The Concussion Crisis

by Linda Carroll

  NFL concussion studies: Details on the NFL MTBI Committee’s conclusion that multiple concussions did not lead to long-term consequences came from Elliot J. Pellman et al., “Concussion in Professional Football: Neuropsychological Testing—Part 6,” Neurosurgery 55:1290–1305, 2004. Details on the committee’s conclusion that it was safe to return certain players to the same game in which they were concussed and that that might extend beyond the pros to college and high school players came from Elliot J. Pellman et al., “Concussion in Professional Football: Players Returning to the Same Game—Part 7,” Neurosurgery 56:79–92, 2005.

  Fallout from NFL studies: Gerard Malanga’s quote came from “N.F.L. Study Authors Dispute Concussion Finding,” New York Times, June 10, 2007.

  Football participation statistics: Figures for colleges and secondary schools came from the National Center for Catastrophic Sports Injury Research’s 2010 report titled “Annual Survey of Football Injury Research: 1931–2009.” Figure for youth leagues came from USA Football’s “2007 Youth Football Participation Index Study.”

  Lack of concussion knowledge in college football: Data came from a 2003 study led by JoEllen Sefton at Central Connecticut State University for her master’s thesis titled “An Examination of Factors That Influence Knowledge of and Reporting of Head Injuries in College Football.”

  Incidence of concussion in high school football: Disparity statistics based on comparison of numerous epidemiological studies. In player surveys, the low rate of 15 percent came from Michael McCrea et al., “Unreported Concussion in High School Football Players: Implications for Prevention,” Clinical Journal of Sports Medicine 14:13–17, 2004, while the high rate of 47 percent came from Wayne Langburt et al., “Incidence of Concussion in High School Football Players of Ohio and Pennsylvania,” Journal of Child Neurology 16:83–85, 2001. In trainer surveys, the low rate of 4 percent came from M. McCrea et al., “Standardized Assessment of Concussion in Football Players,” Neurology 48:586–88, 1997, and John W. Powell and Kim D. Barber-Foss, “Traumatic Brain Injury in High School Athletes,” Journal of the American Medical Association 282:958–63, 1999. The reasons players gave for not reporting came from McCrea’s Clinical Journal of Sports Medicine article and Sefton’s thesis.

  Early college football: Analysis pieced together from multiple sources. Background and some details came from John Sayle Watterson, College Football: History, Spectacle, Controversy (Baltimore: Johns Hopkins University Press, 2000). Description of playing style, John L. Sullivan’s quote, and Theodore Roosevelt’s ultimatum came from Bruce K. Stewart, “American Football,” American History, November 1995. Description of Harvard’s flying wedge came from several sources, including Scott A. McQuilkin and Ronald A. Smith, “The Rise and Fall of the Flying Wedge: Football’s Most Controversial Play,” Journal of Sport History 20:57–64, 1993.

  Theodore Roosevelt’s intervention: History based on multiple sources, notably John Sayle Watterson, College Football: History, Spectacle, Controversy (Baltimore: Johns Hopkins University Press, 2000). Roosevelt’s quote on football as a metaphor came from Theodore Roosevelt, The Strenuous Life: Essays and Addresses (New York: Century, 1899). His letter to Ted Jr. came from Joseph Bucklin Bishop, ed., Theodore Roosevelt’s Letters to His Children (New York: Charles Scribner’s Sons, 1923).

  Hockey head injuries: Details on Eddie Shore, Ace Bailey, and Gordie Howe came from Arthur Pincus, David Rosner, Len Hochberg, and Chris Malcolm, The Official Illustrated NHL History (London: Carlton Books, 1999). Details on Bill Masterton’s death and its impact came from Richard Beddoes, Stan Fischler, and Ira Gitler, Hockey! The Story of the World’s Fastest Sport (New York: Macmillan, 1969).

  Physics of hockey hits: Data on the force of peewee hockey hits and its comparison to college football came from J. P. Mihalik et al., “Characteristics of Head Impacts Sustained by Youth Ice Hockey Players,” Journal of Sports Engineering and Technology 222:45–52, 2008.

