had a concussion? Did he know how to evaluate it and treat it? No. But that wasn't his concern. His concern was to prepare Rocky to fight, not medically manage him."

I can imagine a scene in the politically correct version of Rocky 2012:

INT: BOXING RING: CORNER: ROCKY JR. SLUMPS IN THE CORNER

Rocky Jr.: "I can't think out there Mick, I see double, the lights bother me, I have a headache"

Mick Jr.: "What month is it? Snap out of it Rock! What's the date, the day, the year? Tell me the damned months in reverse order Rock!

How to recover from concussion

Some folks require "peace and quiet to recover from a severe concussion", others are able to "shake off a mild concussion", while others simply "brave a concussion".

Cumulative Effects=Get it Right the First Time

So, Flyers' forward Simon Gagne is out for the season after returning too early following a concussion this season:

"James Kelly, a concussion specialist at the University of Colorado department of neurosurgery, told Gagne on Wednesday that his initial brain injury had never healed. Consequently, it got progressively worse with subsequent blows to the head.

"It's one concussion," Gagne said Kelly told him. "It got worse and worse. Every time I was getting hit to the head, the symptoms were coming back."

This does not bode well for players like Gerald Wallace, who suffered his 4th concussion in four years:

"Wallace visited a neurologist Tuesday, four days after the forward was knocked unconscious when he was hit in the face with an inadvertent elbow from Sacramento's Mikki Moore. It was Wallace's fourth concussion in four years, an all-too-familiar statistic for football players, but almost unheard of in basketball.

While Wallace is out indefinitely, there are concerns about his long-term health and questions about what can be done to protect him when he returns.

Let's hope that Wallace takes his time coming back. Concussion testing guidelines can only take you so far, but if the players are going to deny symptoms, there isn't much to protect them.

Concussion becoming an common adjective?

Concussions have become so commonplace, the term is being used as an analogy outside of the sports pages. From food descriptions:

"The cucumber was crisp and juicy. Above the sweet, fresh, salty, marine taste of the geoduck, other flavours spun around like the stars of a cartoon concussion"

...to veterinary diagnoses:

"...the owl had been hit by a car about three weeks ago and was sitting on the side of the road with a concussion and an eye injury.

Even in the sports pages, the term needs creative modifiers, as in this minor league re-cap:

"Bell was later taken from the arena on a stretcher, and was hospitalized overnight with what Phoenix coach Brad Church called "an extreme concussion."

Extreme concussion?

Off the Beaten Path

Concussions come from a variety of sources:

Ice-dancing:

"That performance came first despite Chris dropping Frankie on her head while attempting a difficult manoeuvre during training on Friday. "I was really embarrassed. She said it wasn't my fault but she has mild concussion and her neck's been hurting ever since so I still feel like an idiot.:

Acting like a Jackass (link warning: TMI):

"This is not the first time father-of-one Johnny has been taken to hospital following a botched stunt.... while filming Jackass: The Movie in 2002, he was knocked out by one of his castmates and had to be treated for concussion.

Snowmobiling:

"A 13-year-old Mount Vernon boy who was unconscious for nearly 20 minutes after driving a snowmobile off a 20-foot waterfall Sunday was treated and released from St. Joseph Hospital the same day...Family members reported they could not awaken Janicki for nearly 20 minutes after the fall.... he was treated for facial injuries and a concussion

And just getting a cup of coffee:

"A visiting student from Rochester Institute of Technology slipped and fell on the sidewalk in front of the Starbucks Coffee on Saturday. The student hit her head and blood was seen in the snow where she fell... the report said she appeared to be visibly drunk, as were the other people with her, who were said to be extremely intoxicated and less than cooperative. The emergency medical technicians at the scene of the incident said she appeared to have a possible concussion and a small laceration on her head."

Be careful out there!

The "grim reality"

Being a Philly guy, I suppose I am partial to home-spun news.It may only be two sentences in an article, but Phil Sheriden doesn't waste a word:

"The concussion epidemic in professional ice hockey is another issue that forces us to question just how much we're willing to ignore to enjoy these sports. Watching Simon Gagne follow the path blazed by Eric Lindros and Keith Primeau is slow torture, if you're a fan. Imagine what it must be like for the players.

