Closed Head Injuries in Football

When his eight concussions in nine NFL seasons forced New York Jets wide receiver Al Toon to retire on November 27, 1992, the event was overshadowed by another, arguably more serious injury.

Two days later, in a contest between the Jets and Kansas City Chiefs, teammate and defensive end Dennis Byrd suffered a fractured vertebra when he collided violently with teammate Scott Mersereau, leaving Byrd partially paralyzed and requiring surgery to stabilize his spine.

The lack of national media coverage given to Toon's forced retirement did not, however, lessen the seriousness of the post-concussive effects endured by the player. Headaches, nausea, dizziness and bouts of vertigo, all left Toon-a three-time All-Pro selection-shaken, emotionally as well as physically.

Despite the relative minor impact that had caused the blow, Toon's post-concussion symptoms lingered longer than in past episodes. According to published reports, for days following his last concussion, Toon found it hard to read, watch television or simply concentrate for extended periods of time.

While today the effects of the post-concussive symptoms may take less of a daily toll, Toon still suffers the aftershock of so many devastating blows. "I've been very fortunate to get back to where I am," the soft spoken Toon says from his home in Madison, Wis.

"I'd say that for all practical purposes my recovery would be deemed successful considering where I was shortly after my final concussion in the league. I still have concentration problems, sensitivity, irritability sometimes. It's just something that apparently I have to deal with. Things have gotten better."

Pittsburgh's Merril Hoge

Like the fortunate Toon, other players-Merril Hoge, Chris Miller, Don Beebe and Troy Aikman-have escaped apparently unscathed from life-threatening injury. In the NFL, a game where players often get knocked unconscious, no one has died from a blow to the head. Not yet, anyway. Concussions though, are mysterious entities. Not fully understood by players, or by the medical authorities who study them.

Several high school athletes haven't been as fortunate as Toon, Hoge and Miller-all of whom have been forced to retire from the game they loved. Younger athletes often conceal from their coaches the lingering effects of a blow to the head. These athletes continue to play-unaware what they are doing is not only foolish but perhaps deadly.

Take, for instance, the case of high schooler Adrian Guitterez. A running back on the Monte Vista (Colo.) High football team, Guitterez suffered a concussion and then returned to play two weeks later before he was asymptomatic.

Concealing his post concussion symptoms from coaches, Guitterez played and, in doing so, put himself at serious risk for second-impact syndrome (SID). Following a tackle early in the third quarter, Guitterez became disoriented and collapsed. He died five days later.

Like Toon's forced retirement, many of the issues related to closed head injuries-including their serious and sometimes irreversible after-effects-have simply not received the media attention they deserve. Three notable incidents during the past NFL season have heightened the media glare around the phenomenon.

Beebe, Stan Humphries and Steve Young all suffered severe concussions. For Young, it was his third concussion in 10 months. While Young and Beebe returned to play within weeks of their head injuries, Humphries' symptoms lingered. All should be considered fortunate.

Concussions affect individuals differently. No one can predict how long post-concussive side effects will last. Perhaps as a result of the severity and popularity of the three players mentioned above, public awareness has raised.

Perhaps now we are at a level where the seriousness and magnitude of the closed head injury phenomenon no longer can simply be pushed out of the spotlight. Perhaps now we are at a point where something will be done to prevent further injuries.

Based primarily on the estimations of some of the NFL's top brain injury experts, it is conceivable that anywhere from 450 to 600 concussions, as most brain injuries are classified, have occurred since the time of Toon's retirement. That breaks down to approximately one every two or three games.

Of course, this estimate cannot accurately reflect the total number of concussions, especially with all the "dings" and "bell ringers" that go unreported.

Studies done at the high school and collegiate levels estimate that anywhere from five to 20 percent of the 1.5 million participants suffer concussions annually.

"And so the message is don't block and don't tackle with the head. You're asking for trouble both for the head and the neck if you do."
Dr. Robert C. Cantu

According to reports, brain injuries are the number one cause of death in all sports-not solely football. In Education Digest, Ken Schroeder suggests that injuries to the brain account for somewhere between 65 to 85 percent of all football fatalities.

