Big Hit – Concussions and the culture of athletics

It takes one hit to change a life.

One hard hit, fall or tackle. That can be enough for a concussion. The result, at best, is a few hours of headache, dizziness and nausea. At worst, the injury leads to a lifetime of excruciating pain and depression.

Concussions aren’t a new topic. They’ve made headlines again and again. According to studies by the CDC, anywhere from 1.6 to 3.8 million concussions are incurred in the U.S. every year. It’s an inescapable part of athletics, yet experts remain unsure how to diagnose a concussion, and even more unsure how to treat one. Proper tools for prevention, diagnosis and treatment are still under research, but the main key to solving the concussion problem revolves around the culture of athletics itself.

The day Seau died

Few days have changed the world of football more than the day that USC alumnus Junior Seau died. It was a Wednesday in May 2012. Seau’s girlfriend found him sprawled on the floor, a self-inflicted gunshot wound to his chest. He left behind no note, only the scrawled lyrics of his favorite country music song — “Who I Ain’t” — on a piece of paper on the kitchen counter.

A year later, studies by the National Institutes of Health showed that Seau had a degenerative brain disease caused by multiple concussions when he committed suicide.

It came as a shock to the culture of football. Seau was a 12-time Pro-Bowler, 1992 NFL Defensive Player of the Year and a two-time AFC champion who would be posthumously inducted into the NFL Hall of Fame. He played hurt, he played hard and he challenged every offense he faced with his athleticism and his relentlessness. But, in the end, every hit and tackle was chipping away at Seau’s brain. The game of football killed one of its finest players.

The day that Seau died, former USC quarterback Todd Marinovich received a text from a teammate. It had been years since he’d seen Seau, but he’d followed his former teammate’s career with pride. When he read that Seau was dead, that Seau had taken his own life, he couldn’t believe it.

“It was unthinkable,” Marinovich said. “It floored me. It took my breath away. That wasn’t the Seau I knew.”

The Seau he knew was so full of life he almost burst with it. He walked into practice with a grin that crinkled the corners of his eyes. He spent endless hours in the weight room when he was sidelined for low grades. He was single-minded, too focused on football to be caught at frat parties or bars. And he was joyful — “God, was he joyful,” Marinovich said — in love with the game, in love with the team and in love with life.

And 23 years later, he killed himself. It was unthinkable, Marinovich said.

One year later, Marinovich received another text. This one was more expected. Another former teammate, a linebacker,  had died from extreme hypertension after a long struggle with alcoholism. His name was Scott Ross. Marinovich had spent the last year on the phone, trying to help Ross fight a battle with his own mind.

The Ross he’d been speaking to was not the same Ross he adored in college, who once chased Marinovich across campus for 40 minutes, shouting out a mix of curses and laughter. Ross had changed.

In his final years, he was inconsolable. Something was deeply disturbed. Marinovich couldn’t put a finger on it, but he felt the desperation in Ross’s voice as they spoke on the phone. His friend was damaged.

“What both of them became … It was different,” Marinovich said. “Something broke in them. We need to figure out how to keep these players from being broken.”

Marinovich lost two teammates in two years. They were both men he looked up to, men whose presences  he cherished. They were also both linebackers.

“It’s not an easy job,” Marinovich said of the position. “They take hits again and again and again. It’s relentless. It’s exhausting to watch. I couldn’t do what they did. I’m not sure if anyone is really meant to.”

According to a study by Popular Mechanics, the average defensive back unloads up to 1,600 pounds of force in a single tackle, often resulting in a G-load three times the force of a barrel roll in a fighter jet. A defensive player might land 100 of these hits in a single game, leading to concussion after concussion.

There wasn’t a culture surrounding concussions when Marinovich was playing with Seau and Ross. When they were playing, an especially hard hit to the head provoked a quick sideline check-up. If the trainer diagnosed a concussion, the player sat out for a play, maybe two. But then they went back in the game. They almost always went back in.

