BY RYAN O’CONNOR

In his 25-plus years as athletics trainer at Salem High School, Sean Cox has witnessed his share of hard hits to the head.

And he’s seen the ramifications.

Football player Matt Starr, for instance, experienced an early-season concussion – a jarring injury of the brain resulting in disturbance of cerebral function and sometimes marked by permanent damage.

After missing a week of action, he returned to play, then experienced another head trauma several games later. Starr not only lost the remainder of his 2003 gridiron schedule, but the majority of the wrestling season as well.

The one thing Cox has never dealt with is a player’s death, though he knows others have been in that situation. That’s why Cox and many other trainers, team doctors and coaches are constantly re-educating themselves on the dangers of repeated head trauma.

It wasn’t long ago, after all, that a player took a hard hit to the head, answered a few questions and was swiftly inserted back into a game. Now, re-entry isn’t so easy.

“A football player who whacked his head in a football game in 1982 would kind of stumble off the field, and we’d kind of kid about it – ‘Oh, my ears are ringing,’ ‘You got your bell rung.’ – that kind of stuff, and as soon as they improved and became functional, they were right back in there,” said Cox. “We didn’t care so much about a little dizziness, a little headache, a little upset stomach. They went back in.

“Now we know you have kids that are not completely healed from a head injury, and then they get hit again, and it can even be kind of minor, but it causes their brain to shut down rather quickly. I mean, they can die in a couple minutes,” he added. “It doesn’t happen very often, and I try not to operate scared, but it’s a great motivator to make sure a kid is fully recovered before you let them play again.”

The data

According to a recent study published by, among others, Dr. Barry P. Boden and Dr. Robert C. Cantu in the July 2007 edition of the American Journal of Sports Medicine, roughly seven direct catastrophic football head injuries occurred each year between 1989 and 2002 in scholastic athletics.

Catastrophic injuries are defined as direct – resulting from participation in the skills of a sport – or indirect – resulting from systemic failure secondary to exertion while participating in a sport. Each classification is further subdivided into three categories:

• fatal – the injury causes the death of the athlete;

• nonfatal – the injury causes a permanent neurologic functional disability; and

• serious – while severely injured, the athlete has no permanent functional disability.

Youth and high school players face a greater risk of catastrophic injury, and those with a prior head injury, especially in the same season, are more likely to suffer another trauma.

Though Boden’s study indicated no clear reason for a higher incidence of catastrophic injuries among high school vs. college football players, Gregory Soghikian, the former West High School and current Bedford High School team physician, said some coaches and researchers point to inexperience.

“One of the problems may be that kids haven’t learned to hit properly. They use their head as a weapon,” said Soghikian.

He also said younger athletes may be at greater risk because their skulls are not fully developed.

“Their cranium, or brain shell, has not fully matured and is not as strong as an adult cranium,” said Soghikian. “There is a presumption a developing brain is more susceptible to being disturbed … physically. The electrical pathways are more easily scrambled, but the exact reasons why, we don’t know.

“At the same time, the younger brain seems to have the ability to heal quicker,” he added. “I don’t know if it’s because that area heals better or if the brain has the ability to set up different pathways and sort of bypass the injured area.”

Boden’s study also noted there were 497 reported fatalities on the gridiron between 1945 and 1999, and 69 percent were caused by brain injuries, with a spike in deaths from 1965 to 1969 when football was flourishing and equipment wasn’t keeping pace with the sport’s popularity.

While the number of deaths may seem relatively low, research headed by Dr. Kimberly G. Harmon at the University of Washington’s Sports Medicine Clinic indicated that, of the roughly 1.25 million athletes playing high school football each year, up to 20 percent sustain a concussion during their career.

Laura C. Decoster, executive director of the New Hampshire Musculoskeletal Institute, said there is no New Hampshire-specific concussion data available.

There were, according to the New Hampshire Interscholastic Athletic Association, 3,305 state athletes who played high school football in the 2004-05 academic year.

Assuming Harmon’s national study translates proportionately to New Hampshire, up to 661 of 2004’s state high school football athletes have suffered or will suffer a concussion while playing the game.

Double trouble

Joe Cacciatore, a certified athletics trainer at Pelham High School, said concussions generally occur from a collision but sometimes happen when an athlete’s head hits the ground or another surface. The force of impact is hard enough to cause the brain to rebound off the skull or bruise at the direct site of impact. While one in five high school football players face a serious head injury, Soghikian said concussions are not limited to “contact” sports such as football, lacrosse and hockey.

