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Concussions Come to a Head

Research Project Is Designed to Help NFL Gain Insight on Widespread Injury

By Guy Gugliotta

Washington Post Staff Writer

Friday, November 7, 2003; Page D01

OTTAWA -- The scene plays out on TV screens every Sunday. The quarterback throws a pass, the wide receiver turns to catch it, and then, in a timed move as subtle as a battering ram, the safety slams into the side of the pass-catcher's head. Maybe the receiver holds the ball; maybe not. Maybe he gets up; maybe not.

"Actually, it takes about 15 milliseconds," said biomechanical engineer Christopher Withnall, winding the blurred videotape back and forth, frame-by-frame, the receiver's head rebounding like a billiard ball again and again. "We can see the moment right before the hit and the moment right after, but not the exact moment. The injury occurs in the blink of an eye."

Withnall researches concussions for the NFL as part of a $2 million project that is the most ambitious study of its kind ever undertaken. For a league in which several high-profile players in recent years have missed games because of head injuries or in some cases have been forced to retire, the study has given researchers unprecedented information on how and why concussions occur. It also should provide insights into how to prevent and treat them, and how to lessen their lingering after-effects.

Researchers believe the study will have broad implications -- for helmet design and other safety measures -- in the NFL and other professional leagues, such as the NHL, which also has had several of its brightest stars sidelined or forced into early retirement by concussions. Its findings ultimately could profoundly affect college and high school athletics.

The study confirmed professional football is indeed a violent game. Between 1996 and 2001, NFL teams reported nearly 900 concussions -- an average of 150 per season. When players suffer the injury, they do so in collisions at relative speeds between 17 mph and 25 mph, with the player being hit enduring impacts averaging 98 times the force of gravity.

Despite the increasing size and speed of the players, however, the study shows the concussion rate is relatively constant year by year. Most concussions result from helmet-to-helmet collisions but are rarely face-to-face. The most common impact occurs when the hitter slams the top of his helmet into the side of an opponent's head. Hitters seldom suffer concussions.

The study began in 1994 amid concern that an epidemic plagued the league, with several players losing games to head injury or -- beginning with New York Jets Pro Bowl wide receiver Al Toon in 1992 -- being forced by concussions to retire. Frustration with a lack of scientific information led the NFL to build its own data base virtually from scratch. At the Ottawa-based "human impact" research firm Biokinetics, hired by the NFL to study concussion physics, Withnall's team is testing padding for the side of a player's helmet below the ear, an area the new research shows is particularly vulnerable. The new data easily can apply to high school or college football or be adjusted to analyze other sports. NFL researchers are building a computer model to conduct electronic "virtual" tests of any conceivable helmet design -- for football, ice hockey, lacrosse or other contact sports.

Elsewhere in football, researchers are extending the NFL's work. At Virginia Tech, head team physician Gunnar Brolinson is leading a multi-year study to measure head impacts by placing multiple sensors inside Hokies players' helmets. Brolinson says some collisions approach 130 times the force of gravity -- 30 Gs higher than comparable NFL figures.

"The NFL has really done a service by using laboratory work to create a [scientific] standard for concussion," said Micky Collins, assistant director of the University of Pittsburgh Medical Center Sports Concussion Program. "It is ground-breaking work."

In the NFL, scientists had a near-perfect population for a concussion study: several thousand men around the same age, all in excellent health, all doing the same job in front of cameras that record the collisions as they happen. "You never get that with auto accidents," Withnall said. "Here you get before, during and after."

The nearly 900 concussions reported by NFL teams between 1996 and 2001 included everything from momentary "stingers" and "standing eight-counts," to debilitating hits that left victims with headaches, amnesia, lethargy and depression that endured for weeks or even months. The NFL study lists 25 symptoms denoting concussion, ranging from unconsciousness, dizziness and "fog" to confusion and personality change.

"I had constant migraine headaches from August 15" to early October, said Tennessee Titans tight end Frank Wycheck, who missed six games this year after two concussions in less than a month. "I had a headache every day. You're miserable, and it isn't any fun."

It can be much worse in those cases where concussions have ended careers: "It felt like an earthquake," said former Pittsburgh Steelers and Chicago Bears running back Merril Hoge of the hit he absorbed after catching a pass against the Kansas City Chiefs in 1994. "I couldn't get off the ground. My eyes were open, but I don't remember anything," he said. "I played a couple of more plays, but on tape I look like I was drunk."

Hoge's retirement five weeks later, after a second concussion that briefly stopped his breathing and put him in intensive care for two days, triggered the beginning of the study. Hoge left football specifically because of concussions, following Toon, who suffered nine concussions in eight years. As time passed, concussions retired others, among them star quarterbacks Troy Aikman of the Dallas Cowboys and Steve Young of the San Francisco 49ers. Aikman didn't remember playing in the 1994 NFC championship game after receiving a blow.

"At one point I was representing 26 quarterbacks who kept getting concussions, and no one was doing anything about it," said California-based agent Leigh Steinberg, who counted Young and Aikman among his clients. "I held 'concussion conferences' where players listened to experts talk about causation and consequences so that our players were at least not in a state of denial."

