In an office adorned with brightly-colored athletic jerseys on every wall, Kevin Crutchfield—director of LifeBridge Health's Comprehensive Sports Concussion Program—practices neurology as if it's a stand-up act. During this morning's concussion clinic, Crutchfield reaches into his doctor's bag ("my toy bag," he calls it) to produce a small oregano-filled canister to test a patient's sense of smell, then guides another patient to walk heel-to-toe toward what he calls his "time-out" corner, and holds yet another young man hostage to ensure that—despite headaches caused by a series of football- and ice-hockey-related collisions—the patient hasn't lost his ability to laugh at Crutchfield's never-ending arsenal of corny jokes.
"This is what I call my numbskull treatment," says the neurologist as he numbs the teenager's skull before injecting him with an occipital nerve block to alleviate severe headaches. (The patient alternately winces in pain and smiles.)
Laughing matters aside, Crutchfield, who learned the tricks of his trade during a residency at Walter Reed National Military Medical Center, approaches his role with missionary zeal as he spreads the gospel of concussions to patients (including Ravens and Orioles players), parents, athletic directors, and anyone else within earshot. His message is loud and clear: Concussions are a medical issue to be reckoned with, and, if not treated correctly (ideally, within 48 hours in Crutchfield's book), can cause devastating problems, both long- and short-term, to the brain.
Within the past four years or so, concussions, commonly found in high-contact sports, have become a topic of increasing concern and controversy as stories of the injury's aftermath—early dementia, depression, visual processing, and even death—come to light. Although researchers have studied the issue for decades, about four years ago, "the NFL admitted they had a problem," says Crutchfield, a former soccer player himself at St. Mary's College. "They stopped sweeping it under the rug." Landmark congressional hearings in 2009 led to more stringent rules in the NFL, preventing players from returning to practice or a game if significant signs of a concussion were shown.
These days, the spotlight shines on the playing fields of youth sports—from the lacrosse rec leagues at Brooklandville's Meadowood Regional Park to the football field at Dulaney High School—amplifying the need to tend to these injuries seriously and urgently at every level. What happened in the NFL, says Andrew Tucker, Ravens' head team physician and medical director of sports medicine at MedStar Union Memorial Hospital, has "focused our attention even more so on concussions and on the importance of taking very conservative care not only in the football league, but in youth sports where people start their careers."
Fourteen-year-old Coral Dittmar, who attends George Fox Middle School in Pasadena, was playing club field hockey when an out-of-control ball socked her straight in the temple.
"It completely knocked her off her feet," recalls Coral's mom, Ginny. "She had a huge bump that looked like a horn sticking out of the top of her head."
After being evaluated at a local emergency room, Coral was sent on her way. "We were told it was just a bad contusion," says Ginny. "They said because she hadn't lost consciousness or vomited, it wasn't a concussion." But a year and a half after the initial accident in October 2010, Coral still suffered from balance and memory issues. After a referral to Crutchfield's clinic, Ginny learned that her daughter had, in fact, suffered a concussion. "I thought that if it was a concussion, it would have been something they'd pick up that day," says Ginny. "I never expected she'd still be suffering."
In part, because there is no standardization of concussion care, Coral is one of many kids who didn't even know that they had a concussion until much later.
"We are still fighting the mentality of, 'Oh you dinged yourself,'" says Bill Ashton, sports medicine manager at LifeBridge Health. "We like to say, 'It's not just a sprain, it's your brain.' Kids need to understand you need your brain for everything. It's not like treating a pulled muscle or a broken arm."
Part of the issue, experts say, is that concussions can be tricky to diagnose. "Brain injury is what we call the silent epidemic," says Bryan Pugh, executive director of the Brain Injury Association of Maryland. "You look typical, but the eggs are scrambled."
Though there's still a long way to go, the hope is that Maryland's new youth concussion law (House Bill 858) signed on May 19, 2011, to protect student athletes from the dangers of concussions, will finally raise long-overdue awareness. (Maryland is the 18th state in the country to introduce such a law.) Now, when a concussion is suspected, the law mandates that a student be removed "from practice or play and returned only after clearance by an appropriately licensed health-care professional."
And although the law is new, it has already had a dramatic impact on the way in which concussions are handled.
"In the olden days, it was no exercise for a week and then it was okay to go back into the game," says Paul Bernstorf director of athletics at St. Paul's School for Boys. "The severity of the injury didn't matter. Now, it's a gradual re-entry to play." (Interestingly, private schools are exempt from the law as it is written, but most schools have their own protocol to protect students.)