  Pat LaFontaine’s story: Narrative based on multiple sources. A first-person account, including the dialogue with the first neurologist he consulted, came from Pat LaFontaine, Companions in Courage: Triumphant Tales of Heroic Athletes (New York: Warner Books, 2001). The most helpful magazine articles included Leigh Montville, “Can’t Quit Now,” Sports Illustrated, August 24, 1997, and Mark Herrmann, “An American in Transition,” Rinkside, January 1999. The account of the events leading to his retirement was pieced together from numerous news stories from all four New York City dailies.

  Eric Lindros concussion controversy: Details came from multiple newspaper and magazine articles.

  Incidence of hockey concussions: The statistic comparing NHL to NFL players came from newspaper research in “NHL Watches as Concussions Rise,” Orange County Register, September 23, 2007. Data comparing concussions rates for U.S. college men’s and women’s hockey to each other and to football came from Jennifer M. Hootman et al., “Epidemiology of Collegiate Injury for 15 Sports: Summary and Recommendations for Injury Prevention Initiatives,” Journal of Athletic Training 42:311–19, 2007.

  Lack of concussion reporting in youth hockey: Data came from I. J. S. Williamson and D. Goodman, “Converging Evidence for the Under-Reporting of Concussions in Youth Ice Hockey,” British Journal of Sports Medicine 40:128–32, 2006.

  J. Scott Delaney’s research: Narrative based on his studies and on quotes and information in Christopher Nowinski, Head Games: Football’s Concussion Crisis (East Bridgewater, Mass.: Drummond, 2007). Details on Delaney’s pro football research came from J. Scott Delaney et al., “Concussions during the 1997 Canadian Football League Season,” Clinical Journal of Sport Medicine 10:9–14, 2000. Details on his college research came from J. Scott Delaney et al., “Concussions among University Football and Soccer Players,” Clinical Journal of Sport Medicine 12:331–38, 2002.

  Prevalence of problem in all sports: College data came from Kevin P. Kaut et al., “Reports of Head Injury and Symptom Knowledge among College Athletes: Implications for Assessment and Educational Intervention,” Clinical Journal of Sport Medicine 13:213–21, 2003. High school data came from Ellen E. Yard and R. Dawn Comstock, “Compliance with Return to Play Guidelines Following Concussion in U.S. High School Athletes, 2005–2008,” Brain Injury 23:888–98, 2009.

  Incidence of soccer concussions: Comparisons based on data from Luke M. Gessell et al., “Concussions among United States High School and Collegiate Athletes,” Journal of Athletic Training 42:495–503, 2007.

  Melissa Inzitari’s story: Narrative based on interviews with Melissa Inzitari, Katrina Majewski, and Jill Brooks, Ph.D. Additional details came from Peter Keating, “Heading for Trouble,” ESPN The Magazine, March 23, 2009, and “Soccer: Head Start on Safety,” Newark Star-Ledger, November 20, 2002. Brooks’s research was described in the chapter titled “Concussion Management Programs for School-Age Children,” which she contributed to Ruben J. Echemendía, ed., Sports Neuropsychology: Assessment and Management of Traumatic Brain Injury (New York: Guilford Press, 2006).

  Chapter 4: Sudden Impact

  Part I—Brian Radke’s story: Narrative based on interviews with Brian and Nova Radke. Background information came from interviews with Jovita Bollig, Nova’s mother, and Mike Bloomer, a friend who served with Brian in Iraq and remained close after they both returned to the Phoenix area. The quote from Brian’s Walter Reed neurologist came from Jim Naughton, “Saving Sergeant Radke,” Neurology Now, September/October 2006.

  Part II—Chari Abb’s story: Narrative based on interviews with Chari Abb; her mother, Chari Stoesser; Mark Sementilli, Ph.D.; and Tom Thompson. Background information came from an interview with Chris Abb and from Theodore Tsaousides and Wayne A. Gordon, “Cognitive Rehabilitation following Traumatic Brain Injury: Assessment to Treatment,” Mount Sinai Journal of Medicine 76:173–81, 2009.

