CONCUSSIONS

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CONCUSSION BASICS

*(first few paragraphs from the Henry Ford Health System)

What Is A Concussion??
Simply put; a concussion is a "brain sprain."  It is a transient disruption in brain functioning due to mechanically induced trauma to the brain. When an athlete hits an object or is hit, his/her brain can bang into the skull as well as twist/stretch.  Additionally, when the head makes contact with something, energy is created that travels through the brain disrupting brain functioning. *NB: While this article mainly cites sports articles and speaks mostly towards athletic concussions, the fact remains that a concussion by any type of ballistic impaction is still a concussion. No single sport is singled out in these articles but it would be safe to assume that the bulk of cocussion injuries occur during boxing, football, soccer and ice hockey. Likewise, people in car accidents can and often do sustain concussions and Motor Vehicle Crash victims should get no less consideration than the athlete in a concussion discussion.

What Happens During A Concussion?
Our brain maintains a delicate balance between the chemicals that are inside and outside of its cells.  During a concussion the membranes (the outer layer) of the brain cells are distorted causing chemicals that are normally on the outside to rush inside the cells forcing out the chemicals that are normally inside the cell.  This starts a large cascade of chemical changes in the brain.  In trying to re-establish normalcy the brain's demand for energy (glucose or sugar) increases by about 150% of normal, while the brain's ability to deliver the required glucose drops to only 50% of normal.  This mismatch between supply and demand is what causes the symptoms and cognitive problems seen after a concussion.

 

Types Of Sports Concussions:
Presently, sports concussions are divided into simple and complex.  A simple concussion is when there is no overt or detectable damage to the brain itself.  A complex concussion is when there is overt or detectable damage to the brain itself such as a bruise or a bleed.  Some may also be familiar with a concussion grading system: Grades 1, 2, & 3.  However, there are over 20 different grading systems published (non specific to kids) and none have been derived from research.  They are primarily descriptive and mostly dependent upon loss of consciousness and immediate recovery.  None of the grading systems have empirically established treatment guidelines and have not been shown to accurately determine recovery rates.

Epidemiology Of Sports Concussion:
There is an estimated 300,000 sports related concussions annually.  There are several factors that determine the rate of concussions in a given sport.  However, American style football has the highest rate with other sports like ice hockey, soccer, lacrosse and field-hockey not far behind.  Gender and age are also important factors with younger athletes being more vulnerable.  In general, the research suggests about a 10-15% (some as high as 20%) rate of concussions in contact sports.

What To Expect If You/Your Child Has A Concussion:
Immediately-
NB: A person does not have to have a loss of consciousness (LOC) to have a concussion.  However, if there was LOC; even if only momentarily, then there was a concussion.  Immediately after a concussion an athlete can be confused and disoriented with difficulties recalling events immediately before or after.  Their balance can be off and they can repeat themselves.  Irritability is common as well as headache and sensitivity to light and sound.  Below are common symptoms that can follow after a concussion:

    * Headache
    * Poor balance
    * Nausea/Vomiting
    * Fatigue
    * Irritability
    * Tearfulness/Sadness
    * Feeling slowed down
    * Increased sleep
    * Decreased appetite
    * Feeling "foggy"
    * Decreased sleep
    * Sensitivity to light or noise
    * Blurred vision
    * Poor memory/concentration
    * Dizziness

After-  Symptoms can linger for several days (and in some cases longer).  Headaches, fatigue, irritability, fogginess, and memory problems are common, but not the only symptoms.  Sometimes there can be whiplash (neck injury) and poor balance (vestibular problems).

 

concussion-2What To Do If Your Child Sustains A Concussion?
Typically concussions are transient injuries that do not require extensive medical treatment.  However, they must be monitored closely and often soon after the actual event to detect any medical complications that may develop and require urgent medical attention.  Your child should be evaluated immediately after the concussion with close monitoring for any signs of worsening symptoms.  If there is evidence of worsening symptoms (such as lethargy, headache, vomiting, stiff neck, slurred speech, and confusion) then immediate medical care is required.  If you child was not evaluated on the field/ice/court, then you might want to contact your child's physician for advice or seek an emergency room evaluation.  When in doubt check it out.

Why All The Concern?
It is important not to return an athlete to play before they have fully recovered from a concussion.  The human brain has not fully matured until the early 20's.  Younger brains take longer to recover from a concussion and may be more vulnerable to the effects of another concussion when it has not healed or fully recovered from the previous one.  This is called second impact syndrome (SIS).  SIS occurs when the brain losses its ability to control blood flow and the pressure builds up to unsafe levels and damages the brain. SIS happens in response to a second concussion before the athlete has been able to heal from the previous one.  SIS is extremely rare, but has led to rapid, severe and permanent brain injury.  Thus the importance of making sure a young athlete fully recovers before retuning to play.

When An Athlete Is Ready To Return?
A gradual, incremental approach is recommended.  First an athlete must be symptom free and not have any cognitive problems (memory or concentration). Then a return to play protocol (RPP) can begin.  This is when an athlete is slowly reintroduced to competitive athletics with exertional testing, then non-contact practice, contact practice, and game play.  There should be approximately 24 hours between each step and the athlete cannot have any return of concussion symptoms.  If concussion symptoms return the athlete must rest (no exercising) until all symptoms have resolved.  Then the RPP can be started from the beginning again.

The Best Method For Determining Recovery:
The best method for determining recovery from a sports concussion is through assessing performance sensitive to the effects of a concussion: namely symptoms, cognitive abilities, and balance.  Tasks such as memory, concentration, reaction time, and how quickly you think are the most sensitive measures of a concussion, while neurological examinations, neuroimaging (CT and MRI) are notoriously insensitive in detecting a sports concussion. The best method for measuring the effects of sports concussion is through baseline testing of an athlete.  This way one can directly compare testing after a concussion to how the same individual performed before he/she was concussed.  Thus baseline testing has become the "corner stone" of any sports concussion safety program.  Innovative computerized testing has been developed specifically for this and takes 30 minutes to complete.  The testing is simple, easy to understand, and can be administered in small group settings.  We recommend ImPACT as it is the most widely used sports concussion software.  It has been extensively researched and studied and Dr. Podell was instrumental in the original development of it.

*New Research as of January, 2011:

Research links head injuries to dementia, ALS, Alzheimer's Scientists reported Tuesday they have some of the best evidence yet to support long-held theories that repeated blows to the head may cause nerve-degenerative diseases like Lou Gehrig's disease and Alzheimer's.

