Concussion series: Brain damage links documented

Educating coaches, media exposure bring more focus on prevention, treatment and return to action

cwhite@ledger-enquirer.comAugust 24, 2010 

This is the third and final story in a series on concussions and how sports organizations deal with the aftermath.

Chris Nowinski gained notoriety as a college football player at Harvard and became a celebrity as a professional wrestler.

But Nowinski is best known as an author and activist. His 2006 book “Head Games: Football’s Concussion Crisis” is often credited with bringing the long-term effects of the sort of head trauma regularly suffered by athletes to the national forefront, and his pleas for attention to the subject have drawn coverage from many of world’s largest media outlets.

Once Nowinski singled out the NFL in his book and was profiled on ESPN, interest began to grow. In 2007, New York Times sports reporter Alan Schwarz began chronicling sports-related concussions and their lingering effects on athletes, winning several prestigious awards while exposing the issue further. It did not take long for interest to spread. The NFL passed new rules regarding the treatment of concussions in 2007, the NCAA recently followed with similar guidelines and now the movement is trickling down to high school athletic associations.

“It’s exciting to finally see people moving in the right direction, said Nowinski, who wrestled as Chris Harvard and retired in 2004 after suffering several concussions. “It’s just going to take a little time and we’ll start seeing the results.”

Nowinski’s crusade to break open research and spread education on the issue didn’t stop with his book. In 2007, he and Boston University professor of neurosurgery Dr. Robert Cantu co-founded the Sports Legacy Institute to solve what it deemed the concussion crisis through research, education and prevention.

Nowinski’s group began pushing for further study of the few available brain samples from deceased athletes, including former NFL players, and is encouraging living athletes to donate brain samples after their deaths.

Nowinski hopes to get more information about the role of concussions and repeated impact on the brain. Both have been linked to chronic traumatic encephalopathy, a progressive degenerative brain condition. And in many cases, the brain samples show signs of extensive and premature aging or share qualities with samples taken from people with dementia.

Sparking interest

In some instances, a connection is being drawn between the damage done by concussions and an athlete’s death.

In 2006, Nowinski convinced the family of former NFL player Andre Waters to have a brain sample analyzed. Waters suffered several concussions during his playing career and fell into depression, a common symptom of concussions and similar brain trauma, before overdosing on painkillers. It was later found Waters suffered from CTE.

That finding led Nowinski to urge researchers to look at samples of the brain of former NFL offensive lineman Justin Strzelczyk, who exhibited what family and friends described as signs of bipolar disorder leading up to his death in a car crash after leading police in a high-speed chase in 2004. Nowinski suspected the changes Strzelczyk’s family saw and the erratic behavior leading to his death were signs of brain damage. Strzelczyk, too, was found to have had CTE.

Those first high-profile examples sparked interest in the topic.

“In 2006, nobody wanted to talk about athletes and brain damage, “Nowinski said. “When we started getting more brain samples from players who had CTE, like Andre Waters, then the media got interested. And once the media got interested, the conversation about this really began.”

Nowinski urged officials to examine a brain sample from professional wrestler Chris Benoit, who suffered multiple concussions through his wrestling career. Benoit killed his family before hanging himself in 2007. The examination showed such extensive signs of damage and dementia that one of the researches likened Benoit’s brain sample to one from an elderly Alzheimer’s patient.

It also came as no surprise to Nowinski that a brain sample from former Cincinnati Bengals player Chris Henry, who died in December after falling or jumping out of a moving truck during an argument with his wife, showed evidence of CTE.

And this month Nowinski began promoting new research from Boston University and the Department of Veterans Affairs that found repeated head trauma, including concussions, can lead to motor neuron disease, which includes ALS or what is often called Lou Gehrig’s disease. The researchers studied the brains and spinal columns of 12 people, including those of two NFL players, a professional boxer and a military member. Each was found to have CTE and three showed signs of motor neuron disease.

The findings showed proteins created by head traumas had traveled down the spine and led to the degeneration of motor neurons, causing conditions that could appear much like those of ALS. The study opens the door to the possibility Gehrig did not suffer from the condition named after him but instead from a similar condition possibly caused by head trauma. Gehrig is believed to have suffered several concussions in his playing career, and the research sheds some light on why former NFL players are diagnosed with ALS at a rate eight times higher than the general population.

Now more than 50 former athletes’ brains have shown signs of CTE and the latest research paints a grim picture of what many athletes are experiencing, a trend Nowinski said he hopes to find ways to curb for future generations of athletes.

“I just want to prevent bad outcomes for athletes, Nowinski said. “So many athletes are losing their careers to post-concussion syndrome and losing their long-term abilities to CTE. Somebody has to be speaking up about this.”

Prevention

While Nowinski is focusing on education, Vin Ferrara has devoted his career to prevention.

After being diagnosed with his first concussion as a seventh-grade football player, his mother told him he was done playing with the sport. He convinced her to allow him to play again, and he would conceal four or five more concussions through his playing career.

Like Nowinski, Ferrara played football at Harvard, where he started at quarterback. He was drawn to sports medicine after dealing with a torn ACL and several shoulder surgeries, and went on to earn degrees from Columbia’s medical and business schools after graduating from Harvard in 1996.

In May 2004, he combined his interests and founded Xenith with the intention of developing a new approach to preventing head injury.

“I just knew we needed better head protection, Ferrara said. “That was a piece of the puzzle. It wasn’t the whole thing, but it was a big piece.”

Xenith began producing helmets that feature a bonnet suspended in the helmet shell and surrounded by a series of air-filled shock absorbers. When impacted, the absorbers compress by releasing air at a rate linked to the force of the blow. Ferrara said he the idea was inspired by observing the way a nasal spray bottle’s nozzle used internal pressure to regulate the stream of medicine regardless of how soft or hard someone squeezed it.