  Chapter 5: Through the Cracks

  Anne Forrest’s story: Narrative based on interviews with Anne Forrest. Background information came from Sherri Dalphonse, “
‘I Wanted My Brain Back,’ ” Washingtonian, March 2007.

  Hidden TBIs: Discussion based on interviews with Wayne Gordon, Ph.D., and Tamar Martin, Ph.D. Some details came from Wayne A. Gordon et al., “The Enigma of ‘Hidden’ Traumatic Brain Injury,” Journal of Trauma Rehabilitation 13:39–56, 1998, and Wayne A. Gordon, “Mild Traumatic Brain Injury: Identification, the Key to Preventing Social Failure,” Brain Injury Professional 5:8–11, 2008. Background information came from “Studies Cite Head Injuries as Factor in Some Social Ills,” Wall Street Journal, January 29, 2008.

  Michael Zacchea’s story: Narrative based on interviews with Michael Zacchea.

  TBI in the military: Information was drawn from a variety of sources, including interviews with Charles Hoge, M.D.; Wayne Gordon, Ph.D.; and Warren Lux, M.D. Also helpful was the ABC television special To Iraq and Back—Bob Woodruff Reports, which aired on February 27, 2007. Details were also drawn from several studies, including Charles W. Hoge et al., “Mild Traumatic Brain Injury in U.S. Soldiers Returning from Iraq,” New England Journal of Medicine 358:453–63, 2008; Charles W. Hoge et al., “Care of War Veterans with Mild Traumatic Brain Injury—Flawed Perspectives,” New England Journal of Medicine 360:1588–91, 2009; Susan Connors et al., “Care of War Veterans with Mild Traumatic Brain Injury,” New England Journal of Medicine 361:536–37, 2009; and Timothy Walilko et al., “Head Injury as a PTSD Predictor among Oklahoma City Bombing Survivors,” Journal of Trauma 67:1311–19, 2009.

  Chapter 6: Playing Defense

  Mark Lenkiewicz’s story: Narrative based on interviews with Mark and Diane Lenkiewicz and with Mark Lovell, Ph.D.

  Development of neuropsychological testing: History based on interviews with Mark Lovell, Ph.D., and Joseph Maroon, M.D. Additional background came from several newspaper and magazine stories, including Michael Farber, “The Worst Case,” Sports Illustrated, December 19, 1994. Details of the college study came from a chapter by Jeffrey T. Barth and colleagues titled “Mild Head Injury in Sports: Neuropsychological Sequelae and Recovery of Function,” which was published in Harvey S. Levin et al., eds., Mild Head Injury (New York: Oxford University Press, 1989).

  University of Pittsburgh Medical Center concussion program: Mark Lovell’s background and his clinic’s development based on interviews with Lovell, director of the UPMC Sports Medicine Concussion Program. Background information on the clinic came from interviews with Michael Collins, Ph.D., assistant director of the concussion program, and Freddie Fu, M.D., director of the UPMC Center for Sports Medicine.

  Ben Roethlisberger’s concussions: Details on the motorcycle crash and concussion came from multiple newspaper and magazine accounts. Details on the management of his football concussions came from an interview with Joseph Maroon as well as multiple newspaper stories in the Pittsburgh Post-Gazette and New York Times, including “Roethlisberger Case Stirs Debate Even after He Passes Concussion Tests,” New York Times, November 5, 2006.

  Angelica Kruth’s story: Narrative based on interviews with Angelica and Doreen Kruth and with Mark Lovell, Ph.D.

