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.