Sometime during pre-season football practice at the University of Utah on the third Sunday this August, a lineman took a wicked hit and checked out of the universe. Exactly when and how it happened, he can't remember. In fact, the 285-pound athlete doesn't remember much about that practice at all, nor about the hours before and afterward.
"I'm not sure when it happened because I kept playing on it. Then about three-quarters of the way through practice, I couldn't do anything right. They pulled me out and started checking me," he says. (The player's name is omitted to protect the integrity of an ongoing scientific study.)
After further examination, the team trainers confirmed that the lineman had sustained a concussion. Then they did a strange thing: They gave him a battery of neurological tests. The tests were simple but mentally taxing drills -- listening to a series of numbers and repeating them back in opposite order, listening to a group of words and trying to recall them several minutes later. Each drill is designed to utilize a different brain function and, by inference, to test the well-being of different parts of the brain.
Actually, this was the second time our dazed lineman endured these drills. Designed by psychologists Michael Collins and Mark Lovell of the Henry Ford Health System in Detroit, the battery of eight tests was part of an ongoing study that sought to gauge the long-term effects of concussions on college athletes. Since it began, 393 National Collegiate Athletic
Association Division IA football players have taken the tests in order to
track how quickly those who have sustained concussions recover their mental
faculties.
The results of the first data, which tracked 16 cases of concussions, were troubling. The data -- published in the September issue of the Journal of the American Medical Society -- indicated that players who endured multiple concussions may suffer long-term declines in brain functions. Even worse, players who had preexisting learning disabilities who sustained multiple concussions seem even more likely to suffer permanent impairments.
But most convincing of all is the data from those who reported two or more past concussions: Their initial baseline mental functionality tested markedly lower than that of their less-shook-up counterparts, who had reported sustaining only one or no past concussions.
"We found that athletes who had experienced two or more prior concussions in the past ... performed significantly worse in tests in our battery relative to those who reported having one concussion or zero concussions. The two-or-more concussion group had deficits related to speed of information processing. They were not processing information as quickly as those people who had one or zero concussions," says Collins. "It's kind of like your Pentium III computer becomes a Pentium II computer or your 486 becomes a 386."
Should college football players stop playing ball after one, two or three concussions? To be fair, the same question applies to any collegiate sport where concussions occur often. In addition to football players, soccer players and wrestlers sustain the injuries somewhat regularly. Still, football, with its nasty hits and unmatched explosive physical contact, is the king of concussion sports and thus a natural for concussion studies. According to Collins, about one in three college football players has experienced a concussion at some point during his pre-college or college career.
More people sustain concussions than you might think. The Centers for Disease Control and Prevention estimates that 1 million Americans with Traumatic Brain Injuries (TBIs) are treated and released each year from emergency rooms. Head trauma is a leading cause of disability in kids, adolescents and young adults. "It's an epidemic," says Joseph Bleiberg, a psychologist at the National Rehabilitation Hospital in Washington who is conducting a similar concussion study on the entire cadet population at West Point.
What exactly is a concussion? Think of the skull as an egg shell and the brain as the yolk floating within the egg white. If the egg shell gets spun or tilted but not shattered, the yolk inside is jostled. But outward signs that the yolk has moved are negligible. Similarly, the physical manifestations of Mild Traumatic Brain Injuries (MTBIs -- read, concussions) are so subtle that CAT scans and MRI machinery can't spot them.
The symptoms, too, are subtle and often pass beneath the radar. "There has been a tremendous misconception that a concussion is a loss of consciousness when an athlete gets knocked out," says Collins. "However, there are many other signs that someone has had a concussion, like confusion, dizziness, loss of balance, fine-motor-coordination difficulties, personality change, headache, nausea and vomiting."
And the players themselves are often in the dark. "Until I had mine, for me I can say I never knew exactly what a concussion was or what it did. I always thought you had to be knocked unconscious, like in a coma. I didn't know you could be coherent and think you were all right even though you really weren't," admits the Utah lineman.