Autopsies of 12 athletes who died with brain or neurological disease showed a distinctive pattern of nerve damage - and fingered some potential culprits. All had repeated concussions during their careers. Three of the men had been diagnosed with amyotrophic lateral sclerosis, also known as ALS or Lou Gehrig's disease, the star baseball player who died of it. Experts in brain injury said the study, published in the Journal of Neuropathology & Experimental Neurology, pointed to new areas of research and possible ways to prevent long-term damage from concussions.

"If you could somehow give a person a drug, you could potentially prevent an illness like amyotrophic lateral sclerosis," Dr. Jeffrey Bazarian of the University of Rochester Medical Center in New York said in a telephone interview. The findings also point to an urgent need to watch veterans of the wars in Iraq and Afghanistan, many of whom suffer brain injuries from explosions, accidents and blows to the head from other causes, the experts said.

"This is the first pathological evidence that repetitive head trauma experienced in collision sports might be associated with the development of a motor neuron disease," Dr. Ann McKee of Boston University School of Medicine and colleagues wrote in the report, available at link.reuters.com/fab65n. McKee's team studied the donated brain and spinal cords of 11 professional football players or boxers and one hockey player. All had a newly characterized disease called chronic traumatic encephalopathy, or CTE, in which dementia set in years after repeated concussions.

>PROTEIN CULPRIT

Three of the men also were diagnosed with ALS, a member of a family of diseases called motor neuron disease, which cause progressively worse paralysis. The researchers looked specifically for a protein called TDP-43. They found it in the brain and in the spinal cords of the men - which could explain the ALS-like symptoms. Scientists know that damaging one nerve can sometimes set off a cascade of other nerves dying, for reasons that remain poorly understood. TDP-43 could be involved. Bazarian, who was on an Institute of Medicine Committee that released a report in 2008 linking concussions to later-life neurologic diseases, said the finding could help explain studies that show Iraq war veterans have a higher-than-normal rate of ALS, for example.

Drugs including the hormone progesterone, monoclonal antibodies and the antibiotic minocycline are being studied to see if they can stop the process of nerve destruction that follows injuries such as a blow to the head or stroke. The findings will be difficult to substantiate because ALS is so rare, said ALS expert Martina Wiedau-Pazos of the University of California Los Angeles.

"We think there already are different forms of ALS," she said - potentially with different causes.

David Hovda, director of the UCLA Traumatic Brain Injury Research Center, said brain injury is very common with 1.5 million cases in the United States alone each year.

"Whether by itself in isolation it causes ALS, I do not think that this paper proves that. What I think it does is raise worries that individuals who had a career of exposure to repeat concussions … have a greater likelihood of developing motor neuron disease," he said.

>You're asking, "But Lou Gehrig didn't hit his head, did he?"

concussion-3

The Yankees legend had a well-documented history of significant concussions on the baseball field, and perhaps others as a football halfback in high school and at Columbia University. Remember, they didn't use batting helmets back then and the football "helmets" were a joke; simple leather skull caps more or less.

News reports during his career show that he was knocked unconscious at least four times while at bat, playing first base and in a post-game brawl with fellow baseball icon Ty Cobb. Given that, it's possible that Gehrig's renowned commitment to playing through injuries like concussions, which resulted in his legendary streak of playing in 2,130 consecutive games, could have led to his condition.

Gehrig's symptoms first surfaced in 1938 when his hands began to ache and his legs and shoulders gradually weakened. At spring training in 1939, even casual observers could see that something was quite wrong. That May, he missed his first game in 14 years, ending his historic streak, and by June he was headed to the Mayo Clinic in Rochester. At the time, ALS was a virtually unknown disease, and doctors described it as a form of "infantile paralysis" resembling polio. With no known cause or cure, it eventually causes the loss of muscle control throughout the body. ALS had been in the medical books since 1869, but after 1939, everyone knew it as "Lou Gehrig's Disease."
_______________________________________________________________________

 

>"Recommendations for grading of concussions"

Leclerc S, Lassonde M, Delaney JS, Lacroix VJ, Johnston KM.

McGill Sport Medicine Clinic, McGill University, Montreal, Canada. Cited at Sports Med, 2001, Vol. 31(8): 629-36

  1. . Universal agreement on concussion definition and severity grading does not exist. Grading systems represent expertise of clinicians and researchers yet scientific evidence is lacking. Most used loss of consciousness and post-traumatic amnesia as markers for grading concussion. Although in severe head injury these parameters may have been proven important for prognosis, no study has done the same for sport-related concussion. Post-concussion symptoms are often the main features to help in the diagnosis of concussion in sport. Neuropsychological testing is meant to help physicians and health professionals to have objective indices of some of the neurocognitive symptoms. It is the challenge of physicians, therapists and coaches involved in the care of athletes to know the symptoms of concussion, recognise them when they occur and apply basic neuropsychological testing to help detect this injury. It is, therefore, recommended to be familiar with one grading system and use it consistently, even though it may not be scientifically validated. Then good clinical judgement and the ability to recognise post-concussion signs and symptoms will assure that an athlete never returns to play while symptomatic.

 

concussion-4 

MRI of a severely concussed brain. Note the discolored region in the Temporal Lobe.

___________________________________________________________________

 

>"The Concussed Athlete"
Alan H. Weintraub, MD

Sports related brain injuries represent approximately 20% of the 1.5 million brain injuries estimated annually in the United States. Concussion, a term synonymous with "Mild Traumatic Brain Injury" (MTBI), is an alteration in mental status due to biomechanical forces affecting the brain which may or may not cause loss of consciousness. This article will provide an overview of the challenging problems facing clinicians responsible for the health of athletes in recognizing and appropriately managing concussion.

Definition and Neurobiology: "Mild" traumatic brain injury (MTBI) or concussion is becoming an increasingly recognized injury resulting from both contact and in some circumstances, non-contact sports.1, 2 The most widely accepted definition of concussion was originally proposed by the Congress of Neurological Surgeons in 1964. This stated "concussion is a clinical syndrome characterized by the immediate and transient post-traumatic impairment of neural function." Therefore, trauma which leads to mental status alteration without a clear-cut loss of consciousness was considered a form of concussion.3 The distinction between these "milder" forms of brain injury and more serious injury is based on the absence or presence of disturbed consciousness including post-traumatic amnesia and other post-traumatic historical and physical findings. While MTBI can occur with direct trauma to the head during contact sports, it can also occur as a result of collisions or falls from all forms of athletic activity.4 This even includes events whereby sufficient force is applied in a so-called "whiplash mechanism."5 In 1974, Gennarelli and Ommaya created an animal model of TBI. In this model, 3 of the 6 grades of concussion did not involve loss of consciousness. They demonstrated that brain injury can occur from angular or linear forces applied to the brain. Frequently, in human experiences both forces act together with a rotational component and are more likely to cause diffuse axonal injury associated with shearing forces affecting brain tissue. Most recently, it has been noted that axonal swelling and metabolic changes occur following these forces.

