The Scarsdale Inquirer – Hometown newspaper of Scarsdale, New York 10583

Scarsdale Inquirer/Jim MacLean

Dr. Dennis Cardone of the NYU Langone Medical Center presented information on lingering symptoms of concussions during the “Head Injuries and Concussions in Sports: What You Need to Know” lecture at Scarsdale High School last month.

By TODD SLISS

Scarsdale sophomore Caroline Knapp is a typical student-athlete who excels at field hockey and lacrosse. She’s a hard worker, an intense player and a fun-lover. And like most athletes, she did not report the symptoms of what she would later find out was a concussion she got from being hit in the head with the lacrosse ball at an away game April 10.

A concussion occurs when the brain hits against the skull, shakes violently, swells and has other negative effects on the body. Dr. Gerard “Rusty” Varlotta of Scarsdale and the NYU School of Medicine, who ran the “Head Injuries and Concussions in Sports: What You Need to Know” lecture at Scarsdale High School last month, calls it a “mild traumatic brain injury” that has become a “silent epidemic.”

Only a few people on the field realized Knapp had been struck that day, and she got back to work against Greenwich Academy. She finished the game. She never complained. The next day, she told her parents she had been hit and had a headache. Like their daughter, they didn’t think much of it and Knapp went to school and practice the next day. Finally when she couldn’t make it through practice, she fessed up that not all was right with her.

In Knapp’s words:

“It hurt a lot. I was kind of in a daze for the rest of the game. I remember trying to refocus a lot and I would get frustrated when I would mess up something simple. At the end of the game I was like, ‘Wow, my head really hurts.’ I just didn’t think much of it, maybe just a bruise.

“Then in the morning I couldn’t get up. I was like, ‘There’s something wrong here.’ I was just lying there. It was kind of scary. Then when I finally got up everything was a lot slower. My thought process was a normal pace, but trying to speak, it took an extra second for it to come out, which is very scary.

“I actually played in practice that day and I got very nauseous, my headache got a lot worse. Then I sat out the rest of practice.”

Knapp told the coaches what she was feeling and went to the doctor that night. The doctor told her it was a concussion.

Did she not know the symptoms of a concussion? Did she not care? Was she trying to be brave? Perhaps a little of everything. Now she understands the ramifications of continuing activity with a potential head injury. Another blow to her head could have killed her or set her on the path for problems throughout her life.

The number 1 problem, according to many of the medical and non-medical professionals who spoke last month at the high school, is that most concussions are not reported or diagnosed, and therefore athletes can do further damage to themselves both mentally and physically.

One of the high school’s trainers, Brandon Schmitt, who works closely with long-time trainer Tim Tyler, discussed on-field management of concussions at the lecture. If it is suspected that an athlete has a concussion, the vitals are checked first, then the spine if the athlete can’t get up. Next is the disposition of the athlete. Schmitt said that knowing the athlete can help make a better diagnosis.

What to look for:

• Physical symptoms: headache, visual problems, dizziness, noise/light sensitivity, nausea/vomiting, balance problems, numbness/tingling

• Cognitive symptoms: fatigue, fogginess, drowsiness, difficulty concentrating/remembering, cognitive slowing

• Neuropsychiatric: more emotional, sadness, nervousness, irritability

• Sleep (not on field, but determined within the next 24-48 hours): difficulty falling asleep, sleep more/less than normal.

Schmitt noted that amnesia is seen in only 20 percent of concussions and a brief (30 seconds or less) loss of consciousness is not always a symptom. Also, girls are twice as likely to suffer concussions as boys playing the same sport, which is one of the many mysteries of concussions.

Schmitt said — and medical doctors later agreed — that the best predictor is “fogginess,” “or the inability to concentrate.” In Scarsdale a SCAT2 test is administered to determine the response of the athlete through several cognitive and physical tests. Schmitt noted that ImPACT testing, where athletes are tested before the season to establish a baseline, can be helpful to “avoid a premature return to sport.” He called it “a more objective measure,” though again, it’s not flawless.

In November 2008, the third International Conference on Concussion in Sport was held in Zurich and guidelines for easing recently concussed but symptom-free athletes back into action were recommended. Schmitt went through the steps at the lecture:

1) no activity — test until asymptomatic

2) light aerobic exercise

3) sport-specific training

4) noncontact drills

5) full contact-drills

6) finally, game play.

If there is any return of symptoms at any time, the athlete must start from the beginning again. The process, when uninterrupted, would take at least five to seven days, though doctors urge that all decisions be on a case-by-case basis.