Depending on whose figures you choose to believe, football is responsible for anywhere from 100 to 250,000 concussions annually. Moreover, studies also have proven a player who experiences a concussion becomes at least four times as likely to experience another subsequent concussion.

Further clouding the discussion and analysis of the closed head phenomenon is the fact that there is no one clear-cut definition of what a concussion is or how to determine the seriousness of a particular concussion, nor are doctors in agreement on the manner in which athletes should be allowed to return to play.

The bottom line is that concussions are confusing and potentially deadly.

What Is a Closed Head Injury?

Any discussion concerning closed head injuries would be incomplete if it weren't just a little bit confusing. The very nature of the injury is nebulous. But what exactly is the difference between a closed head injury and a concussion? One of the most noted authorities on the subject, Dr. Robert C. Cantu, Chief of the Neurosurgery Service at Emerson Hospital in Concord, Massachusetts, described the nearly synonymous relationship between the two.

"When we speak of closed head injuries (as a whole), we really mean those kinds of injuries to the brain in which there is not structural evidence of any bleeding or disruption of brain tissue," Cantu said.

"More than 90 percent of all athletic head injuries are concussions, and so concussion is by far and away the most common athletic head injury and the most common athletic closed head injury.

When asked what happens when a player suffers a concussion, Cantu explained it as a "transient alteration of nerve function."

"You can think of the nerve cells as being stunned. Sometimes there is actually microscopic damage, in which there is some tearing and death of nerve cells and tearing of the nerve fibers from cells so that they're never totally repaired."

Because the brain, like the spinal cord, is incapable of regeneration, once these nerve fibers and cells tear, they cannot and will not return to their former state. What's gone is gone.

"Some common types of brain injuries we would not refer to as closed head injuries would be things like an epidural hematoma, a subdural hematoma, an intracerebral hematoma, or a subarachnoic bleed, or a massive stroke," Cantu says. These are things where there are structural problems that have been shown within the skull going on in the brain that have led to problems."

Often grouped as catastrophic brain injuries, the aforementioned injuries which Cantu speaks of all involve bleeding. Unless there is bleeding or some other form of structural abnormality, a CAT scan will not detect a concussion-hence, part of the problem with detecting them.

While a concussion remains the classic example of a closed head injury, the actual defining of what constitutes a concussion has undergone a significant redefinition since 1994. At that time, the standard definition of a concussion was "all over the place," according to Dr. Elliot Pellman, a team physician for the New York Jets and head of the NFL subcommittee on mild traumatic brain injury.

"When I saw a player in consultation that year for mild traumatic brain injury, a well-known chairman of neurology, from Los Angeles, wrote down in his notes that his player did not suffer a mild traumatic brain injury because he did not have loss of consciousness. And that was indicative how far astray everyone in the medical community was (at that time). Those of us who saw these injuries the most realized it was not true, but yet no one had really changed the definition."

Since 1992, the process of defining concussions involved the launching of an all-encompassing study by the league to determine both the extent and severity of the problem. According to Pellman, this study served to not only universalize the injury reporting methods of each and every NFL team, but was intended to make the tracking of the phenomenon of closed head injuries more thorough.

As a result, the NFL now has a working definition of what constitutes a concussion-but still not a clear one. The league's definition includes literally dozens of symptoms including: dizziness, headache, nausea, loss of appetite and ringing in the ears, to name only a few.

Perhaps the best definition of a concussion is to say that it is a blow to the head that causes, in most cases, a temporary impairment of cerebral function including, but not limited to, the alteration of consciousness, the disturbance of vision and equilibrium, slowed mental processing, fatigue, memory and attentional problems, depression, headache, dizziness or simply just confusion. In other words, hard to define.