  Chapter 7: Anatomy of a Brain Injury

  Part I—Phineas Gage’s story: Narrative based on the original medical papers published by the treating physician. Chief among those were John M. Harlow, “Passage of an Iron Rod through the Head,” Boston Medical and Surgical Journal 39:389–93, 1848, and John M. Harlow, “Recovery from the Passage of an Iron Bar through the Head,” Publications of the American Medical Society 2:327–47, 1868. Also referenced was Henry J. Bigelow, “Dr. Harlow’s Case of Recovery from the Passage of an Iron Bar through the Head,” American Journal of the Medical Sciences 20:13–22, 1850. A debt is owed to the world’s leading authority on the case for reprinting those medical papers and providing comprehensive details in Malcolm Macmillan, An Odd Kind of Fame: Stories of Phineas Gage (Cambridge, Mass.: MIT Press, 2000). Details on the modern neuroimaging of the skull came from Hanna Damasio et al., “The Return of Phineas Gage: Clues about the Brain from the Skull of a Famous Patient,” Science 264:1102–5, 1994. Perspective and background was provided in Antonio R. Damasio, Descartes’ Error: Emotion, Reason, and the Human Brain (New York: Grosset/Putnam, 1994), and John Fleischman, Phineas Gage: A Gruesome but True Story about Brain Science (Boston: Houghton Mifflin, 2002).

  Part II—Broca’s brains: Details on Broca’s patients and his discovery came from Francis Schiller, Paul Broca: Founder of French Anthropology, Explorer of the Brain (Berkeley: University of California Press, 1979), and J. M. S. Pearce, “Broca’s Aphasiacs,” European Neurology 61:183–89, 2009. MRI scans of Broca’s brains described in N. F. Dronkers et al., “Paul Broca’s Historic Cases: High Resolution MR Imaging of the Brains of Leborgne and Lelong,” Brain 130:1432–41, 2007.

  Part III—H.M.’s story: Details on Henry Molaison’s life, surgery, and impact on memory research came from William Beecher Scoville and Brenda Milner, “Loss of Recent Memory after Bilateral Hippocampal Lesions,” Journal of Neurology, Neurosurgery & Psychiatry 20:11–21, 1957; Philip J. Hilts, Memory’s Ghost: The Strange Tale of Mr. M and the Nature of Memory (New York: Simon & Schuster, 1995); and “H.M., an Unforgettable Amnesiac, Dies at 82,” New York Times, December 5, 2008.

  Chapter 8: Deciphering the Damage

  Discovery of diffuse axonal injury: Details came from an interview with John Polvishock, Ph.D., and from John Povlishock et al., “Axonal Change in Minor Head Injury,” Journal of Neuropathology & Experimental Neurology 42:225–42, 1983; J. Hume Adams et al., “Diffuse Brian Damage of Immediate Impact Type: Its Relationship to Primary Brain Stem Damage in Head Injury,” Brain 100:489–502, 1977; and Thomas A. Gennarelli et al., “Diffuse Axonal Injury: An Important Form of Traumatic Brain Damage,” Neuroscientist 4:202–15, 1998.

  Smith research on axon stretching: Discussion based on interviews with Douglas Smith, M.D., and on Douglas H. Smith and David F. Meany, “Axonal Damage in Traumatic Brain Injury,” Neuroscientist 6:483–94, 2000; Min D. Tang-Schomer et al., “Mechanical Breaking of Microtubules in Axons during Dynamic Stretch Injury Underlies Delayed Elasticity, Microtubule Disassembly, and Axon Degeneration,” FASEB Journal 24:1401–10, 2009; and Tracey J. Yuen et al., “Sodium Channelopathy Induced by Mild Axonal Trauma Worsens Outcome after a Repeat Injury,” Journal of Neuroscience Research 87:3620–25, 2009.

  Axonal injury in mild TBI: Information came from P. C. Blumbergs et al., “Staining of Amyloid Precursor Protein to Study Axonal Damage in Mild Head Injury,” Lancet 344:1055–56, 1994.

  Research on duration of concussion effects: Information came from interviews with David Hovda, Ph.D., and from Atsuo Yoshino et al., “Dynamic Changes in Local Glucose Utilization following Cerebral Concussion in Rats: Evidence of a Hyper- and Subsequent Hypometabolic State,” Brain Research 561:106–19, 1991; and David A. Hovda et al., “Diffuse Prolonged Depression of Cerebral Oxidative Metabolism following Concussive Brain Injury in the Rat: A Cytochrome Oxidase Histochemistry Study,” Brain Research 567:1–10, 1991.

