Jerious Norwood: Concussions and the Three Strike Rule

Marc SilbermanContributor ISeptember 20, 2009

ATLANTA - SEPTEMBER 13:  Jerious Norwood #32 of the Atlanta Falcons against the Miami Dolphins at Georgia Dome on September 13, 2009 in Atlanta, Georgia.  (Photo by Kevin C. Cox/Getty Images)

Jerious Norwood, the Falcons' No. 2 running back, left today’s game against the Carolina Panthers with a reported head injury after taking a hard hit at the end of a six-yard run.  He did not return.

This appears to be his third reported head injury—each one in the past year.

He sat out this year’s preseason game on Sept. 3 after suffering a head injury on Aug. 29 when he went helmet to helmet with Antonio Cromartie of San Diego. He returned for week one against Miami and rushed for seven yards on two carries and had 49 yards on five receptions.

In October 2008 (week eight), it was reported Norwood suffered a head injury and was limited in practice for the week but returned to play week nine, not missing a game.


The Sports Medicine Literature

More than 60 years ago, in 1945, Dr. Quigley developed the three-strike rule, wherein an athlete who experiences three concussions in a season is out for the season. It was based on experience, not scientific data, and the rule was followed by physicians for many years.

More than 30 years ago, Gronwall and Wrightson studied 20 young adults who sustained two concussions and found after their second concussion that:

(1) The rate at which they were able to process information was reduced more than in those who had been concussed only once.

(2) Those who had two concussions took longer to recover than those with only one concussion. They reported in the Lancet in 1975, “The effects of concussion seem to be cumulative, and this has important implications for sports where concussion injury is common.”

In 2003, Dr. Julian Bailes, et al. conducted a survey study of over 2,500 retired NFL players and found that those players who sustained three or four concussions during their career were twice as likely to develop major depression later in life as those who had not had a concussion.

And in 2008, the Center for the Study of Traumatic Encephalopathy (CSTE) was created as a collaboration between Boston University School of Medicine and the Sports Legacy Institute (founded by Christopher Nowinski and Robert Cantu, M.D.) to better understand the long-term effects of repeated concussions.


Chronic Traumatic Encephalopathy

Using brain tissue from deceased former NFL athletes who sustained multiple concussions, the CSTE uncovered extensive, deep brown protein tangles flecked throughout the brain of athletes who died in their 40's, closely resembling the brains of 80-year-old’s with Alzheimer's disease. The progressive disease is termed chronic traumatic encephalopathy (CTE).

Repetitive trauma to the brain that occurs with multiple concussions, damages parts of the brain that control emotion, rage, hypersexuality, even breathing. Sufferers may experience memory loss, sleep problems, mental fatigue, emotional instability, erratic behavior, depression, and impulse control problems, progressing eventually to full-blown dementia.

The Center for the Study of Traumatic Encephalopathy, along with other research institutions, has now identified traumatic encephalopathy in six out of six brains studied in the late tragic NFL football players John Grimsley, Mike Webster, Andre Waters, Justin Strzelczyk, Terry Long, and Tom McHale.

And just this week the first active NFL players (Baltimore Ravens center Matt Birk, Seattle Seahawks linebacker Lofa Tatupu, and Arizona Cardinals receiver Sean Morey) announced that they will donate their brains and spinal cord tissue upon death.


So when will Jerious Norwood, slated to have more carries in 2009, be back?

1.  There remains NO evidence based recommendations with which to guide the physician.

2.  The grading systems previously used to classify and determine return to play have been abandoned.

3.  The cornerstone of concussion management is rest, both cognitive and physical, until all symptoms resolve, then a graded program of exertion over a week before returning to contact sport.

4.  Persistent abnormal brain imaging (MRI), abnormal neuropsychological test results (cognitive tests), ongoing clinical signs (what the physician tests such as balance), or symptoms (what the player may complain of or often hide), would preclude an athlete’s return to play, regardless of the number of concussions.

If we have learned anything, there is no such thing as a mild concussion.

If I was a betting man, I’d bet he won’t be back next week.


Marc Silberman, M.D.