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A Perplexing Foe Takes an Awful TollThere's No Consensus on Handling Concussions By JAMES C. MCKINLEY JR.
Lindros, in fact, may not return again this season because of a severe concussion two months ago, and his athletic future is in doubt. His ordeal began in March, when for nine days after an opponent elbowed him in the head, team trainers and doctors gave Lindros ibuprofen and head massages -- even though he had suffered three previous concussions and said he complained daily of headaches, nausea and, eventually, memory loss. He played in four games before he was finally sent to a Chicago neurologist, who said he had sustained a severe concussion. Lindros said he had longed for the team to take him off the ice, but could not bring himself to ask. There is an unwritten code of stoicism among players in hockey, as there is in football, boxing and other contact sports. "I tried to explain my symptoms and that things were not real good, but I was not going to pull myself out of the game," Lindros told reporters. "I was hoping the team would take me out, knowing what went on and expressing to them for days about my headaches." Fifteen years ago, athletes like Lindros shrugged off concussions as minor injuries. Football players derisively called them "dings" or "getting your bell rung." Only in recent years have scientists begun to understand what happens to the brain when it is severely shaken: how one concussion, if not given time to heal, can make an athlete more vulnerable to other ones, and how multiple concussions can lead to permanent brain damage. In the last year alone, elite quarterbacks like Steve Young and Troy Aikman have been laid out unconscious on the field, and hockey players like Lindros have been dazed after collisions on the ice. Concussions remain one of the most dangerous and perplexing injuries in sports, an invisible and unpredictable wound that has curtailed the careers of some of North America's greatest sports heroes, from Roger Staubach of the Dallas Cowboys to Pat LaFontaine of the Rangers. And even though awareness about the danger of multiple concussions has grown, athletes, agents, trainers and coaches on all levels of sports are still struggling with how to cope with the injury. While researchers have not been able to answer definitively how long it takes the human brain to heal, the American Academy of Neurology has devised broad guidelines on when it is safe for an athlete to return to play. But trainers and team physicians, especially at the professional level, disagree about what guidelines, if any, should be followed. "We simply don't have a standardized diagnostic technique and that means it's sort of done on a hit-and-miss basis," said Leigh Steinberg, an agent who represents 140 professional athletes, including 22 pro quarterbacks. "We need to have some consensus on when it's acceptable to have a player put back into the game." The National Football League has no guidelines on returning to play after a concussion. Although the National Hockey League has reached an agreement with the players association on a protocol for returning to play after a concussion, it is not being enforced. In practice, officials in both leagues said, such decisions are left up to team trainers and doctors. There are about 160 concussions in the N.F.L. and 70 in the N.H.L. each year, league officials said. Since 1997, all N.H.L. teams and about two-thirds of N.F.L. teams have tested players' cognitive skills at the beginning of a season so trainers have a baseline against which to measure a player after a concussion. The N.H.L. encourages teams to keep players off the ice until they regain the mental skills they had before the injury. But in practice these decisions are still made on a case-by-case basis, usually by trainers and team doctors who are not neurologists, players and union and league officials say. Sometimes mistakes are made. "It's not a fool-proof program yet," said Tim Wharnsby, a spokesman for the N.H.L. Players Association. One major problem is that athletes face enormous pressure to continue playing, not only from peers, who sometimes ridicule them for being weak, but also from coaches and owners, who at times place the team's immediate needs above the athlete's long-term health, many players said. "They don't have guidelines," said Merril Hoge, a football analyst for ESPN and a former Chicago Bears running back who had to retire after two concussions in 1994. "There is an enormous amount of pressure on the player, the owner and the doctor to get that player back out there." Lindros Diagnosis Slow in Coming Though concussions occur most often in football, hockey and boxing,
there is some evidence that soccer players are not immune from the
injury and that, over time, heading the ball may cause brain damage.
A Dutch study of 53 professional soccer players published last year
found the soccer players performed poorly on tests of memory, language,
recognition and planning when compared with a control group of 27
swimming and track athletes.
