The impact of mild traumatic brain injury extends far beyond the gridiron – concussions can happen anywhere, including playing fields, bike paths, and war zones.
Kenneth Kutner, PhD, who specializes in head injuries and has been the team neuropsychologist for the New York Giants for 30 seasons, joins us to talk about what the latest research has revealed about concussion and how it affects physical health and cognitive function.
From the military to the NFL, and even in the corporate boardroom, this invisible injury is finally emerging from the shadows.
Plus… why don’t woodpeckers get concussions?
Phil Stieg: Hello I’d like to welcome Dr. Kenneth Kutner, a neuropsychologist and national expert in the evaluation and treatment of concussion. As team Neuropsychologist for the New York Giants for 30 seasons, he was the lead author of the Sideline Concussion Checklist, one of the first Sideline diagnostic tools utilized in the NFL. Today we will learn about the importance of concussion awareness and advancements in the field of concussions that will help players of all levels as well as the general public. Ken, thanks so much for being with us today.
Kenneth Kutner: Thank you so much for having me with you.
Phil Stieg: So let’s start off so everybody’s on the same page. What is a concussion?
Kenneth Kutner: A concussion is a brain injury, a traumatic brain injury. Technically, we call it a mild traumatic brain injury. Years ago, players would just call it getting their bell rung or getting a ding, and so no one really paid any attention to it. But now we’re aware that a concussion is a real condition, and we need to take care of it appropriately.
Phil Stieg: Technically, what’s really happening to the brain inside the skull when a person experiences a concussive episode?
Kenneth Kutner: So the brain is attached at the brain stem, but it’s actually floating in fluid, and the fluid is a shock absorber. So essentially what’s happening is there’s a jolting of the brain inside the skull. The brain is thrown forward, it’s thrown backward, and it turns. It’s actually that turning that we think is a problem more than the acceleration / deacceleration. Second, the brain is jolted, but also there’s some chemical changes that occur in the brain. The body sends fluid to that area to help heal it.
What happens in a concussion? There’s more fluid going, and so we get an increase of glucose that occurs to the area. Then there’s a shortage of it, and that’s called hyperglycolysis to hypoglycolysis. But essentially it’s a neurochemical cascade, and that neurochemistry changes. So what’s happening to the brain is biomechanical.
Phil Stieg: How do people think about getting diagnosed? Are there Cat scans, MRI scans, blood tests that we do? Or is it more of a clinical me looking at the patient kind of thing?
Kenneth Kutner: It would be nice if we had a test for concussion, but there is none. It is really diagnosed by histories. So we look at the signs, we look at the symptoms. At this point, there is no test for this. The CT scan does not help us. The MRI does not help us. So it’s diagnosed clinically.
Phil Stieg: People who’ve watched NFL football games have at one time or another seen an injured player taken into a blue tent on the sidelines. You know, the player goes in there and it’s some mystery. Since you are one of the original authors on the sideline, concussion checklist, can you go through what happens in the blue tent?
Kenneth Kutner: So essentially what we do in the tent is we assess the player for concussion. So what gets them into the tent? A referee can do a medical timeout. A referee on the field can say, I’m concerned of a concussion. There could be an athletic trainer in the booth called “Eyes in the Sky,” and he or she can say, “I’m concerned. Maybe there’s a concussion, call a medical time out.” Actually, a coach can do this. Another player can do this. So there are a lot of eyes on the player. That increases the chance that we’re going to pick this up.
Phil Stieg: What does the person who experiences a concussion complain about immediately after the episode? And then what are some of the long term things that you see as you follow up with them in the office?
Kenneth Kutner: Headache, blurred vision, dizziness, nausea. These are the kind of things that the players have immediately in the first few minutes and hours after. As the minutes and hours go by, what do we get? The player gets irritable. The player has difficulty focusing. The player is very tired. So we kind of see a change in the person. And then over the subsequent weeks, we may see the person has difficulty with sleep. Maybe they’re getting a little bit sad. Maybe they’re having difficulty at school. These symptoms change as time moves on.
Phil Stieg: And it’s important, though, that if a player does describe those early symptoms that you characterized, they’re taken out of the game. That’s what’s changed over the years as we’ve become better at diagnosing what a concussion is. Correct?