Following concussion;  frequently there may be no objective neuroanatomic or physiologic measure which can be used to determine injury severity. Studies are under way to further define the pathophysiologic basis for why a seemingly mild insult may lead to an "injury - induced vulnerability and clinical symptomatology." Experimental studies have demonstrated that for up to 3 days following a concussion or more severe cerebral insult, there is a reduction in cerebral blood flow which would normally be well-tolerated, but renders the brain susceptible to physiologic and anatomical neuronal cell loss.8

Although not entirely understood in terms of its underlying cellular mechanisms, experimental studies have identified following acute injury, a period of enhanced metabolic vulnerability.8 This consists of an increase in glucose metabolism and the relative reduction in cerebral blood flow rendering the brain in a state of metabolic induced cellular vulnerability. In experimental MTBI, this metabolic dysregulation may play a role in prognostication. Therefore, the "mis-match" between glucose demand and fuel availability is the key to future research correlating those cellular changes with clinical manifestations the athlete may be experiencing.

 

Medical Management of Concussion: There are a number of health concerns which need to be addressed at the time of a suspected concussion.9, 10 These include:

   1. Appropriate management of the injured athlete at the time of the injury to identify potential neurosurgical emergencies, ie, subdural, epidural, and intracerebral hemorrhages.
   2. Prevention of catastrophic outcomes related to a loss of central vascular auto-regulation from repeated concussion occurring over a short span of time - Second Impact Syndrome.
   3. Avoidance of cumulative cognitive deficits and chronic post-concussive somatic, behavioral and emotional symptomatology.
   4. Clinical decisions regarding return to play.
   5. Treatment considerations

Recognition and Acute Management: The early signs and symptoms of concussion (seconds to minutes) may include a brief disturbance of consciousness or a lack of awareness of surroundings, nausea, vomiting, headache, dizziness, or vertigo. Athletes on the field or sideline may display impaired attention manifested as a vacant stare, delays in response time, or the inability to focus. Additional deficits may include slurred or incoherent speech, uncoordination, disorientation, memory impairments, or emotional reactions out of proportion to the situation. Any observable or documented loss of consciousness should also be noted and may represent a more serious injury. Later signs of concussion (hours to days) may include persistent headache, dizziness/vertigo, diminished attention, concentration and memory, nausea or vomiting, fatigue, irritability, intolerance of loud noises or bright lights, anxiety and/or depression, and sleep disturbance. The "post-concussive syndrome" is when somatic, cognitive, and/or emotional deficits persist for weeks or months following injury.

It is recommended that all athletes suspected of having a concussion undergo an objective and quantifiable initial assessment which includes a mental status exam and neurological screen including exertional provocative measures.10 The Standardized Assessment of Concussion (SAC) (Table 1) was developed to establish a quantitative valid standardized systematic sideline evaluation for the immediate assessment of concussion in athletes.11 The Sideline Concussion Checklist (SCC-B) is a checklist that "provides a systematic and structured format for evaluating physiological, neurological, and cognitive effects associated with concussion." It includes evaluation of pupil size, orientation, fine motor dexterity, coordination, symptoms, vision, gait, attention, concentration, memory, and exertional symptoms. It takes about 3 minutes to administer. The SCC-B is a checklist, not a scale, and has not been empirically validated. Close observation and serial reliable assessments of the injured athlete are critical to the prevention of serious or catastrophic complications and for the avoidance of cumulative, cognitive, emotional, or behavioral impairments.

Table 1. Sideline or Quick Clinical Evaluation:
Mental Status Testing:
>Orientation: 
    Time, place, person, and situation (circumstances of injury)

>Concentration: 
    Digits backward (ie, 3-1-7, 4-6-8-2, 5-3-0-7-4). Months of the year in reverse order.

>Memory: 
    Names of teams in prior contest.
    Recall of 3 words and 3 objects at 0 and 5 minutes.
    Recent newsworthy events.
    Details of contest (plays, moves, strategies, etc.)

>Exertional Provocative Tests:
    40 yard sprint, 5 sit-ups, 5 knee-bends

>Neurological Tests:
    Strength
    Coordination and agility
    Sensation

Any appearance of associated symptoms is abnormal, eg, headaches, dizziness, nausea, unsteadiness, photophobia, blurred or double vision, emotional liability, or mental status changes.

The purpose of "concussion" grading systems are that one can reliably assess depth and duration of disturbed consciousness including post-traumatic amnesia in order to differentiate mild, moderate, and severe injuries. There have been more than 15 concussion grading systems utilized to assess the severity of an injury.3, 4, 10, 13, 14 It is the variability of presenting symptoms which complicates any grading system. Most grading systems are based on clinical observations. These grading systems have led to numerous anecdotal guidelines assessing injury severity and subsequent recommendations regarding return and/or exclusion from the sport. These recommendations should be seen as guidelines only rather than scientific fact. Despite concern regarding scientific validation of any specific classification system, the majority of clinicians are familiar with the Cantu Classification System,14 Colorado Guidelines or the Classification System endorsed by the American Academy of Neurology. (Table 2)14, 10 It is hoped that further research and validation of these guidelines will lead to more specific management and return to play recommendations.  *PTA= post traumatic amnesia

Table 2. Concussion severity classifications
Grade:                     Cantu Guidelines            Colorado Guidelines                              
Grade 1 (mild)           No LOC                           Confusion without amnesia   
                                 PTA < 30 min                     No LOC                                             

Grade 2 (moderate)    LOC < 5 min                     Confusion with amnesia   
                                   PTA> 30 min                     No LOC                                            

Grade 3 (severe)         LOC> 5 min                      LOC
                                   PTA> 24 hours 

 

(*continued below with the American Academy of Neurology Guidelines)

 

Grade:                        AAN Guidelines                  *SX=symptoms

Grade 1 (Mild)            Transient confusion, No LOC/ Concussive SX resolve < 15 min  

Grade 2 (Moderate)   Transient confusion, No LOC/  Concussive SX last > 15 min

Grade 3 (Severe)         Any LOC either brief (sec's) or prolonged (min's)

{Table 2.  Adapted from Cantu, RC. Guidelines for return to contact sports after cerebral concussion. Phys Sportsmed. 14:75-83, 1986; Colorado Medical Society. Report of the Sports Medicine Committee: Guidelines for the Management of Concusussions in Sport. (revised). Denver: Colorado Medical Society, 1991; Report of the quality standards subcommittee. Practice Parameter: The management of concussion in sports (summary statement). Neurology, 1997: 48:581}

Prevention of Complications. The differential diagnosis and pathophysiology of concussion requires prompt recognition. It is important to rule out more severe neurosurgical injuries such as skull fracture, subdural or epidural hematoma or intracerebral hemorrhage.