  Research on loss of plasticity: Discussion based on interviews with David Hovda, Ph.D., and on Christopher C. Giza et al., “Experience Dependent Behavioral Plasticity Is Disturbed following Traumatic Brain Injury in the Immature Brain,” Behavioral Brain Research 157:11–22, 2005; Christopher C. Giza et al., “N-Methyl-D-Aspartate Receptor Subunit Changes after Traumatic Injury to the Developing Brain,” Journal of Neurotrauma 23:950–61, 2006; Igor Fineman et al., “Inhibition of Neocortical Plasticity during Development by a Moderate Concussive Brain Injury,” Journal of Neurotrauma 17:739–49, 2000; and Daniel J. Olesniewicz et al., “Repeated Measures of Cognitive Processing Efficiency in Adolescent Athletes: Implications for Monitoring Recovery from Concussion,” Neuropsychiatry, Neuropsychology, & Behavioral Neurology 12:167–69, 1999.

  Metabolic cascade: Discussion based on interviews with David Hovda, Ph.D.; Edward Hall, Ph.D., director of the University of Kentucky Spinal Cord and Brain Injury Research Center; and Jonathan Lifshitz, Ph.D., also with the Uni
versity of Kentucky Spinal Cord and Brain Injury Research Center. Some details came from Christopher C. Giza and David A. Hovda, “The Neurometabolic Cascade of Concussion,” Journal of Athletic Training 36:228–35, 2001.

  Imaging: Discussion based on interviews with David Hovda, Ph.D.; Mark Lovell, Ph.D.; and Michael Lipton, M.D., Ph.D. Some details came from Marvin Bergsneider et al., “Dissociation of Cerebral Glucose and Level of Consciousness during the Period of Metabolic Depression following Human Traumatic Brain Injury,” Journal of Neurotrauma 17:389–401, 2000, and Michael L. Lipton et al., “Diffusion-Tensor Imaging Implicates Prefrontal Axonal Injury in Executive Function Impairment following Very Mild Traumatic Brain Injury,” Radiology 252:816–24, 2009.

  Link between Alzheimer’s and TBI: Narrative constructed from interviews with Douglas Smith, M.D., and from Kunihiro Uryu et al., “Multiple Proteins Implicated in Neurodegenerative Diseases Accumulate in Axons after Brain Trauma in Humans,” Experimental Neurology 208:185–92, 2007; Victoria E. Johnson et al., “A Neprilysin Polymorphism and Amyloid-beta Plaques following Traumatic Brain Injury,” Journal of Neurotrauma [epub 2009, ahead of print]; Xaio-Han Chen et al., “A Lack of Amyloid Beta Plaques Despite Persistent Accumulation of Amyloid Beta in Axons of Long-Term Survivors of Traumatic Brain Injury,” Brain Pathology 19:214–23, 2009; and Victoria E. Johnson et al., “Traumatic Brain Injury and Amyloid-Beta Pathology: A Link to Alzheimer’s Disease?” Nature Reviews Neuroscience [epub 2010, ahead of print].

  Chapter 9: A Pocketful of Mumbles

  Jerry Quarry’s story: Narrative based on numerous newspaper and magazine articles chronicling his background, career, and decline. A special debt is owed to Steve Wilstein for his October 24, 1995, Associated Press feature providing the most comprehensive firsthand account of Quarry’s descent into dementia. Another indispensable account came from William Plummer, “A Life on the Ropes,” People, February 19, 1996. Additional details and quotes came from Pete Hamill, “Blood on Their Hands,” Esquire, June 1996; “Damaging Blows for Boxing,” Newsday, July 10, 1996; “Jerry Quarry,” Cyber Boxing Zone, September 1998; obituaries in The New York Times, Newsday, and Washington Times; and information from the Jerry Quarry Foundation for Dementia Pugilistica.