Kenneth Kutner: Oh, that has changed. We would initially evaluate a player – we would test the player every 15 minutes – and if the concussion resolved, it appeared that they improved. We may return them to the game if they’re fully asymptomatic. Now you have a concussion. We suspect a concussion, you’re out, you’re out of the game. We actually pull the helmet. These players are warriors. They don’t want to be removed from a game. So what do we do? We hide their helmet. We remove their helmet. They can’t go back in without a helmet.
Phil Stieg: So then it doesn’t stop there. They go back into the locker room, and they go through this thing called the Sports Concussion Assessment Tool. Describe for the listeners what happens there.
Kenneth Kutner: Well, this is a structured assessment. So, what happens is the player is evaluated for their awareness, their orientation. They forget what day it is, what game they’re playing, what stadium they’re in. They’re evaluated for their vision. Any difficulty with vision. Sometimes everything looks good in a player. His gait is good, they can walk good, their eyes are fine. However, when you start to ask them questions and you start to test their memory, then there’s impairment.
The idea is, how do you assess a player with a concussion? We do it with their walk, we do it with their vision. We do it with their level of alertness. We do it with their memory and concentration. A concussion can be an invisible injury. So if we get ten neurosurgeons to look at a player who had a concussion and just look at a player, they’re normal. They look good on neurological exam. So we need specialized cognitive questions.
Phil Stieg: That gets in a little bit that I wanted to talk about is this is not something that just happens at the game. There’s the whole preseason thing that you go through with your team of neuropsychologists. Can you describe that for the listeners?
Kenneth Kutner: Yes. All players that come into the Giants as well as other NFL teams. This happens also before there is a Formula One race. The race drivers are evaluated before the season starts. Professional soccer, NBA. So these players are evaluated. I have a baseline assessment when we test the players and we test them two ways. We do computerized testing and we do what we call one-to-one traditional testing. This way I have a baseline and I can determine if there’s been a change after that. So, we compare before and after and the individual needs to return to baseline and they need to be evaluated by an independent neurotrauma specialist to return to play.
Phil Stieg: So the NFL concussion protocol has really evolved, as you said, since 1994. Why did that occur? And define what you see as the greatest advancements in that protocol.
Kenneth Kutner: I think it’s occurred for a number of reasons. First of all, we have more information on what a concussion is. And concussion is really a mild traumatic brain injury. We used to believe it was a dink. There’s really no problem. People would get returned to the same game. They might be given ammonia, smelling salts to wake up. But I think the first thing is that we realize a concussion is a real condition, something we need to look at. I think second of all, there’s been a lot of media attention. So right now sports is in a fishbowl.
Phil Stieg: Do you feel like all of the other sports are equally as committed to modifying their sport to protect the players?
Kenneth Kutner: Great questions. Some of these sports have embraced the concussion protocol. Other sports, from my perspective, we’ve been kind of dragging them into it. For example, in NASCAR and Formula One, it took a while, but now the people in Formula One say, we don’t want a race car driver driving this vehicle 240 miles an hour if they’re concussed – that doesn’t really help what’s going on. I also think what’s interesting in sports, too, is that we have a lot of attention to women. Women actually have a little bit of a lower threshold for concussion than men do. They also have a little bit of a slower recovery than men do. So we need to pay attention to some of these gender differences too.
Phil Stieg: That’s the other thing too interesting in terms of recovery or treatment of concussion. And again, we’re not talking about somebody that’s had a bruise on their brain. Their Cat scans and MRI scans are normal. In the old days, we used to say, go into a dark room, wear sunglasses, don’t use your computer, don’t watch TV, avoid contact, yada, yada, yada. Now it’s get them back into their environment quickly. Explain that. And why have we changed our approach towards the management of concussion?
Kenneth Kutner: There was a period of time where doctors were putting these players in a cocoon, shut them down, put them in a dark room, no light, no radio notes, TV, no phone. We never did that with the Giants. I had thought that’s turning off the computer and when you turn it back on, you have to reboot it. Don’t reboot the brain. Keep the brain going. So it was this thought that if the brain was concussed, they’re going to get worse by all the stimuli.
New research has shown that actually the earlier return to light activity, the earlier return to cognitive tasks, gives what’s called symptom reduction. So what that means is they do better when we don’t shut them down. And so the research has really supported that.
