Silent epidemic preys on young athletes Sunday, June 11, 2006 By LINDY WASHBURN STAFF WRITER It's a minute

into the second half of a close junior-varsity basketball game. Fair Lawn has stolen the ball and is fast breaking downcourt. Reed Nicol, a sophomore guard for Northern Highlands, gives chase. The player goes for the shot. Reed leaps to block it. His foot slips on the glossy hardwood. His back smashes into the wall. His head whiplashes back. He hits the floor, face down, with a sickening thud. The ref blows his whistle. A teammate's question hangs in the air: "Are you all right?'' Reed opens his eyes, so close to the floorboards he can see the grain in the wood. Someone rolls him over. His pupils are dilated. "You have a concussion,'' the athletic trainer tells him. Almost one in five high school athletes in a contact sport suffers a concussion each season, experts say. Nationally, the Centers for Disease Control and Prevention estimates there are 300,000 sports concussions a year. Professional athletes get most of the attention, especially when well-known players like New York hockey great Pat LaFontaine and Jets receiver Wayne Chrebet retire early after repeated concussions. Muhammad Ali exemplifies the lifelong consequences of repeat blows to the head. But it's not the pros we should be worrying about. Teen athletes, according to new research, are far more vulnerable. They suffer many more concussions than adults and their brains and nervous systems take longer to recover. Even minor concussions -- the "dings" and "bell ringers" athletes shrug off -- cause changes in the brain that last for days. After one concussion, they are more than three times as likely to suffer another. Young athletes who return too soon are especially at risk. Another hit can overwhelm their body's ability to regulate blood flowing to their brains. This "second-impact syndrome" can cause irreversible brain damage -- or worse. At least two young athletes in the nation die each year as a result.

"Head injury is the silent epidemic," says Jill Brooks, a Far Hills neuropsychologist who treats brain injury patients. Most of her post-concussion patients are high school students. In New Jersey, emergency rooms treat at least 10,000 people a year who've lost consciousness in sports-related concussions, but experts estimate as many as 75,000 more go unreported. On the sidelines, athletic trainers struggle to protect their players' brains -- and futures -- in a culture that teaches athletes to shake off a hit. New tools can help schools deal with this invisible injury and determine whether it's safe for an athlete to play. Yet few schools have applied for a grant to acquire these tests. Most players, like Reed, will recover completely after a period of headaches, sleepiness and difficulty focusing in class. Others -- one in 10, some experts say -- suffer long-term symptoms. They are more likely to develop post-concussion syndrome, where fogginess, headaches, poor concentration and disturbed sleep persist. Their personalities may change permanently. Such symptoms forced Dave Showalter to leave college. He'd received many hits in a football career that began in fourth grade, but a helmet-to-helmet collision during a warm-up for a Rutgers University game ended his career. Sleepless nights were followed by partial amnesia. His grades plummeted. As his memory faltered, he grew embarrassed and anxious. Football had been the center of his life, but now he couldn't even exercise. Finally, he withdrew from college. Four years later, Showalter is trying to get back into school. He says he thinks straighter now, stutters less and feels "more intelligent." Still, he falls asleep while reading. And when he wants to talk about a show he saw on the History Channel, he finds it "hard to get at the part of my brain holding that knowledge. "If I could do anything to help kids understand what could happen to them with a concussion, I would," he says. Dizziness, loss of memory No sport is immune to concussions. Baseball players take line drives to the head. Lacrosse goalies get kicked in the head diving for a save. Wrestlers are thrown to the mat. Gymnasts plummet from the uneven bars. Giovvani Mancini, an 18-year-old soccer midfielder once took a "rocket kick" in the forehead. The Lakeland Regional High School senior was lethargic and headachy for days. "I had an athlete hit in the head with a discus once in track," says Robb Rehberg, coordinator of athletic-training clinical education at William Paterson University.

