Yankee Catcher Tries Super-Sized Helmet On For Size To Ward Off Head Injuries

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Posted on 13th March 2010 by Gordon Johnson in Brain Injury

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New York Yankee catcher Francisco Cervelli is taking a lot of ribbing from his teammates about the new super-sized helmet he’s wearing. But he doesn’t care if he looks funny. After sustaining two concussions, he is opting for safety over vanity.

At spring training in Tampa, Fla., Cervelli spoke plainly to The Star-Ledger of Newark. “Big leagues, my friend,” he said. “I’ll do whatever it takes to stay here forever.” http://www.nj.com/yankees/index.ssf/2010/03/ny_yankees_catcher_francisco_c_2.html

Cervelli, a back-up catcher, has started to wear a big, bulky batting helmet. It is like a helmet that Mets player David Wright donned after he got a concussion. http://www.usatoday.com/sports/baseball/al/2010-03-11-3455119442_x.htm

The old-style helmets last summer failed to protect both Cervelli and Wright from pitches that can reach speeds of 94 mph. Just last Saturday, Cervelli was hit in the head again. He was given an OK by a neurologist, but will now be wearing the new helmet.

Yankee Joe Posada is now calling Cervelli “The Great Gazoo,” a Martian on “The Flintstones” that wore an enormous green helmet. Good natured humor. We hope that everyone in baseball realizes that vanity should never come before brain safety.

NFL and Concussion Hearings – Neurologist Joseph Maroon of Pittsburg Testimony

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Posted on 13th January 2010 by Gordon Johnson in Brain Injury

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Among those testifying at Congressional hearings on the NFL and Concussion was Joseph Maroon, M.D., of the Department of Neurosurgery at the University of Pittsburgh Medical Center. The hearings were held in Detroit on January 4, 2010. Maroon is also the Team Neurosurgeon, The Pittsburgh Steelers and has been on the NFL _s Mild Traumatic Brain Injury (MTBI) Committee since it was created in 1994.

Maroon called the Congress’s attention to what advances in the way in the NFL treatment of concussion since 1994. He said in his prepared remarks:

Our committee was specifically charged in 1994 with initiating and supporting independent scientific research to further the understanding of the causes, diagnosis, treatment and prevention of concussion.

This work has involved research on helmet standards, injury data collection and analysis, and an ongoing study of the long _term effects of concussions on NFL players. As a result, the NFL in recent years has initiated educational and preventive measures, guidelines for the management of concussions, and rule changes to eliminate unnecessary hits that can lead to concussions. Since the formation of the committee in 1994, there has been a significant positive culture change in the NFL on the issue of concussions. I have personally witnessed this culture change among NFL teams and players and I am confident that it will continue in a positive direction.


Clearly there was insufficient culture change between 1994 and 2009, to make a significant difference, which is why the hearings in October of 2009 caused such a stir. Maroon commented on the changes since October:

I am here today to report on additional steps relating to concussions that the NFL has taken since the October 28 hearing. The long _running arc of improvement continues.

The NFL now has stricter return _to _play guidelines. It includes the addition of an independent neurological consultant for each team approved by the medical advisors of the NFL and the NFL Players Association. The 2009 statement on return to play says that a player who suffers a concussion should not return to play or practice on the same day if he shows any signs or symptoms of a concussion. It also states that once a player is removed for the duration of a practice or game, he should not be considered for return _to _play activities until he is fully asymptomatic, both at rest and after exertion, has a normal neurological examination, normal neuropsychological testing, and has been cleared to return by both his team physicians and the independent neurological consultant.


If you read the above statement carefully, it really makes no sense. If a player suffered a concussion, by definition if a player “suffers a concussion” he would show a sign or symptom of concussion. What Maroon left out, is sign or symptom of a concussion at what point. As a football fan, I understand the enormity of keeping a star player out of a game, potentially a playoff game, because he was knocked woozy on one play. But if you are going to provide a guideline, then provide it. If there is any return to play after a concussion in the same game, then you must clearly state at what point in time, 15 minutes, 30 minutes, a quarter of the game, the symptoms must have cleared.

My biggest quarrel with what Maroon states here is the abandonment of the stated time period of not returning if the player is found to have the “signs or symptoms of a concussion.” Most sport and concussion guidelines specific 7 days or longer period for the concussion that is still symptomatic for more than a short period of time after the original injury. The best part of the guidelines is putting that finite “no play” period because it required the serial follow-ups, that are the most sensitive determination of the severity of a concussion. Leaving the finite “no play” time period out, guts the guidelines.

