Helmet Reveals Data About High School Football Player's Broken Neck

For the crowd watching an Illinois high school football game last fall, it was a sickening feeling watching one of their Unity Rockets' cornerbacks collapse to the ground after delivering a heads-down tackle on an opposing running back (see video here.) 

For Steven Broglio, an assistant professor of kinesiology at the University of Michigan, it was a mixed feeling of concern and curiosity as to the extent of the injury.  Since 2007, Broglio has been collecting data on the violent collisions that occur in high school football and their contribution to concussions and other head injuries.

Unity players use helmets with padded sensors called the Head Impact Telemetry System.
Using a sensor similar to what is used in car air bags, the HITS helmets record and transmit the magnitude of each impact and its location on the helmet to a computer located on the sideline within about 10-20 seconds.  Broglio is able to monitor these collisions and alert the coaching staff if an impact exceeds the threshold known to cause concussions, about 90-100 g-force. Listen to Broglio describe the HITS research.

In the last four years, Broglio has recorded over 120,000 football collisions with 25 resulting in a concussion for the player.  However, on this night, he would record data on a much more rare injury - a broken neck.  After briefly losing consciousness on the field, the Unity cornerback was taken to a hospital emergency room and was diagnosed with a concussion and a stable left C6 facet fracture, otherwise known as a broken neck.  Data from the collision showed the hit occurred at the top right side of the helmet at a amazing 114 g-force.  Just for comparison, a shuttle launch is about 3 g-force while a rolling fighter pilot sustains about 5-10 g-force.

Thankfully, the player was released from the hospital 48 hours later with a hard neck collar.  While his football season was over, he returned to play basketball twelve weeks later.

Broglio describes the encounter in a letter to the New England Journal of Medicine.

The goal of the research is to perfect the technology so that similar, less expensive systems can be used on many more football sidelines.  Broglio said a number of other researchers at universities across the nation, including Virginia Tech, the University of North Carolina and Dartmouth, also are using the system as the basis for studies of biomechanical processes caused by concussions and traumatic brain injuries. The current system has a price tag of about $60,000 while the customization to each helmet costs an additional $1,000.  "Ultimately, we're trying to use these measures to predict concussion," Broglio said. "If someone exceeds a certain level then we would know they have a concussion and we could pull them."

With the recent attention to concussions at the NFL level, there is hope that research will also benefit high school and college players. "To us, the larger public health issue is with the 1.5 million high school kids that play football each year. Not the 1,500 that play in the NFL," Broglio said.

Related Articles: New Return-To-Play Guidelines For Sports Concussions and NFL Concussions Taking Bigger Toll On Players

Body Checking In Youth Hockey Causes More Brain Injuries

Youth hockey players in the Atom division of Hockey Canada are more than 10 times likely to suffer a brain injury since bodychecking was first allowed among the 9 and 10-year-olds, says a study led by St. Michael's Hospital neurosurgeon Dr. Michael Cusimano.

The findings, published online in the journal Open Medicine, add to the growing evidence that bodychecking holds greater risk than benefit for youth and support widespread calls to ban the practice.

According to the researchers, led by Cusimano, director of the Injury Prevention Research Centre at St. Michael's Hospital in Toronto, the odds of visiting an emergency department due to a brain injury from bodychecking increased significantly among all minor hockey players after Hockey Canada relaxed bodychecking rules in the 1998/1999 season. At that time, the organization allowed, for the first time, body contact among 9 and 10 year-olds in the Atom division.

The team examined the records of 8,552 male youth 6-17 years-old who attended one of five emergency departments in Ontario for hockey related injuries that occurred before and after the rule change. Researchers found more than half of hockey-related injuries were a result of bodychecking. What's more, the risk of a head or neck injury, including concussions, increased across all minor hockey divisions.
"Our work confirmed the fact that body checking is the most common cause of injury in hockey. While proponents argue lowering the age for bodychecking helps players learn how to properly bodycheck and reduces injuries at older ages, our study clearly showed the opposite ― the risk of all injuries and especially, brain injuries, increases with exposure to bodychecking," Cusimano said. "While all age groups showed increases in injuries, the youngest were the most vulnerable and that bodychecking puts youth unnecessarily at the risk of the long-term effects of brain injuries, such as cognitive and social-behavioural problems."

For some time, researchers like Dr. Cusimano have called on organizations like the NHL to take more leadership in reducing the incidence of brain injuries. In recent weeks, pressure has mounted on the NHL after Pittsburgh Penquins captain Sidney Crosby and Montreal Canadiens' Max Pacioretty suffered serious concussions that sidelined both players.

"Ice hockey is a sport with great potential to increase the health of individuals but practices that increase the risk for the vast majority of players must be minimized," Cusimano adds. "It is now very clear that there is no benefit to any one or any group to continue to allow bodychecking. Hockey organizers, sponsors, the media, coaches, trainers, and players and parents must come together to advocate for multifaceted approaches that include changes to the rules to reduce the risk of injury."

