Head-On Collision

Concussions and Other Brain Injuries Raise Troubling Concerns

By James Eppard | Posted on 06.05.13 – Feature, People & Places

Head-On CollisionHead-On CollisionHead-On Collision

Will Lane was no stranger to bonejarring hits when last year he found himself horizontally splayed on the pitch during a lacrosse match. The junior goalie for Hood College had entered the game with a reputation for tenacity and putting it all on the line—a trait borne out by four diagnosed concussions and an intimate knowledge of their side effects.

He was dazed and confused following his first concussion, in middle school, when he was upended on a basketball rebound and landed on his head. He had tunnel vision after his second concussion, the result of a cross-check to the head playing high school lacrosse. He played on, urging his defense to better protect him while quietly marveling at his blurred periphery. Severe headaches followed his third concussion, the consequence of a cleat meeting his chin in a freshman soccer match. Again, he suspected a concussion but stayed in the game. In his sophomore year, again tending goal in soccer, he lost consciousness for about a minute after landing on his head. He’d vaulted for a high corner kick and was upended again.

“All of this is hearsay. I don’t remember any of it,” Lane says in an interview earlier this year. “I don’t remember before the corner kick. The first thing I remember is 45 minutes later when I’m being taken to the hospital.”

Then last February, Lane was guarding the pipes in a lacrosse match against Shenandoah University when he picked up a loose ball, exited his protective crease and broke off down the sideline. He got blindsided in an unsportsmanlike hit that leveled him. When he got up he laughed, resolving not to let his opponents sense weakness. “Of course the adrenaline’s going at that point,” he recalls. “And I don’t believe you should go down and stay down if you’re hurt because that means the other person won.”

Lane stayed on the field and would earn the win through three quarters of play that saw eight saves. But in the fourth quarter he’d lost track of the game, his fifth concussion causing befuddlement at the scoreboard.

“I went to one of my defensemen and said something to the nature of, ‘How are we up 8 to 3? How did we get on this end of the field? Did we score? Is that why we’re on this end of the field?’” Lane says. “He immediately threw me off. He said, ‘Go to the sideline.’ And that was the end of my career.”

Many Concussions Go Unreported

Each year, as many as 3.8 million brain injuries—mainly concussions—occur in the U.S., many of them unreported, according to the Centers for Disease Control and Prevention. Almost 10 percent are sports-related, but the number grows to 30 percent in kids ages 5-19. High school football players alone account for about 100,000 diagnosed concussions a season, with other contact sports like lacrosse, soccer and wrestling not far behind.

Reports in recent years of retired NFL players struggling with the cumulative effects of brain injuries— brought on by repeated head blows— have caused schools and parents to question how safe their kids are in youth sports, where concussions are reported with increasing frequency.

In just the past few years, 43 state legislatures, including Maryland, have responded with new laws that remove athletes from the playing field when concussions are suspected. The rules also put in place a series of thresholds and guidelines for athletes’ graduated return to play. In short, athletes suspected of having concussions must be removed from a game or practice for the day and can’t return until they’re cleared by a healthcare provider certified in the management of concussions. Meanwhile, coaches, players and parents are educated about concussion signs and risks. And educators are expected to fall in line if kids need special or extraordinary accommodations.

Kevin Crutchfield, a neurologist and director of the Comprehensive Sports Concussion Program at LifeBridge Health in Baltimore and a leading voice in the legislation that passed in Maryland last year, says several factors account for the rise in concussion reports.

“We’re paying more attention to it,” says Crutchfield, who is also an independent neurologist for Baltimore’s Ravens and Orioles, as well as Major League Soccer’s D.C. United. “And there’s more kids playing athletics at a higher level. There’s certainly more women playing and they seem to be more susceptible in certain sports to concussions than males. And our athletes are bigger, faster and stronger, so the kinetic impact is increasing.”

There have been 242 reported cases of head injuries where Frederick County Public Schools student-athletes were removed from play, according to Perry Baker, supervisor of athletics and extracurricular activities for FCPS. Some 7,623 students play fall, winter and spring athletics, so Baker is glad to see the state codify guidelines that FCPS had already been operating under for several years.

“It’s a positive change and I think all of us are much more aware of making sure that the health and safety of our student athletes is the first priority,” Baker says. “The more aware you become the more cautious you become. So we may pull a kid out of a game that doesn’t necessarily have a concussion. Our numbers have probably increased in terms of head injuries for that reason. But I see that as a positive thing, making sure all of our kids are safe to play.”

Signs of a Concussion

  • confusion or feeling dazed
  • clumsiness
  • slurred speech
  • nausea or vomiting
  • headache
  • balance problems or dizziness
  • blurred vision
  • sensitivity to light
  • sensitivity to noise
  • sluggishness
  • ringing in ears
  • behavior or personality changes
  • concentration difficulties
  • memory loss

Software Comes Into Play

To help measure the severity of concussions, some schools are buying software to test athletes’ cognitive functions. Players take a 30-minute test in the pre-season to create a baseline of their brain functions; they’re tested again if they’re suspected of having a concussion, and the difference between the two tests shows roughly the degree players need to recover to resume playing.

Several Frederick County high schools voluntarily offer the test, called ImPACT, , including Urbana and Thomas Johnson. Montgomery and Washington counties have similar piecemeal approaches. By contrast, Carroll County requires all athletes to be tested every two years.

“We use the ImPACT program as another tool to help us,” says Steve Nibbs, athletic director at Gov. Thomas Johnson High School. “If that athlete gets another concussion then we have something to see where they are. It’s not going to be the cure, so to speak. But it’s another tool that can helpus determine where they are and how much they have to do in order to get back to playing again.”