Schmitt said educating the parents on continuing the evaluation for the next day or two is key, and that being “vigilant” is important.

On Monday, April 23, almost two weeks after her concussion occurred, as part of being eased back into action, Knapp rode the stationary bike for 12 minutes before she started getting nauseous. She was told to stop and now she must wait until symptoms subside before she starts the process over again. It is possible — by no means a given — that had she come out of the game immediately and been checked out, she could be back in action already, or at least closer to it.

By the law

Expected to pass through New York State Legislature in July is the Concussion Management and Awareness Act, which requires all schools to have a plan in place to deal with serious brain injuries and to educate communities about the dangers.

SHS athletic director Bob Siracuse, trainers Tyler and Schmitt and school nurse Karen Steefel are preparing a concussion management team, which would also include the school physician and principal.

“This is a new thing statewide,” Siracuse said, but while some schools have plans in place, few districts have policies regarding concussion management. “There is a return-to-play piece to this and it’s all recommendations from the state, so no one is working blindly, which is nice. They’re giving you lots of information from medical doctors’ input based on science.”

Educating the public, the coaches and other medical experts was the goal of Varlotta’s concussion discussion. A big component, as officials are learning, is educating the athletes, too.

Athletes need to understand the potential seriousness of a head injury and be completely honest about how they feel, Schmitt said. “If they don’t get that component, the honesty, then you can run into some trouble,” he said. “You can have an athlete sustain a concussion without any objective symptoms. Subjectively they may have a headache and dizziness and nausea, but you can’t see those things. They have to be reported by the athlete, or there’s no way to tell.”

Siracuse brought up another potential issue — the school can only base its decisions upon what happens at high school games and practices, not at any outside activities. (And as one doctor pointed out at the lecture, concussions can occur outside of athletics, too.)

“If the kid is in a club program in whatever sport it is and if they don’t report it to the school, that’s going to fall through the cracks,” said Siracuse. “You can only recommend to the parents and the kids that if something happened they have to let us know so we’re in the loop.”

Who will have the final word on clearing students to play? Will it be the school physician? The athlete’s physician? Any physician who will clear the athlete to play? That was something that at the lecture 1986 Scarsdale graduate Alan Schwarz, who has covered concussions and NFL extensively for the New York Times brought up. He called it “shop-a-doc,” a practice that disgusts him.

The medical experts

Dr. Dennis Cardone of the NYU Langone Medical Center followed Schmitt’s speech with a list of late symptoms that can pop up for days or weeks: persistent low grade headache, light headedness, poor attention and concentration, memory dysfunction, easy fatigability, irritability and low frustration tolerance, intolerance of bright lights or difficulty focusing vision, intolerance of loud noises/sometimes ringing in ears, anxiety and depressed mood, sleep disturbance.

Among the points he highlighted were: the importance of an “individualized approach to each athlete,” with age, gender and severity taken into consideration as there is no real way to predict who is at risk for worse injury and recovery time. Certain younger kids are not as developed and parents were urged not to put them in harm’s way. One parent with a child under age 10 asked about her son doing mixed martial arts; the consensus was that it was too dangerous for young kids.

There is great danger, Cardone said, in taking another blow to the head before the previous concussion is healed. When the brain is still swollen from the previous injury, there may be nowhere for the brain to go after another blow. The second blow could be fatal.

“We understand concussions better than we did five years ago, than we did 10 years ago,” Cardone said. “But, boy, oh, boy, we still have a long way to go to finally understand how to really protect our athletes best.”

Dr. Barry Jordan, a neurologist at Burke Rehabilitation, has experience working with boxers and is on the NFL Player’s Association’s brain and head injury committee. He noted that there are more severe and more serious head injuries, but concussions are the most common.

According to Dr. Jordan, the Center for Disease Control estimated there are 300,000 concussions are year, 100,000 in football. They are more common for younger players and those who have had previous concussions and those who already suffer from migraines. And once you’ve had one, it can take less impact to cause another, and longer to recover.

When it comes to heading a soccer ball — a popular question among parents — Dr. Jordan eased some minds when he said, “My clinical opinion is that when you keep things at a lower exposure, I think your risk of having long-term problems is going to be a lot less.” He said it’s “relatively safe for kids to head the ball above a certain age. I don’t think anyone has scientifically determined what is the appropriate age, but the key issue is that they have proper instruction.”

While more is being learned, he said, rule changes to make games safer, improvements in protective gear, education, proper medical coverage and research are all important.