The neuronal insult from concussion causes an acute increased demand for intracellular glucose and subsequently this is believed to alter the regulation of cerebral blood flow. These changes, resulting in a heightened metabolic vulnerability and must be recognized in avoidance of a catastrophic "second impact syndrome." The Second Impact Syndrome (SIS) is felt to be caused by a loss of autoregulation of the vascular components of the brain. This "SIS" occurs when an athlete sustains a second brain or neuronal insult before recovering from the initial insult. This may result in massive cerebral edema over seconds to minutes resulting in permanent damage and/or death. It has been most reported in boxers and football players with the majority of cases reported in children and adolescence. The Malignant Brain Edema Syndrome 3,12 is also a poorly understood and rare condition that may occur in young children following a single brain trauma. The pathophysiology of this condition resembles SIS with the loss of vascular autoregulation and resultant diffuse brain hyperemia. In these situations there may be a rapid decline leading to coma and possibly death. Therefore, an athlete that has sustained a concussion should not be allowed to return to practice or competition while symptomatic or displaying ANY signs of concussion.1-3, 9, 10,13, 14

 

concussion-6Seizures or "concussive convulsions" in collision sports are an uncommon but traumatic symptom following concussion.12 These concussive convulsions occur within seconds of impact and are not felt to be associated with structural brain injury. It is speculated that the concussive impact itself creates a transient functional decerebration akin to the cortico-medullary disassociation seen in convulsive syncopy. These players frequently have a good outcome and do not display any evidence of structural cerebral injury or long-term neuropsychological damage. Therefore, it is felt that these events are relatively benign, late seizures do not occur, and anti-epileptic therapy is not indicated. Also, there should not be necessarily a future prohibition from participating in collision sports and the overall management plan should center on the appropriate treatment of the concussion injury itself.3

Assessment. Following the initial assessment of concussion, utilizing the SAC or SCC-B, a more detailed neuropsychological evaluation may be useful.6 Also a detailed neurological examination may be necessary. Follow-up neuroimaging studies may also be useful. Acutely, CT scans are more readily available and can detect bleeding or swelling that may require neurosurgical intervention. More sensitive MRI techniques may detect subtle anatomical and/or physiologic injury which may correlate with longer lasting post- concussive symptomatology and may help guide treatment.

Return to Play. Theoretically, acute return to play decisions should be based on the assumption that there is neurovascular intracerebral stability with re-establishment of normal chemical and ionic environments within the brain. Therefore, medical consensus is that any athlete who is continuing to experience signs or symptoms of concussion would preclude their ability to return to practice or competition. Controversy exists within the medical community regarding the theoretical or emperical guidelines and return to play decisions.15 The American Academy of Neurology has published "Return to Play Guidelines."4,10 (Table 3) These guidelines should not be viewed as fixed standards of care and return to play decisions should be made on an individual basis.15

Table 3. Management of concussion in sports:
Grades of Concussion

>Grade 1 
   1. Transient confusion (inattention, inability to maintain a coherent stream of thought and carry out goal-directed movements)
   2. No loss of consciousness

>Grade 2  
   1. Transient confusion
   2. No loss of consciousness
   3. Concussion symptoms or mental status abnormalities (including amnesia) on examination last more than 15 minutes

>Grade 3 
   1.  Any loss of consciousness  a) Brief (seconds)     b) Prolonged (minutes)

Management Recommendations:

>Grade 1 
   1. Remove from contest
   2. Examine immediately and at 5-minute intervals for the development of mental status abnormalities or post-concussive symptoms at rest   and with exertion

>Grade 2 
   1.  Remove from contest and disallow return that day
   2.  Examine on-site frequently for signs of evolving intracranial pathology
   3.  A trained person should re-examine the athlete the following day
   4.  A physician should perform a neurologic examination to clear the athlete for return to play after one full asymptomatic week at rest and with exertion

>Grade 3 
   1. Transport the athlete from the field to the nearest emergency department by ambulance if still unconscious or if worrisome signs are detected (with cervical spine immobilization, if indicated)
   2. A thorough neurologic evaluation should be performed emergently, including appropriate neuroimaging procedures when indicated.
   3. Hospital admission is indicated if any signs of pathology are detected, or if the mental status of the athlete remains abnormal.

Treatment Considerations: The natural history of post concussion symptomatology is improvement over time.16 However, a small percentage of injured athletes may continue to complain of somatic, behavioral and/or emotional symptomatology lasting one or more years post injury.15 Repeated concussions can cause cumulative cognitive, emotional, and behavioral impairments.17

This may include impaired attention, concentration, memory, and slurred speech. Even when concussive events are separated by months or years, there may also be a stepwise decline in a person's abilities. Symptoms may be evident even when no abnormalities are detectable on further detailed neurological exams. Also, an athlete with a history of concussion may also be more likely to suffer subsequent concussions compared to an athlete who has never had one, an area requiring further study.

Recent studies indicate that an early preventative model is effective in the management of MTBI.18 Education focused on the understanding and management of symptoms has been empirically demonstrated to reduce the number and duration of symptoms.17, 19 Early selective neuropsychological evaluation of attention, memory, information processing, and executive functioning provides a framework in the management of symptoms and structuring a gradual resumption of activities.6

It is also helpful to manage neuromedical and somatic symptoms of pain, headaches, cervicogenic and vestibular dysfunction, irritability, sleeplessness, and mood dysfunction. "Rational" pharmacotherapy and a brief program of goal specific rehabilitation services frequently are useful during the early recovery period.18 In our experience, pharmacologically stabilizing sleep induction and maintenance patterns with low dose SSRI's or sedating tricyclic antidepressants have an immediate positive effect on symptom presentation.

For life reintegration issues, such as school and/or work, a program designed to gradually increase tolerance for cognitive demands and organized problem-solving strategies can be helpful.19 Since chronic dysfunction following MTBI is often accompanied by negative emotional sequelae, it is important to address secondary factors by teaching athletes to cope with symptoms, resume activities, and avoid over-dependence on the healthcare system.19

Summary: It is important to identify and educate others about optimal prevention of concussion in sports. Implementing sideline evaluations and treatment recommendations will help to prevent further morbidity and fatal injury including the second impact syndrome and persistent post-concussive symptomatology. Preventative tools include rule changes, and the further development of design changes in helmets and other protective equipment. Ongoing research regarding education, risk factors, and the early detection of concussion using reliable and valid assessment tools, such as the SAC and SCC-B, are crucial to further guideline improvement.