Getting the NHL On-board

There is an article on ESPN's web site (also referring to a really interesting video from CBC's Fifth Estate on Chris Benoit), calling on the NHL to "embrace concussion research":

"If the NHL proposed a study or investigation for such an effect, I'd be first in line," Keith Primeau, a 15-year NHL veteran who retired in 2006 because of post-concussion symptoms that still pop up from time to time in his life... "For me, for the day-to-day [post-concussion effects], I think I'm over the worst of it. I've been feeling really good in the last four months. It's been the most comfortable I've been in some time."

Referring to the possible long-term implications of his concussions, Primeau says:

"I've resigned myself to the fact I'm always going to have [symptoms] to deal with, and I hope that they'll be very intermittent, as they've started to become. But I know I'll always have these setbacks. They are a reminder of exactly the price I've paid."

"[Non-concussed players] can't possibly comprehend the severity and long-term ramifications of head injuries... as a sufferer, even I don't know what the ramifications are. I believe at some point in my life there's going to be a consequence; I just hope it's later rather than sooner."

While the NHL has a mandatory concussion testing program, there has never been any data released or published, although it is not known if the blame lies with the NHL or the NHL Players Association.

An Academic Injury

It is great to see a discussion of the social and academic changes following concussion, as found in Brown's newspaper:

Much as they would like to, they cannot treat concussions - the most common prescription is a healthy dose of rest. In time, patients recover on their own. But the meantime can be stressful for collegiate athletes in ways that have no relation to school or sport.

(One student) recalls his injury changing all aspects of his lifestyle - athletic, academic and social.

"I didn't watch TV without my sunglasses on for a month," he says. "You wouldn't believe how it affects your social life."

...one of the harshest symptoms of his concussion was a social awkwardness that accompanied him wherever he went. "It's something that not too many people around you understand," he says. "You don't walk around with a sign up saying, 'I'm concussed.'"

...an injury - especially one as private as a concussion - could intensify the already-demanding pressures of Brown's academic and social environment.

"I think they affect academics not only in terms of material retained, but there is a very real concern that any injury makes you feel very self-conscious, especially within the academic milieu of Brown. You worry you're going to appear dumber than everyone else," she says. "Many injuries are visual - someone's got a cast, someone's got an ice pack - and we have a certain amount of sympathy. But when you have an injury like a concussion, and it isn't necessarily explained to everyone, I think that itself becomes an embarrassment and a frustration."

Concussion Treatment?

Folks at the University of Buffalo have come up with a concussion treatment program:

"...the program entails controlled exercise at a level of stress that does not trigger the symptoms. Its effect is to correct imbalances in brain mechanism brought on by the initial blow, which cause the illness and headaches."

It isn't clear how exercise can alter the metabolic cascade following concussion, so it will be interesting to see if this paradoxical "treatment" is helpful.

New ION 4D Helmets in Super Bowl

A few players on the Giants will be wearing the new ION 4D Helmet this Sunday:

"According to the company that makes it, the helmet features a unique design that reduces the risk of concussions... if you look closely at the helmets of the four players on the Giants, offensive linemen David Diehl, Grey Ruegamer and Guy Whimper and long snapper Jay Alford, you'll notice that their helmet looks different than those of their teammates."

Perhaps more interesting is the Riddell Revolution IQ HITS, with:

"Head Impact Telemetry System (HITS™): On-board electronics record every impact, allowing players to upload and evaluate each occurrence on their home computers.... also provides the guidance necessary to understand and address a suspect impact if it is detected."

