School of hard knocks

Mental agility test helps gauge whether an athlete has recovered from a concussion

Like a blur. That's how Sam Robinson describes the fog that enveloped his life after he slammed his head on the ice during a preseason hockey game and blacked out for several minutes.

Diagnosed with a concussion, the Winchester High School junior was instructed by his doctor to not play for four weeks. But when he returned, things still weren't right, on or off the ice. The search for answers led his family, and eventually the school, on a mission to ensure that no other student athletes return to play before their concussions are healed - a move that can lead to long-term, or even permanent, damage.

Now, four years later, Winchester High is joining a small but growing number of Massachusetts schools that require a new kind of screening. It uses what look like video games to measure an athlete's baseline brain skills - memory, problem solving, reaction time - before the season. That way, after an injury, a retest can accurately reflect whether the brain is back to normal, allowing a safe return to competition.

"We needed to step up and make sure our student athletes were returning to play safely," said Mark Robinson, Sam's father and president of the Winchester Sports Foundation, the booster club that is paying the $1,000 yearly fee to test Winchester High athletes who play contact sports, from football to cheerleading.

"We saw personally with our own child coming back too soon," he said, "and we knew this was a national issue."

The roughly 30-minute test consists of several games involving flashing images. In one, the test taker is directed to hit the space bar each time they see a repeat image. In another, the goal is to hit the space bar each time a white circle followed by a black square appears in a rapid sequence of varied shapes.

The move toward screening in high school contact sports comes as researchers launch a center at Boston University School of Medicine to scrutinize the long-term effects of repeat concussions in professional athletes.

Over 3.5 million sports and recreation-related concussions occur annually in this country, according to the Centers for Disease Control and Prevention, with the majority happening at the high school level. Yet the signs and symptoms may be subtle and often misunderstood by athletic trainers and coaches, resulting in young athletes returning to the field or court too soon. That leaves them vulnerable to repeat concussions, which can create long-term memory, mood and learning problems. Several NFL players have reported debilitating headaches, dizziness and bouts of depression after years of suffering repeat head injuries.

"A great majority of mild concussions are being missed at the high school level," said Dr. Robert Cantu, co-director of the Neurologic Sports Injury Center at Brigham and Women's Hospital in Boston, and the specialist consulted by Winchester High in choosing its pre-season computer testing software.

Cantu said that often high school coaches and other team personnel lack training to spot concussion symptoms, which can be subtle. Unlike a broken bone that shows up on an X-ray, there is no simple way to diagnose the injury. Confounding the problem is the widespread misunderstanding that unless you black out, it's not a concussion.

Cantu is an ardent supporter of preseason and post-concussion computer testing. Also necessary, he said, are a neurologic exam and monitoring to make sure all post-concussion symptoms have cleared. Classic concussion symptoms include headaches, nausea, vision and balance problems, feeling sluggish or foggy, and changes in sleep patterns.

Concussions are caused by violent shaking or a blow to the head, and trigger a cascade of chemical changes in the brain that is rarely pinpointed by a standard MRI or CAT scan. Because of the lack of diagnostic tools, physicians, trainers and others have long disagreed about how long it takes for the brain to heal.

If there is a second injury while an athlete's brain chemistry is readjusting, evidence suggests that it can cause more permanent injury to the cells.

Studies have also indicated that high school athletes in general need more time to recover from concussions than their college counterparts, although scientists are still probing the reason. Dr. Mark Lovell, a researcher and director of the University of Pittsburgh Medical Center Sports Medicine Concussion Program, has found that high school students with concussions needed at least twice the recovery time of college athletes who had more severe injuries.

"In high school, the brain is still developing," Lovell said. "Certainly in college the brain is still developing but not at the steep rate we would see in high school students."

Lowell said that teenagers who suffer a concussion while recuperating from an earlier brain injury can endure chronic headaches, memory problems and irritability.

"We have kids we are treating who are several years out from this [repeat] injury who have problems in school and need special education plans," he said.

Lovell designed one of the concussion screening tests, called ImPACT, that is routinely used by teams in the National Football and Hockey leagues, as well as by a number of public and private schools in Massachusetts, including Brookline High and Buckingham Browne & Nichols, a K-12 private school in Cambridge.

Buckingham Browne & Nichols started concussion screening five years ago for all students grade 9 through 12, and this fall added 7th- and 8th-graders. The schools' athletic trainer, Kathy Gruning, said they see about 10 students a year with concussions and the screening helped take the guesswork out of sending a student back to competition.

"This is objective data to look at so kids can't say, 'I feel fine, I feel fine,' but then we give them an objective test and know that it doesn't correlate with what they are saying," she said.

For older athletes who have endured years of head injuries, the result can be permanent memory problems, depression and even dementia, research suggests. The issue has become a flashpoint in the NFL after several players, including former Patriots linebacker Ted Johnson, publicly shared their stories of physical struggles.

Johnson recently announced that he intends to donate his brain after he dies to the newly-formed center at Boston University that is studying a progressive, degenerative disease of the brain found in retired athletes with a history of repetitive concussions. Called Chronic Traumatic Encephalopathy, the disease has been diagnosed in five former NFL players after their deaths.

Cantu, the Brigham and Women's neurosurgeon and cofounder of the new center, theorizes that some day, researchers may discover that the earliest signs of the degenerative disease in pro-athletes' brains may have started during their high school years.

"It makes sense because what we are dealing with is a cumulative issue," he said.

For Sam Robinson, the former Winchester High hockey player, there have been no repeat concussions since his injury four years ago. He recovered and now plays hockey at Wesleyan University, where he was voted MVP of his team last year. He said he learned since his injury about the consequences of a too-hasty return.

"Some people just brush it off," he said. "I don't brush it off."

Kay Lazar can be reached at klazar@globe.com