In order to make sports safer and increase awareness about sports related concussion, interdisciplinary efforts of medical personnel, trainers, coaches, officials, parents, and participants are necessary. This will ultimately allow young players to reach their fullest potential beyond sports and in life.

>CONCUSSION:
Post Concussion Syndrome - Cosotin: Simple time tested remedy for Post Concussion Syndrome (Cosotin.com)

Neurological Injury Law - Find proven trial attorneys Washington Maryland Virginia (injury-brain.steinmitchell.com)

Concussion - What Causes Concussion? Concussion Signs & Symptoms (Healthline.com)
DEFINITION: Concussion is a change in mental status caused by trauma (shock). It is accompanied by confusion, loss of memory, and, sometimes, loss of consciousness.
DESCRIPTION:A concussion occurs when the head hits or is hit by an object. A concussion can also occur when the brain is pushed against the skull with a strong force. In such cases, parts of the brain that control mental function may be damaged. The injured person may become disoriented (confused) and may briefly lose consciousness.

The U.S. Centers for Disease Control and Prevention (CDC) estimates that about three hundred thousand people experience mild to moderate concussions each year as a result of sports injuries. Most of these people are men between the ages of sixteen and twenty-five.

A concussion usually gets better without any long-term effect. On rare occasions, it is followed by a more serious injury called second-impact syndrome. Second-impact syndrome occurs when the head receives a second blow before the original concussion totally healed. Brain swelling may increase, resulting in a fatal condition. Since 1984, more than twenty people have died from second-impact syndrome.
CAUSES

*NB:Motor vehicle accidents and sports injuries are the major causes of concussion. *In motor vehicle accidents, concussion can occur without an actual blow to the head. Instead, concussion occurs when the vehicle starts or stops suddenly. In such a case, the brain is pushed strongly against the skull. Contact sports, especially football, hockey, and boxing, are leading causes of concussion. Other significant causes are falls, collisions, or injuries due to bicycling, horseback riding, skiing, and soccer.

The risk of concussion from football is extremely high, especially at the high school level. Research shows that about 1 in 5 high school football players suffer concussion or more serious brain injury at some point during their high school football career. The comparable rate at the college level is 1 in 20.

Concussion and lasting brain damage is also very common among boxers. After all, the goal of this sport is to knock out an opponent, that is, to give him or her a concussion. For this reason, the American Academy of Neurology (a group of doctors who specialize in problems of the nervous system) has called for a ban on boxing.
Concussion: Words to Know

Amnesia:
    Loss of memory sometimes caused by a brain injury, such as concussion.
Parkinson's disease:
    A disorder of the nervous system that includes shaking, muscular weakness, stiffness, and problems with walking.

Repeated concussions over many months or years can eventually cause more serious brain injury. For example, boxers can develop a form of permanent brain damage called "punch drunk" syndrome or dementia pugilistica (pronounced dih-MEN-sha pyoo-juh-LIS-tuh-kuh). Perhaps the best known example is the great boxer Muhammad Ali. Ali eventually developed Parkinson's disease (see Parkinson' disease entry), believed to be caused by head injuries sustained while he was active as a boxer.

Young children are likely to suffer concussions from falls or bumps on the playground or at home. Child abuse is another common cause of concussion.
SYMPTOMS-Symptoms of concussion include:

    * Headache
    * Disorientation (confusion) as to time, date, or place
    * Dizziness
    * Vacant stare or confused expression
    * Speech that is difficult to understand
    * Lack of coordination or weakness
    * Amnesia (loss of memory) about events just preceding the blow
    * Nausea or vomiting
    * Double vision
    * Ringing in the ears

These symptoms may last from several minutes to several hours. More severe or longer-lasting symptoms may indicate more severe brain injury. If a person loses consciousness, it will be for several minutes at the most. If unconsciousness last for a longer period, a more serious form of brain injury may have occurred.

Doctors use a three-point system to determine the seriousness of a concussion. This system helps them to choose the appropriate treatment:

    * Grade 1: No loss of consciousness, brief confusion, and other symptoms that clear up within 15 minutes.
    * Grade 2: No loss of consciousness, brief confusion, and other symptoms that clear up in more than 15 minutes.
    * Grade 3: Loss of consciousness for any period of time.

Days or weeks after the original concussion, certain symptoms may reoccur. These symptoms are called post-concussion syndrome. They include:

    * Headache
    * Loss of ability to concentrate and pay attention
    * Anxiety
    * Depression
    * Sleep disturbance
    * Inability to tolerate light and noise.

DIAGNOSIS: Anyone who receives a concussion must be watched very carefully after the accident. It is important to notice how long unconsciousness lasts and how serious the symptoms seem to be. These signs are indications of how serious the brain injury was, and are important in deciding how to treat the patient.

A medical professional can decide how serious a concussion is with some simple tests. He or she may examine the pupils of the patient's eyes, test the patient's coordination and sense of feeling, and observe his or her memory, orientation, and concentration. Patients with mild concussions do not require hospitalization or further tests. Those with more serious injuries may need some form of brain test, such as a computer-aided tomographic (CAT) scan.
TREATMENT

The symptoms of concussion usually clear up quickly and without lasting effects. Medical specialists decide how soon a person can return to sports activities based on the severity of his or her injury. All treatment plans are designed to prevent a second blow to the head during recovery. A second blow may cause very serious long-term brain damage.

A Grade 1 concussion is usually treated with rest and continued observation only. The person can return to sports activities the same day if a medical professional approves and all symptoms are gone. If a second concussion occurs on the same day, the person should not be allowed to continue contact sports until he or she is free of symptoms for one week.

A person with a Grade 2 concussion must discontinue sports activities for the day. He or she must be observed by a medical professional and be observed throughout the day until all symptoms have disappeared. If symptoms become worse or continue beyond a week, further brain tests, such as a CAT scan, may be necessary. The person cannot return to contact sports until one week after symptoms have disappeared and a medical professional has given permission.

A person with a Grade 3 concussion should be seen immediately by a medical professional. If symptoms are severe, brain tests and hospitalization may be necessary. Prolonged unconsciousness and worsening symptoms require immediate examination by a neurologist.

A neurologist is a doctor who specializes in problems of the nervous system. The patient should be carefully observed after discharge from medical care. If symptoms reappear or become worse, further neurological tests may be necessary.

A person with a Grade 3 concussion should avoid contact sports for at least a month after all symptoms have disappeared. If brain tests indicate that brain swelling or bleeding has occurred, the athlete should give up contact sports for the season and, if symptoms are bad enough, indefinitely.

