‘An invisible injury’

Research shows concussions can have significant long-term effects

February 24, 2013


FAIRMONT — By the time Damon Waters started playing football at Fairmont State University in 2009, he already had suffered three concussions as a high school ath­lete at Grafton, one of which was a helmet-to-helmet hit with another boy that resulted in a 5-second black­out and a feeling of confusion for the rest of the game.
“I had a tingling sensation down my spine and through my hands and feet,” said Waters, now a senior at Fairmont State. “I didn’t say anything to any­one. I tried to keep playing.”
“As the game progressed, I just had horrible confusion. I wasn’t sure where I was.”
During his three years of playing at Fairmont State, he experienced another three con­cussions. During one game in the spring of his redshirt fresh­man year, he landed on his head twice. Even before the second hit, he felt foggy, but did not tell anyone.
The second concussion was not as bad, but he felt dizzy right away and let the trainers know immediately.
“I was pulled out early as soon as it had happened,” he said. “I knew what had been done.”
Then, last spring, Waters wanted to cut block a defensive lineman and got a knee to the head.
He brushed it off and went home, where he began to have a terrible migraine headache. Things did not get better when he met with his family for lunch at a restaurant, and when Waters realized he had no appetite, he knew that was a hallmark of his previous concussions.
His growing headache and nausea did not help, and so he called Bob Cable, Fairmont State’s athletic trainer, who told him to go to the emergency department at United Hospital Center to get a magnetic reso­nance imaging (MRI) test.
Waters was diagnosed with his sixth concussion and soon had an appointment with Dr. Russell Biundo, a physical medicine and rehabilitation specialist who deals with, among other ail­ments, brain injuries.
And about a week after that, Waters decided he no longer would play football. Now a sen­ior on a five-year plan, he has a double major in accounting and Spanish and a minor in informa­tion technology.
“I knew I wasn’t going to go pro, and I knew I was going to need a professional career path,” Waters said. “I would need my brain for the rest of my life. So I met with the head coach and Bob Cable, and we were all in agreement that it wasn’t in my best interest to play anymore.”
While Waters was playing football in high school, research was emerging indicating that concussions could have long-term effects, especially on ath­letes who suffer several blows to the head during the course of their sports careers.
“We see more and more con­cussions than in the past in chil­dren and adults who play sports,” said Biundo, who prac­tices at UHC and also serves as an assistant clinical professor of orthopedics at the West Virginia University School of Medicine.
For a long time, athletes thought that getting knocked in the head was “part of the game. It was a normal thing. Now there is such an awareness of it, and we’re getting patients because of it,” Biundo said.
In Biundo’s practice, the ath­letes he treats have a milder form of traumatic brain injury than someone who, say, has been in a serious car accident.
But in recent years, several high-profile athletes have suf­fered violent deaths, often at their own hands, and repetitive brain injuries have been targeted as contributing factors.
One of the latest cases was linebacker Junior Seau, who played for the San Diego Chargers, the Miami Dolphins and the New England Patriots in a nearly 20-year football career.
Last May, Seau was found dead of a self-inflicted gunshot wound. His family donated brain tissue to be studied at the National Institute of Neurological Disorders and Stroke, part of the National Institutes of Health. The NIH did not release any information about what was found, but in January, Seau’s family, who say his brain showed signs of trau­ma, sued the National Football League (NFL), which conducted a study in 2007 on the long-term effect of concussions.
Many of these athletes have received a post-mortem diagno­sis of chronic traumatic encephalopathy (CTE), defined by the National Institute of Institutional Health and Safety (NIOSH) last September as a neurological disease that can occur years after exposure to repetitive concussive injuries, in a report on the website of the Center for Disease Control and Prevention (www.cdc.gov).
CTE can lead to symptoms similar in neurological diseases such as Alzheimer’s and Parkinson’s Disease.
“Muhammad Ali, he’s a clas­sic person who has cumulative damage,” Biundo said. “Even though you may recover from a concussion, you may have a brain injury, and the more you are injured, the more severe the brain injuries can be. Another injury makes it more difficult for you to recover because the brain is losing its resiliency. It’s a cumulative effect.”
Biundo and his colleague, Dr. Peter Alasky, a sports medicine physician at UHC, treat athletes with concussions to make sure they do not go back to their sport until they are ready.
Concussions generally are identified by symptoms as opposed to an X-ray or an MRI, said Alasky, who also serves as a volunteer team doctor for the Fairmont State football team.
“It’s an invisible injury, based on a clinical diagnosis,” he added.
Doctors and athletic trainers should assess four functions of the brain after an athlete has suf­fered an injury that might result in a concussion, Alasky said.
They are:
• Physical — “Either they have a headache or they feel dizzy or they just don’t feel right,” Alasky said.
• Cognitive — “That affects their thinking. They feel like they are in a fog or they feel slow.”
• Emotional — “They may feel sad or depressed.”
• Sleep problems — “They may have insomnia or say they weren’t able to sleep.”
Doctors also should check to see if the athlete has problems balancing.