Researchers are using this helmet to relate the physics of the collision and incidence of concussion:

"Players who look like they have been hit really hard aren't necessarily the ones who will sustain the most brain damage, said Kevin Guskiewicz, professor of exercise and sport science and director of the Sports Medicine Research Laboratory at the University of North Carolina, Chapel Hill. "There's no relationship between the magnitude of the impact and the clinical outcome"

Other findings showed that a single knock to the head at an impact greater than 90g doesn't always result in immediate concussion symptoms, such as headache, nausea, blurred vision or ringing in the ears. In fact, location, not necessarily force, seemed to play a significant role in brain injury. Six out of 13 players that sustained a concussion had experienced impacts at the top of the their head, as opposed to the side."

Everything you need to know about concussion, from the Wakeboarding community

Who would've thought that a comprehensive and informative article about the pathophysiology and effect of concussion would show up in a Wakeboarding website. Some snippets:

"Let's start with a little lesson about the brain...

What actually happens when somebody gets a concussion...

After sustaining a concussion, the symptoms may last anywhere from a few minutes to several days or even longer. It is important to recognize when the symptoms completely fade away and know that until they are gone, you should avoid anything that may cause the brain to be rattled around even a little bit...

Basically, what really matters when returning to a sport is making sure you wait for all of your symptoms to disappear...

Whether you're a rider, driver or passenger out on the boat, knowing what a concussion is and what symptoms to look for can make a big difference when you or someone you know suffers a blow to the head....

Time and Rest

It is good to see an article get it right from the start:

A healthy brain will dictate Macartney's return to racing

...the injury Macartney sustained in a scary crash during the Hahnenkamm downhill Jan. 19 at Kitzbühel was a severe concussion — and the only thing that can fully heal a bruised brain is time and rest. A lot of rest. Doctors have instructed the 30-year-old U.S. Ski Team veteran downhiller to rest and let his brain heal.

Nine days post-injury, and he still has symptoms:

"The medical team at USSA will measure Macartney’s brain function and alertness with impact tests built around the baseline test Macartney took when he was 100 percent healthy. Six days after the accident, in which Macartney crashed off the final jump of the Streif course and banged his head multiple times on the icy track and losing consciousness, he was battling a slight headache and a general feeling of cloudiness.

“It’s an overall feeling of cloudiness, not as sharp on the recollection of certain people’s names,” Macartney said. “[I’m] going through things and saying, ‘oh yeah, what was that thing I was just talking about half an hour ago.’ A lot of that stuff is still not 100 percent.”

Concussion Stories

It seems like there are more and more news articles mentioning concussion every day. Many of these articles appear to be reporting old news or how concussion testing is becoming more common, such as this story, though:

"...says the Panthers also took extra precaution when it came to a concussion. Every player with Carolina would have to take a computer test that measured your memorization and reaction time to a series of questions, and they'd write down your score... after you had a concussion, you had to take that test again. Until your score was back up to your original score, you didn't play."

Or this story about a baseball player with post-concussion syndrome 2 years after hitting his head:

"Koskie has suffered from postconcussion syndrome since he was hurt on July 5, 2006, while backpedaling to catch a popup... the symptoms lasted for months, and the Milwaukee medical staff thought he was experiencing anxiety or that the problem was in part mental... Koskie, who estimates he'd had anywhere from 8-15 mild concussions in his professional career, remembers feeling so tired for so long.

"I look back and say to myself, 'I decided to do that?' " he said. "I wasn't thinking properly. You think at the time you're OK, but then when you get tested and your cognitive skills are so poor, you realize in what kind of shape you're in.

And this article about the process a high school football player experienced recovering from a concussion last season:

"As he walked off the field with his teammates for halftime, he said, he knew things weren't right.

"I felt like I was in a cartoon," the senior receiver said. "I couldn't remember where I put my helmet. I put down my helmet and couldn't find it"... during the game he "felt silly" and was "cracking jokes." Everything was humorous, he said. Afterward, things weren't so funny. Hopkins suffered headaches and nausea after the game and went to the emergency room.

To compound his head injury, Hopkins was involved in a car accident in which his head hit a window. His concussion worsened. He had taken the ImPACT test once after his concussion on the football field. A week later he took it again.

"I did really bad" ... he did finally return to the field for the final two games. "It was another piece of reference I could bring to my neurologist. It gave me an idea how bad the injury really was. It really gave me an idea where I stood."