PROGNOSIS: There are usually no long-term effects of a single concussion. However, symptoms of post-concussion syndrome may last for weeks or months. The risk of a second concussion in contact sports is even higher than the risk for a first concussion. For that reason, a person who has received a concussion needs to avoid contact sports until the first concussion has entirely cleared up. When a person has suffered a number of concussion, close and constant observation is warranted as well as a change in lifestyle.  For example, if an athlete has had multiple concussions then it is probably time to stop playing that sport permanently as well as any other contact sport. With car accident victims, multiple concussions can occur and it is well advised for that patient to become acutely aware of his/her driving environment and avoid collisions at all costs.


PREVENTION: Many cases of concussion can be prevented by using certain types of protective equipment. These include seat belts and air bags in cars, and helmets in contact sports. Helmets should also be worn when bicycling, skiing, or horseback riding. Soft material, such as sand or matting, should be placed under playground equipment. Young people should think about the value of high-contact sports, such as boxing, football, and hockey, compared to their risk for head injuries. They may decide to take part in sports activities that are fun to participate in, but less risky to one's health.

FOR MORE INFORMATION:

Books:

Gronwall, D. M. A., Philip Wrightson, and Peter Waddell, "Head Injury-The Facts: A Guide for Families and Care-Givers," New York: Oxford University Press, 1998.

Stoler, Diane Roberts, "Coping With Mild Traumatic Brain Injury," Garden City Park, NY: Avery Publishing Group, 1998.
Organizations

American Academy of Neurology, Monographs, 1080 Montreal Avenue St. Paul, MN 55116-2325. (800) 879-196

Foreman S, Croft A, "Whiplash Injuries: The Cervical Acceleration/Deceleration Syndrome," 3rd Ed., Lippincott Williams & Wilkins, Maryland, 2002

Dr. Haberstroh is a Somerville and Boston Chiropractor.

_________________________________

NFL makes concussion meeting mandatory NFL commissioner orders
doctors, trainers to attend summit in June.

More on NFL Updated: 3:26 p.m. ET May 2, 2007

NEW YORK - NFL commissioner Roger Goodell, who disclosed last week that the NFL will make baseline neuropsychological tests mandatory for the 2007 season, is requiring all team medical personnel to attend a meeting on concussions next month. NFL spokesman Joe Browne said Tuesday that Goodell has ordered all 32 teams to send its doctors and trainers to a June 19 meeting in Chicago for the first league-wide concussion summit. "At no time should competitive issues override medical issues," Goodell said last week. "Safety comes first."
Under Goodell's new policy, all players will be required to take a baseline neuropsychological test - determining cognitive abilities, memory and motor skills - by the start of the 2007 season. That way, when a player has a concussion, he can be tested to determine what neurological changes have taken place.  Some players have had baseline tests recently. Under the new policy, those players will not require another test. But those who haven't had a test will be required to have one. NFL officials said some teams administer those tests on a regular basis, while other teams administer the tests only after a concussion.

concussion-7Goodell has acknowledged players often fight the medical staff to get back into games after suffering head injuries.  "We're protecting the players against the players," he said.

Concussions among NFL players have drawn attention in recent months. A forensic pathologist who studied the brain tissue of Andre Waters after his suicide last November concluded Waters had brain damage resulting from multiple concussions during 12 years as an NFL safety. In addition, the Boston Globe and New York Times reported in February that 34-year-old Ted Johnson, who spent 10 years as a linebacker with the New England Patriots, shows early signs of Alzheimer's disease.  Johnson said he began to deteriorate in 2002 with a concussion during an exhibition game against the New York Giants. He said he had another concussion four days later after coach Bill Belichick prodded him to participate in a full-contact practice, even though he was supposed to be avoiding hits.

News of the Chicago meeting first was reported by ESPN.com.


Concussions Tied to Depression in Ex-N.F.L. Players

By ALAN SCHWARZ - Published: May 31, 2007

The rate of diagnosed clinical depression among retired National Football League players is strongly correlated with the number of concussions they sustained, according to a study to be published today.  The rate of diagnosed clinical depression among retired National Football League players is strongly correlated with the number of concussions they sustained, according to a study to be published today.

As the most comprehensive study of football players to date, the paper will add to the escalating debate over the effects of and proper approach to football-related concussions. The study, which will appear in the journal of the American College of Sports Medicine, found that of the 595 players who recalled sustaining three or more concussions on the football field, 20.2 percent said they had been found to have depression. That is three times the rate of players who have not sustained concussions. The full data, the study reports, "call into question how effectively retired professional football players with a history of three or more concussions are able to meet the mental and physical demands of life after playing professional football." In January, a neuropathologist claimed that repeated concussions likely contributed to the November suicide of the former Philadelphia Eagles player Andre Waters. Three weeks later, the former New England Patriots linebacker Ted Johnson (Pictured below) not only revealed that his significant depression and cognitive decline had been linked by a neurologist to on-field concussions, but also claimed that his most damaging concussion had been sustained after his coach, Bill Belichick, coerced him into practicing against the advice of team doctors.

concussion-8

While consistently defending its teams' treatment of concussions and denying any relationship between players' brain trauma and later neurocognitive decline, the N.F.L. has subsequently announced several related initiatives. The league and its players union recently created a fund to help pay the medical expenses of players suffering from Alzheimer's disease or similar dementia. Last week, N.F.L. Commissioner Roger Goodell announced wide-ranging league guidelines regarding concussions, from obligatory neuropsychological testing for all players to what he called a "whistle-blower system" where players and doctors can anonymously report any coach's attempt to override the wishes of concussed players or medical personnel.  The N.F.L. has criticized previous papers published by the Center for the Study of Retired Athletes - which identified similar links between on-field concussions and both later mild cognitive impairment and early-onset Alzheimer's disease - and reasserted those concerns this week with regard to the paper on depression. Several members of the league's mild traumatic brain injury committee cited two main issues in telephone interviews this week: that the survey was returned by 69 percent of the retired players to whom it was mailed, and that those who did respond were relying solely on their memories of on-field concussions. One committee member, Dr. Henry Feuer of the Indiana University Medical Center and a medical consultant for the Indianapolis Colts, went so far as to call the center's findings "virtually worthless."