Mild: No loss of consciousness; post-taumatic amnesia less than 30 minutesMay return to play if asymptomatic for 1 week.
Moderate: Loss of consciousness less than 5 minutes in duration or post-traumatic amnesia lasting longer than 30 minutes but less than 24 hours in durationMay return to play if asymptomatic for 1 week.
Severe: Loss of consciousness for more than 5 minutes or post-traumatic amnesia for more than 24 hoursShould not be allowed to play for at least one month. May return to play if asymptomatic for 1 week.

The Grading of Concussions

Perhaps the common denominator of all concussions, however severe they may or may not be, is the state of mental confusion which a player experiences. Often a "Grade 1", the mildest form of a concussion, is referred to as "having your bell run," or more simply as a "ding." According to Cantu, the slang term ding refers to "that most mild concussion in which you're kind of dazed, but you're alert and you're recognizing, for the most part, what is going on around you.

"It is very hard for anybody to really know whether somebody has had a head injury or not when those most minor ones occur, especially if they last only a very brief period of seconds to a minute or so. It's not real easy to recognize the most minor concussion unless it's a pretty astute observer."

Complicating the mater even more is the general lack of consensus between medical authorities on grading the severity of a concussion. At present, there are any number of different grading systems in existence, each of which provides a slightly different slant on the severity and relative grade of a concussion.

Cantu drew up his own grading system in 1986, one that grades concussions based on a more holistic approach. Instead of relying on a single defining characteristic such as how long a player is rendered unconscious, Cantu's Grading Scale (See chart) takes into consideration how long a player is unconscious as well as how long post-traumatic amnesia symptoms last before determining whether a concussion is of a moderate or severe grade. Cantu's system is one of the most practical to use in an on-the-field setting, providing the user with a simple yet definitive measure of a concussion's severity.

"Where the problem occurs in grading of concussion is not so much in the most minor one," Cantu says. "Most people are pretty much in agreement about what's the most minor. It's the different grading systems that talk about what's the difference between a moderate concussion and what's a severe concussion."

"It's kind of silly in my opinion to think that a concussion that causes somebody to end their career is a lesser concussion than someone else who is unconscious for a few seconds but within a minute or two is O.K. again. You can't just look at one aspect, meaning unconsciousness or just amnesia, but you need to look at the total picture when you are grading people.

"When you're talking about concussions you can't simplify beyond whether somebody is unconscious or not then how long, and you can't simplify it beyond whether somebody has cognitive problems and for how long. If someone has (symptoms) for a long time and it is going to end their career, that's obviously the most severe that you can be. And somebody who has them for ten or fifteen minutes that's really not that big of a deal."

Under Cantu's guidelines, if a player loses consciousness for five minutes or less, he has suffered a Grade 2 concussion. Or, if the player simply experiences post-traumatic symptoms for more than 30 minutes but less than 24 hours, he too is considered to have a Grade 2 or moderate concussion. Cantu says that physicians can generally spot such a concussion easily, especially when it includes the loss of consciousness.

In order for a concussion to be classified as the most severe form of concussion, Grade 3, a player must be unconscious for more than five minutes or suffer post-traumatic symptoms for 24 hours or more. According to Cantu, treatment of this type of concussion should mirror that of the individual for whom cervical spine fracture is suspected-the athlete should be immobilized until he regains consciousness and indicates the origin of the injury. Finally, those athletes incurring severe concussions should be hospitalized for clinical observation to insure that the athlete simply has a concussion and not one of the more serious catastrophic brain injuries mentioned earlier.

Steve Young, like Troy Aikman, has had more than his share of concussions, and his doctors were very cautious in making sure he wasn't exposed to second impact syndrome.

Second Impact Syndrome

While neurologic observation and proper treatment remains most important for the severely concussed, one should not overlook the significance proper evaluation plays in any head injury for two very important possibilities-post concussive syndrome and second impact syndrome.

That's the important thing," says Hoge who suffered two Grade 2 concussions in a five week span in 1994, the second of which forced him to retire. "When somebody has a head injury in any sport it's critical to re-evaluate it immediately and then for that doctor and that person to follow that diagnosis-that's where it's critical. Because you come back too soon you do fall in the risky area of second impact syndrome."