Source: St. Michael's Hospital and Michael D Cusimano, Nathan A Taback, Steven R McFaull, Ryan Hodgins, Tsegaye M Bekele, Nada Elfeki; Canadian Research Team in Traumatic Brain Injury and Violence. Effect of bodychecking on rate of injuries among minor hockey players. Open Medicine, Vol 5, No 1 (2011)

See also: New Return-To-Play Guidelines For Sports Concussions and Youth Sports Concussions Double In Last Ten Years

Computerized Concussion Testing Yields More Cautious Return To Play Timeline

When computerized neuropsychological testing is used, high school athletes suffering from a sports-related concussion are less likely to be returned to play within one week of their injury, according to a study in The American Journal of Sports Medicine. Unfortunately, concussed football players are less likely to have computerized neuropsychological testing than those participating in other sports.

A total of 544 concussions were recorded by the High School Reporting Information Online surveillance system during the 2008-2009 school year. Researchers looked at each of those instances to see what caused the injury, what sport was being played, what symptoms were experienced, what type of testing was used, and how soon the athletes returned to play.

When looking at the causes and duration of concussions, the research found that:

* 76.2% of the concussions were caused by contact with another player, usually a head-to-head collision
* 93.4% of concussions caused a headache; 4.6% caused loss of consciousness
* 83.4% experienced resolution of their symptoms within a week, while 1.5% had symptoms that lasted longer than a month.

Computerized neuropsychological testing was used in 25.7% of concussions, and in those cases, athletes were less likely to return to play within one week, than those athletes for whom it was not used. Interestingly, however, researchers found that injured football players were less likely to be examined using the computerized neuropsychological testing than injured athletes participating in other sports.

"Although it is now recognized as one of 'the cornerstones of concussion evaluation,' routine neuropsychological testing in the setting of sports-related concussion is a relatively new concept," write the authors, William P. Meehan III, MD, Pierre d'Hemecourt, MD, and R. Dawn Comstock, PhD. "This is the first study, of which we are aware, to query the use of computerized neuropsychological testing in high school athletes using a large, nationally representative sample."

Source: High School Concussions in the 2008-2009 Academic Year: Mechanism, Symptoms, and Management. The American Journal of Sports Medicine, 2010; 38 (12): 2405 DOI: 10.1177/0363546510376737

See also: NFL Concussions Taking Bigger Toll On Players and Football Players May Still Injure Brain Even Without A Concussion

New Return-To-Play Guidelines For Sports Concussions

The American Academy of Neurology (AAN) is calling for any athlete who is suspected of having a concussion to be removed from play until the athlete is evaluated by a physician with training in the evaluation and management of sports concussion.

The request is one of five recommendations from a new position statement approved by the AAN's Board of Directors that targets policymakers with authority over determining the policy procedures for when an athlete suffers from concussion while participating in a sporting activity.

According to the Centers for Disease Control, sports-related concussions occur in the United States three million times per year, and among people ages 15 to 24 are now second only to motor vehicle accidents as a leading cause of traumatic brain injury.


"While the majority of concussions are self-limited injuries, catastrophic results can occur and we do not yet know the long-term effects of multiple concussions," said Jeffrey Kutcher, MD, MPH, chair of the AAN's Sports Neurology Section, which drafted the position statement. "We owe it to athletes to advocate for policy measures that promote high quality, safe care for those participating in contact sports."

According to the new statement, no athlete should be allowed to participate in sports if he or she is still experiencing symptoms from a concussion, and a neurologist or physician with proper training should be consulted prior to clearing the athlete for return to participation.

In addition, the AAN recommends a certified athletic trainer be present at all sporting events, including practices, where athletes are at risk for concussion. Education efforts should also be maximized to improving the understanding of sports concussion by all athletes, parents and coaches. "We need to make sure coaches, trainers, and even parents, are properly educated on this issue, and that the right steps have been taken before an athlete returns to the field," said Kutcher, who is also director of the University of Michigan's Neurosport program.

In 1997, the AAN published a guideline on the management of sports concussion that defines concussion grade levels and provides recommendations. The guideline is currently being updated.

Source: American Academy of Neurology

See also: NFL Concussions Taking Bigger Toll On Players and Youth Sports Concussions Double In Last Ten Years

NFL Concussions Taking Bigger Toll On Players

NFL players with concussions now stay away from the game significantly longer than they did in the late 1990s and early 2000s, according to research in Sports Health (owned by American Orthopaedic Society for Sports Medicine and published by SAGE). The mean days lost with concussion increased from 1.92 days during 1996-2001 to 4.73 days during 2002-2007.

In an effort to discover whether concussion injury occurrence and treatment had changed, researchers compared those two consecutive six-year periods to determine the circumstances of the injury, the patterns of symptoms, and a player's time lost from NFL participation. Those time periods were chosen because concussion statistics were recorded by NFL teams using the same standardized form. It recorded player position, type of play, concussion signs and symptoms, loss of consciousness and medical action taken.