While some studies suggest that concussions among student athletes are on the rise, it is hard to say whether sports have become more competitive or whether, with growing awareness, the reporting rates are simply higher. Crutchfield has his own theory. "Athletes are bigger, and they are faster these days, so the force of impact is greater. . . . It's like running into a train."
When Crutchfield joined Sinai in 2008, he recognized a need to grow a comprehensive clinic that specifically addressed the multifaceted issues surrounding sports concussions. By fall 2009, he helped expand the mild brain-injury program of Sinai's Berman Brain & Spine Institute and initiated the development of the Comprehensive Sports Concussion Program, the first integrated interdisciplinary mild brain-injury program on the East Coast.
Eighteen-year-old Kyler Barrett, a recent graduate of Marriotts Ridge High School in Howard County, is among the clinic's many patient athletes. Barrett was first injured in the fall of 2009, during a high-school football game. "He never came out of the game," recalls his mother, Robin. "We don't know when it happened. He said he felt a little 'off,' but he thought he was hungry." Two days later, Kyler was diagnosed with a "mild concussion" at a local hospital. And though the symptoms have ebbed and flowed, nearly three years (and 10 doctors) later, Barrett is still suffering. Under Crutchfield's care, he will possibly undergo surgery to alleviate his crippling headaches.
"I know people who have had concussions and they talk about headaches," says Barrett. "But I wish that all I had was the headaches. I've had violent mood swings, depressions, sleep issues. Over time you learn to cope with it."
With cases this severe, some parents are re-evaluating their decision to let their children play contact sports at all.
Betsy Berner's daughter Naomi, a multisport athlete at Park School, has sustained two concussions (although one was the result of a fluky accident off the field.). Now, Betsy struggles with whether or not to let Naomi play.
"I guess you have to weigh the risk of injury against the very real benefits like leadership, teamwork, increased strength, and agility that are derived from playing team sports," Betsy says. "I don't know what the answer is."
But Michael Dvorkin, an orthopedic surgeon whose son, Garrett, plays football at Gilman, puts his faith in the coaches and educators at that school.
"Gilman School considers its athletes' health and well-being their first priority," he says. "As a parent, this eases my mind and I have complete trust in the program."
Crutchfield says that when a child gets concussed, parents often have one of two extreme reactions: Either they remove the child from the field of play entirely or they rush him back too soon.
"I would hope that every parent is more concerned with their child's brain as opposed to a sport," he says, noting that as awareness has increased, parents have become more cautious.
But he feels that if the concussion is treated properly—that is, as an emergency and within the first 48 hours—the risks of permanent brain damage are greatly decreased.
Too much delay in treatment (or the wrong kind of treatment) as was the case with Kyler Barrett, can result in no resolution of symptoms or lead to surgery, says Crutchfield. "If I can [immediately] guide the brain down the proper path of recovery, it's so much easier than six months or a year later," he notes.
Thirteen-year-old Grace, the daughter of WBAL-TV anchor Lisa Robinson, was one of the lucky ones. She was referred to Crutchfield's clinic within 48 hours of a collision during basketball practice at The Bryn Mawr School where she was captain of her middle-school team.
"The other player's head hit me right on the side of my face," recalls Grace, who had also suffered a concussion the previous year. "I was hurt so badly, I couldn't see straight, and my coach had to help me walk to the trainer's office."
Although Grace was back at school the next day, Robinson recalls getting a phone call at the station. "They said, 'You have to come get Grace. She just doesn't seem herself.'"
In Crutchfield's office the next day, it became clear that Grace had, in fact, suffered a concussion. "He did the balance test with me, and my balance was awful," says Grace. "He referred me to do the Wii Fit every day as therapy."
Within several months, Grace was able to return to sports and feel more like her old self. Though happy to be symptom-free, she was less happy about saying a final farewell to the clinic. "On our last appointment she turned to me and said, 'You mean I don't get to go anymore?'" says Robinson, laughing at the memory.
Kid-friendly is exactly what Crutchfield is aiming for as he establishes his clinic as the go-to place for young athletes. "The message to kids when they walk through the doors is that this is their clinic," he says.
And if it's up to Grace, who has become something of an expert on the matter, the concussed will keep coming to Crutchfield.
"Every time she sees someone who appears to have a concussion," says Robinson, "she gives out Dr. Crutchfield's number." Adds Grace, "I've given the balance test right there on the court."