Whether it’s a batter hit in the head with an 85-mph fastball or two basketball players colliding during play, concussions occur on all playing surfaces, he said. That’s why it’s important for coaches and players to become educated about the risks.

The biggest concern for medical professionals today is second-impact syndrome.

According to a 1999 assessment by Harmon, second-impact syndrome was first described in 1973 and involves a player returning to action before symptoms from a prior injury have subsided.

“A second blow to the head, even a minor one, can result in a loss of autoregulation of the brain’s blood supply,” said Harmon. “This leads to a vascular engorgement and subsequent herniation of the brain that is usually fatal.”

Between 1992 and 1999, Harmon said 17 cases of second-impact syndrome were reported in football alone.

The pressure to play No one denied it, not the coaches, not the trainers, not the doctor and not the player. All parties involved said the same thing: the pressure to have an athlete on the playing surface is undeniable.

Dave Tremblay has coached at both the youth level, mentoring Pop Warner teams with the Hooksett Hurricanes for seven years, and in high school, where he took over as Pembroke Academy head coach in 2007.

He said his experience is that high school athletics trainers tend to be more conservative than EMTs and nurses on the Pop Warner sidelines.

Tremblay said because trainers have the final say, high school athletes are less likely to be reinserted into a game after a hit to the head.

“Trainers at a high school game have liability concerns, especially because most of them are contracted by the school district,” he said. “If they send a kid back in there, it’s on them.”

For a coach, that creates some frustrating moments.

“There are definitely times when our trainers say (a player) can’t go back in, and I think they can,” added Tremblay. “We have some kids take some pretty good hits, and you can usually tell if the kid really got their clock cleaned … but it’s probably good, in those situations, that (the decision) is taken out of the coach’s hands.”

Cox said he understands the pressure and feels it too, but noted most coaches today are like Tremblay: They want to win but, first and foremost, respect the health of their athletes.

There have been times when a physician has given a player the thumbs up to return to action, and Cox balked.

He said his approval is contingent on a player remaining asymptomatic following physical exertion tests such as backpedaling and running.

In fact, both Cox and Soghikian said the clock for a player’s return doesn’t begin to tick until symptoms have completely subsided. Sure, the parents are disappointed at times, sometimes angry, but Cox simply lets them know playing isn’t an option. He’s even called the doctor and explained his position, and nearly every time, the doctor acquiesced.

“That’s one of those battles I have chosen to fight,” said Cox. “Sure I (get pressured). Of course I do … I’ve never had it happen, but if a coach disagreed with me and I had to walk out onto the field, stop the game and physically remove (a player) myself, I would.”

But there is no greater pressure than from the players themselves.

“They expect each other to be able to play and not react to an injury,” said Goffstown’s head football coach, Rob Cathcart. “If someone has a sprained ankle, they play through a sprained ankle. If it’s a separated shoulder, they play with a separated shoulder. That’s the mentality you want a football player to have. But with a head injury, the idea they’re now susceptible to a greater injury, that’s the tough one to get kids to understand.”

Cathcart said he’s had players argue with him on the sideline. Bow High’s hockey coach, Tim Walsh, knows the feeling.

“I don’t even listen to the kids,” said Walsh. “If a kid gets his head hurt, and he says he’s fine, I don’t believe it because they’re supposed to say that. You want them to want to play. Until a trainer or doctor says, ‘OK,’ I don’t even pay attention. A concussion (is) different.”

But the greatest fear of concerned adults is the injury only the player knows about. Starr, a sophomore when he suffered his season-ending concussion in 2003, said trainers and coaches knew of only three or four of the seven or eight significant head injuries he experienced in high school.

“If it was serious enough, I couldn’t hide it, but once I learned the symptoms, I pretty much figured out what I had to do to keep playing,” he said. “I was just a stupid high school kid. It was pride. I didn’t want to show weakness.”

Starr said he hasn’t competed in a contact sport since 2006, but admitted he may suffer from short-term memory loss.

“The kid who has a minor bell-ringing, who decided not to tell his coach or trainer because he doesn’t want to be taken out of a game or miss games, and then they get a second injury shortly thereafter, those are the ones we worry about, and those are the ones most at risk of serious injury, even dying,” said Soghikian.

“That’s my anxiety,” said Cathcart. “That’s where I think the culture lies in that a kid won’t tell anyone because he’s afraid he will let his teammates down.”

But Soghikian said things are changing.

