"tough" even in dementia

In advance of a congressional hearing on the impact of football on the brain, the NFL has backed off of claims that the dementia findings in retired NFL players are unreliable.

In a new round of "he-said/she-said" the NFL is pointing at the Union, who is pointing at... well, it is not clear:

But the outside data on which he primarily based this conclusion was not only mishandled — the wrong numbers were taken from one published study, grossly overstating worldwide dementia rates — but the analysis also included several faulty assumptions, experts said in later interviews. Correcting for these errors indicated rates of dementia among N.F.L. retirees about four to five times the expected rate.

“This was a preliminary effort at the request of the union to understand the facts,” said Ell, adding that he was acting as a lawyer for the union. “I understand now that it was flawed. I believe the union wants the true facts to come out and welcomes inquiries into this area.”

Meanwhile, the now-demented ex-football players are sticking to the "tough guy" creed.

Rayfield Wright's caregiver, Jeannette DeVader, said that Wright had all the signs of early-onset dementia — including short-term memory loss and frequently getting lost — but that he would not see a neurologist, let alone apply to the 88 Plan. Wright confirmed that he did not want what he called the stigma: “Players don’t want to look at themselves that way. The truth is, you really don’t want to know.”

The wife of one player experiencing early-onset dementia, who asked not to be identified, said she would not apply for the 88 Plan while her husband was coherent enough to understand it.

“He would be devastated,” she said. “They were so proud as players. They’re not going to admit any weakness now, and I’m not going to break his heart by doing it for him.”

I didn't anticipate minimization of symptoms this late in the game...

the perils of youth...

A number of years ago, I became involved in an ongoing research project with a colleague (pardon the shameless plug) looking at the effects of concussion on youth athletes. We found evidence of long-term effects of concussion on cognitive functioning in small sample, and then validated and extended these effects in a much larger sample. Essentially, we concluded:

seem to be subtle yet significant prolonged neuropsychological effects in youth athletes with a history of two or more previous concussions.

Cut to 2009, and a recent case reported in today's NY Times reveals that the long-term effects of concussions on the brains of professional athletes extends to the brains of high school and college athletes who never played professionally.

“I’ve looked at more than 1,000 brains, and I’ve never seen this in any individual living a normal life — it’s only through head trauma,” said Dr. Ann McKee, an associate professor of neurology and pathology at the Boston University School of Medicine and co-director of its Center for the Study of Traumatic Encephalopathy. “The fact that we are seeing this disease, and it had a devastating effect on their lives, now in a 42-year-old who never played in the N.F.L. indicates that it’s a more pervasive problem than we recognize. What are we doing with our kids? Are we doing enough to protect against their developing this awful condition?”

Long Term Effects

A new study "commissioned by the NFL" found that Alzheimer’s or other similar memory-related diseases occur at a greater rate in NFL players than the general public:

...have been diagnosed in the league’s former players vastly more often than in the national population — including a rate of 19 times the normal rate for men ages 30 through 49.

While this is a good first step for the NFL to recognize the relationship between repetitive concussions and long-term changes in the brain, they are not quite ready to accept these findings:

An N.F.L. spokesman, Greg Aiello, said in an e-mail message that the study did not formally diagnose dementia, that it was subject to shortcomings of telephone surveys and that “there are thousands of retired players who do not have memory problems.”

“Memory disorders affect many people who never played football or other sports,” Mr. Aiello said. “We are trying to understand it as it relates to our retired players.”

So, if I understand Aiello's logic: there are many people who get in car accidents and do not have head injuries, and there are many people who have head injuries from activities other than car accidents... therefore, car accidents and head injuries may not be related?

I hope this relationship gets cleared up before we start seeing Collegiate athletes experiencing brain changes as well. Anyone who saw Florida QB Tim Tebow sustain a concussion and then vomit on the sidelines has to wonder when the NFL and NCAA will realize that these severe concussions will have a cumulative effect. Fortunately, it appears that he is receiving proper treatment, including:

...daily testing and we continue to monitor the resolution of his symptoms.... "I talked to him for a minute," (Coach) Meyer said. "This isn't like a turf toe or a shoulder, this is a concussion."... According to Meyer, Tebow is not allowed to read or watch television "until later in the week -- maybe Thursday."