"The professional soccer players showed impaired memory,
planning and recognition skills when compared to other athletes,"
one of the report's authors, Dr. Barry Jordan of the University of
California at Los Angeles, said. "The mental impairment is subtle
and would go unnoticed by most people."
In addition, the researchers found forward and defensive players, who
head the ball most often, showed greater mental deficits than players in
the midfield and goal positions. The players' level of impairment
appeared to be tied to the number of concussions they had received and
the frequency of heading the ball, Jordan said.
A 14-ounce soccer ball kicked at full power on a corner kick can move
50 to 60 miles an hour, hitting a player's head with as much as 175
pounds of force. The Dutch players studied had taken an average of 800
headers each in their careers. More than half had experienced at least
one concussion.
Another study of teenage players in Michigan also raised troubling
questions about the relationship between heading the ball and
concussions. The two-year study followed 57 soccer players between the
ages of 11 and 14 and found more than half regularly reported symptoms
of concussions, like ringing in the ears, for several hours after
practices, said Dr. David H. Janda, the director of the Institute for
Preventive Sport Medicine in Ann Arbor, Michigan.
More troubling, Janda said, is that in the second year of the study,
the 57 players showed very slight but statistically significant drops in
scores on memory and information processing tests, compared to baseline
tests done at the beginning of the study. The players who had headed the
ball the most recorded the biggest drop-offs, he said.
"We believe these head-impact events are cumulative, and after a
certain point you see a reduction in cognitive skills," Janda said.
-- JAMES C. MCKINLEY JR.
Over the next nine days, he complained daily to the the team's trainer, John Worley, of severe headaches, Lindros's lawyer and others close to him said. He was treated with over-the-counter analgesics and massages before games. Eight days after the injury, the team finally sent him to a dentist, out of concern that his jaw might have been injured. The following day, he played a game in Denver. He said later that he could not remember what he was supposed to do on his shifts. The next day, the training staff, in consultation with a team doctor, decided Lindros was suffering from migraines and put him on the disabled list. They sent him to a Philadelphia neurologist, Dr. Stephen Silberstein, who specializes in headaches. Silberstein said the root of Lindros's symptoms had been a concussion and, after treating him for the migraines, sent him to Chicago to see Dr. James Kelly. Kelly is one of a handful of neurologists who have studied sports concussions and who spearheaded efforts by the American Academy of Neurology in 1997 to come up with a consensus on guidelines for returning to play. The guidelines were intended to help coaches and doctors avoid catastrophic head injuries to players. After two days of examinations, Kelly said Lindros's concussion had been more severe than Silberstein thought. Given the player's history of past concussions, Kelly prescribed a long rest until his symptoms disappeared completely. Lindros, who declined to be interviewed for this article, is still trying to fight his way back. But he has clearly become more vulnerable to brain injuries. On May 5, in his first scrimmage during rehabilitation, he suffered yet another concussion -- his third this year -- when he collided with a defenseman. Lindros was hit in his jaw and mouth, and again suffered headaches and other symptoms. He will be sidelined for at least another two weeks. Kelly said Lindros had risked a more serious injury by continuing to skate for four games after the concussion in early March. "His symptoms worsened because of returning too early," Kelly said. Zack Hill, a spokesman for the Flyers, declined repeated requests for interviews with the team's doctors, trainers or other team officials. But Worley, the Flyers' trainer, defended his decisions in comments to The Philadelphia Daily News; he said Lindros had complained of nothing worse than headaches and had told trainers he was feeling better throughout the week after the injury. "I feel confident in the decisions that were made with the information we were all presented with," Worley said. Sort of Like 'A Small Seizure'