Maroon did get it right when he addressed the most serious problem in implementing the any guidelines, changing the culture of the sideline, the locker room so that players aren’t short sighted or intimidated into not fully reporting concussions. He stated:

The 2009 statement also addresses the responsibility of the players. It states that players are encouraged to be candid with team medical staffs and fully disclose any signs or symptoms that either they themselves or their teammates are showing that may be associated with a concussion. The nature of concussions, which can be difficult to diagnose in the absence of loss of consciousness, places an important responsibility on players to put their health above competitive considerations. This is the policy of the league with respect to its teams _ medical decisions must override playing considerations _ and it is extremely important that the players commit to meeting that standard.

In December, the NFL, in conjunction with the Centers for Disease Control (CDC), produced a public service messaged directed primarily at young athletes and their parents and coaches on the importance of head injury awareness. The theme is _Take Head Injuries Out of Play _ and the message has been airing and will continue to air on NFL game telecasts throughout the playoffs. This PSA also was sent to a group of conference commissioners of college sports so that they could adapt for their use on
television and with their athletes.


According to Maroon, the NFL is trying to make a difference outside of its own games:

In addition, the NFL is working with the CDC and other organizations on educational material for young athletes and high school coaches, and to develop an overall certification program for coaches at those levels addressing player health and safety.

Further, John Madden, in his role as a special advisor to Commissioner Goodell, is chairing a committee of coaches that is exploring ways of providing players with a safer environment to reduce the risk of head trauma in practices.



All positive steps. The biggest step is the publicity that these hearings have created on one simple theme: Concussion can be serious.

Congressional NFL Hearings – Dr. Ronald Benson Testifies about Neuroimaging Advances

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Posted on 6th January 2010 by Gordon Johnson in Brain Injury

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I began my treatment of the Congressional hearings on the long term brain damage of concussion in the NFL yesterday at my Brain Injury Lawyer Blog – http://www.waiting.com/blog/2010/01/nfl-concussion-hearings-in-congress.html I will continue that discussion on this blog for the next several blogs, as I tackled an even more important topic at http://waiting.com/blog that of why an experienced brain injury attorney is even more important in a severe brain injury case than it is in a non-coma brain injury case.

Much of the controversy at the hearings was over the statements of Ira. R. Casson, M.D., formerly co-chair of the NFL concussion committee, that there was insufficient scientific evidence to prove this narrow question: Whether playing NFL football causes permanent brain damage. Fortunately, Dr. Casson’s academic skepticism was not the sole testimony heard by the committee. The committee also heard about evolving neuro-imaging techniques in the diagnosis of concussion, principally from Ronald Benson, M.D. of Department of Neurology, Wayne State University Medical School. Dr. Benson’s prepared remarks begin much differently than Casson’s:

I would like to share with you some observations from eight years of evaluating traumatic brain injury cases, the vast majority of which I obtain neuropsychological testing and advanced MRimaging:
  • 1) People with TBI are frequently misdiagnosed, often by multiple physicians;
  • 2) The most frequent diagnostic category given is psychiatric—anxiety, depression, conversiondisorder;
  • 3) Two neuropsychologists studying the same patient may differ considerably regarding existence of TBI;
  • 4) TBI symptoms overlap considerably with those of “primary” psychiatric disorders;
  • 5) Without the ability to “see” the brain injury with imaging, there is no completely objective way to determine what is TBI and what is something else, e.g., posttraumatic stress, conversion, malingering;
  • 6) People with brain injury seem to vary considerably in severity of symptoms and recovery in the face of similar falls, crashes, etc. This may speak to population differences in resistance to injury or effectiveness of neural recovery mechanisms and is in agreement with Collins, et al. who found large differences in recovery from single concussion (North American Brain Injury Society Annual Meeting, 2009);
  • 7) Advanced MR imaging techniques, including susceptibility-weighted (SWI), diffusion tensor (DTI) and MR spectroscopy (MRSI) are able to reveal brain injuries where CT scans and conventional MRI appear normal.
That was a hell of an introductory statement from Dr. Benson. He seemed to capture the challenge in representing the survivors of brain injury in those seven bullet points. He goes on to detail the excitement of using state of the art MRI techniques to diagnosing mild traumatic brain injury, which I will discuss in future blogs. But today, I want to focus on the first six bullet points.

1. Misdiagnosis. Frankly all six points could all be summarized with the statement that because the diagnosis of TBI is subjective, that misdiagnosis of the existence and severity of brain injury is the norm.