Various Observations & Ironies

...a "Roughneck" getting concussed.

...retired NFL/Current AHL player writes about concussions on his blog.

..in the "Extreme" Games (aka: X Games)a "little concussion" forces a competitor to sit out... not so extreme after all?

...story-starved Super Bowl media identify post-concussion syndrome from Tom Brady wearing sunglasses

Helmets and Skiing

Let's not forget the inherent dangers of our favorite winter sport:

"American skier Scott Macartney was released from a hospital Wednesday, four days after he suffered a concussion and was placed in a medically induced coma following a crash during a World Cup downhill race.... Macartney was clocked at 140 km/h when he crashed Saturday in Kitzbuehel... he lost his balance at the final jump and fell on his head, the impact breaking his helmet. He briefly lost consciousness and organizers said at the time he had a brain contusion."

"A Bucks County man has died while skiing at the Steamboat Ski Area in Colorado, but authorities say they haven't determined the cause of death. (The skier) was found dead on an intermediate ski run on Tuesday, where he was skiing with his daughter and friends when he fell behind. They reported him missing when he failed to show up at the base."

" A 15-year-old skier from Oklahoma died Friday at Wolf Creek Ski Area after smashing into a tree.... he apparently suffered head and neck injuries, though results of an autopsy were not yet available... the skier was wearing a helmet."

        (Sources: here, here, and here).


Some point to helmets as a precaution:

"While helmet use has increased about 5% annually for the past several years to nearly 40% for skiers and snowboarders, "it still isn't where we'd like it to be... they are advised for skiers at any age and level of experience."

While others say helmets do not save lives:

"...a new study reports that although more people are donning helmets, wearing them hasn't decreased accident-related deaths. The National Ski Areas Association's report said that about 37 people have been killed each year on the slopes, for the past ten years, a rate that has not decreased since helmet use became more widespread.

"More people are wearing helmets and they prevent injuries... the helmet has a way of deflecting force a way from the skull and the brain itself."
"

Interestingly, one researcher (Jasper Shealy, a professor emeritus at the Rochester Institute of Technology in Rochester) conducted research that found skiing fatalities were most likely to occur on wide, smooth and well-groomed intermediate-level "blue" trails.

However, the potential benefits of wearing a helmet seem obvious:

"Wearing a helmet doesn't give you license to do the most dangerous stunts possible. But if you take a spill, having one is still the best idea considering the alternative.
Once you fall and hit your head you'll realize why"

"You can't really have fun if you're dead," said a snowboarder. "Concussions suck.""

The many faces of concussion

A recent article in the Boston Globe stated:

"By the end of the season, it's a good bet every team will have had at least one player with a concussion... the truth is, it's a very dangerous game, with a schedule that is far too long - one that leads to players getting hurt..."

However, some teams disguise concussions:

"Center Sergei Fedorov missed his second straight game last night, and there's a chance he might be out until after the All-Star break... Fedorov was hit hard by Phoenix defenseman Keith Ballard early in the third period of a game Thursday. The Blue Jackets aren't sure whether Fedorov suffered a concussion. He's said to be experiencing flu-like symptoms."

Even high school teams are dealing with the issue, although some appear to be relying on CT-scan results:

"...missed his third straight game with a concussion... CAT scans came back OK, and it is just a matter of time before he can return."

At least concussion has received top billing as the NFL's worst injury, when referring to Crosby's ankle injury:

"Look, Crosby has a bad ankle, not a concussion... he hasn't died. The NHL will survive him missing the all-star snoozefest in Dixie"

"Huge" Implications

A new study out of the Montreal Neurological Institute identifies depression as a "physical outcome" of mild brain injuries:

"When athletes get depressed after suffering a concussion, coaches, other players and even doctors tend to take the symptom lightly, writing it off as a psychological fallout of being sidelined from the game.

But a new Canadian study suggests depression is actually a physical outcome of such head injuries, which appear to undermine activity in key regions of the brain."