Contrary to popular belief, a concussion is not a bruise to the brain caused by hitting a hard surface. Indeed, no physical swelling or bleeding is usually seen on radiological scans. The injury generally occurs when the head either accelerates rapidly and then is stopped, or is spun rapidly. This violent shaking causes the brain cells to become depolarized and fire all their neurotransmitters at once in an unhealthy cascade, flooding the brain with chemicals and deadening certain receptors linked to learning and memory. The results often include confusion, blurred vision, memory loss, nausea and, sometimes, unconsciousness. "It is sort of like a small seizure," said Dr. David A. Hovda, the director of the Brain Injury Research Center at U.C.L.A. Hovda's research with rats suggests that it takes tremendous energy for the brain to correct the chemical imbalance. The chemical changes associated with even a minor concussion in rats last at least 10 days, he said. Hovda and other researchers say changes to the human brain start to resolve themselves immediately, but the recovery time seems to vary. It depends not only on the severity of the blow, they say, but also on how many previous concussions a person has suffered. Neurologists say once a person suffers a concussion, he is as much as four times more likely to sustain a second one. Moreover, after several concussions, it takes less of a blow to cause the injury and requires more time to recover. In some instances, athletes suffer a second concussion before their brain has recovered from the first. In rare cases, the second injury can lead to what doctors call second impact syndrome, in which massive swelling of the brain causes pressure inside the skull that chokes off the flow of fresh blood and leads to death or irreparable brain damage. It was concern over second impact syndrome among adolescents that led Kelly and several other prominent neurologists to push the American Academy of Neurology to establish guidelines for returning to play. The guidelines divide concussions into three grades of severity, with a prolonged knockout being the worst. In essence, the academy recommends that athletes whose symptoms -- headaches, nausea, amnesia, blurred vision -- do not clear up within 15 minutes, or who lose consciousness even briefly, be kept out of competition until their symptoms have disappeared completely for at least a week. But doctors on an N.F.L. committee that is studying concussions, as well as many team doctors and trainers, have criticized these guidelines, saying they are not supported by research. "We don't know whether being knocked out briefly is any more dangerous than having amnesia and not being knocked out," said Mark R. Lovell, a neurologist at the Henry Ford Hospital in Detroit who is a consultant for both the N.F.L. and the N.H.L. "We see people all the time that get knocked out briefly and have no symptoms," he added. "Others get elbowed, go back to the bench and say, 'Where am I?' " Lovell says that because each brain is organized differently, every athlete responds differently to brain injuries. This explains why some boxers have a glass jaw, while others can take immense punishment without being knocked out. Lovell designed the neuropsychological testing programs used by the N.F.L. and the N.H.L. He advocates that team doctors evaluate players before the season and then after each concussion, looking for slight changes in memory and information processing speed. The head of the N.F.L. committee is Dr. Elliot Pellman, an internist who is team doctor for the Jets and the Islanders. Pellman also contends that so little is known about concussions that one-size-fits-all guidelines make no sense. He says team doctors should be allowed to use "the art of medicine" to determine when a player is ready to return after a concussion. "You really have to hope that the doctors that deal with this have a lot of experience with it, use the tools available and are not affected by the outside din," he said. Pellman said his committee had overseen a study to discover what sort of football collisions cause concussions, using computerized analysis of game footage and crash-test dummies to re-create collisions. The study's preliminary findings suggest that most football concussions happen during head-to-head collisions and that blows to the ear are especially likely to produce concussions, Pellman said. He said the hope is to eventually pressure equipment manufacturers to devise safer helmets. Other research has suggested even soccer players are prone to head injuries. A recent Dutch study that compared 53 professional soccer players to 27 elite runners and swimmers showed the soccer players had impaired cognitive skills compared to the other athletes. Among professional football and hockey teams, Pellman said, the awareness of the problem has grown. "I think everyone is profoundly careful now, maybe even too cautious, because nobody wants to make a mistake," he said. But Kelly, who is also a consultant for the Bears, says the preseason neuropsychological testing is not being done uniformly across the N.F.L. and that some teams have refused to participate. Nor are all trainers as diligent about checking for concussions as they should be, he said. "Some football trainers send people who are unconscious back into a game," he said. "What is it going to take to get these guys on board?" Quarterbacks Are Highly Vulnerable
Chris Miller was forced to retire from football prematurely
after sustaining numerous concussions, including this one while he was with the
Rams in December of 1995.