Kelly Osback, a Fair Lawn High School senior, got her first concussion playing softball. Her second came while cheerleading, when she tried to catch a girl who had been thrown too hard. "I lost my balance catching her, and fell on my back. I hit pretty hard," she said. Her head hurt and she was dizzy afterward. Researchers now say the more concussions a player has sustained, the longer it takes to heal -and the more vulnerable they are to subsequent concussions. Sometimes it doesn't even take a blow to the head. A sudden stop in a car or a blow elsewhere on the body may cause the head to jerk, leading to the same effect. Melissa Sietsma, 18, an elite soccer player from Fair Lawn, has had five concussions. A striker, she was on a breakaway drive at a tournament two years ago when a defender hip-checked her. She broke her fall with her head. The fall erased her memory of the game -- she can recount the details only because she has watched the videotape and left her seasick and dizzy. She couldn't stand without help and didn't know what state she was in. She suffered another about six months later during a hard-fought game at the State Cup semifinal. A defender deliberately kicked her in the head after they both fell while going for the ball. Sietsma blacked out. She was nauseous, dizzy and disoriented for a week -- longer than the first time. Her neurologist said she should quit soccer. But the senior wouldn't dream of it: She plans to play at SUNY Oneonta. At her father's insistence, she now wears a protective headband to play. If she takes even a small hit, like an elbow to the head, she is benched for the rest of the game. New research suggests that may not be enough and that schools and doctors need to do more to protect young athletes, said Dr. Robert Cantu, a national expert on concussions. He is chief neurosurgeon and director of sports medicine at Emerson Hospital in Concord, Mass. Among the findings: Loss of consciousness is no indicator of how bad a concussion is -- significant damage occurs even when a player doesn't black out. Most concussions, in fact, do not involve knockouts. Common guidelines that allow a player to return to the game if symptom-free after 15 minutes are inadequate. Even minor "dings" cause memory loss that worsens in the following week. Helmets don't prevent concussions. The brain is like an egg yolk inside an eggshell formed by the skull. The helmet keeps the shell from breaking, but the yolk still sloshes around. Sometimes it hits twice, once at the sudden stop, and then again when it bounces back to the other side. "Helmets are not made to prevent concussion," says Mark Lovell, medical director of the Sports Medicine Concussion Program at the University of Pittsburgh Medical School. "They're made to prevent severe brain injury and skull fracture."

Rich Ippolito, 17, was wearing a helmet when he was sacked during a Wood-Ridge High School football game. "My neck snapped back, and I hit the ground," he says. "I blacked out." The athletic trainer called an ambulance. The hospital ruled out a skull fracture, but he suffered headaches and nausea for days. But many "concussed" players never seek medical care. Some outright lie to get back into the game. "Advil was my friend," says Pete DeFelice, the 21-year-old coach of girls lacrosse at Northern Valley-Old Tappan High School. He figures he's had 20 concussions since his first as a little boy playing rec soccer. He used to treat himself with ice on the back of his neck. He'd lie down and wait for the headaches, nausea and dizziness to pass. Only once did he go to the hospital -- when he was accidentally kicked in the head as a lacrosse goalie for Indian Hills High School. The image of a player shaking off his injury as the crowd cheers is burnished each time a sports announcer marvels at a player's heroics. That culture must change, says Phil Hossler, an athletic trainer at East Brunswick High School. "Don't make heroes of people with concussions," said Hossler, a member of the concussion committee of the Brain Injury Association of New Jersey. "The person is more important than the score." Difficult to diagnose A concussion's damage is invisible, unlike a twisted ankle or broken arm. Concussions "are potentially one of the most serious, yet the most difficult to diagnose injury in sports," Hossler says. For trainers and team doctors, decisions about benching an athlete are nerve-racking. Coaches, parents and athletes are pushing hard to get back in the game. The sideline checklists schools use can't really tell how bad the damage is, experts say. "If you say, 'Does your head hurt?' and they know that a 'No' will get them back in the game, they're going to lie," Hossler says. An Elmwood Park High School football player never told a soul he'd sustained a concussion during a game three years ago, even though his nausea was so extreme he couldn't eat for the rest of the weekend and couldn't go to school on Monday. Still feeling sick, he went to class and football practice on Tuesday, but had to stop playing because he was nauseous, dizzy and short of breath. The school's athletic trainer, Danielle Keelan, questioned him and deduced he'd had a concussion.

