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Raising Consciousness About Concussions

New Computer Test Makes NFL Teams More Savvy in Brain Injury Evaluation

By Tracy L. Ziemer
January 24, 2001

Former New York Jets wide receiver Al Toon described it like a cannonball hitting his head. A neuropsychologist likened the impact to that of a car accident.

They're talking about concussions -- jarring blows to the head that result in the brain being slammed against the skull and can lead to dizziness, memory loss and, in extreme cases, even death. When the Baltimore Ravens and New York Giants go head-to-head on Super Bowl Sunday, chances are good at least one player will sustain a concussion.

In a sport in which girth is good and a player proves his mettle by sustaining teeth-rattling hits, concussions are an increasing concern among league officials, doctors and players. That's why some NFL teams are beginning to use a new technology called ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing), to make them more savvy in evaluating brain injuries and to help them better determine when it's safe to send a player back in to play.

"It's something you don't want to play with," said Rick Burkholder, head athletic trainer for the Philadelphia Eagles, which began using ImPACT late in the season. "If you sprain an ankle, it comes back. If you hurt your brain, it doesn't come back. This is serious stuff."

Concussion Testing Goes High Tech

The American Association of Neurological Surgeons estimates that more than 250,000 head injuries in the U.S. are incurred while playing football at all levels, and that 10 percent of college players and 20 percent of high school players sustain brain injuries in any given season.

What was once known as just "getting your bell rung," concussions are now taken far more seriously as trainers and players get better educated in the long-term effects of brain injury. And because studies have shown that players who have suffered one concussion are at a greater risk to have another, doctors have tried to get a better handle on determining when it's safe to go back on the gridiron.

"I think we're becoming more scientific" about concussions, said Burkholder. "Before, sometimes you'd ask questions and they wouldn't be hard enough. 'Are you OK?' and the player would sayd, 'Yeah, I just had my bell rung,' and we'd say, 'He seems OK, put him back in.' There were no hard and fast rules, and then we'd see all kinds of problems down the road."

The American Academy of Neurology advises a 15-minute wait to return to play in even the mildest cases of concussion. During that time, team doctors and trainers will ask orientation and mental acuity questions of a player who's been slammed into the turf to check his mental awareness. Anyone who's had "a big-time hit," as Burkholder describes them, will have a CT scan to check for any bleeding or swelling of the brain.

ImPACT, the first computerized testing system to evaluate the severity of concussions in athletes, takes that testing one step further. The system also replaces a time-consuming written form of testing, taking NFL teams from the Flintstones' era to the Jetsons'.

Baseline Testing Provides Benchmark

Mark Lovell, Ph.D., the director of the Center for Sports Medicine Concussion Program at the University of Pittsburgh medical Center (UPMC Health System), and neurosurgery professor and Pittsburgh Steelers team neurosurgeon Joseph Maroon, M.D., teamed up to develop ImPACT. Currently, only the Eagles and Steelers use the computerized testing method while other teams still employ the paper and pencil version of the test.

"With concussions, we generally see a decline in memory performance and what we call a speed of information processing problem," explained Lovell. "I liken it to a Pentium 3 computer that's running as an old 386."

That's why concussion evaluations like ImPACT tend to focus on memory questions. NFL players and professional hockey players undergo neuropsychological testing before the start of each season. Such an evaluation is known as baseline testing and includes a neurological exam and short tests that measure short- and long-term memory, concentration and motor skills.

Once a player suffers a concussion during the season, he takes the test again 24 hours later. Those results and any follow-up tests are then compared with his baseline testing to give team doctors an idea of when a player has returned to normal and can play again.

The system replaces a similar paper and pencil evaluation that the Stellers began using more than a decade ago and which other NFL teams slowly adopted. Hailed as a promising advancement in dealing with concussions, the paper and pencil test is useful but has proved too expensive and too time consuming.

A series of paper tests can cost a team as much as $2,000 for just one football player, according to Burkholder. But ImPACT enables NFL teams to test all players for less than that. Testing that would otherwise take days now takes hours with a computer. Experts say ImPACT also tests players more accurately because it can better detect the speed in which players are answering questions and asks questions randomly to guard against memorization.

"Now, I have ImPACT loaded on four [computer] stations and can test a guy any time I want...The impact is that much greater," said Burkholder, who's been an athletic trainer for 14 years, including six years with the Steelers.

Hoge Case Raised Awareness

"When we started this research almost a decade ago, it really wasn't taken that seriously," said Lovell, who oversees the neuropsychological testing programs for the NFL and National Hockey League, plus 44 high schools that use ImPACT and a number of Division I-A college football teams nationally.

"A big turning point was in 1994 when Merril Hoge was injured," he continues. "He was part of our baseline testing program with the Steelers, so when he was injured while playing with Chicago, he came back to us for testing after the injury and we found a huge drop [in neurocognitive performance] after he was injured."

Hoge suffered a carerr-ending blow to the head in a 1994 game a few weeks after sustaining a concussion. Last summer, an Illinois jury awarded Hoge $1.55 million in a medical malpractice suit against a former team doctor who Hoge contended cleared him to play too soon after the first concussion. (Hoge is an analyst for ESPN. ESPN, like ABCNEWS.com, is owned by Disney.)

Concussions have been the quiet concern of the NFL and other sports leagues for some time, but have become a real health concern in recent years as concussions have forced players like Toon and Hoge to retire early. San Francisco quarterback Steve Young retired last summer after suffering his fourth concussion in three years, and Dallas Cowboys quarterback Troy Aikman recently suffered his 10th career concussion in 12 seasons.

The issue resonates even at the high school level, where more coaches and trainers are carrying card-sized guidelines for detecting concussions. The Brain Injury Association said it distributed 20,000 cards to coaches in Michigan, for example, so they have a list of concussion symptoms handy whenever a player goes down.

No matter the developments in equipment, experts agree there will always be concussions in sports, from soccer to ice skating to football. The risk, for some, does not outweigh the feeling of playing.

"We can never underestimate the drive for some of these kids to play," Lovell says. "We can build a better mousetrap in terms of equipment, but we can't expect it'll completely eliminate concussions."


Sidebar: Grades of Concussion
The American Academy of Neurology outlines symptoms for the three grades of concussion:

Grade 1
1. Transient confusion (inattention, inability to maintain a coherent stream of thought and carry out goal-directed movements).
2. No loss of consciousness.
3. Concussion symptons or mental status abnormalities on examination resolve in less than 15 minutes.

Grade 2
1. Transient confusion.
2. No loss of consciousness.
3. Concussion symptoms or mental status abnormalities (including amnesia) on examination last more than 15 minutes.

Grade 3
1. Any loss of consciousness, either brief (seconds) or prolonged (minutes).

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