Many athletes often deny obvious symptoms and return to play before they are physically ready to do so.

Such was the case with the Colorado high schooler Guitterez and even with the Bears' Hoge, who when he returned to practice a short six days after his initial head trauma, put himself in danger of suffering what medical authorities now refer to as second impact syndrome.

According to the Journal of Sports Medicine there has been a direct link established that "suggests that sequential minor impact may occasionally lead to major cerebral pathological conditions" such as "catastrophic brain injury."

Serving as the national counsel for Schutt Sports, Phillip M. Davis has 30 years of experience in defending head injury litigation and has watched the phenomenon of second impact syndrome develop.

"In about half of the head injury cases I see, there is a history of some prior trauma which the player conceals from the coaches, the doctors, or whoever because he wants to play," Davis said from his Boston office. "He'll tell his friends he has headaches, they'll see him eating aspirin-but he'll...continue to play and it puts him at risk for a much more serious episode that involves brain swelling. It's a phenomenon that we're just now discovering and there may be a relationship of the healing time between the first head impact and subsequent trauma. It has yet to be clearly defined in medical journals and so forth, but I'm convinced that this is a syndrome, it does occur, and that coaches need to understand it."

According to Dr. Cantu, second impact syndrome occurs in individuals who have suffered some sort of prior head trauma and haven't allowed the brain time to recover completely before sustaining another, often times milder second impact. Upon receiving such an additional blow to the head, Cantu said the individual can lose "auto regulation of blood flow to the brain, which leads to massive increased intracranial pressure, brain herniation and death in about half the cases."

Adolescents are at risk for the syndrome from even one serious head injury, Cantu said, estimating that there are only 1 or 2 such occurrences each year. Pinpointing the exact incidence rate is somewhat more difficult.

"We don't really know the real incidence because we don't really know how many of those 1.5 million (participating in football) have played symptomatic with a concussion, so we don't really know if the incidence is one in a hundred or one in a thousand or one in ten thousand-we really don't know."

Once a player sustains a concussion, he is at least four times as likely to concur another, perhaps more severe brain injury. Taking into account this data, perhaps the best way to prevent closed head injuries is to keep players from getting them. But in order to do that, coaches, parents and athletes alike must understand what causes them.

Imagine an egg in a glass bowl. The yellow cente represents your brain and the egg whites surrounding it serve as a sort of built in shock absorber.

What Causes A Concussion

Imagine an egg in a glass bowl. The yellow center represents your brain and the egg whites surrounding it serve as a sort of built in shock absorber-the egg's cerebrospinal fluid, designed to cushion the yolk against outside forces. If you start to slowly slosh the egg from one side of the bowl to the other, you can see the brain's natural injury prevention mechanisms at work. Get violent with the egg-now that's the equivalent of a concussion.

According to Cantu, most concussions happen in one of three methods. When helmet to helmet contact occurs between players such as when a linebacker tackles a running back. When a player is thrown to the ground, banging his head against the natural or artificial turf. Or when a blow is so severe as to cause a sort of whiplash effect in the recipient.

In this third scenario, "acceleration forces are part of the head indirectly, and that is when somebody for instance would be hit very violently from behind and the head is snapped back very forcefully," Cantu said.

"You can actually be concussed in that manner just like you can be concussed uncommonly by a very forcible blow to the chest, especially if the individual didn't see the blow coming."

When collisions such as these occur, there are two main types of acceleration forces applied to the brain that cause concussions-linear and rotational. The type of force simply depends on the type of hit.

"If two people collide perfectly forehead to forehead that would be a situation where most of the forces would be purely linear, purely front to back," Cantu said. "The brain is like jello inside of a bowl and it first gets hit in the front so it slides to the back of the skull, and it bounces off the back of the skull and slides back to the front-it just oscillates back and forth."

While both types of forces can produce mild, moderate, or severe concussions, rotational forces tend to wreak more cerebral havoc often producing a "greater chance to tear neurons and tear their fiber track," Cantu says.