Even with baseline testing and concussion legislation, much of the responsibility still falls on athletes to report telltale symptoms— headache, nausea, dizziness, blurry vision, sensitivity to light. That is why so much effort is spent convincing players of the perils of untended head injuries. Certified trainers can usually sleuth a concussion by issuing a battery of sideline tests, like standing on one foot or listing the months of the year backwards. But left to themselves, athletes might opt to quietly ride out their symptoms rather than risk losing valuable playing time.

“A lot of kids, they say, ‘I’m not telling anybody’ because they know nowadays that the protocol is if you have a headache, you have symptoms, you can’t play,” says Chrissy Barnowich, a trainer at Thomas Johnson. “So a lot of them try to hide it.”

“It’s getting through that, trying to break through that mentality, that we have to work to,” says Nibbs.

Eliminating or at least reducing the disincentive to self-report injuries is behind amendments Kevin Crutchfield wants to make to the state’s current legislation. It’s his belief that only qualified neurosurgeons and neurologists have the breadth of knowledge to properly assess and clear athletes who sustain concussions. He contends that under-qualified healthcare providers are missing key signs, potentially consigning injured kids to weeks of at-home brain rest when what they might have is an undiagnosed neck injury compounding their problems. Crutchfield sees about 100 cases a week through referrals from primary physicians and stumped medical providers. If athletes knew they would get the best care first, he believes, they would be more likely to report their injuries.

“If we had a care pathway and got them back to school quickly and got them back to competing quickly when it’s safe, they’re going to be more likely to admit their problem because they know there’s a treatment and an avenue,” Crutchfield says.

A principal reason behind the widely adopted return-to-play guidelines is to prevent a second impact to a healing brain. Concussions on top of each other are cumulative, and young brains are still developing. Even a minor blow to a concussed brain could be catastrophic, causing uncontrolled swelling, bleeding and possibly death. The condition, called second impact syndrome, is believed to have killed a 22-yearold Montgomery County man during football practice at Frostburg State University in 2011.

“The problem here is kids or athletes are going out before they are fully recovered,” says Sandesh Pandit, a sports medicine physician at Parkway Neuroscience and Spine Institute in Hagerstown, which has a walk-in urgent care center specializing in sports-related injuries. “And when that happens it is not only a cumulative effect, it’s one plus one is not only two, it’s one plus one is four or five.”

‘No Video Games, No Texting’

Rest remains the bedrock for healing from a concussion. “And when we say rest it is not only physical rest but cognitive rest,” Pandit says. “No video games. No texting. Because all of those things stimulate your brain, not let you heal.”

The vast majority of concussions are better in two weeks, Crutchfield says. Anything longer than that, he urges seeing a specialist. “Otherwise you run the risk of a kid missing too much school, not being able to graduate with their friends on time, developing chronic pain symptoms, getting depressed from the chronic pain and increasing their risk of suicide,” he says. “That’s everything we see in our clinic.”

The state’s guidelines on what to do after a concussion were years in the making. How to prevent them still falls on equipment manufacturers and the various sports governing bodies, and the players themselves. There’s a history of rule changes in sports to protect players—eliminating chop blocks and spearing in football, for example, and banning checkingfrom- behind in hockey. Limiting elbow-to-head contact has been shown to decrease injuries in soccer, a sport where evidence increasingly indicates young women are at a greater risk of concussions than men. Balancing protecting players with preserving the game’s integrity is part of the natural evolution of sports.

“If you’re looking at a football practice, you might eliminate a day or two of full-pad practice,” says Perry Baker, the FCPS athletics supervisor. “It might be increasing safety factors on equipment—better helmets, shoulder pads— it might be working with our officials to call a tighter game to make sure kids aren’t hitting illegally or unsafely.”

The subject of helmets alone—in football and lacrosse—raises multiple perspectives. Dr. Crutchfield, who works with the Ravens, says the next generation of helmets needs to be lighter, reducing neck strain, which can contribute to injuries. The idea of introducing helmets in women’s lacrosse, meanwhile, raises the specter of increasing the sport’s head-to-head contact, which could translate into concussions.

In March, the American Academy of Neurology revised its 15-year-old concussion guidelines to be more in line with the NFL and most state legislatures with regard to return-toplay protocols. The group moved away from a generalized grading of concussions to a more nuanced case-bycase approach that echoes the growing body of evidence that every concussion is unique. The report pointed out that concussion risks were greatest in football and rugby, followed by hockey and soccer. The greatest risks for women were in soccer and basketball.

“I don’t think we’re going to get rid of all of them,” says Steve Nibbs, the athletic director at Thomas Johnson, referring to head and neck injuries. “That’s a pretty high order there. But at least everybody is working towards helping make the situation better and have less of those types of injuries.”

Will Lane never played again after the hit last February. He’s a 21-year-old senior this year at Hood, studying environmental science and biology, which he hopes to parlay into a job restoring large-scale ecosystems. He’s also a student-coach for the lacrosse team, a position that keeps him close to a game he loves. He has no second-guesses about ending his playing career at its height.

“Don’t get me wrong. It wasn’t easy,” he says. “But it wasn’t a hard decision to make when I was feeling like absolute crap. Because after the last concussion I was fatigued, I had headaches; I had all this stuff for two-three-four weeks. And I’m still trying to get my stamina back that I had beforehand.”

As a player, Lane says he put team loyalty ahead of his own safety by staying on the field after concussions. As a coach, he recognizes the wisdom of guidelines designed to keep injured players off the field.

“There were points where I probably came back from my concussions a little earlier than I should have,” Lane says. “I honestly think that’s why they’ve created those guidelines—because of what I think I would probably do and what a lot of other people probably did. So going through and seeing the effects of the concussions and looking back on it I completely understand. And when you look at professional athletes I completely understand why the legislation was put in place.”