Phil Stieg: You’ve been involved with the NFL for, like you said, 30 years. Is it your sense that the team of doctors on the sideline are the ultimate individuals responsible for making that decision as to whether a player has had a concussion?
Kenneth Kutner: Well, the ultimate decision, the player in the NFL needs to be cleared by the team physician. With the Giants, we have a nice gentleman, Dr. Scott Rodeo, just a world renowned orthopedic surgeon. But to get to that point, a process has to occur. So essentially one person doesn’t make that decision in isolation. So the individual needs to return to baseline on the testing. Once they return to baseline, once they are at the same level of memory concentration, they are then evaluated by an independent neurotrauma specialist, and that individual is not directly affiliated with the team. Once that’s cleared, then at that point the team physician makes a decision. Now what happens is, one, the athletic trainer says, yeah, I think they’re ready to go, or no, the player says, I’m not ready yet. The neuropsychologist says they have or have not returned. So no, it’s not a one person decision.
Phil Stieg: In your 30 years of experience, why is there this variability in the recovery? Some people bounce back, boom, and they’re ready to go. And other people, they have these lingering symptoms. Is there anything that you know that helps predict that?
Kenneth Kutner: Yes. First of all is, what is the history of concussions? So players that have had no prior concussions, they’re going to recover faster. Individuals with a number of concussions, there’s going to be a slower period of recovery.
Second of all is, what is the interval between concussions? So it may be that a player has a concussion. Let’s say the player is pulled out of games for two weeks. During the third week back, they sustain another concussion. So that interval, right? That time between two concussions is really short, and I think that makes for a longer period of recovery. I also believe that there are other factors that are involved too.
There is a lot of psychosocial factors these days. At the same time, maybe they have a knee injury, they have a shoulder injury. So, there is that psychosocial aspect also.
Phil Stieg: You have an interesting story about trying to get back in the saddle too fast, an individual that made an inappropriate loan. So, what’s your story?
Kenneth Kutner: So, yes, I received a call from the CEO of a large bank, and I can’t mention the name, but a very large bank, one of the largest banks in the world. And the CEO called me up and said we had a vice president, and he sustained a concussion on Saturday. He’s a weekend warrior. So he was playing in flag football, supposed to be no tackles, but this player was hit, was tackled. His head hit the ground and he was dazed and disoriented. Not bad enough to go to the emergency room, not bad enough to be evaluated.
Essentially. He goes home, takes a few aspirin. Not a great idea because that can increase bleeding. Goes back into work on Monday and he proceeds to give a loan for $300 million to a third world country that was on the blacklist. Now, when the CEO called me up, he said, that money is already gone. We can’t retrieve that money. And so at that point, I said, okay, I’ll evaluate the employee. I evaluated him. I said, yes, he’s not ready to return to the job yet. And the CEO said, yeah, we’re keeping him away from the loans. He’s not giving any more loans.
But here’s a good example of a player gets a concussion. He’s a weekend warrior. There’s no medical attention. There’s no awareness of it, and he returns. And it was a big problem. I believe it affected his bonus at Christmas, but I didn’t follow up on that.
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Narrator: Imagine trying to punch a hole in a tree by slamming into it with your nose. You’d probably end up with a splitting headache, some broken bones and a massive concussion! That is, unless you’re a woodpecker – the jackhammers of the bird world.
[Audio of a pileated woodpecker drumming on a tree]
Woodpeckers make a distinctive drumming sound as they beat their beaks on tree trunks. During the loudest drumming, a woodpecker’s beak strikes a surface around 25 times per second. They sometimes slam their heads into trees with up to 1,400 g’s of force. To put that into perspective, it takes less than 100 g’s of force to cause concussion in humans.
So why don’t woodpeckers pound themselves into unconsciousness or end up with brain damage?
For decades, scientists theorized that there was some kind of shock absorber between the beak and skull that cushioned woodpecker brains from harm. That hypothesis has inspired designs for shock-absorbing helmets used in football and other high-contact activities.
However, new research suggests that scientists may have been banging on the wrong tree.
Scientists recently recorded high-speed videos of woodpeckers. For the first time, they tracked how the birds’ heads moved after impacts, to measure shock absorption in the skull. After a hit, a woodpecker’s beak and head stopped at the same rate, moving stiffly in unison like the head of a hammer. The woodpeckers’ brains absorbed the full impact, with no “shock absorber” as protection.