Concussions in Baseball

One does not typically think of baseball as an at-risk sport, save for the occasional collision in the outfield or on the base path. However, there has been significant attention in USA Today, the NY Times, The Washington Post, ESPN News, and online news providers, (both recent and older articles) regarding concussions in baseball:

David Wright is hit in the head by a pitch (ESPN video)

Hikiro Kuroda is hit by a line drive in the head (NBC article, YouTube video)

Scott Rolen is hit in the head by a pitch (Tornoto Star article)

(from 2005) Carlos Beltran and Mike Cameron collide in the outfield (NY Mets article with video link)

Interestingly, there is a new batting helmet designed to prevent concussions in baseball (NY Times Article), but players do not necessarily like the look/feel:

“No, I am absolutely not wearing that,” Mets right fielder Jeff Francoeur said with a laugh after seeing a prototype, as if he were being asked to put a pumpkin on his head. “I could care less what they say, I’m not wearing it. There’s got to be a way to have a more protective helmet without all that padding. It’s brutal. We’re going to look like a bunch of clowns out there.”

Before making any judgments, it's not like we all wear crash helmets when we drive...

Back from another hiatus...

Not sure why I take such long breaks at times, but I am back from my self-imposed break. I do not get many e-mails about this blog, but do occasionally receive suggestions for posts.

Recent comments pointed to a YouTube clip on the use of mouthguards to prevent concussions, as well as recognition of the benefits of mouthguards at the recent Concussion Summit meeting.

With respect to that recent meeting, the 3rd Consensus Statement on Concussion in Sports was published, with the disclaimer (I paraphrase):

Readers are encouraged to copy and distribute freely the Zurich Consensus Statement… (it) is not subject to any copyright restriction. The authors request, however, that the Zurich Consensus Statement be distributed in full and complete format.

So, I provide a link to the pdf file of the 3rd Consensus Statement.

Concussions in the NBA

Interesting article out of Sacramento today about an increase in concussions in the NBA. They even interviewed David Hovda:

When I hear that a player has had four of them or five or six, I honestly always double that number. They have usually also had some before or in practice or in pickup games.

In an odd twist, they make several references in the article to mouthpieces, but nothing by way of substance:

He doesn't always actually wear the mouthpiece.

Unlike football, though, there are no potential equipment advances or rule changes to help counter head injuries in basketball. There are mouthpieces to act as something of a shock absorber and advice to be careful. That's about it.

No changes. No concerns about what four concussions could mean in the future. Just a mouthpiece.

Hopefully, Gerard Wallace, quoted in the article as having sustained multiple concussions, won't end up with CTE...

"I just want to sit on the porch, watch my kids play sports, grow old, fat, gray-headed, big-bellied... however you want to call it. It's one of those things that I never worry about. You can never worry about that."

News Flash: Wrestling is Dangerous (and fake)

(disclaimer: I am not a wrestling fan. Really, I am not!) In what can be referred to as an "interesting twist" or "ironic outcome," WWE CEO Vince McMahon sustained a concussion during a stunt:

Some thought Orton made a mistake when he really kicked McMahon. But he didn't, in fact both Vince and Stephanie were happy with the way in turned out. We all know it is storyline, so Vince knew it was coming.

In fact, Vince asked for the kick to the head by Orton. That is right, Vince came up with the idea. See for a long time now, Vince has said he wants wrestling to be more realistic.

Not much detail about the actual concussion, but I thought it was a worthy topic to break my hiatus, especially in light of the fact that the WWE now requires baseline assessments for all wrestlers:

...all WWE talent undergo tests of brain function, including memory, processing speed, and reaction time. An initial analysis is conducted for new WWE talent to gather baseline results before they participate in any in-ring activity for WWE, and then thereafter as circumstances warrant if head trauma is suspected.

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?