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.