Dr. Ira Casson, the co-chairman of the committee, said, "Survey studies are the weakest type of research study - they're subject to all kinds of error and misinterpretation and miscalculation."  Regarding the issue of players' recollection of brain trauma, Dr. Casson said: "They had no objective evaluations to determine whether or not what the people told them in the surveys was correct or not. They didn't have information from doctors confirming it, they didn't have tests, they didn't have examinations. They didn't have anything. They just kind of took people's words for it." According to other experts, the 69 percent return rate was quite high for such survey research, which has been widely used to establish preliminary links between smoking and lung cancer, explore the relationship between diet and health, and track trends in obesity and drug use. After reading the depression study and considering the league's issues with recollective survey research, Dr. John Whyte, the director of the Moss Rehabilitation Research Institute in Philadelphia and an expert in neurological research methodology, said he did not share the league's criticisms. "To the person who says this is worthless, let's just discard a third of the medical literature that we trust and go by today," said Dr. Whyte, who has no connection with either the N.F.L. or the Center for the Study of Retired Athletes, which is partly funded by the N.F.L. players union. "Here, the response rate was good and not a relevant issue to the findings. We have some pretty solid data that multiple concussions caused cumulative brain damage and increased risk of depression, and that is not in conflict with the growing literature. "Do I think this one study proves the point beyond doubt? No. Does it contribute in a meaningful way? You bet."

 The study, which underwent formal, anonymous peer review before publication, reported that of the 595 players who recalled sustaining three or more concussions on the football field, 20.2 percent said a physician found they had depression. Players with one or two concussions were found to have depression 9.7 percent of the time, and those with none, 6.6. (Respondents were on average 54 years old and had played almost seven seasons in the N.F.L. A minimum of two seasons was required for inclusion in the study.)  The study considered concussions sustained in high school and college as well, not just in the N.F.L. Because the diagnosis of concussions has undergone substantial refinement since the 1960s and 1970s, when many of the survey respondents had played, a modern description of symptoms - such as nausea or seeing stars following a strong blow to the head, not simply being knocked unconscious - was provided. Members of the N.F.L. concussion committee criticized the use of such a retrospective definition. They also cited a mail survey by doctors at the University of Michigan, results of which were published two months ago in the same American College of Sports Medicine journal, that found the self-reported incidence of depression among retired N.F.L. players to be 15 percent - similar to that of the general population - and that such depression was strongly correlated with the chronic pain many N.F.L. retirees experience. The associate editor-in-chief of the journal who handled the review of both papers, Dr. Thomas Best, said in a telephone interview yesterday that the studies did not conflict. Dr. Best explained that the Michigan study did not consider concussions specifically, and that the North Carolina study in fact used statistical tests to account for players' chronic pain and found that the strong correlation between number of concussions and depression remained virtually unchanged.

"The North Carolina paper is not saying that N.F.L. players are or are not at risk for depression," said Dr. Best, the medical director of the Ohio State University's Sportsmedicine Center. "What we learned from the paper is that there's a correlation between the number of concussions sustained and depression they experience later in life." Mr. Goodell said last week that the league's concussion committee had just begun its own study "to determine if there are any long-term effects of concussions on retired N.F.L. players."  Dr. Casson, the committee's co-chair, said that players who retired from 1986 through 1996 would be randomly approached to undergo "a comprehensive neurological examination, and a comprehensive neurologic history, including a detailed concussion history," using player recollection cross-referenced with old team injury reports. He said that the study would take two to three years to be completed and another year to be published.  Given that the average N.F.L. retirement age from 1986 to 1996 was approximately 27, a random player from that period would be approximately 46 at the N.F.L. study's completion, eight years younger than those considered by the paper being released today. Dr. Kevin Guskiewicz, the center's research director and the principal author of the study, said that even with those differences he was confident the N.F.L. study would corroborate his group's conclusions. "It sounds as if they need to study the question themselves to believe the findings," Dr. Guskiewicz said. "I think they're going to be very surprised at what they find, compared with what they've been led to believe by members of their own committee."


AP IMPACT: NFL players hide, fear concussions

November 18, 2009

"You know how a bell vibrates? That's how my brain was going at that time," he said. "I think five minutes later, I came back to myself. I went back out there and played football."

What Cartwright never did when the hit happened? He never told Washington's medical staff his head ached.

He's not alone. Thirty of 160 NFL players surveyed by The Associated Press from Nov. 2-15 replied that they have hidden or played down the effects of a concussion.  The AP embarked on the most extensive series of interviews about concussions since the subject became a major issue this season, talking to five players on each of the 32 teams - nearly 10 percent of the league - seeking out a mix of positions and NFL experience to get a cross-section of players. While not a scientific sampling, many of the players answered with startling candor.

"You get back up, and things are spinning," Giants backup quarterback David Carr said, "but you don't tell anyone."

Now the NFL wants players to keep tabs on each other and tell their teams if they believe someone else has a head injury. Told of the AP's findings, NFL spokesman Greg Aiello said in an e-mail that commissioner Roger Goodell spoke to NFL Players Association executive director DeMaurice Smith last week about "the importance of players reporting head injuries, no matter how minor they believe they might be. The commissioner said that process needs to include players observing and reporting to the team medical staff when a teammate shows symptoms of a concussion."

What emerged from the AP's interviews was a wide-ranging, unprecedented look at the way active players think about head injuries in a world where "getting dinged" and "seeing stars" - and the potential long-term effects of concussions - are deemed a frightening but perhaps inevitable consequence of their job.

"Part of the game," Pittsburgh Steelers cornerback Deshea Townsend said.

Indeed it is. In recent weeks, high-profile players Brian Westbrook of the Philadelphia Eagles and Clinton Portis of the Redskins - neither of whom was surveyed by the AP - have been sidelined by concussions. Westbrook missed two games, then returned Sunday, only to leave in the second half with another concussion. The NFL says its data shows an average of one reported concussion every other game - about 120 to 130 concussions per regular season. Of the 160 players interviewed by the AP, half said they've had at least one concussion playing football; 61 said they missed playing time because of the injury.

"We're obviously concerned by the data and by the information," NFLPA assistant executive director George Atallah said. "We believe that there's more relevant data and information that the league has on these issues that we'd like for them to share with us in confidence."

During the AP interviews, some players quickly replied they never had a concussion, then realized they weren't sure, such as Tampa Bay Buccaneers defensive tackle Chris Hovan, a 10-year veteran, who said: "I probably was just too young and too dumb to realize it."  Not that it's necessarily easy to miss - or mask - the symptoms.

"Everyone can clearly see that you have a concussion: You are walking around like you are drunk," Seattle Seahawks defensive back Roy Lewis said.

Kansas City Chiefs wide receiver Bobby Wade told the AP he's never tried to hide a concussion but is sure it happens frequently in the NFL. "You see guys with their eyes rolling in the back of their heads," he said. "You see guys shaking their head trying to get it together. If there was a doctor evaluating them, I'm sure they would say, 'Your brain has taken trauma.'"