Researchers found that in 2002-2007 there were fewer documented concussions per NFL game overall, especially among quarterbacks and wide receivers. But there was a significant increase in concussions among tight ends. Symptoms most frequently reported included headaches, dizziness, and problems with information processing and recall.

Significantly fewer concussed players returned to the same game in 2002-2007 than in 1996-2001 and 8% fewer players returned to play in less than a week. That number jumped to 25% for those players who lost consciousness as a result of the injury.

"There are a number of possible explanations for the decrease in percentages of players returning to play immediately and returning to play on the day of the injury as well as the increased days out after (a concussion) during the recent six year period compared to the first six year period," write authors Ira R. Casson, M.D.; David C. Viano, Dr. med.; Ph.D., John W. Powell, Ph.D.; and Elliot J. Pellman, M.D. "These include the possibility of increased concussion severity, increased player willingness to report symptoms to medical staff, adoption of a more cautious conservative approach to concussion management by team medical personnel and a possible effect of changes in neuropsychological (NP) testing."

Source:  SAGE Publications and I. R. Casson, D. C. Viano, J. W. Powell, E. J. Pellman. Twelve Years of National Football League Concussion Data. Sports Health: A Multidisciplinary Approach, 2010; DOI: 10.1177/1941738110383963

See also: Football Players May Still Injure Brain Even Without A Concussion and Youth Sports Concussions Double In Last Ten Years

Football Players May Still Injure Brain Even Without A Concussion

Thomas Talavage, co-director of the Purdue MRI Facility, prepares to test a Jefferson High School football player. (Credit: Purdue University photo/Andrew Hancock)

A study by researchers at Purdue University suggests that some high school football players suffer undiagnosed changes in brain function and continue playing even though they are impaired.
"Our key finding is a previously undiscovered category of cognitive impairment," said Thomas Talavage, an expert in functional neuroimaging who is an associate professor of biomedical engineering and electrical and computer engineering and co-director of the Purdue MRI Facility.

The findings represent a dilemma because they suggest athletes may suffer a form of injury that is difficult to diagnose.

"The problem is that the usual clinical signs of a head injury are not present," said Larry Leverenz, an expert in athletic training and a clinical professor of health and kinesiology. "There is no sign or symptom that would indicate a need to pull these players out of a practice or game, so they just keep getting hit."

Findings are detailed in a research paper appearing online this week in the Journal of Neurotrauma.
The team of researchers screened and monitored 21 players at Jefferson High School in Lafayette, Ind.
"The athletes wore helmets equipped with six sensors called accelerometers, which relay data wirelessly to equipment on the sidelines during each play," said Eric Nauman, an associate professor of mechanical engineering and an expert in central nervous system and musculoskeletal trauma.

Impact data from each player were compared with brain-imaging scans and cognitive tests performed before, during and after the season. The researchers also shot video of each play to record and study how the athletes sustained impacts.

Whereas previous research studying football-related head trauma has focused on players diagnosed with concussions, the Purdue researchers tested all of the players. They were surprised to find cognitive impairment in players who hadn't been diagnosed with concussions.

The research team identified 11 players who either were diagnosed by a physician as having a concussion, received an unusually high number of impacts to the head or received an unusually hard impact. Of those 11 players, three were diagnosed with concussions during the course of the season, four showed no changes and four showed changes in brain function.

"So half of the players who appeared to be uninjured still showed changes in brain function," Leverenz said. "These four players showed significant brain deficits. Technically, we aren't calling the impairment concussions because that term implies very specific clinical symptoms, such as losing consciousness or having trouble walking and speaking. At the same time, our data clearly indicate significant impairment."

The findings support anecdotal evidence that football players not diagnosed with concussions often seem to suffer cognitive impairment.

Researchers evaluated players using a GE Healthcare Signa HDx 3.0T MRI to conduct a type of brain imaging called functional magnetic resonance imaging, or fMRI, along with a computer-based neurocognitive screening test.

"We're proud of our association with Purdue and feel longitudinal studies will provide a valuable platform to better study brain injuries," said Jonathan A. Murray, general manager of cross business programs for GE Healthcare.

The research could aid efforts to develop more sensitive and accurate methods for detecting cognitive impairment and concussions; more accurately characterize and model cognitive deficits that result from head impacts; determine the cellular basis for cognitive deficits after a single impact or repeated impacts; and develop new interventions to reduce the risk and effects of head impacts.

"By integrating the fMRI with head-based accelerometers and computer-based cognitive assessment, we are able to detect subtle levels of neurofunctional and neurophysiological change," Nauman said. "These data provide an opportunity to accurately track both the initial changes as well as the recovery in cognitive performance."

(Credit: iStockphoto/Bill Grove

The ongoing research may help to determine how many blows it takes to cause impairment, which could lead to safety guidelines on limiting the number of hits a player receives per week.  "We're not yet sure exactly how many hits this is, but it's probably around 50 or 60 per week, which is not uncommon," Nauman said. "We've had kids who took 1,600 impacts during a season."