She called the boy's father and told him his son needed medical attention. But the father said he thought it was a stomach virus and promised to keep an eye on his son. The next day, Keelan saw the teen in the lunchroom, and he complained of pressure behind his eyes. Keelan called the boy's father again and insisted he take him to the hospital. The teenager had suffered a concussion and developed a subdural hematoma, a slow leakage of blood from many small vessels into the area between the brain and its tough outer lining. Left untreated, it would have caused death or severe brain injury. "Had I not been around to see him, he might have died," Keelan says. To this day, the boy has problems concentrating. Even at the hospital, it is difficult to diagnose a concussion. CT scans and MRIs are used primarily to rule out skull fractures and bleeding in the brain. They don't detect the changes in cell chemistry caused by a concussion -- which affect the brain's higher-level work, such as memory, concentration, reaction time and coordination. "When in doubt, sit 'em out," says Hossler, author of "Getting A-Head of Concussions: The Athlete's Neighborhood Watch Program." To help young athletes, the state Brain Injury Association is encouraging schools to use computerized concussion tests developed for professional football and hockey teams. One of the most widely used tests, the University of Pittsburgh Medical School's ImPACT Test -- for Immediate Post-Concussive Assessment and Cognitive Testing -- works like a video game. It gauges attention span, verbal and visual memory, problem solving and reaction time to onehundredth of a second. The 20-minute test is taken before the season and again after a concussion. Athletes aren't cleared to play until their results return to baseline. "The benefit of baseline testing is you can't fake it," Hossler says. The Brain Injury Association offered grants to 100 New Jersey high schools to begin using ImPACT. But only 34 expressed interest. Ten in North Jersey received grants: Don Bosco Preparatory High School in Mahwah, DePaul Catholic High School in Wayne and the public high schools in Wood-Ridge, Ridgewood, Glen Rock, Tenafly, Northern Highlands Regional, Lyndhurst, Pequannock and Chatham. In Pequannock, the football team physician, Paul Ostergaard, pushed for the program a few years ago after a harrowing experience. During the national anthem at a state championship final in 2001, a player's father informed him that his son had suffered a concussion three days earlier. "Watch out for my kid," he said.

The coach's game strategy called for the teen to play a major part and Ostergaard felt he couldn't summarily bench him. "He was hit a couple of times," Ostergaard says. "In the second half, his performance was subpar. He sat out for several plays." That night Ostergaard began looking for tools to rationalize decisions about athletes with concussions. The schools adopted the program on a voluntary basis for athletes. It was mandated for Pequannock's middle and high school students in 2004. "It takes the guesswork out of who's hurt and who's not hurt," Ostergaard says. About 30 students have been retested after injuries. Several, including a starting quarterback, have been benched when their scores did not measure up to their baseline. One girl was kept out of gym for a year -- even after her pediatrician had cleared her for sports -- because her test results were significantly below the norm. Ostergaard also uses the test to make teachers aware that an athlete with a concussion may need special treatment. Students who have suffered concussions not only need to rest physically, they need to rest their minds. They may need additional time for tests, help taking notes or a reduction in their homework. Megan Maher, a 16-year-old shortstop for the Wood-Ridge High School softball team, said her teachers gave her a break after she was hit in the head and blacked out during a game this spring. "I had this tired look when I went into class," she says. "I hated bright lights. I was unfocused." Reed Nicol, who was injured in January 2005, needed weeks to get back to normal -- a time when he had trouble concentrating in class and found it difficult to stay awake. During that period, he had such a hard time focusing that he couldn't finish a trigonometry test. Dr. Gerald Tramontano, a Mount Arlington neuropsychiatrist, estimates that 10 percent to 12 percent of patients with concussions have long-term symptoms. The students most likely to suffer permanent symptoms, he notes, are those who have attention deficit disorder, a learning disability, psychiatric illness or even a family member with those diagnoses. Katrina Majewski, a field hockey standout recruited to play at Rutgers in 2003, was hit in the head with a ball during practice before her freshman year. She suddenly found herself struggling to stay in college. She bit her tongue to keep from falling asleep in class. But the worst part was the emotional roller coaster. As a freshman, "nobody knew the real me," she says. "They thought this new me was it." The "new" Majewski was irritable, teary and snappish.