Players acknowledged staying on the field despite feeling "dazed" or "woozy" or having blurred vision, because, in Miami Dolphins guard Justin Smiley's words, "It's what you're taught." Some talked about not wanting to let down the team. Others mentioned the importance of avoiding any sign of weakness in a sport where "warrior" and "gladiator" are viewed as compliments of the highest order. And then there is the fear of losing a roster spot in a league where the absence of guaranteed contracts makes some players willing to sacrifice their well-being somewhere down the road for a paycheck in the here-and-now.

"If you're a 'bubble' guy, you might want to be out there," Tennessee Titans long snapper Ken Amato said, "so they don't have to bring someone else in."

Players spoke frankly about being afraid of getting the sorts of long-term problems seen in boxers; about hoping they will be able to remember their career highlights once they retire; about their wives' constant concern; about whether they'll be able to see their "kids grow up and have kids," as Houston Texans offensive lineman Eric Winston put it.

Others told of memory loss during and after games, of not being able to recall what particular play calls meant, or of "talking gibberish" to teammates on the field.

"The only thing I remember is coming out of the tunnel at the beginning of the game. And then - a big gap," St. Louis Rams linebacker David Vobora said of a concussion he got this season. "But I played the whole game, until the last series, when I started asking guys questions, and they looked at me like I was crazy."

Asked whether they worry more about concussions than any other injury, 30 of the interviewed players said yes.

"It's hard," Baltimore Ravens center Matt Birk said, "to rehab your brain."

Vonnie Holliday, a defensive end for the Denver Broncos, likened the pounding his head takes to "being in a car crash 20, 30 times a game."

"I do often think about the damage I'm doing to my brain and my nervous system," Holliday said. "When does it catch up with you?"

Two-thirds of the players the AP interviewed said the NFL is significantly safer than it used to be with regard to the risk of concussions, thanks primarily to changes in rules and equipment, particularly helmets and mouthpieces. But there are caveats.

"Players are bigger, faster, stronger," Baltimore's Birk said, echoing other athletes. "It's simple physics: Force equals mass times acceleration. It is a violent game, and there are inherent risks to the game itself. ... Collisions are becoming more intense."

About half of the surveyed players said they've been paying attention to recent news about NFL head injuries. That includes a congressional hearing last month, when Rep. Linda Sanchez, D-Calif., said the NFL's resistance to accepting a link between multiple head injuries in NFL players and brain disorders such as dementia and Alzheimer's reminded her of tobacco companies denying a link between smoking and disease. At that hearing, Rep. John Conyers, D-Mich., asked the NFL and its players' union to turn over medical records for an independent review.

As attention to concussions has increased, so have the efforts by the NFL and the players' union to address the issue - including working to update the joint letter and brochure they sent to all locker rooms in 2007 to educate players about head injuries. Goodell told Congress he expects to announce "shortly" new funding for concussion research and that the NFL is trying to learn about "new practice techniques that will reduce the risk of head trauma outside of the games themselves."

Dr. Joseph Maroon, the Steelers' team doctor and member of an NFL committee on concussions, called the subject a "major priority" for the league. In a telephone interview, he cited an ongoing study in which helmet manufacturers' products are being tested and noted the NFL mandate of 2007 that every player undergo neurological testing in the preseason to establish a base line against which results can be compared in case of a concussion. Dr. Thom Mayer, the NFLPA's medical director, said there are "good trends" in data he has seen, showing that "it appears that concussions are slightly down from where they have been" and that "it appears players are being held out, when they have a concussion, longer - maybe twice as long." He did not give specific numbers. In the AP interviews, players with more than a half-dozen seasons in the NFL said the league, its teams and the union do take the issue more seriously now than at the start of their careers.

"They are more careful, the doctors and trainers," Chicago Bears defensive tackle Anthony Adams said. "They're better (at) watching for symptoms of what might be a concussion."

Still, concerns abound.

One player voiced his feelings this way: "It worries me, because I have aspirations after the game to work. I'd like to be able to remember everything. I feel like in some ways, my short-term memory isn't as good as it was, already. I don't know if that's from getting older. I don't know. But you only get one brain, obviously." The words of a grizzled veteran? No. That's 26-year-old Colin Allred, a Titans linebacker midway through his second NFL season. Other players discussed the difficulties of determining when someone does, indeed, have a concussion and nervousness about accumulating multiple head injuries.

 

concussion-9"The unfortunate thing in our business, more times than not, is that either guys don't know it or don't let somebody know it and continually play through those kinds of situations, where it's week after week, it's hit after hit, where they're not coming out of games and they never get healed," said Arizona Cardinals quarterback Kurt Warner, who's had two concussions in a 12-year NFL career. "And I think that's probably - and I'm just guessing - where the biggest effects are down the road, is guys that may not have a record that they had 10 concussions but probably had that or more so and just played right through it."

 

*Austin Collie (#17) playing for the COLTS was "sandwiched" between two Eagle players in 2010 and was concussed so badly he had to be wheeled off the field. His season was done that night.

Several players said they refuse to allow themselves to contemplate the dangers of their sport because it would become impossible to perform well while devoting any shred of thought to concussions.

"You could easily die in a car," New England Patriots tight end Benjamin Watson said, "but you don't think about it, because you're focused on what you're doing."

There also is some dark humor.

One player joked about eating through a straw at age 45, and Dallas Cowboys linebacker Keith Brooking said: "I tend to use it as an excuse with my wife when I forget something. She tells me to do something, and (I say), 'I've been hit in the head a lot, Baby. Sorry. I forgot.'"

Cowboys backup quarterback Jon Kitna spoke in more serious terms. "I firmly believe you can be paralyzed on any play, and I believe there's going to come a time when somebody's going to die on the field from a hit on the field. Because the game is getting so fast, the big guys are getting bigger, and the little guys are getting littler, but the collisions are getting greater. That's the scariest thing for me," Kitna said. "What else are you going to do? Shut the game down?"

___

AP Sports writers Andrew Bagnato, Bob Baum, Gregg Bell, Tim Booth, Cliff Brunt, Dave Campbell, Tom Canavan, Mike Cranston, Schuyler Dixon, Josh Dubow, R.B. Fallstrom, David Ginsburg, Fred Goodall, Pat Graham, George Henry, Chris Jenkins, Larry Lage, Mark Long, Michael Marot, Brett Martel, Janie McCauley, Alan Robinson, Kristie Rieken, Andrew Seligman, Arnie Stapleton, Doug Tucker, Howard Ulman, Teresa M. Walker, Dennis Waszak Jr., John Wawrow, Joseph White, Bernie Wilson, Steven Wine and Tom Withers, and AP freelance writers Dave Hogg, Josh Katzowitz and Mike Sharesky contributed to this report.

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