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Give your head a rest

When it hurts, don't try to play through the pain. You could have a concussion. Tips for avoiding and recovering from a concussion

When I heard the story of former New England Patriots linebacker Ted Johnson -- the repeat concussions he suffered while playing, his early retirement from the NFL, the possible relationship of head injuries to his seemingly inevitable slide toward dementia -- I winced.

I recalled my own experience as a player, when head injuries were considered a part of the game. In high school, the streaks of paint we'd accumulate on our helmets from our opponents' were cool badges of honor; in college, the first week of full-contact practice always included a headache that lasted three days. We had jargon for the daze that followed skull-rattling hits: you got a dinger, had your bell rung, got tattooed.

In the two decades or so since I played, concussion awareness has rapidly evolved. Doctors and athletic trainers know so much more about how to detect and treat brain trauma. The protective ability of sports helmets has vastly increased, and the rate of serious concussions has plunged. Some college and pro sports teams even require athletes to take preseason mental-acuity tests for comparison if and when concussions occur.

Yet for all the advances, neurologists and other medical experts can't fully prevent perhaps the largest hurdle in preventing head injuries: human nature.

Too many people would rather look cool than skate or ski with a helmet. It's easy for soccer players to believe that lingering headaches are simply the price of a great header. It's hard for football players to resist the game's macho culture -- and in Johnson's case, the pressure to compete -- after a mind-scrambling hit.

"We basically have no love, honor, or respect for the brain," said Dr. Daniel Amen, a psychologist, author, and professor of psychiatry and human behavior at the University of California-Irvine School of Medicine. "I always say, we care more about our faces, our boobs, our bellies, and our butts than our brain. That's just crazy."

The brain is perhaps the body's best-protected organ, its delicate, butter-soft tissue cushioned by fluid and encased in the hard, bony skull. If the head and neck are jerked or suddenly jarred, however, the momentum can cause the brain to slam against the interior of the skull.

Imagine the brain is Jell-O, sitting in a bowl, representing the skull, said Dr. Robert Cantu, co-director of the Neurological Sports Injury Center at Brigham and Women's Hospital. Tap the side of the bowl, and "the Jell-O oscillates to the other side and then comes back." A hard blow to the head, he said, can also cause the brain to twist and swirl against the skull, which stretches and strains the nerve cells and pathways that send signals from the brain to the body.

"That oscillation causes a shearing or tearing of nerve fiber tracks and, if severe enough, nerve fibers themselves," said Cantu, who is also the chief of neurosurgery at Emerson Hospital in Concord. "It causes temporary interruption of [brain] function" that only time can fully restore.

"Nerve cells do not really regenerate," he said. "They are thought of as being in a metabolic hibernation -- they're still alive but they're not working."

By now, the story of Johnson, a stalwart who helped the Patriots win three Super Bowls, is well known to most football fans. Last month, he told The Globe he sustained a serious concussion after a vicious hit in an NFL game but practiced again under pressure from his coaches before his brain had fully healed and took another hard blow to the head. Since then, he says, he has struggled with depression, drug addiction, and memory loss; neurologists fear that he could develop dementia at a young age.

Johnson said he made his story public after the suicide of Andre Waters, 44, another hard-hitting former NFL player who suffered repeat concussions during his career. A neurologist who examined Waters's brain tissue said it resembled that of an 85-year-old Alzheimer's patient and speculated that repeat brain trauma was to blame.

It's such repeat concussions that pose the real danger, said Dr. Arthur L. Day, a neurosurgeon at Brigham and Women's.

"If you are not recovered from a concussion, then you are susceptible to more and repeated injuries by successive degrees," Day said. Even milder concussions over long periods of time, he said, "do lead to much higher incidence of chronic disease" in the brain.

Cantu said that if nerve cells have not yet returned to normal function after an initial concussion, even minor changes in blood pressure or oxygen levels that wouldn't affect a normally functioning brain can harm it. A second blow "can produce dramatically greater injury than it would have if it had been occurring to a normal brain," he said.

"That's why the insult from the second [concussion] can be thought of as an exponential injury -- one and one equaling five, in terms of severity, rather than one and one equals two," he said.

Arlene Korab, executive director of the Brain Injury Association of Massachusetts, said mild concussions -- dizziness, and disorientation rather than blackouts -- are easy to ignore. Unlike a broken leg or torn ligament, she said, concussions and brain trauma aren't obvious, and a dedicated athlete who wants to compete "is not going to volunteer it." For that reason, Korab said, she believes cases like Johnson's and Waters's are the tip of the iceberg.

In the NFL, "very often, they don't report it," she said. "They're paying you good money to play the sport. You're not going to say, 'Gee I have a headache.' "

That means elite football players are unlikely to quit after one or two concussions, "unless they're unconscious for any length of time," Korab added. "Unless you're [knocked] unconcious, the public doesn't think it's serious."

Both Amen and Korab agree that awareness has improved; Amen's clinic conducts brain scans of NFL players, and Korab said attendance at clinics the Brain Injury Association sponsors has grown each year. More professional football and hockey teams are studying the problem seriously, and even some high schools are using advanced techniques like the mental acuity exams. And Johnson's story has brought the issue to the forefront.

But the sports culture that Johnson blames in part for his problem will be much more difficult to change.

Recalling her 5-year-old grandson's experience in youth hockey, Korab noted that children have to wear helmets to play, but "they're dinged all the time." Most coaches take it seriously, she said, but some tell their young players to "Be a man -- get back out there. That toughens you up."

"It doesn't toughen you up," Korab said. "It makes your brain a little bit worse."

1) Wear a properly fitted helmet for sports activities, including football, biking, wrestling, boxing, skiing, snowboarding, ATV riding, or motorcycling

2) If you suspect you have a concussion, get checked out by a doctor. Sometimes, symptoms such as headaches, irritability, poor concentration, sleep problems, and loss of taste and smell don't begin until some days after the injury.

3) Rest is the best medicine. Talk to a doctor before taking any medication. For a headache, take a mild analgesic such as acetaminophen or ibuprofen, but avoid aspirin, which may contribute to bleeding.

4) Take it easy for several weeks after a concussion, until well after any headaches, fatigue, nausea, impulsiveness, and crankiness have disappeared. Once you have one concussion it takes less of an impact to cause a second one, which is likely to be much more serious, particularly in people under 20.

SOURCES: The Mayo Clinic, www.mayoclinic.com

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