Even at this point, players are both ignorant about concussions and insistent about wanting to "push through" the injury. "Sometimes players get caught up in that," Wycheck said. "Coaches can't see what the X-ray says, or see under the ice bag on your knee, but this is more serious than a knee. You only got one brain."

This first set of research papers from the NFL study appeared in the October issue of the scientific journal Neurosurgery , for the first time documenting the physics of concussions -- how hard is the hit, where is it applied and how long the impact lasts.

Withnall and his Biokinetics team examined league-supplied videotape of 182 concussions and in 31 cases had enough camera angles and a clear enough picture to actually recreate the collisions in the lab using crash dummies.

Some of the findings were predictable: 61 percent of concussions were caused by a player colliding with an opponent's helmet or face mask; 16 percent resulted from shoulder or arm hits; and another 16 percent occurred when the back of a player's head struck the ground. The remainder were caused by another part of an opponent's body or were impossible to determine.

But there were surprises. The team saw almost no face-to-face collisions, and the striking player -- usually a defender -- virtually never suffered a concussion. Instead, the concussed player was almost always hit from the side, often on the lower half of the face, and usually by the crown of an opponent's helmet -- like a torpedo.

"Players can see the face-to-face hit coming and get out of the way ," said David C. Viano, a biomechanical engineer based out of Bloomfield Hills, Mich., who coordinates the concussion project for the NFL. "They get hit when they're looking somewhere else."

To get the same effect of the force of the hits in the lab, Withnall dropped one helmeted dummy head into another from a height of 30 feet, and, when the head didn't travel fast enough, he used bungee cords for extra acceleration. When Withnall studied headgear by smashing a sledgehammer into the side of a dummy's head, fast-frame cameras showed the helmet deforming for an instant before the head -- and its contents -- bounced against the padding inside.

"The best way I can describe it is like a mold full of Jell-O," said Elliot Pellman, the internist who oversees the study as chairman of the NFL's Committee on Mild Traumatic Brain Injury. "You bang it, and the Jell-O wiggles away. It's not like it's smashing against the side of the skull, but either chemically or receptor-wise, things start falling out of place."

In subsequent editions of Neurosurgery and other journals stretching over the next two years, researchers will use the NFL's data to analyze more questions that have both baffled and fascinated doctors and trainers for decades. Even before the NFL study began, researchers had realized the number of concussions may not be as important as frequency: "If you have a concussion and allow the brain to recover fully, you should have a good outcome 95 percent of the time," said the University of Pittsburgh's Collins. "Every clinician would agree, though, that if an athlete still has symptoms of a first concussion he should not be out there."

And while Biokinetics has made graphs for the concussions it has studied, Withnall cautioned that "we don't get videotape of linemen kicking each other in pileups," so the analysis may be skewed toward the violent, high-visibility hits endured by quarterbacks and wide receivers. At Virginia Tech, Brolinson said sensors in lineman's helmets were showing "interesting" results, for "where a receiver may show three high loads [impacts] per game, linemen may see 20 impacts of 50 Gs."

The NFL researchers also intend to write a separate paper on repeat injuries, but Viano said they are having trouble finding a statistical method to present the data. "It's going to be tricky and interesting," Viano said. "There's a popular wisdom that your risk goes up geometrically after the first concussion. So far that doesn't appear to be the case, but it's going to require a lot more work."

Another imponderable is whether some players are more prone to concussion than others. "We may never know," Pellman said, noting, however, that only a "very small percentage" of players suffer the prolonged "post-concussion syndrome" that can end careers.

"Surprisingly little was known about this subject," Pellman said. "This is all new information that we want to hand over to the scientific community. We hope it leads to better prevention, better understanding, better treatment and better equipment, not only for the pros, but for all football players and athletes in other contact sports."

Pellman's interest in concussions was forced on him beginning in the late 1980s, when he became the Jets' team physician, a position he still holds. He was advising Toon and feeling a growing sense of frustration because nobody knew anything about concussions.

"There was no formal education, and most of your knowledge was based on anecdotes and stories from other physicians," he said. "When Al began to have his injuries, fainting and other issues -- at that point I couldn't put it together."

Concussions in pro football were hardly a rarity. Former congressman, vice presidential candidate and pro quarterback Jack Kemp suffered 11 concussions between 1957 and 1970 and never missed a game. "I used to talk about it when I got into politics," Kemp said. "I'd tell people that 'now that I've had 11 concussions, I'm ready to run for Congress.' "

But serious concussion was no joke. Kemp can remember both of his bad ones -- in college, when his head bounced off someone's knee, and at Shea Stadium, when a tackler upended him on the sideline so that he landed on his head on a frozen field. "I was out for about 15 minutes, and I forgot the previous four or five plays."

Still, over the years, concussion myths persisted: "You wear a helmet, you assume you're protected," said Hoge, now 38 and an analyst for ESPN. "All I thought back then was that if you knew who you were and could count to five you were okay."


A lab test at research firm Biokinetics simulates a collision of helmet to helmet as part of a study in effects of concussions. (Biokinetics and Associates)

© 2003 The Washington Post Company

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