A concussion on this play forced Buffalo's Jim Kelly from a game
in December 1996.
Young, who is 37, was sidelined for most of the season after sustaining a concussion in late September, his fourth in three years. He is still pondering whether to continue playing, people close to him said. Aikman sat out two games last November after he suffered concussions in consecutive weeks. He has had six in his professional career, but never previously missed a game because of a concussion and says he does not intend to retire. Neither Young nor Aikman was willing to be interviewed about his injuries. Their silence is a measure of both the macho culture of football and, people close to the quarterbacks say, the fear that talking publicly about their concussions makes them even more vulnerable to defenders. "It makes them a target on the field," said Steinberg, the agent who represents Aikman and Young. But other football players whose careers are already over said that for many years the injury had not been considered very important. Some said the guidelines Kelly and others have proposed would have helped extend their playing days. Al Toon, once a mercurial wide receiver for the Jets, said it was not uncommon for him to play the week after a concussion. He retired in November 1992, after neurologists informed him that his cognitive skills were deteriorating. He said at the time that he had endured as many as 10 concussions. Not only was it taking longer and longer to recover after each one, but the threat of permanent damage also loomed large in his mind. "Typically I played the next week," he said. "It didn't feel like I was doing something detrimental in the long term. But it took less and less of a blow to create the same amount of impact." Toon, who now owns real estate and a bank in Madison, Wis., said that for four years after he retired he had trouble remembering information and focusing on events around him. "It was kind of a dark and gloomy low point," he said. A study presented last week at the American Academy of Neurology's annual meeting suggested that many retired football players endure similar symptoms. Researchers surveyed 1,090 former N.F.L. players and found more than 60 percent had suffered at least one concussion in their careers and 26 percent had had three or more. Those who had had concussions reported more problems with memory, concentration, speech impediments, headaches and other neurological problems than those who had not, the survey found. Some former players remain bitter about their treatment. Hoge said team doctors in Chicago allowed him to play the week after he suffered a severe concussion in a preseason game against Kansas City in August 1994. The Bears never gave him a neuropsychological examination, he said, and the team doctor approved his return to play after a telephone conversation. "It's just been treated as no big deal," Hoge said. "At the very least you need an expert evaluation." Five weeks later, he was hammered on a tackle in a game against Buffalo and collapsed on the next down. His vital signs vanished for a few seconds. He spent two days in an intensive-care unit, and was told by neurologists that his eight-year career was over. For a year, Hoge said, he could not stand bright lights and had dizzy spells. He struggled with arithmetic, and reading was difficult. He also had no sense of direction. "It's one of the most helpless feelings I ever dealt with," he said. "I would get lost in my own neighborhood." Seven Concussions and Retirement
Detroit's Larry Murphy was unconscious for several minutes after
he collided with another player and slammed into the boards in early February.
Donald Brashear of the Canucks was
knocked to the ice unconscious after he was struck in
the head by the stick of Boston's Marty McSorley.
"I really don't remember anything until sitting in the training room looking up at the TV and it was the last period," he recalled in a recent interview. "My memory recall was blocked out for 45 minutes." It was the sixth concussion of his career. The team doctor let LaFontaine back on the ice the following week, but he could barely play. LaFontaine said he could not sleep and suffered migraines. He found he could not keep up with the play on the ice. After he soldiered through six games, he went into a team executive's office and, in his words, "broke down." Neurologists determined he was suffering from the effects of multiple concussions. "I shouldn't have been doing anything for at least three weeks," LaFontaine said. "Every doctor said just be thankful you didn't get hit during those three weeks." It took LaFontaine six months to recover. For weeks he would not leave the house or shower. When the symptoms vanished, he said, it was as if someone plugged in a telephone line again. The following year, he tried to make a comeback, signing with the Rangers. He played 67 games, but then collided with a teammate and received another concussion. It took several months to recover, so in the summer of 1998, he decided to hang up his skates. "The bottom line is, the minute a concussion
occurs it has to be dealt with," he said. "The
symptoms have to be cleared for at least a week."
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