“A patient only needs to exhib­it only one of the domains to be diagnosed with concussion,” Alasky added.
The “cure” for a concussion is to rest and avoid returning to a sport before a full recovery.
“The reason we want to be conscious of that is second-­impact syndrome,” Alasky said. “That’s what they are trying to prevent. It’s a rare thing that hap­pens, but it’s actually where if someone goes back too early, their brain starts to swell because it hasn’t healed. The brain can herniate through the skull and the person can die.”
Alasky referred to Zackery Lystedt, who was injured during a football game at the age of 13. He stayed in the game and even­tually collapsed, according to information on the CDC’s web­site.
He spent three months in a coma and the state of Washington, where the injury took place, eventually passed a bill in his honor. The Lystedt Law attempts to protect young athletes from returning to a game too soon by requiring written per­mission from a medical profes­sional before an injured athlete can return to the game.
Cable, the Fairmont State ath­letic trainer who worked with Damon Waters, has seen a lot of changes in how concussions are regarded during his 23-year career.
“The more research that is done, the more we realize the damage that is being done with a severe blow to the head,” Cable said.
Cable has followed the find­ings of an acquaintance of his, Dr. Julian Bailes, the former chairman of WVU’s department of neurosurgery in the School of Medicine. Bailes has been one of the leaders in diagnosing CTE in deceased athletes.
“We had a situation that occurred here with a young man, a baseball player who misjudged a fly ball and got hit in the head,” Cable said.
The player had suffered other concussions as well.
“He spent a year being observed by Dr. Bailes,” Cable said. “It took him almost a year before Dr. Bailes felt comfortable with him playing.”
And while football has gotten a lot of attention as a sport where the players suffer concussions, Cable has seen it in many others as well.
In fact, earlier this month, a member of Baylor University’s acrobatics and tumbling team fell off of a pyramid while competing at Fairmont State and had to be taken to UHC.
“She was dropped in a warm-up and received a blow to her head,” he said. “She had to go to UHC to be looked at and had to be cleared to fly home.”
He also remembers a football player that he took out of a game. “He stood on the sidelines and threatened to beat me up.”
The player’s injury caused him to act in an aggressive manner, although later, he did not remem­ber what he said to Cable, the athletic trainer said.
“When it was all over, he was sorry about it,” Cable said. “To this day, we laugh about it.”
But Cable knows concussions are no laughing matter, and he welcomes the guidelines that have emerged that help coaches and athletic trainers deal with an athlete who has been injured.
Now Fairmont State uses return-to-play guidelines that, once an athlete has become asymptomatic for a concussion, has the player doing a little more each day and building back up to re-enter the sport, as long as he or she remains asymptomatic.
Different organizations have come up with return-to-play guidelines, including the Sports Legacy Institute (sportslega­cy. org), which was founded in 2007 in Boston by Dr. Christopher Nowinski and Dr. Robert Cantu in response to the growing number of athletes suf­fering brain trauma in sports.
When players first get injured at Fairmont State, Cable or a col­league will ask questions such as, “What is your name?” “What is the score?” and “What time is it?”
“Then we go back and check for retrograde information: ‘What time did you get up this morn­ing? “What time did you get to the facility this morning?'” The presence of other symp­toms also help make a diagnosis.
“If they have headaches or blurred vision or anything like that, we’re going to err on the side of caution,” Cable said.
And after players have been cleared to return to a sport, they do that gradually.
To start, “We give them a 15-20 minute workout, and the first thing we do is change the level of their head. We make them do something like squat thrusts or push-ups, something where the head is up and down and chang­ing levels.”
The athlete also might spend five or 10 minutes on a treadmill or an elliptical machine in order to work up a sweat.
“If they continue to be asymp­tomatic for another 24 hours, we progress to where we will do a more sport-specific stuff like jog­ging or running, or if it’s a bas­ketball player, light shooting.”
That goes on for maybe half an hour to 45 minutes, and then once again, they wait for 24 hours to see if the athlete remains asymptomatic.
“It’s a step-by-step process,” Cable said. “For seven days, they each do a little more. And if all goes well, on the seventh day, they do a full-scale practice and they should be able to play with no limitation.”
The NCAA also has weighed in with information on its web­site, www.ncaa.org, including a fact sheet for coaches, outlining signs and symptoms to look for; and a fact sheet for athletes and what they should do if they believe they have suffered a con­cussion.
In Damon Waters’ case, Cable supported the student’s decision to end his football career after experiencing three concussions in high school and then three more in college.
“That’s a problem we see in college,” Cable said. “There are so many high schools that don’t have athletic trainers that are on the field during the game who can ID a concussion and do the tests to determine if the athlete has one. They say, ‘Oh, you’ll be all right.’ Then they come to col­lege and we find out there are four concussions before they come to us. It becomes a concern for us, absolutely.”
Waters has not decided what he will do after he graduates in 2014. He works out at the gym but avoids contact sports such as football.
“I feel fine,” he said. “I haven’t had a blackout period in a while. I don’t feel like this will be long-term at all.”