The research paper was written by Nauman, Leverenz, Talavage, Katie Morigaki, a graduate student in the Department of Health and Kinesiology, biomedical engineering graduate student Evan Breedlove, mechanical engineering graduate student Anne Dye, electrical and computer engineering graduate student Umit Yoruk, and Henry Feuer, a physician and neurosurgeon in the Department of Neurosurgery at the Indiana University School of Medicine.

Feuer is a neurosurgical consultant to the National Football League's Indianapolis Colts and a member of NFL subcommittees assessing the effects of mild traumatic brain injury.

The researchers studied the football players last season and are continuing the work this season.
The helmet-sensor data demonstrated that undiagnosed players who didn't show impairment received blows in many areas of the head, but the undiagnosed players who showed impairment received a large number of blows primarily to the top and front. This part of the brain is involved in "working memory," including visual working memory, a form of short-term memory for recalling shapes and visual arrangement of objects such as the placement of furniture in a room, Nauman said.
"These are kids who put their head down and take blow after blow to the top of the head," said Nauman, who also is an associate professor of biomedical engineering and basic medical sciences and leads Purdue's Human Injury Research and Regenerative Technologies Laboratory. "We've seen this primarily in linebackers and linemen, who tend to take most of the hits."

Helmet sensor data indicate impact forces to the head range from 20 to more than 100 Gs.
"To give you some perspective, a roller coaster subjects you to about 5 Gs and soccer players may experience up to 20 G accelerations from heading the ball," Nauman said.
Head impacts cause the brain to bounce back and forth inside the skull, damaging neurons or surrounding tissue. The trauma can either break nerve fibers called axons or impair signaling junctions between neurons called synapses.

The findings suggest the undiagnosed players suffer a different kind of brain injury than players who are diagnosed with a concussion.

"To be taken out of a game you have to show symptoms of neurological deficits -- unsteady balance, blurred vision, ringing in the ears, headaches and slurred speech," Leverenz said. "Unlike the diagnosed concussions, however, these injuries don't affect how you talk, whether you can walk a straight line or whether you know what day it is."

The fMRI reveals information about brain metabolism and blood flow, showing which parts of the brain are most active during specific tasks, Talavage said.

"One of the most challenging aspects of treating concussions is diagnosing the part of the brain that has been damaged," he said.

The fMRI data from before, during and after the season were compared to see whether there was any difference in brain activity that indicated impairment. The players also were studied using a standard cognitive test to show how well they were able to remember specific letters, words and patterns of lines.

The work may enable researchers to learn whether high school players accumulate damage over several seasons or whether they recover fully from season to season. The researchers have found that players diagnosed with concussions or who showed marked cognitive impairment had not yet recovered by the end of the season.

New preliminary data, however, suggests the players might recover before the start of the next season, but additional research is needed to determine the extent of recovery, Talavage said.
The work brings together faculty members from Purdue's College of Engineering and the new College of Health and Human Sciences along with research partners at GE Healthcare. The multidisciplinary team includes researchers specializing in neuroimaging, brain health, biomechanics, clinical sports medicine and analytical modeling.

The research group, called the Purdue Acute Neural Injury Consortium, also is studying ways to reduce traumatic brain injury in soldiers who suffer concussions caused by shock waves from explosions.  "There are numerous parallels between head injuries experienced by soldiers and football players," Nauman said.

Other researchers in the consortium are Dennis A. Miller, a sports medicine expert; Charles A. Bouman, the Michael J. and Katherine R. Birck Professor of Electrical and Computer engineering and co-director of the Purdue MRI Facility; and Alexander L. Francis, an expert in learning and cognitive processing and an associate professor of speech, language and hearing sciences.

The work has been funded by the Indiana Department of Health and GE Healthcare. The researchers would like to extend their study to more high schools and are seeking additional funding for the work.
Researchers are working to create a helmet that reduces the cumulative effect of impacts, said John C. Hertig, executive director of the Alfred Mann Institute for Biomedical Development at Purdue.

"We're funding the development of a novel injury mitigation system created by researchers at Purdue for use in sports or military helmets," Hertig said. "This technology is targeted at mitigating the collective impacts absorbed by the brain in such a way as to dissipate the harmful energy that occurs during repeated impacts. Football linemen, soccer and hockey players, and others will benefit from the re-engineering of a sports helmet design created by Eric Nauman and his team."

Source:  Purdue University and Thomas M. Talavage, Eric Nauman, Evan L. Breedlove, Umit Yoruk, Anne E Dye, Katie Morigaki, Henry Feuer, Larry J. Leverenz. Functionally-Detected Cognitive Impairment in High School Football Players Without Clinically-Diagnosed Concussion. Journal of Neurotrauma, 2010; : 101001044014052 DOI: 10.1089/neu.2010.1512

See also: Hockey Hits Are Hurting More and Lifting The Fog Of Sports Concussions

Youth Sports Concussions Double In Last Ten Years

A new study from Hasbro Children's Hospital finds visits to emergency departments for concussions that occurred during organized team sports have increased dramatically over a 10-year period, and appear to be highest in ice hockey and football. The number of sports-related concussions is highest in high school-aged athletes, but the number in younger athletes is significant and rising. The study is published in the September 2010 issue of Pediatrics and is now available online ahead of print.