While this contradicted earlier assumptions about woodpecker skulls, the findings made sense. The researchers calculated that an impact-absorbing skull would reduce the power behind the bird’s pecks. That could actually increase their risk of brain injury, as they would have to pound much harder to get the same results.
But if woodpecker skulls don’t have shock-absorbers, how do the birds prevent brain trauma? Scientists are still looking for answers.One possibility is that the low mass of the woodpecker’s tiny brain makes it much more resistant to damage – the same way an ant doesn’t break a leg every time it drops off your picnic table to the ground.
So it may turn out that sometimes being bird-brained is better than being big-brained!
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Phil Stieg: I want to get into a little bit of the controversial area. There’s been a lot of talk about the long term effects of multiple concussions and its role in the development of chronic traumatic encephalopathy. because it is complex. Could you give us a little bit of background on the Mike Webster story?
Kenneth Kutner: Mike Webster was the center on the Pittsburgh Steelers. He was the strength of the offensive line. He played years and years and years, took a lot of hits, and had a reputation for just being an Iron Man
Phil Stieg: The reason he was called Iron Mike was partially also because of his career, wasn’t at the University of Wisconsin. He never missed a game. He never missed a game with the Steelers. And the rules of football were quite a bit different back then.
Kenneth Kutner: Yes. So his reputation for being an Iron Man was he would shake off all these injuries, he would get hit in the head and he just stayed in the game. He stayed in the game. He would not leave. You’d have to pull him out with a bulldozer. And so this happened year after year after year during the season and during playoff games.
After he died, his brain was looked at. This was the first NFL brain that was being looked at. And when the brain was looked at, the neuropathologist saw some difficulties and some problems in the brain and said, I think that this is similar to what the boxers get, “dementia pugilistica,” very similar. And so he sent the single case in to be looked at. And at that time, that was really the beginning of CTE from a neuroscience perspective, that case being looked at and being published. When that single case came in, none of us reviewing this had a clear idea whether this was from repetitive head injury because the individual also had other medical problems, also had other substances in the body. As research has gone on and it was published, we are finding more about CTE.
Now, CTE, there’s a lot of media hype with it also. And some people may feel every retired player has CTE. What is CTE? It’s really a protein called Tau, and it deposits on the brain. We call it tauopathy. So what do you see in the brain? You see tauopathy and you see the player has irritability, they have memory, they have concentration problems. There’s still a lot developing with CTE. We are still learning more and more about it.
Phil Stieg: Don’t you think that it’s important for people to understand that we didn’t know all this back in 1994? We now know it. And I think that it’s my experience that people are trying to make concerted efforts to protect players from this in the future.
Kenneth Kutner: I really think that what we want to do with CTEs, do more research. There are a lot of other factors. The idea is lets prevent repetitive head injuries. Let’s let the brain recover before you put them back to play. So that’s really what my message. “bullet point” is. Diagnose a concussion accurately at the game. Pull the player from the game. Do not return the player to practice of the game until they have recovered. Let’s make sure the concussed brain has resolved, it has improved, it has restored before you put them at risk for another game.
Phil Stieg: You’re also extremely active in working with a number of retired NFL football players in their rehabilitation. What are you doing, number one? And then what have you found in terms of their response to the efforts you’ve made?
Kenneth Kutner: So the retired players that I evaluate, they range from the hall of Fame, the gold jacket gentlemen, to individuals that maybe have not played an NFL game, but they were on a practice squad, they played in European league. So what we see are players that have gone anywhere from just being on the sidelines or practice squad all the way up to the hall of Fame people. I’m finding a number of things. Some of these individuals have post concussion syndrome. So it does not mean because you have these head injuries, you automatically get CTE. So some of these individuals have post concussion syndrome, and that is a persisting permanent condition, a little bit more irritability, a little bit more difficulty with sleep and focusing. And there are also some other individuals that actually have cognitive slippage, a word for more of a decline, a dementia like condition.
Phil Stieg: And we haven’t even talked about the military blast effect and all those things. You are involved with the DoD. Can you make a comment about how the military is managing this as well?