The ups and downs have leveled off, says Majewski, now a senior. Still, she needs extra time on tests, help taking notes and teachers who understand she will be absent when a migraine hits. She has not returned to field hockey. "You can't go out and exercise after a concussion, and you can't even study as hard," Hossler says. You need brain rest as well as exercise rest." E-mail: washburn@northjersey.com *** Tens of thousands of elementary and middle-school children play Pop Warner football, Little League baseball and recreational sports. Their coaches are usually amateurs and don't have the field backup of an athletic trainer, as most high schools do. The children suffer fewer concussions, because they are lighter and move more slowly than high school athletes, generating less force in their collisions. Still, between 3,000 and 6,000 5- to-14-year-olds visit New Jersey emergency rooms with concussions each year, estimates Wes Rutland-Brown of the Centers for Disease Control and Prevention's injury prevention branch. The kids may run into goal posts or get kicked in the head by a teammate. Concussions among younger athletes are often more serious and the kids take longer to recover, says Dr. Robert Cantu, a national concussion expert and chief neurosurgeon and director of the department of sports medicine at Emerson Hospital in Massachusetts. "There's a growing concern among a number of us that the young brain, injured before it's structurally mature, may have more cognitive impacts," Cantu said. Organized sports have minimized injury by having kids play together who are matched according to size, weight and age. Still, Cantu, knows personally of a Pop Warner player who died and another who took more than a year to recover from a brain injury. Or they may fall from a bike or skateboard without a helmet. "You add wheels to a kid's momentum, and the forces involved in a head injury go up astronomically," says Dr. Philip LaStella, the emergency department director at Pascack Valley Hospital. "They're always playing or riding on an asphalt road or concrete." -- Lindy Washburn *** LEARN MORE ABOUT CONCUSSIONS

 A free tool kit for coaches, called "Heads Up: Concussion in High School Sports," is available from the federal Centers for Disease Control and Prevention. It contains fact sheets for athletes and parents, a coach's guide to concussions, a wallet card for quick reference, posters for the gym, as well as a video. The kit can be downloaded or ordered through the CDC Web site: cdc.gov. On the site's home page, do a search for "coaches tool kit." The CDC also is developing a kit for coaches of younger athletes. Information about the Brain Injury Association of New Jersey's public education effort on sports concussions can be found at sportsconcussion.com. The association's key message: "If there is any doubt that a player might have sustained a concussion, the player should be removed from the game or practice." The group is offering 100 high schools $650 grants to implement a program of baseline neuropsychological testing for athletes. Several other test programs are available, including CogSport (CogSport.com) and HeadMinder (HeadMinder.com). Books "The Heads-Up on Sport Concussion," by Gary S. Solomon, Karen M. Johnston and Mark R. Lovell details the physiology, assessment and treatment of concussions. humankinetics.com. "Getting A-Head of Concussion: Educating the Student-Athlete's Neighborhood," co-authored by Phil Hossler, head athletic trainer at East Brunswick High School. lapublishing.com. *** Signs and symptoms A concussion is a disturbance in the brain's function caused by a direct or indirect force to the head. Loss of consciousness may or may not occur. A concussion may result in a variety of symptoms, including: Headache, a feeling of "pressure in the head" Neck pain Balance problems, dizziness Nausea, vomiting Vision problems Hearing problems/ringing in ears Feeling "dinged" or "dazed" Confusion, feeling as though "in a fog" Drowsiness, fatigue More emotional than usual, irritability Difficulty concentrating or remembering.

Later symptoms may include: Sadness, nervousness or anxiety Trouble falling asleep Sleeping more than usual

 Sensitivity to light or noise Symptoms may worsen over the first 24-48 hours, and usually resolve on their own. Patients should not be left alone and should not drive a motor vehicle. Athletes who have suffered a concussion should stay away from sports until they are completely recovered and free of symptoms. Experts recommend a gradual return to exercise, starting with simple aerobic activity like walking or riding a stationary bike. That should be followed by light sideline exercise in game skills, practice in non-contact drills, then full-contact drills and finally competitive play. If headaches, dizziness or nausea return, the player should stop, rest more and go back to the previous level.