In a review of national databases of emergency department (ED) visits, there were 502,000 visits to EDs for concussions in children aged 8 to 19 years in the period from 2001 through 2005; of those 65 percent were in the 14- to 19-year old age group while 35 percent were in the 8- to 13-year-old age group. Approximately half of all the ED visits for concussions were sports-related, and an estimated 95,000 of those visits were for concussions that occurred from one of the top five organized team sports: football, basketball, baseball, soccer and ice hockey.

The researchers also note that in the period from 2001 through 2005, approximately four in 1,000 children aged 8 to 13 and six in 1,000 aged 14 to 19 had an ED visit for a sport-related concussion.
Lisa Bakhos, MD, is a recently graduated fellow who was practicing at Hasbro Children's Hospital at the time she led the study. Bakhos says, "Our data show that older children have an overall greater estimated number of ED visits for sport-related concussion compared to younger children. Younger children, however, represent a considerable portion of sport-related concussions, approximately 40 percent."

The researchers found that ED visits for organized team sport-related concussions doubled over the time period depicted and increased by over 200 percent in the 14- to 19-year old age group, while overall participation decreased by 13 percent in the same time period. Bakhos comments, "What was striking in our study is that the number of sport-related concussions has increased significantly over a 10-year period despite an overall decline in participation. Experts have hypothesized that this may be due to an increasing number of available sports activities, increasing competitiveness in youth sports, and increasing intensity of practice and play times. However, the increasing numbers may also be secondary to increased awareness and reporting."

James Linakis, MD, PhD, is a pediatric emergency medicine physician with Hasbro Children's Hospital and its Injury Prevention Center and is the senior author on the paper. He comments, "Our assessment highlights the need for further research and injury prevention strategies into sport-related concussion. This is especially true for the young athlete, with prevailing expert opinion suggesting that concussion in this age group can produce more severe neurologic after-effects, such as prolonged cognitive disturbances, disturbed skill acquisition, and other long-term effects."

Despite the apparent increase in concussions in youth athletes, there are no comprehensive return-to-play guidelines for young athletes. The researchers also note that there are no evidence-based management guidelines for the treatment of these injuries, while there is agreement that young children cannot be managed in the same way as older adolescents.

Linakis, who is also a physician with University Emergency Medicine Foundation and an associate professor at The Warren Alpert Medical School of Brown University, says, "Children need not only physical, but cognitive rest, and a slow-graded return to play and school after such injuries. As a result of this study, it is clear that we need more conservative guidelines for the management of younger children who suffer concussions." Return-to-play assessments might include such strategies as neuropsychological testing, functional MRI, visual tracking technology and balance dysfunction tracking.

Bakhos concludes, "What this research tells us is that we need additional studies to provide guidance in management, prevention strategies and education for practitioners, coaches and athletes."


Source: Lifespan and Bakhos, Linakis, Lockhart, Myers, Linakis. Emergency Department Visits for Concussion in Young Child Athletes. Pediatrics, 8/30/2010 DOI: 10.1542/peds.2009-3101

See also: Body Checking Not The Main Cause Of Youth Hockey Injuries and Science Fair Project Leads To New Sports Concussion Test

Body Checking Not The Main Cause Of Youth Hockey Injuries

Hockey fans likely would assume that body-checking -- intentionally slamming an opponent against the boards -- causes the most injuries in youth ice hockey. But they would be wrong.  Findings from a new study, the largest and most comprehensive analysis to date of young hockey players, show that 66 percent of overall injuries were caused by accidentally hitting the boards or goal posts, colliding with teammates or being hit by a puck.

Only 34 percent of the injuries were caused by checking. Moreover, the accidental injuries were more severe than those from body checks.

These results, which appeared in June issue of the British Journal of Sports Medicine, were a surprise to many, including the researchers at the University at Buffalo who conducted the five-year study.

"There is an image of body checking as a form of violence that is condoned by the game of hockey," says Barry Willer, PhD, UB professor of psychiatry and rehabilitation sciences and senior author on the study.  "However, this study found that body checking did not account for a large proportion of injuries. Perhaps as important, body checking did not lead to a rise in intentional injuries."


The youth ice hockey program in Burlington, Ontario, Canada was the base of the study. The researchers compared injury rates overall for the three levels of competition: "house leagues," where there is no body checking; "select," in which checking is allowed at age 11 and older; and "representative," for the most skilled players, which allows checking in all divisions at age nine and above.
 
They also examined injury rates as level of competition and players' age increased, and how injury rates varied in games versus practices. The data covered 3,000 boys ages four to 18 for a total of 13,292 player years. Only injuries that kept a player off the ice for at least 24 hours were included.
Their analysis of the data shows that there were three times more accidental injuries than body-checking injuries in the house leagues -- 92 versus 30. Willer says accidents at this level of competition primarily are caused by players watching the puck instead of what's in front of them, of not playing "heads-up," which coaches try to instill at all levels.

