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Quarterback Troy Aikman of the Dallas Cowboys sits on the bench after suffering a concussion during a game against the Philadelphia Eagles at Veterans Stadium in Philadelphia Pennsylvania.
It has been misunderstood and mishandled through generations of athletes. But as 32 National Football League teams toil through training camp, gearing up for the season, the issue of sports concussions - and their repercussions - has come into sharp focus. Dialogue and debate have been fueled by recent initiatives by the NFL to tackle the problem - and claims by a Pittsburgh doctor that multiple traumatic concussions contributed to early dementia, severe depression and the deaths of four former players.
But across the board, from boxers to hockey players to NASCAR drivers to steeplechase jockeys, there appears to be a greater awareness of the dangers of multiple concussions - and more steps are being taken to protect the participants from potential long-term harm.
"The key is education," said former New Orleans tight end Ernie Conwell, a member of the NFL Players Association executive committee. "It's about educating our own players and really letting them understand the severity of concussions."
In April, veteran sports agent Leigh Steinberg and Hall of Fame quarterback Warren Moon held a concussion summit in Marina Del Ray, Calif., where it was underscored that 350,000 athletes sustain varying degrees of head injuries playing sports every year in the United States, and that number only includes those who lost consciousness. The full number, factoring in lesser concussions - often referred to as having your bell rung - raises the total to an estimated 3.8-million annually.
Steinberg has had first-hand experience representing future Hall of Fame quarterbacks who coped with concussions: not just Moon, who had six, but Steve Young and Troy Aikman, who were forced to retire because of them.
"What are the stakes?" Steinberg said at the conference. "It's one thing to go out and play football and understand that when you turn 40, you can bend over to pick up your child and have aches and pains. It's another thing to bend down and not be able to identify that child."
Two months ago, NFL commissioner Roger Goodell convened a leaguewide symposium in Chicago, where doctors and trainers from every team huddled with leading neurologists who have been helping shape league policy in the field of brain injuries.
They discussed myriad ways of improving how the league deals with concussions. Among the highlights:
- Making baseline neuropsychological testing of all players this season official league policy starting with the regular season. The tests allow teams to compare mental functioning of an athlete before and after a concussion, and strictly enforcing rules that players keep their helmet chin straps properly buckled.
- The immediate establishment of a "whistle-blower" program, encouraging anyone to anonymously report incidents in which a player is pressured to return to action before he is ready.
"We're continuing to learn in this area, so if we can make better decisions going forward, we will certainly try to do that," Goodell said. "But I think the evidence is that our doctors have made excellent decisions about returning players to games."
Not everyone agrees with that assessment. Before the Super Bowl on Feb. 4, the New York Times and Boston Globe published stories about former New England Patriots linebacker Ted Johnson, who said he was rushed back onto the field before he had recovered from a concussion. Johnson described how he suffered a string of subsequent concussions, knocking him into retirement and into a deep, persistent depression.
"I don't shave, don't shower, don't brush my teeth - you just don't care," Johnson said in a segment of HBO's Real Sports with Bryant Gumbel, describing how he often feels now for days on end.
Johnson's battle with depression is one of several post-concussive traits identified by Dr. Bennet Omalu, a Pittsburgh neuropathologist who has made news by studying the brains of four deceased NFL players.
Omalu, an authority on suicide and forensic pathology at the University of Pittsburgh, examined the remains of three former Steelers linemen who experienced severe depression - Mike Webster, who died at 50 of a heart attack in 2002 after experiencing many personal problems; Justin Strzelczyk, who was killed at 36 when he crashed his pickup while eluding police during a chase in 2004; and Terry Long, who committed suicide in 2005 at age 45 - as well as former Philadelphia Eagles defensive back Andre Waters, the onetime USF assistant who took his life at 44 in November in Tampa.
In each case, Omalu found brain damage that he said would have produced depression and advanced dementia in four relatively young men, claiming that Waters had the brain tissue of an 85-year-old man exhibiting early symptoms of Alzheimer's.
Those findings have been disputed by the NFL and were not supported by many doctors at the Chicago concussion summit. Some, such as Dr. Robert Cantu, who has treated Ted Johnson, are more open to Omalu's findings than others, though not yet ready to embrace them.
"I think there's significant data that would suggest that multiple concussions can have cumulative effects," he said. "... (In) virtually all sports where there are incidents of head injury, there are individuals who go on to suffer consequences after that."
Dr. Ira Casson, co-chair of the NFL's concussion committee, has a different view.
"In my opinion, the only scientifically valid evidence of chronic encephalopathy (brain disease) in athletes is in boxers and some steeplechase jockeys," he said. "I disagree with Dr. Cantu on that. But let me say that there are ongoing studies to determine that and this forum is a very good one ... to discuss these issues and benefit the health and safety of NFL players."