2. TBI is Often Labeled Psychiatric. I have said this before and will say it again: The challenge in diagnosing and treating brain injury is not in afixing a label of organic or psychiatric on the symptoms, but on treating the entire spectrum of brain related disability. Any TBI diagnostician who labels an emotional symptom after concussion as psychiatric or pre-existing, is missing the point. Brain injury impacts the emotions and those with pre-existing emotional problems are those most likely to be impacted.

3. Neuropsychologists Disagree. As is now common knowledge within the field of brain injury, neuropsychology is as polarized as our politics and almost on party lines. Neuropsychology is made up believers and non-believers that concussion can cause permanent brain damage. There is a lot of objective and subjective evidence for the believers to rely on. There is the academic skepticism of (similar to what Dr. Casson testified to) for the non-believers to rely on. There is no middle ground. For that reason, virtually every forensic case has two neuropsychologists who radically disagree.

4. TBI Symptoms Overlap. The neurons and the emotions are both in the brain. It is fundamental that one cannot injure neurons without effecting emotions. It is less evident but as true that one cannot impact emotions without changing neurons. Our brain’s hard wiring is the synergistic total of our genetic organic network and the sum of the changes to that network as a result of our experiences and pathologies that occur whether by disease, by trauma or via living.

5. Without Seeing the Pathology, No Objective Way to Prove TBI. I disagree with Dr. Benson to some degree on this issue. Differential diagnosis is not about looking at the results of some test, in any field of medical science. It is about a learned professional looking at the clinical history, listening to the patient’s story and reviewing more objective tests. Without the subjective application of an experienced mind to the entire spectrum of the problem, no diagnosis can be made, certainly not in a field as complex and subjective as brain injury. Neuroimaging may improve the accuracy of such diagnosis in the future but the goal is not to find an objective test we can rely on but to have better and less biased professionals engage in more thorough differential diagnosis. There is no 15 minute diagnosis of brain injury and no 15 minute solution.

6. Outcome unpredictable. Something I wrote over a decade ago was an essay entitled “Miracles and Tragedies.” http://tbilaw.com/essays.mildsevere.php I wrote that essay as I contemplated the “miracles in severe cases”and the “tragedies in so-called mild cases.” Such ironic criss-crossing of outcomes has been a universal theme of my career. I am continually amazed at how much better catastrophically brain injured survivors can get while aghast at how many mild brain injury survivors get worse and worse. I have gained greater insight into the problem since I wrote that essay but only because of the frequency that the criss-crossing of outcomes occurs. It is heartening to see a nationally recognized doctor educating Congress about that irony.

In our next blog more about advances in MRI and neuroimaging.

Sport Concussion Guidelines Should be Applied to Real World Brain Injuries

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Posted on 11th September 2009 by Gordon Johnson in Brain Injury

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Continuing with our football quarterback analogy about the difference between confusion and amnesia, lets also focus on another material area where the brain injured athlete gets better diagnostic methods directed towards them than the average member of the public: serial follow-up exams. A little over a decade ago, the Brain Injury Association of the U.S.A. in working with the American Academy of Neurology developed the first set of the “sport and concussion guidelines.” That first set did several really important things, the most notable was that it clarified that a loss of consciousness was not necessary acute event for a diagnosis of a concussion. The Sport and Concussion guidelines were not the first time that was clarified, but it was the first time it came from the Neurological national association.

From a long term standpoint, the most important thing those guidelines did was to create return to play guidelines. If an athlete who was not knocked out ceased to be symptomatic within 15 minutes of the concussion, then that athlete could return to the game. If they continued to be symptomatic after 15 minutes, then they could not return to a game for seven days after they ceased to be symptomatic. As this rule created a waiting period from the time they ceased to have brain injury symptoms, it required the training staff and or team doctors, to continue to do followup exams, every day after the injury. If you franchise quarterback can’t go back in the game for seven days after apparent recovery, you will make sure they get checked out every day.

Sadly, no non-athlete gets that kind of serial followup. Since no one sees any serious risk of harm for returning to work too soon, no one really makes any effort to determine whether the symptoms are occurring on day two, day three. That is so tragic, because there is really no doubt that if we did evaluate mild traumatic brain injury survivors at 24 hours, 48 hours and 72 hours, that we would probably be able to distinguish between almost all of those who were at risk for long term disability.

In our next blog, we will discuss why it can take up to 72 hours to be able to tell how serious a concussion or mild traumatic brain injury is.