The "select" level tallied the least injuries (28) with more than half intentional, as players first experience checking. In the most experienced league, however, 59 percent of the 96 injuries were unintentional, but the number of intentional injuries (39) was the highest of all the categories, as competition level increases.

As the researchers predicted, as the level of competition and players' age increases, so did injuries. "Game injuries were much more frequent among the highly skilled players on rep teams," says Willer. Rates during practice were low across all age groups and divisions.  Willer notes that this study doesn't answer two important questions: at what age should body checking be allowed in youth hockey, or should it be allowed at all?

"The study does suggest," says Willer, "that, regardless of whether young players are allowed to body check, unintentional contact with the board, the ice or other players are important sources of serious unintended injury. To avoid these accidents, hockey coaches must teach players to keep their heads up, rather than looking down at the puck."

Sources: University at Buffalo and Darling et al. Intentional versus unintentional contact as a mechanism of injury in youth ice hockey. British Journal of Sports Medicine, 2010

See also: Science Fair Project Leads To New Sports Concussion Test and Lifting The Fog Of Sports Concussions

Hockey, Concussions and TBI

Photo by Yong Kim/Philly.com Staff Photographer

Dan's note: I am very pleased to publish this guest post from Chelsea Travers. She is an outreach representative for CareMeridian, a subacute care facility, with locations throughout the Western United States for patients suffering from traumatic brain injury, spinal cord injury or medical complexities, such as neuromuscular or congenital anomalies.

By Chelsea Travers

Hockey is arguably one of the most physical professional sports. Hockey players are constantly getting body checked, slammed into boards, falling to the ice, slapped by a stick, hit by a dense, speeding puck or getting punched during a fight. If that isn’t bad enough, hockey players take part in one of the longest regular seasons of any sport, effectively taking on harsher pain for a longer amount of time throughout the year.    

Risk of injury couldn’t be clearer as it is common to see hockey players missing their front two teeth. With all of the injuries that can occur, one of the most dangerous is a traumatic brain injury (TBI). A TBI is a silent injury that can cause harm to the mind and body of an individual. An injury to the head or brain can alter someone’s life and can even require long-term rehabilitation and care from a skilled nursing facility. These injuries are often far too common in the sport of hockey and if not properly treated can permanently leave a hockey player's life more challenging than the game they play.

TBI is an injury that Philadelphia Flyers player Ian Laperriere knows all too well. Last month, in an NHL playoff game with the New Jersey Devils, Laperriere took a slap shot to the face that immediately caused him to bleed excessively from the wound above his eye and lose sight. Laperriere was diagnosed with a brain contusion after having a MRI a few days later. While Laperriere may have originally thought that losing sight in one of his eyes was the worst of the two injuries, in reality the bigger concern could wind up being the long-term effects of the brain injury.

Concussions may sometimes be dismissed as minor injuries because the physical nature of most sports causes them to occur regularly. However, they are still head injuries where the brain is forced to move violently within the skull, possibly changing its function permanently. When the brain moves in such a manner, it can bruise, bleed, and even tear, which can cause irreversible damage to the victim. 

For a sport like hockey this type of injury is very common and unfortunately at times ignored. Many hockey players don't take into account the possible effects of the injury. As it might not seem like a serious problem exists at first, they keep on skating as if nothing occurred. Being unaware of the injury makes it much more dangerous because a mild brain injury can turn into a life threatening injury in a very short period of time without immediate medical treatment.

Studies by the National Academy of Neuropsychology's Sports Concussion Symposium in New York have shown that since 1997, 759 NHL players have been diagnosed with a concussion. Broken down, that averages out to 76 players per season and 31 concussions per 1,000 games of hockey. That is far too frequent of an occurrence for such a serious injury. It's a frightening statistic that should send up a red flag to hockey officials that actions need to be taken to further prevent this type of injury.

The best, and sometimes only, treatment for TBI is prevention. For the National Hockey League, new rules are being considered that preserve the game but also help protect the players. Rule changes concerning blindside hits, rink size (which effects players space from each other and their proximity to walls), and stronger helmet requirements all have been considered to help curb TBI and its effects. This demonstrates that the NHL is aware of the seriousness of the injury and is taking proactive steps to help prevent it from happening.

Hockey is one of the most popular sports in North America and has millions of people participating in it every year. Unfortunately, the sport comes with the risk of a TBI.  With the right awareness of the injury and the necessary precautions in place, the game should be able to continue with players excited to lace up their skates and enjoy it. 

See also: Lifting The Fog Of Sports Concussions and Hockey Hits Are Hurting More

Science Fair Project Leads To New Sports Concussion Test

A simple test of reaction time may help determine whether athletes have sustained a concussion (also known as mild traumatic brain injury) and when they are ready to play again, according to a study released February 15 that was presented at the American Academy of Neurology's 62nd Annual Meeting in Toronto last month.