Using fMRI, researchers looked at concussed athletes with and without depression:

"The tests revealed that all the depressed athletes had reduced activity in the areas of the brain that have been linked to major depression. Further analysis found lower grey matter density in those areas, too."

The actual research article (link is to the abstract) identifies reduced activation in the dorsolateral prefrontal cortex and striatum and attenuated deactivation in medial frontal and temporal regions ans conclude that:

"...depressed mood following a concussion may reflect an underlying pathophysiology consistent with a limbic-frontal model of depression. Given that depression is associated with considerable functional disability, this finding has important clinical implications for the management of individuals with a cerebral concussion.

10-day follow-up

Flyers player Joffrey Lupul can remember the collision in which he sustained a concussion and a spinal bruise 10 days ago:

"Even when I was on the ice I kind of knew what happened... I just could not get up. I remember thinking to myself, "Try and get up,' but I couldn't."

While his sensation is returning to normal, the concussion symptoms still linger:

".. he will be examined either tomorrow or Thursday. Paul Holmgren said Lupul no longer had tingling in his hands, but was still suffering from concussion-like symptoms."

Don't you know that it's different for girls...

With basketball season in full-swing, let's not forget that women tend to experience concussions at a rate almost 2:1 over men. Here is a great example of how physical and dangerous woman's basketball can be:

"The latest episode took place Thursday against Michigan. The 5-foot-3 Malone was involved in a collision before halftime, forcing her to miss the first 12 minutes of the second half. Once her headache cleared, she was allowed to return...

Late in the game, a Michigan player swung her elbow and nailed Malone in the eye. Malone remained on the ground for several seconds."

The player appears to have some insight into the dangers, but not a lot...:

"Since I got that first concussion, any small hit will probably cause another one," Malone said. "I passed the (concussion) test barely. It's good that I passed it but it's still a little nerve wracking."

Returning to the same game after sustaining what appears to be a concussion, and then lowering threshold for sustaining another; is it worth it?

Concussion on XBOX 360?!?

It is pretty scary that simulations of NFL games have players leaving the game from concussions:

"...but Jones absorbed a vicious hit from SS Rodney Harrison and looked rattled. However, it was Harrison who got the worst end of it suffering yet another concussion that will sideline him for the rest of the game."

Gradual onset, gradual recovery

Here is an example of a player who didn't even know he had a concussion for several days:

"I noticed when I got hit that I hit my head and I didn't feel bad the next day -- or the next three or four days..."

"I played two more and it slowly got worse and I felt before the game in Denver [Dec. 23] that something wasn't right."

After sitting out 6 games over 2-3 weeks, gradual return to exertion appears to be the key, with two days of symptom-free biking. However, it doesn't sound like this guy is quite ready:

"It's tough to explain to someone who hasn't had one [concussion]," he said. "It's been a different experience and at times tough days, but I feel better. I've had some good days and you wake up the next morning and feel not as good.

"But I feel optimistic. I still have some slight [headaches] but not as bad as I used to."

Why we need trainers at ALL athletic competitions

Some schools recognize the importance of having trainers on-site during athletic events.

"I had a kid drop out of a drill in practice, he was face down, and I didn't know if it was heat-related, or what," said Nick Collins, the head football coach. "We have kids get hit in practice and we need someone there who is skilled enough to evaluate for a concussion."

I know it is a big jump from college to high school, but imagine if there was no trainer at Washington State, where a college basketball player was struck in the head during a practice, collapsed and appeared to stop breathing.

"...took an elbow to the face during the scrimmage... he went down on all fours, rose to his feet, and walked off the court before falling to his knees, then collapsing on the floor."

the trainer administered mouth-to-mouth resuscitation for one breath before he responded and regained consciousness

Back from a long hiatus

Got wrapped up in life, but hockey season is in full swing. Patrice Bergeron is still experiencing symptoms from a concussion sustained in Oct 2006, Joffrey Lupel is recovering from a concussion and a bruised spinal cord, reporters are listing the the 7 deadly sins associated with hits in the NHL, and even other bloggers are talking about concussions in the NHL.

So much for web dominance!