SECOND IMPACT SYNDROME: Sports Confront Consequences of Concussions

USA Today (Society for the Advancement of Education), May, 2000 by Jeffrey H. Tyler, Michael E. Nelson

EACH YEAR, more than 300,000 people suffer brain injuries while playing a sport, most of which are concussions. In football slang, players say a team member got "dinged" or had his "bell rung." Boxers who get stunned by a blow to the head may be described as "punch-drunk." What an athlete experiences during a concussion is actually a temporary, trauma-induced alteration in mental status. Many concussions occur without the individual ever losing consciousness, but researchers have determined that even a seemingly minor "bell-ringing" in the course of play can cause lasting physical and mental injury, or even result in death.

Sports concussions have become more publicized recently, as celebrity athletes announce early retirement, and tragic accidents and major lawsuits in sports are covered more closely by the media. Nevertheless, such injuries persist across the country in recreational and school sports where clear preventive guidelines for managing head injuries are slow to reach the field.

Studies released by the American Academy of Neurology and the National Brain Injury Association indicate that 10% of college and 20% of high school football players receive brain injuries in any given season. Most of these are transitory, but those who suffer a first concussion may be four times more likely to suffer a second than someone who has never had one.

Researchers have identified a serious series of brain injury events they call second impact syndrome (SIS). According to James P. Kelly, director of the Brain Injury Program at the Rehabilitation Institute of Chicago, SIS occurs when an athlete suffers a mild head injury, returns to play too soon, and suffers what may be a relatively minor second hit before the brain has fully healed. If the second injury occurs while the individual still has symptoms from the first impact, the result can be a rapid, catastrophic increase in pressure within the brain. Effects of SIS include physical paralysis, mental disabilities, and epilepsy. Death can occur approximately 50% of the time.

"SIS can affect anyone exposed to a mild or moderate concussion; there's no age discrimination," notes Kelly. "But it seems to affect teenagers more often because they are the least likely to report their injuries or take the time to recover from a concussion when they do get hurt. They head back into the game too soon, not fully aware of the risks they are taking."

It is unclear how many cases of SIS occur each year in the U.S. because the first injury is not usually reported to a physician. The Center for Disease Control counted 17 cases of SIS between 1992 and 1995, but experts believe that the tree numbers are higher. Most cases involve male adolescents or young adults, who received a second catastrophic concussion while participating in football, boxing, ice hockey, or snow skiing.

The case of Brandon Schultz, a high school football player from Anacortes, Wash., is a prime example of the devastating consequences of SIS. Schultz's recently resolved lawsuit against the Anacortes School District is the first of its kind to argue that a school district was negligent for failing to prevent an SIS injury.

On Oct. 25, 1993, just two weeks after his 16th birthday, Schultz's life changed forever when he made a tackle during the final seconds of the first half of a junior varsity football game. Viewed from the field, and by his parents' home video recording, the tackle looked harmless enough. It did not appear that Schultz made head-to-head contact with another player, let alone received a concussion.

Schultz was slow to get up, but did not appear to lose consciousness. After a minute or two, he stood and returned to the end zone for the halftime huddle. Schultz was able to walk and talk, telling his coach only that his head hurt. Ten minutes later, he collapsed into a fit of seizures before losing consciousness, the result of uncontrollable brain swelling. During this 10-minute period, Schultz's brain essentially exploded inside his skull.

What his parents' game tape did not show is that, one week earlier, Schultz was pulled from play following a concussion that left him momentarily unconscious. He had suffered headaches throughout the week and was held out of practice, but was never referred to a doctor by his coaches.

Schultz is now confined to a neurological facility in California and still suffers daily from the consequences of his injury. His physicians have described his condition as being locked in a state of permanent adolescence. His cognitive functions are impaired, and he requires almost constant supervision because of his ongoing behavioral difficulties. As a result of the many strokes suffered in the aftermath of his injury, Schultz also experiences motor control problems on his left side and must wear a brace to walk.

Seattle attorney Michael E. Nelson [one of this article's authors], himself a survivor of a serious brain injury, was able to negotiate a pre-trial settlement of Schultz's lawsuit. Nelson's legal argument was that the school district was liable for negligence when it failed to require Schultz to see a doctor after his first concussion. The school district's coaches regularly required a medical clearance following even minor orthopedic injuries, but did not do so in the case of Schultz's initial concussion.