“We’re trying to get away from that cultural mentality,” said Soghikian. “Sometimes kids won’t tell you, but they tell their teammates, and more and more often you’re seeing those teammates come up to us discreetly and saying, ‘Hey, so-and-so has a headache’ or ‘So-and-so got hit in the head and didn’t say anything.’ That’s a nice change in culture in that kids are becoming protectors of teammates rather than, ‘Hey … tough it out and get back out there.”

Technology’s impact – good and bad Tremblay said head injuries are becoming rarer, mostly due to technological improvements.

“There are times when they get their bell rung, that’s for sure, but I haven’t seen too many major head injuries,” he said. “We get a lot of broken legs and things of that nature, but with the helmets nowadays, truthfully enough, we don’t see a whole lot of head injuries.”

Cathcart is trying to further reduce the risk. After reading “Head Games: Football’s Concussion Crisis from the NFL to Youth Leagues,” by former Harvard football player and World Wrestling Entertainment employee Chris Nowinski, Cathcart realized the value of good equipment.

[ “We used to be very middle-priced oriented in terms of helmets and other equipment, but after reading that book, we made the decision to go with the top-of-the- line helmets,” said Cathcart. “And the bigger thing that we learned is that virtually as important as the helmets is how you handle the jaw area.”

The Goffstown program made two pieces of equipment available to players. The first, said Cathcart, is the Brain-Pad mouth guard. Unlike conventional mouth guards, which cover only the upper portion of a player’s mouth, the Brain-Pad fits over the lower teeth as well and includes a hole for easier breathing. It allows an athlete to bite all the way down, eliminating a loose lower jaw and, added the coach, drastically reducing the chance of concussion.

The other upgrade GHS is promoting is a chin strap with a hard outer shell. Cathcart said the risks associated with blows to the chin are just as great as hits to the cranium, and a soft chin strap does little to protect a player during a direct hit.

“A lot of people don’t have money to buy a top-of-the-line helmet,” said Cathcart. “But they certainly have the ability to get the $15 chin strap and the $20 mouth guard, which is a whole lot better and greatly reduces your risk.” ]

Unlike football, modern hockey has seen certain technological upgrades actually increase the amount of concussions, said Walsh.

The boards and glass have become stiffer in newer rinks to limit awkward bounces of the puck, Walsh said. In turn, there has been a noticeable increase in head injuries.

“Very rarely is it the openice hit. Sometimes you get a hard elbow or something like that, but usually the wind just gets knocked out you,” said the coach. “The majority (of serious head injuries) have been collisions with the opposing player and the boards. A player’s head gets caught between rigid glass and a 230-, 240-pound kid, and something’s got to give.”

Data from the National Hockey League backs up Walsh’s perception. “The reported concussion rate in the NHL during the last five years is more than triple that of the previous decade,” concluded a study completed by R.A. Wennberg and C.H. Tator and published in August 2003 in the Canadian Journal of Neurological Sciences. “Bigger, faster players, new equipment and harder boards and glass have all theoretically increased the risk of concussion in the NHL in recent years.”

Prevention and, if necessary, diagnosis

While collisions in hockey are inevitable, and Walsh has seen his players absorb and deliver plenty of vicious checks, he said those on the ice can avoid serious injury with intelligent play.

“The biggest thing we tell our kids is when you go after the puck to skate through the puck, not to the puck,” he said. “When you stop moving your feet, that’s when you ask for trouble with that big hit.”

Once that big hit happens, however, there are usually telltale signs something is wrong, and the time for playing games is over.

According to Harmon, early indicators of concussion include headaches; dizziness; confusion; tinnitus, or ringing in the ears; nausea; vomiting; and vision change.

In the long term – extending into weeks, sometimes months and, in extreme circumstances, years – those falling victim to a traumatic brain injury often experience memory disturbances, poor concentration, irritability, sleep disturbance, personality changes and fatigue.

Soghikian said sports medical professionals, to improve diagnoses, are adopting innovative approaches such as neuro-psychological studies.

“Basically, we’re talking about fine-tuned cognitive studies to determine if somebody has some long-term issues related to a head injury,” he said. “… We want to try to get a baseline on the person beforehand to determine any variations.”

Trainers generally adhere to 16 to 20 guidelines for evaluating and grading a head injury. All safety guidelines, said Soghikian and Cox, should be met before an athlete can play again.

The minimum amount of time players miss often depends on the amount of trauma they’ve experienced. Cantu, chief of neurosurgery and director of sports medicine at Emerson Hospital in Concord, Mass., and other researchers recommend an escalating scale based on the severity of the injuries and the number of occurrences.

In many cases, multiple concussions end an athlete’s season, sometimes a career.

That, said Soghikian, is better than the alternative.