Ferrara said the idea behind the innovation is to spread the impact of a hit over as much time and space as possible in the same way the driver of a car feels less force if he gradually stops a car rather than slamming on the brakes.

By finding a way to dissipate the force of a hit to the head, the brain is less likely to be moved or shaken in a way that leads to a concussion.

“The goal is to control how the head moves during a collision, and that’s a tricky thing to do, Ferrara said. “There most helmets fall short is handing low-energy and high-energy hits differently. Every kind of hit needs a unique response, and our challenge was to create a technology that could be adaptive to just about any kind of impact and by doing that prevent concussions.”

Columbus Lions general manager Jeff Gonos contacted Ferrara about the helmets after reading about them in a 2007 New York Times article written by Schwarz. Ferrara and a team of Xenith engineers came to Columbus to test early versions of the helmets on Lions players, and the team became one of the first to use them. The Lions still have about a dozen Xenith helmets in use and have had no reported concussions from players wearing them.

Monitoring

When it’s too late to prevent a concussion, new ways to monitor an athlete’s recovery are being created.

Several companies are producing computer software to tests an athlete’s reaction time and ability to think clearly while answering a series of questions. After several tests typically spread across several days, an athlete’s baseline score is stored.

After suffering a concussion, the test is taken again and the results are compared to the previous tests, giving a better understanding of how an athlete is progressing toward normal brain function.

Some of the earliest adapters have been hospitals and universities, including Columbus State.

Athletes from each CSU sport and the cheerleading team have been diagnosed with concussions, and CSU head athletic trainer and assistant athletic director Julio Llanos said the software has become a valuable tool.

“The series of tests give you a good idea of what someone’s baseline should be,” Llanos said. “Then the results are great at showing you what’s going on after a concussion. It makes it easy to track.”

Phenix City Schools purchased this summer a license from a company called ImPACT to test 500 of its athletes though its web-based system for about $1,000. Many Central-Phenix City varsity athletes, including the football team, have already been tested, and Phenix City Schools director of operations David Wilson said he hopes to have all district athletes tested this year.

“Our mindset behind this was pretty simple,” Wilson said. “Yes, we want our athletes to get back on the field. But probably the most important thing is we don’t want them out there if they’re not ready be there. Physicians are being very cautious of concussions, and this is just another tool to help them make the right decision.”

Wilson said Dr. Ritu Chandra, a pediatrician who first approached Central coaches with the idea of implementing the ImPACT system, is going through the certification process needed to interpret the computer results and will work with the school district in examining athletes.

Muscogee County School District system-wide athletic director Gary Gibson said he is interested in working with high schools and middle schools to purchase a license to test its athletes through ImPACT or a similar service, most likely through fundraising.

“It’s a really neat package that I think can really help our students,” Gibson said.

”Unfortunately, they’re expensive, but I believe there is a lot of interest in getting them in individual schools and that is something we may begin working on soon.”

The computer-based tests have critics, too. Dr. Jimmy Robinson, the Alabama football team head physician and the medical director for DCH SportsMedicine in Tuscaloosa, Ala., said he is wary of a for-profit company’s testing methods and fearful that a doctor or coach may lean too heavily on computer test results when assessing a concussion. Robinson said he prefers using physical examinations and verbal questions designed to test an athlete’s ability to think clearly when making a diagnosis.

“I think too many people are using these computer tests to clear people,” Robinson said.

“They figure that if they pass this test, they’re good to go. But if a neuropsychologist analyzed these kids, they might find they have more symptoms that a computer test didn’t find. It’s another tool to use, but we already have so many other things available that I think work better.”

Working toward a solution

Although the changes took some time to take root, Nowinski said research, education and technology are merging toward a solution.

“If this was 2009, I’d say there was a lot of work to do,” Nowinski said. “But luckily, in just the last six to eight months, every group from the NCAA to the high school organizations, has changed its standards, updated its guidelines and really started talking about the topic. We’ve already taken the first steps.”

Nowinski said the next steps are simple. Education comes first. The National Federation of State High School Athletic Associations offers a free online course that the AHSAA requires and the GHSA recommends its coaches take. Nowinski and Ferrara have written extensively about the importance of education and both took their arguments to the highest level when they were recently called to testify during Congressional hearings on concussions in sports.

Next is adapting practices and games to limit the chance of a concussion.

“You see there are rules now in football where there’s no longer head-blocking or intentionally hitting with the head,” Robinson said. “The NCAA has done a good job with those rules, it’s just a matter of enforcing those rules and I think we’ll see a difference.”

And finally, advances in head protection, such as Xenith helmets, come into play.

Ferrara agreed the issue has quickly gained ground with experts and laymen alike and said he was encouraged by the direction concussion education was headed.

“I would agree with Chris that there has been a sort of dramatic change in the last year, at least to those of us tracking the issue,” Ferrara said.

“I think the average person who has a busy life, it’s possible they haven’t become aware of it. But there’s a lot of awareness out there now that is getting spread in a thoughtful manner.”

Ferrara said it is unlikely concussions will ever be completely preventable, but he envisions a day when the risk of one is no greater in football than in soccer or basketball.

“I see an environment where coaches and administrators are adhering to certain philosophies, and perhaps that means they are all being certified by some group,” Ferrara said. “I think the issue of concussive episodes are largely addressable, and I’m optimistic that the old ways of thinking are being thrown out. I wouldn’t have gotten into this business if I didn’t think there was an opportunity to make a real change. We are definitely going to be relentless in changing it, and there are a lot of people who are like-minded who will make a difference.”

Chris White, 706-571-8571

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