“No player wants to sit,” Marinovich said. “We all wanted back in. Junior, you could try to drag him off the field, and he would fight you the whole way. I’ve had concussions, and I’m certain Junior and Scott and all of those guys had concussions, more than we probably know.”

The culture is different now. Athletes receive concussion education at the start of each season. Last year, the Pac-12 conference cut down the number of contact practices that football teams are allowed to hold and launched a $3.6 million per year Head Trauma Task Force program. But football has only become more intense: the players bigger, the hits harder.

“It’s a violent sport,” Marinovich said. “And it’s a beautiful sport in its violence, its physical nature. That will never change.”

It’s not just football

Senior Sarah Urke can still remember the day she lost her Olympics dreams: Oct. 27, 2009.

Rewind to the start of that summer, when Urke was 16 and life was almost perfect. She moved to Santa Barbara to train with the Aquamaids, a premier synchronized swimming team that groomed athletes for the Olympics. She had no goals for the future besides an Olympic gold medal.

Then, during practice on Oct. 27, a teammate’s kick accidentally slammed into the side of Urke’s head. She surfaced in a daze. Urke sat out for five minutes, swallowed a handful of ibuprofen and dove back in to finish practice. The next morning, she woke up to a dangerous realization — something was horribly wrong.

Urke felt like she was floating. Her head pounded. Her thoughts felt disjointed. She was rushed to the hospital, then referred to a neurologist who had no formal training in treating concussions. He told her to return to physical activity “as tolerated,” so she ignored her symptoms and kept swimming.

That was a mistake. Each day was worse, plagued with dizziness and headaches. A new doctor told her to stop all activity, to stay home from school and avoid watching television.

But it didn’t get better.

When she returned to school in January, Urke couldn’t make it through a class. In February, she moved back to Minnesota and began to process that she might not be going to the Olympics anytime soon.

More than a year later, after countless consultations, a combination of rest, upper cervical realignment and physical therapy finally began to relieve Urke’s symptoms. But at this point, she had missed a full year of high school, spending most of it in bed, listening to audiobooks. And Urke had lost synchronized swimming, the entire focus of her future.

Urke wasn’t a football player. She was a dedicated athlete in a non-contact sport with a likely prospect of making the 2012 Olympic team. But on Oct. 27, 2009, a concussion shattered her world, proving that any athlete can suffer from the effects of head trauma.

Now a USC student, Urke has dedicated herself to the world of concussions. She leads support groups for other concussion victims, heads a club that raises awareness and is dedicating her research as a pre-physical therapy student to treatments for head trauma. Her main goal is to create a better understanding of how to treat a concussion.

“I was so eager to keep swimming that I just powered through the pain,” Urke said. “I know now that I probably hurt myself even more, just with those few weeks that I kept swimming. Athletes have to know when to stop. If you’re in pain, don’t fight through it. It’s not strong to fight through pain — that pain is a sign that your body needs to slow down, or stop, in order to heal.”

Searching for a solution

When it comes to recovery, pain is the ultimate sign that an athlete should stop activity. But what is the cure for a concussion? It’s a question that baffled Urke for years and that continues to challenge experts in the field.

One of the USC faculty members helping Urke to answer this question is Dr. David Baron, vice chair of the Department of Psychiatry and a national leader in concussions research. This spring, a piece of technology, Brain Injury Research Strategies, designed by Baron, won the Maseeh Entrepreneurship Prize Competition, allowing him to test a new way to approach concussion diagnosis.

When discussing diagnoses, Baron emphasized a little-known truth about concussions — they don’t require direct contact to the head. Due to the structure of the head, the brain is relatively loosely fit into the skull. During a collision, a player’s head might whip around, causing the brain to “slosh” against the sides of the skull. This means that a jarring shock to the torso can result in a serious concussion without the head-receiving contact.