As it is, many athletes are loath to sit out. "Most athletes expect to play injured because the injuries are orthopedic. They expect to play with a sprained Achilles' tendon or minor groin pull," says Lovell. "The problem is when they apply that logic to the brain, because the brain is not like a muscle you can tape up and play on when it's 75 percent. It is a non-renewable resource."
So given this new data on concussions, what is the responsibility of the NCAA -- a source of funding for some of Collins' studies -- and the universities to their football players?
In a few rare cases, Lovell believes athletes should not play. He claims that some "appear to be more concussion-prone than others." Still, Lovell and Collins believe that in most cases, the number of concussions matters less than the recovery time allowed. "If an athlete sustains a concussion and the brain is given time to recuperate, we don't feel there are going to be any long-term consequences ... in most cases. It's when the athlete sustains a concussion and then gets placed back in the playing field immediately thereafter [that] the brain jostles around more," says Collins.
The initial findings of the study leave room for debate here -- Bleiberg, the psychologist doing the West Point study, and others are concerned. "People who have had one concussion do OK. Once you have gotten two under your belt, you are starting to enter a different group of people," says Bleiberg. "The literature clearly pointed in that direction. The JAMA papers were the frosting on the cake."
In these groups that have sustained multiple concussions, after-effects are matters of degree -- rarely do they mean life or death. Forget images of punch-drunk Muhammad Ali with shaking fists clamped at his sides. Think instead of days when you just can't remember your locker combination, where you put your car keys. Or, for students, days when even easy answers to a physics test elude you -- a possibility that Lovell and Collins touch on in their paper.
"The real-life effects are a reduction in mental efficiency -- being unable to get as much mental work done per day as before. Getting tired more easily, being unable to concentrate for as long a period of time, making more mistakes," says Bleiberg. "You almost always can still do what you used to be able do, but the quality is not quite as good."
As it stands, far too little data exists for the NCAA to establish any specific guidelines on disqualification due to multiple concussions -- although each year, a few players do get disqualified for this reason. Soon, Collins' study may have the data to make these decisions more common.
At the very least, a concussion issues a wake-up call to many college athletes. "Right after it happened, I was a little scared. I didn't know what was going on. My mind wasn't working right and I didn't know what the feelings were I was having and why I couldn't think straight. Everything was so cloudy," says the Utah lineman.
The research has motivated several other college football teams to participate in the study. Both Collins and Bleiberg are working on easy-to-use computerized models of their test batteries that would allow psychologists to take baseline readings of thousands of athletes. Bleiberg even plans to distribute his test as freeware on the Internet so people can take it at home.
The players who stand to gain the most are the ones at the smaller Division II and III schools -- here trainers are likely to have less training in checking for concussions. Already the study has made a difference at the four participating schools. After taking the test, for example, the Utah lineman was held out for an additional two days.
And at Michigan State, the study helped trainers get a better idea of when a player should return to the field. "The study has helped us. Before, you went by the symptoms: headache, nausea, dizziness -- but they can go away. They said they felt fine and we would let them go back," says Michigan State trainer Sally Nogle. "Now we have a more sensitive test to check how they are functioning. There have been cases where we test them where we think, 'Hey this is not normal yet.' Hopefully it prevented the long-term problems."
And with studies like this, players might gain a better understanding of what hit them. "I don't know how many athletes I have worked with that have said, 'Doc, what's in the future. Am I going to have problems down the road? How many concussions are too many?' We don't have the information to provide to these athletes," says Collins. "That's really the impetus of the study."
Still, given the very slight risk of death and relatively low grade of concussion after-effects, it's likely that many players would keep playing after multiple concussions -- even with this new information. "I love the game of football. I don't think I would give it up even if I did have another concussion," says the Utah lineman. "But I would try not to get hit in the head so much."
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