By the time the final speaker, Dr. Steven Flanagan of NYU Langone and the Rusk Institute spoke at the panel discussion, there wasn’t much left that had not been covered. He did say that the big controversy for over a decade is that there is no real definition of a concussion, though he noted that “change in mental state” seems to be the common denominator. He said there is no blood test or CT scan or MRI to test for it.

During the final Q&A at the lecture, one parent asked about the risk and reward, noting that what he had heard that night added up to “an enormous amount of risk overshadowing the enormous amount of reward.” He asked everyone on the panel if, knowing what they know, would they let their kids play contact sports like football. All who answered said, yes, they would, as long as the conditions in games and practices were safe.

Attendees had been shown slices of brains that were brown in spots instead of white, indicating problems throughout — these were of the afflicted NFL players and also of Alzheimer’s patients. But no one walked away from the discussion knowing how much it might take for an athlete to get to that point. Again, it depended on the patient, but it was clear that years of abusing the brain would be detrimental to an athlete on and off the field.

A female student stood up at the end and said, “As a student-athlete at Scarsdale High School, I’m a senior and I’d have to agree with a lot of what is being said. There aren’t a lot of precautions taken by coaches at the high school and there’s a lot of pressure from coaches to get back into the game. I’ve played a variety number of sports and I’m not singling anybody out, but what would you suggest to maybe Mr. Siracuse, or other heads of the sports departments at the school to advise coaches to stop pressuring children or high school students to get back into the game?”

Dr. Jordan responded that coach training would be part of the new legislation. “That’s not going to solve all the problems, but that’s a good first step,” he said.

Dr. Flanagan added, “I would say one of the really good things about tonight is that we increased awareness about concussions … I think we all realize that there are a lot of good things that our young adults and kids can learn through team sports as long as it’s done in a healthy and a wise way … Our job here and yours as well is to listen to the education we’re providing so we can make things safer for our kids. I think that’s what we’re all here for tonight.”

Dr. Varlotta said he created the program to educate, not create panic. He opened the program by saying, “There is no condemnation in any of these talks of contact sports or collision sports. I’ve played ice hockey for 48 years now and I take care of professional boxers, so I’m not opposed to contact sports, but I do want to make sure there is safety within the participation and that we know what we can do to save people from having significant brain injuries over time.” Varlotta said that the idea was to “eliminate fear of the unknown.”

The wrestler and the writer

Chris Nowinski started off the lecture with a bang. The former All-Ivy defensive tackle from Harvard football turned WWE wrestler never realized that all his medical problems resulted from at least six undiagnosed concussions he suffered as a wrestler — despite matches being scripted — and did not report or lied to medical staff about, instead dealing with pain and his altered mental state. He finally saw Dr. Robert Cantu, who traced the root of the problem to 2003 when Nowinski was 24.

It turned out that Nowinski had not rested after his head traumas and therefore suffered for years afterwards. He finally quit and took on the concussion cause, writing a book called “Head Games” in 2006 and later founding the Sports Legacy Institute at Boston University with Dr. Cantu.

Nowinski began tackling the NFL by challenging with a belief that some of the problems players were having were due to chronic traumatic encephalopathy or CTE. After Dr. Bennet Omalu of Pittsburgh did autopsies on two former NFL players, Mike Webster, 50, and Terry Young, 45, it was discovered both had CTE. Young’s actually led to his suicide. A coincidence? According to Nowinski it was big news; according to the NFL it was nothing. Then Andre Waters, whom Nowinski knew, committed suicide in 2006. Nowinski called Waters’s 85-year-old mother and she agreed to allow a brain test, which came up positive for CTE. This was no longer just a boxer’s disease, referred to as “punch drunk.”

Nowinski contacted Schwarz, who was then a senior writer for Baseball America, but who had freelanced for The New York Times. On Jan. 18, 2007, Schwarz published his first Times piece about concussions and the NFL, which focused on Waters. He thought it would be a one-and-done topic. It wasn’t, and he, too, made a name for himself covering what he saw as an alarming trend, earning a Pulitzer nomination joining the staff of the Times.

Nowinski has helped get over 100 brains in the brain bank for study and over 500 other ex-players have pledged their brains to the bank when they die. Unfortunately, it is a condition that can only be discovered post-mortem. Dave Duerson of the 1986 Bears left a suicide note saying, “Please, see that my brain in given to the NFL’s brain bank.”

At that point the brains studied were 4 for 4 for CTE.