According to a story by NPR; "The test is the idea of Ian Richardson, a Michigan high-school student. The teenager devised it as a quick and simple way to test reaction time for a science fair project.  Richardson's device looks like something out of a 19th-century medical text. It's a hockey puck, with a long rod embedded in the middle. The stick is marked off in centimeter increments.  Turns out Ian Richardson's father, James, is on the faculty of the University of Michigan Medical School. He thought Ian's idea might be a pretty cool on-the-spot way to screen for concussions among athletes"

Dr. Richardson forwarded the idea to James Eckner, MD, of the University of Michigan Department of Physical Medicine and Rehabilitation in Ann Arbor.  Eckner and his colleagues developed a simple, inexpensive device to measure reaction time: a cylinder attached to a weighted disk. The examiner releases the device and the athlete catches it as soon as possible.


For the study, the researchers gave the test to 209 Division I college football, wrestling and women's soccer athletes during their preseason physicals. Then any athlete who had a concussion diagnosed by a physician during the season took the test again within three days of the concussion.

"Research has shown that reaction time is slower after a concussion -- even as long as several days after other symptoms are gone," said Eckner. "But the tests currently used to measure reaction time require computers and special software."

Eight athletes had concussions during the study. Of those, seven of the athletes had a prolonged reaction time after the concussion compared to the preseason time. Catching the object took about 15 percent longer.

"Because of its simplicity and low cost, this test may work well with youth athletes, where there is limited access to computerized testing of reaction time," Eckner said.

Source: American Academy of Neurology

See also: Lifting The Fog Of Sports Concussions and Hockey Hits Are Hurting More

Hockey Hits Are Hurting More

One painful lesson every National Hockey League rookie learns is to keep your head up when skating through the neutral zone. If you don't, you will not see the 4700 joules of kinetic energy skating at you with bad intentions.

During an October 25th game, Brandon Sutter, rookie center for the Carolina Hurricanes, never saw Doug Weight, veteran center of the New York Islanders, sizing him up for a hit that resulted in a concussion and an overnight stay in the hospital.  Hockey purists will say that it was a "clean hit" and Weight was not penalized.

Six days before that incident, the Phoenix Coyotes' Kurt Sauer smashed Andrei Kostitsyn of the Montreal Canadiens into the sideboards. Kostitsyn had to be stretchered off of the ice and missed two weeks of games with his concussion. Sauer skated away unhurt and unpenalized. See video here.

Big hits have always been part of hockey, but the price paid in injuries is on the rise. According to data released last month at the National Academy of Neuropsychology's Sports Concussion Symposium in New York, 759 NHL players have been diagnosed with a concussion since 1997. For the ten seasons studied, that works out to about 76 players per season and 31 concussions per 1,000 hockey games. During the 2006-07 season, that resulted in 760 games missed by those injured players, an increase of 41% from 2005-06. Researchers have found two reasons for the jump in severity, the physics of motion and the ever-expanding hockey player.

In his book, The Physics of Hockey, Alain Haché, professor of physics at Canada's University of Moncton, aligns the concepts of energy, momentum and the force of impact to explain the power of mid-ice and board collisions.

As a player skates from a stop to full speed, his mass accelerates at an increasing velocity. The work his muscles contribute is transferred into kinetic energy which can and will be transferred or dissipated when the player stops, either through heat from the friction of his skates on the ice, or through a transfer of energy to whatever he collides with, either the boards or another player.

The formula for kinetic energy, K = (1/2)mass x velocity², represents the greater impact that a skater's speed (velocity) has on the energy produced. It is this speed that makes hockey a more dangerous sport than other contact sports, like football, where average player sizes are larger but they are moving at slower speeds (an average of 23 mph for hockey players in full stride compared to about 16 mph for an average running back in the open field).

So, when two players collide, where does all of that kinetic energy go? First, let's look at two billiard balls, with the exact same mass, shape and rigid structure. When two balls collide on the table, we can ignore the mass variable and just look at velocity. If the ball in motion hits another ball that is stationary, then the ball at rest will receive more kinetic energy from the moving ball so that the total energy is conserved. This will send the stationary ball rolling across the table while the first ball almost comes to a stop as it has transferred almost all of its stored energy.

Unfortunately, when human bodies collide, they don't just bounce off of each other. This "inelastic" collision results in the transfer of kinetic energy being absorbed by bones, tissues and organs. The player with the least stored energy will suffer the most damage from the hit, especially if that player has less "body cushion" to absorb the impact.

To calculate your own real world energy loss scenario, visit the Exploratorium's "Science of Hockey" calculator. For both Sutter and Kostitsyn, they received checks from players who outweighed them by 20 pounds and were skating faster.

The average mass and acceleration variables are also growing as today's NHL players are getting bigger and faster. In a study released in September, Art Quinney and colleagues at the University of Alberta tracked the physiological changes of a single NHL team over 26 years, representing 703 players. Not surprisingly, they found that defensemen are now taller and heavier with higher aerobic capacity while forwards were younger and faster. Goaltenders were actually smaller with less body mass but had better flexibility. However, the increase in physical size and fitness did not correspond with team success on the ice. But the checks sure hurt a lot more now. 