Setting the baseline
The study of concussions is nothing new. The NFL formed a committee to research ramifications of the head injury in 1994, and regards the current initiative as an extension of that work.
The NHL, meanwhile, examined concussions between 1996 and 2004 and began employing baseline testing for the 1997-98 season - the first league to do so. The NHL has also installed flexible glass that lessens above-the-board impact and made improvements in protective equipment.
The ImPACT program is the primary test in the NFL, already used in some form by 31 of 32 teams - though not the only program used today by sports teams.
It was developed by Mark Lovell, director of the Center for Sports Medicine Concussion Program at the University of Pittsburgh. It stands for Immediate Post-Concussion Assessment and Cognitive Testing, which measures memory, ability to process information, reaction time and an array of other mental functions.
The test, devised in conjunction with Dr. Joseph Maroon, neurosurgeon for the Steelers, is given to athletes at the start of a season when they are in good condition. It provides a useful baseline for evaluating an athlete who sustains a head injury.
In addition to the NFL teams using ImPACT, 18 major-league baseball teams and three NBA teams use the test, as well as hundreds of high school and college football teams, Champ Car and IndyCar circuits, and some NASCAR drivers.
"Neurocognitive testing and symptom assessment is the best single tool that we have now for determining when and if the athlete is fit to play," Maroon said in Chicago. "Mark (Lovell) and I have been working on this for 15 years and the Steelers were the first team to use this. We're very happy to see it's now in 1,500 high schools and many other colleges and professional teams. So that's the best way to go."
Baseline testing is growing in popularity as a tool for assessing concussions because players can't be trusted to assess themselves. The gladiator mentality prevails in sports. Given a choice, athletes - if they can stay on their feet - will usually insist on staying in a game.
"When you're asking a player on the sideline if he wants to go back in the game, the player is going to tell you yes," said Houston Texans tight end Mark Bruener, also a member of the NFLPA executive committee. "When you're in a tight game situation, you don't necessarily make decisions that you think are in your better interest - 30 days from then, or three years from then. ... So if you can create a standardized set of guidelines that the trainers can adhere to, it can protect the player from himself if he's not in a state of mind to make a rational decision."
All-Pro defensive back Troy Vincent, president of the NFLPA, recalls many instances when he was virtually out on his feet while on the field during a game.
"I'm in the huddle but don't know where I'm at, don't know the call and I have a teammate just holding me up," he said. "Because of that gladiator mentality, we just keep going, get some smelling salts and go back in. 'I can get it coach.' "
Vincent said he has had "six or seven" documented concussions in 15 NFL seasons, but 50 or 60 times in his entire football-playing life when he was "dinged" to some degree.
"Oftentimes, I believe we've probably had concussions and don't recognize it," added Conwell, who said he has had four documented NFL concussions but many more counting lesser hits. "You're just on to the next play, on to the next drill in practice. If it's a Class A concussion, just a little dizziness, blurriness - we call it seeing stars - it's hard to put a number on that."
No player wants to leave a game, for fear of being replaced and perhaps losing his job.
"Bottom line, guys are just thinking about job security," Conwell said. "And already there's kind of a counterculture in the NFL of self-treating, of not letting trainers and doctors know when something is wrong with you. You don't want to be labeled as somebody who's injured. ... Guys don't want to say anything about being dinged because they might take you out of the game, or you'll be labeled as a guy who has a soft head."
"You're young. You just want to play in the league," said former Lightning wing Rob DiMaio, 39, whose career is jeopardized because of a September 2006 concussion - and who admitted he likely played through several that went undiagnosed. "A lot of times you get hit a certain way and don't say anything. It's an ego thing, and it's not the smartest thing by any means."
Former NHL player Nick Kypreos understands the pain - physical and emotional - from concussions. A severe one forced him to retire in 1998.
"I think when you see your peers going though some of the same battles, it gets a little easier to sit there and go, 'Well, I'm not alone,' " he said. "There was a big stigma about concussions years ago - 'Nah, he's not that hurt.' He's pulling the 'chute, which is another term for pulling up lame. He's soft. He can't play tough.' ... The more guys go through it, tough guys like Rob DiMaio, the easier it is for another guy to admit he's hurt and that he needs help and proper treatment."
What makes it so difficult, Kypreos added, is that the injury can't be seen: "It's so unlike hurting your knee or separating your shoulder, where there's a timetable and a certain protocol you have to follow. This one, you're in the twilight zone."
But by all indications, the sports concussion issue finally appears to be coming out of the haze.
Information from the Associated Press and USA Today was used in this report; Dave Scheiber can be reached at (727) 893-8541 or firstname.lastname@example.org.