"If you got hit on the side of the head and the other person was coming at you straight on so that you're head was at an angle, you would get some forces going rotational not just linear. It's these rotational forces that can do more damage than the linear forces, though either (one) of them are capable of concussing," Cantu said. "The biggest example of (rotational forces) would be the equivalent of a left-hook in boxing. It doesn't just impart forces straight forward in one direction, but it imparts a swirling or rotational force and that's even more injurious than straight forward, linear forces."

But not every collision-even head to head ones-results in a concussion. When players block and tackle correctly, fewer individuals get hurt.

According to an annual study conducted by the American Football Monthlyes Association Committee on Football Injuries, the number of deaths and head injuries directly related to football has waned significantly since 1976, the year when strict rule changes were first implemented to prohibit the use of the head as the first point of contact during blocking and tackling.

Since 1931 when records were first kept, some 952 athletes have died while playing football at all levels. After the 1976 rule changes, the most fatalities in any one year came in 1986, when 12 athletes died. The overall incidence rate has always been much lower among the sandlot, college, and pro and semipro ranks than it has among high schoolers. And while the rate of incidence continues to be quite minimal, the number of fatalities that result from improper tackling and blocking techniques remains significant. Of the five high school players who suffered fatal injuries in 1996, four resulted from brain injuries while the other came as the result of improper tackling technique.

Frederick O. Mueller, Ph.D., University of North Carolina at Chapel Hill and Chairman of the AFMA Committee that conducts the annual study, feels adamantly about the importance of teaching proper blocking and tackling techniques.

"Coaches need to remind players continually to keep the head out of football," Mueller said. "No player should make initial contact with his head when blocking and tackling."

Unfortunately, many players find this sort of heads-on technique an effective means of doing just that, especially against bigger, stronger foes. Smaller, weaker athletes are prime candidates for concussions, but no more than individuals who play certain positions or a particular brand of football.

Cantu points to the statistic that previously concussed athletes are more likely to be concussed a second time when he speaks of individual concussion threshold.

"It is true that the concussion thresholds of different people are not all the same, and we see that best perhaps in boxing, where people like Muhammad Ali you couldn't knock out no matter how many times you hit him," Cantu said. "Different people play football differently and those that play it in a kamikaze way, using their head as the point of contact for blocking and tackling, are much more likely to have a head injury than those that don't. And so the message is don't block and don't tackle with the head. You're asking for trouble both for the head and the neck if you do."

In the past six months, increased media attention has made the public, coaches and athletes, alike, concussion savvy. But as the experts have testified, their is still a long way to go before we reach a medical consensus. From a more universal definition to the determining of which return to play guidelines should be enforced, and from the grading of severity to the understanding of all the possible after effects, closed head injuries remain both a complex and confusing injury-one whose end result can be as minor as a headache or as serious as death.

"It was a serious deal," Hoge says. "It could have been far worse, it could have been fatal. My life was tested there."

"If addressed correctly, evaluated properly, and then (treatments are) performed correctly a person comes back and plays fine and healthy. They don't run that risk, they don't put themselves in that jeopardy and careers aren't ended by one concussion or two," Hoge says.

Brain injuries need to be taken more seriously.

"The brain injuries need to be categorized into the other group with the spine and the heart. Whatever type of injury happens to those particular parts of the body are considered permanent. The brain hasn't received that kind of attention for what reason I don't know-it just hasn't."

This article on concussions and closed head injuries is the first in a two-part series on this vitally important subject. While we focused on the definitions of the problem in this issue, in our Second Quarter issue we will examine what types of preventative measures can be implemented to reduce closed head injuries in the foreseeable future. Participation numbers are down significantly and there can be no doubt that kids are not playing because their parents are afraid. We must address this crisis through education. We have to educate parents that their sons' coaches are fully informed on the subject and doing all within their power to prevent head injuries. As the trade journal for the football professional, we see it as our job to "teach the teachers."