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Lifting The Fog Of Sports Concussions

A concussion, clinically known as a Mild Traumatic Brain Injury (MTBI), is one of the most common yet least understood sports injuries.  According to the Centers for Disease Control, there are as many as 300,000 sports and recreation-related concussions each year in the U.S., yet the diagnosis, immediate treatment and long-term effects are still a mystery to most coaches, parents and even some clinicians.  

The injury can be deceiving as there is rarely any obvious signs of trauma.  If the head is not bleeding and the player either does not lose consciouness or regains it after a brief lapse, the potential damage is hidden and the usual "tough guy" mentality is to "shake it off" and get back in the game.


Leigh Steinberg, agent and representative to some of the top professional athletes in the world (including NFL QBs Ben Roethlisberger and Matt Leinart), is tired of this ignorance and attitude.  "My clients, from the day they played Pop Warner football, are taught to believe ignoring pain, playing with pain and being part of the playing unit was the most important value," Steinberg said, "I was terrified at the understanding of how tender and narrow that bond was between cognition and consciousness and dementia and confusion".  Which is why he was the keynote speaker at last week's "New Developments in Sports-Related Concussions" conference hosted by the University of Pittsburgh Medical College Sport Medicine Department in Pittsburgh. 

Leading researchers gathered to discuss the latest research on sports-related concussions, their diagnosis and treatment.  "There's been huge advancement in this area," said Dr. Micky Collins, the assistant director for the UPMC Sports Medicine Program. "We've learned more in the past five years than the previous 50 combined."

So, what is a concussion?  The CDC defines a concussion as "a complex pathophysiologic process affecting the brain, induced by traumatic biomechanical forces secondary to direct or indirect forces to the head."  Being a "mild" form of traumatic brain injury, it is generally believed that there is no actual structural damage to the brain from a concussion, but more a disruption in the biochemistry and electrical processes between neurons.  

The brain is surrounded by cerebrospinal fluid, which is supposed to provide some protection from minor blows to the head.  However, a harder hit can cause rotational forces that affect a wide area of the brain, but most importantly the mid-brain and the reticular activating system which may explain the loss of consciousness in some cases.  

For some athletes, the concussion symptoms take longer to disappear in what is known as post-concussion syndrome.  It is not known whether this is from some hidden structural damage or more permanent disruption to neuronal activity.  Repeated concussions over time can lead to a condition known as dementia pugilistica, with long-term impairments to speech, memory and mental processing.

After the initial concussion, returning to the field before symptoms clear raises the risk of second impact syndrome, which can cause more serious, long-term effects.  As part of their "Heads Up" concussion awareness campaign, the CDC offers this video story of Brandon Schultz, a high school football player, who was not properly diagnosed after an initial concussion and suffered a second hit the following week, which permanently changed his life.  Without some clinical help, the player, parents and coach can only rely on the lack of obvious symptoms before declaring a concussion "healed".  

However, making this "return to play" decision is now getting some help from some new post-concussion tests.  The first is a neurological skills test called ImPACT (Immediate Post-Concussion and Cognitive Testing) created by the same researchers at UPMC.  It is an online test given to athletes after a concussion to measure their performance in attention span, working memory, sustained and selective attention time, response variability, problem solving and reaction time.  Comparing a "concussed" athlete's performance on the test with a baseline measurement will help the physician decide if the brain has healed sufficiently.

However, Dr. Collins and his team wanted to add physiological data to the psychological testing to see if there was a match between brain activity, skill testing and reported symptoms after a concussion.  In a study released last year in the journal Neurosugery, they performed functional MRI (fMRI) brain imaging studies on 28 concussed high-school athletes while they performed certain working memory tasks to see if there was a significant link between performance on the tests and changes in brain activation.  They were tested about one week after injury and again after the normal clinical recovery period.

“In our study, using fMRI, we demonstrate that the functioning of a network of brain regions is significantly associated with both the severity of concussion symptoms and time to recover,” said Jamie Pardini, Ph.D., a neuropsychologist on the clinical and research staff of the UPMC concussion program and co-author of the study.  
 "We identified networks of brain regions where changes in functional activation were associated with performance on computerized neurocognitive testing and certain post-concussion symptoms,” Dr. Pardini added. "Also, our study confirms previous research suggesting that there are neurophysiological abnormalities that can be measured even after a seemingly mild concussion.” 

Putting better assessment tools in the hands of athletic trainers and coaches will provide evidence-based coaching decisions that are best for the athlete's health.  Better decisions will also ease the minds of parents knowing their child has fully recovered from their "invisible" injury.




Lovell, M.R., Pardini, J.E., Welling, J., Collins, M.W., Bakal, J., Lazar, N., Roush, R., Eddy, W.F., Becker, J.T. (2007). FUNCTIONAL BRAIN ABNORMALITIES ARE RELATED TO CLINICAL RECOVERY AND TIME TO RETURN-TO-PLAY IN ATHLETES. Neurosurgery, 61(2), 352-360. DOI: 10.1227/01.NEU.0000279985.94168.7F