“If we think this is dangerous to adults, we cannot be asking our children whether or not they want to play,” Nowinksi said. “We have to decide what we’re going to expose them to and we’re going to have to decide the rules by which we play.”

Schwarz started getting calls from other former NFL players who were suffering. He continued telling their stories and “then basically all hell broke loose.” Perhaps the most disturbing thing was the NFL’s and the players association’s denial that playing football and CTE were even remotely related. Of course, Schwarz and Nowinski could not prove the cause, but they certainly had solid ground to stand on.

Schwarz, a self-proclaimed “math geek” who was inspired at Scarsdale High School by Robert Conte — “He was my hero,” Schwarz said — and had planned to become a math teacher before going into journalism, decided to look into the numbers himself. After all, going 4 for 4 with the autopsies was alarming.

“It doesn’t matter how many healthy former players there are,” Schwarz said. “What matters is how many players with the disease there are and what the percentage is.”

The NFL did in fact reach out to former players diagnosed with dementia for its own private study that was leaked to Schwarz. In the report was the fact that ex-players over age 50 were about six times more likely than the national population, and from ages 30-49, 19 times more likely to be suffering from dementia.

“We recognize this not as an NFL issue, but as a public health issue that was greatly affected by what happened at the NFL,” Schwarz said. He also said, “If you handle your children correctly or your players or your patients correctly, a lot of this stuff does not need to happen. It’s very preventable.”

The showdown

Most of Nowinski’s lecture focused on his own story and those professional football players — living and dead — who were suffering from dementia and Alzheimer’s symptoms from undiagnosed injuries, play that is perhaps too rough and letting pride and money get in the way of their safety. But what audience members really wanted to know about is how this would affect kids who would likely not be playing past high school or even college, which is a majority of the population. Do they not engage in collision sports? (That doesn’t leave many options.) Do they stop playing after one concussion? Two?

Unfortunately, the doctors do not have answers to many of these questions. Yet.

Nowinski had to leave early, so he not only spoke first, but took questions before he left, while the rest of the panelists took questions as a group at the end of the program.

Trainer Tyler was granted the final exchange with Nowinski, and it turned sour, fast. “You sure scared a lot of people tonight,” he told Nowinski. “What you didn’t show is a lot of the data out there that shows that there’s a heck of a lot of people that played youth football that don’t have problems, that don’t have this post-concussion syndrome.”

Tyler went on to say that when his own daughter heads a soccer ball three times in a game she might have a headache and ringing in her head and ears and asked, “Should I keep her out of the game because she has concussion symptoms?”

Nowinksi was taken aback by the question and said, “Yes! Are you serious?” About a minute later after they exchange some more words, Nowinski handed the microphone to Varlotta and said, “I’m gonna go back to Boston,” and left before Tyler could have a chance to explain himself.

There was a certain amount of tension in the air for the rest of the presentation.

Later Tyler came on stage and said, “As you heard, I’m not an expert in concussions; I’m certainly learning a lot here like the rest of you tonight. But in my 15 years here at Scarsdale High School I have never, ever, ever put an athlete of ours into a game with signs and symptoms at all of a concussion and we continue to do that. And I would not put my daughter in if she had signs of a concussion either.”

He further explained himself this week: “I think that every time a kid has a headache, it’s not a concussion,” Tyler said. “It needs to be evaluated to see that it’s not. That guy really scared a lot of people and I don’t want him to scare a lot of people into not playing sports. That was my point. There are a lot of great benefits to sports. Kids can die from going back into a game from having a concussion and having their brains bleed. But we tell kids that. When kids lie about their symptoms, that’s why we need ImPACT testing at Scarsdale.”

Tyler admitted that his question and comments to Nowinski “didn’t come across very well,” adding, “We all make mistakes and my words were my mistake, not my actions on the field.”

Tyler said that Scarsdale coaches are instructed at the beginning of every season about concussions. He added, “We need more student-athlete education on concussions, too, and that’s part of the new policies and procedures that the board of ed is going to implement.”

He also pointed to his own experience back in 2002 during a sectional football game at Brewster. “The middle linebacker comes off and he has a headache and he is foggy, he is dizzy,” Tyler said. “I evaluated him. I gave him words and he couldn’t remember the words. All of the sudden the father is with me pressing to put him back in the game and I totally refused to put him back in the game. I went and got Mr. Menna and Dr. McGill (the athletic director at the time and the school superintendent). Concussions scare me.”

And now they scare a lot of others, too.

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