“The nastiest concussion I ever saw came from a player being hit in the shoulder,” Baron said. “It’s all about the trauma that the brain is undergoing, and oftentimes that has nothing to do with an athlete hitting their head.”

This makes it even more difficult to notice when a player incurs a concussion — especially in contact sports such as football or soccer, where collisions are a necessary part of the game. At USC, Director of Athletic Medicine Russ Romano trains athletic staff to observe athletes for symptoms, especially after noticeable collisions.

“An athletic trainer is trained to observe the activity and [train] their student-athletes to look for signs and symptoms of concussion,” Romano said. “USC Athletics has taken great strides to educate all student-athletes about the signs and symptoms of concussion and the need to report those signs and symptoms immediately.”

Though trainers can pull athletes if they’re concerned, it often comes down to a test to determine if that player remains sidelined from future play. The most popular test is the ImPACT test, a computerized system that tracks an athlete’s cognitive abilities before and after an injury. Though it doesn’t actually diagnose athletes with concussions, the ImPACT test works as a first step toward treatment.

There is, however, a major flaw in the ImPACT test’s accuracy, Baron said. ImPACT relies on a baseline test, taken by each athlete at the beginning of the season. After a notable collision, the athlete retakes the test. If performance is lower than the baseline, then the athlete is considered at-risk and is sidelined until a doctor gives a proper diagnosis. Though this works for many athletes, Baron said that it is extremely easy for determined athletes to trick the test by purposefully underperforming their baseline.

“There will always be players who want to play through it, to keep fighting through injuries even when their body is begging them to stop,” Baron said. “And those are the players that will get around [the ImPACT test]. What we need is a solution, some type of diagnosis or test, that can’t be cheated.”

This is the focus of Baron’s work with BIRS, which tracks eye movement and notes slower reaction times. It is harder to fake eye movement than it is to flunk a baseline ImPACT test. Baron and his team hope that this improvement will allow for more accurate results.

What comes after a concussion diagnosis is just as uncertain. Baron said most professionals agree that full rest is necessary after a concussion, followed by a gradual return to full activity. But the timing of concussion recovery remains imperfect and frustrating for concussion experts.

“The problem is that, when it comes down to it, there’s way more that we don’t know about concussions than we do know,” Baron said. “There’s no perfect way to treat a concussion, and different things work for different people. Some players can take huge hit after huge hit, get up, and be perfectly fine. Others, it takes one hit and they’re done, career over. We don’t understand it, not yet.”

To combat this lack of knowledge, Baron stressed that precaution is a necessity in avoiding life-altering damage. Yet, while new restrictions and safer helmets can soften the blows that cause concussions, prevention is a game with too many factors to control. Treatment, Baron said, will change the world of concussions, and it begins with the players themselves.

It’s an unglamorous truth, but a vital one — there isn’t a cure for concussions.

The injury’s danger is that a bulk of the responsibility in the healing process falls directly upon the athletes themselves — athletes who are often young, inexperienced and hungry to constantly play, perform and prove themselves in their sport. In this dynamic, Baron believes that coaches and trainers alike must train their athletes to truly believe that “toughing it out” is neither admirable nor responsible.

In Marinovich’s days of playing, a rub-some-dirt-in-it mentality was accepted, but its consequences are manifesting themselves now.  Concussions are part of popular culture, but their ultimate solution is still far off and intangible. In the meantime, athletes must do the best they can, or pay hefty prices like Urke did six years ago.

“I lost years of my life because of a single kick to my head,” Urke said. “And many others pay a far steeper price. It comes down to whether or not we’re willing to make a change in who we are and how we think about our bodies and our brains. In the end, you only get one brain in this life. You have to protect it at all costs.”

Editor’s Note: A previous version of this article incorrectly stated that Scott Ross had died of suicide. Ross died of extreme hypertension with alcohol poisoning.  It also incorrectly stated that Ross was part of the 1989 team’s secondary; he was not.