Kenneth Kutner: Yes, I have lectured, did some training at Department of Defense. There are some ongoing protocols that we hope will come to fruition. We will come to do research with it. Each war has a different medical focus. So, for example, in the Vietnam War, unfortunately, there are a lot of lower extremity injuries from the booby trap bombs in the Gulf War. In all of these wars, there are really more IEDs explosives. And so individuals are sustaining more direct head impacts in the Gulf War. They are also having these blast injuries. And I think the military is doing a relatively good job with this. The military has a tool called ANAM Automated Neuropsychological Assessment Metrics.
In the Gulf War, there were concerns that there were neurochemicals being released, and at that point, if a soldier was exposed to that, there could be brain effects, neurotoxic effects. So the military developed a tool called ANAM–. And I worked along with them, and they allowed us with the Giants to use the first civilian use of that. And actually, all the New York Giants were baselined on ANAM from the Department of Defense, and we would interpret the results of that.
Phil Stieg: So like any other chronic disease, prevention is the greatest tool. What do you recommend to parents as they watch their kids? To the weekend warriors or to the person that just unfortunately got bumped by a bicyclist riding down the street? Number one, how do we prevent but if we suspect, what should we do?
Kenneth Kutner: The first thing we want to do is to screen the activity. If there is an activity for bicycle riding, make sure the bicycle club requires that they wear a helmet, make sure the kids are wearing a helmet for skiing. I think also listen to the children, and if they say they hit their head or they fell on the ground, that we want to make sure we pay attention to that and assess for that. If there’s a suspected injury, let’s not return the child to that activity. Now, what’s new now is we start having high school athletes and college athletes that have sustained one too many concussions. When should they no longer participate?
Phil Stieg: What is that line? When do you say you’ve had too many concussions? Stop.
Kenneth Kutner: It’s not clear right now. It is not clear. So what happens is basically there’s no specific number of concussions that have occurred. Essentially what I would say is a rule of thumb is one, if there’s persisting problems — the headache never goes away. They always have that fogginess at that point. That’s one too many. Then what you want to do is you want to pull the individual from the activity.
Phil Stieg: We’ve all watched too many Bruce Willis movies and superhero movies. The superhero always gets knocked nearly unconscious and they bounce back. And immediately they’re able to do whatever it is they want to do. How has that changed the way we as humans live? And do you think that that’s a part of the gladiator? I got to stay in the fight, football game, basketball game after an injury?
Kenneth Kutner: Yes, absolutely. Especially the Rocky Movies. You see the Rocky movie where he hit and hit and hit and he’s dazed, disoriented. He’s spitting out blood, but he goes back and he keeps on fighting. The media really shows such an inaccurate, such a misperception of the body and the brain. In reality, if you’re a boxer and you take a really hard hit to the head, your eyes are going to be rolling. and you can get knocked down the next time. When you’re hit in the head with a bat, when you’re punched and knocked down, you may not get up. Now, you may get up, but you’re going to fall down again. You’re not going to go back and fight and beat your adversary. It’s nice for movie, but it’s nonsense.
Phil Stieg: And to be fair, now, players are more respective of, quote, “getting their bell rung”. They do come in, they do report it, and they don’t fight being pulled from the game because they know it. It’s in their best interest. Isn’t that what you found?
Kenneth Kutner: Yes. As players become more and more aware of it. Now, the players this doesn’t occur in a vacuum. I get calls from players wives and from their aunts and what’s going on. And I think that there is pressure on the player, but it does not occur in a vacuum. So players now are more aware of the concussion. They have less of a stigma of not playing. But there is another side to it also. Let’s say you’re a player and you’re in a contract year. A player is like you know what? I’m in a contract year. I don’t want to be pulled from a couple of games.
Theoretically, a player could say, I got the wind knocked out of me. I didn’t get hit in the head. Now, luckily, we have the video to look at that, and we have a lot of eyes in the sky, but it still is not at a point where players are 100% saying, okay, I have symptoms. I want to go. They want to be tough. They want to stay in the game. And there’s a lot of outside factors that are affecting that.
Phil Stieg: Dr. Ken Kutner, thank you so much for taking the time to explain to us what is a concussion, more importantly, to avoid it, and if we do have a concussion, how to treat it and how that has changed over time. And really, the fact that this is all going to be about awareness and getting everybody to think about this more fully, to protect their children and to protect themselves. Thank you so much for being with us today.
Kenneth Kutner: Thank you for having me.