Roundtable: Concussions a concern in non-contact sports

Figure skater Ashley Wagner says she feels the effects of past concussions today, including memory loss and problems with focus. Hannah Foslien/Getty Images

Women's contact sports such as soccer and ice hockey, where head injuries are frequent and inevitable, recently have come under increased public scrutiny regarding their concussion evaluation protocols. But concussions still fly under the radar as an issue in many individual and team sports.

No one knows that better than Olympic and Grand Prix figure skating medalist Ashley Wagner, who will compete in the world championships this week in Boston. Wagner, 24, said she has suffered at least three concussions in training over the past 10 years that went undiagnosed until she self-reported symptoms and believes her cognitive abilities have been permanently affected. Fear of being sidelined prevents many skaters from admitting they're concussed, she said, and few are willing to train with protective headgear. Skaters often train alone or with coaches who aren't trained to spot concussion warning signs.

In cycling road races, the quality of evaluations still varies wildly in post-crash checks along the side of the road and rolling exams, where the rider hangs onto the side of a car. Professional rider Alison Tetrick, 30, who helped to win a bronze medal in a world team time trial for the Italy-based Astana BePink team, is working on a Ph.D. in neuropsychology, motivated by the aftereffects of her own head injuries. She said she doubts cycling would ever alter its rules to allow substitutions and take the pressure off injured athletes. Retired U.S. national soccer team goalkeeper Briana Scurry, 44, an Olympic and World Cup champion whose career was ended by her third and most serious documented concussion, is campaigning for a special head-injury substitution rule in her sport.

ESPN.com Senior Writer Bonnie D. Ford convened a virtual roundtable with these three veteran athletes to discuss concussions, their aftermath, the state of protocols, institutional support and the importance of personal stories in raising awareness. Wagner was interviewed near her training base in Southern California; Scurry in her management company's office in northern Virginia; and Tetrick by email and phone from Australia and Spain, where she was racing with her Cylance pro team over the past few months.

Ford: What were the circumstances of concussions you've suffered in training or competition?

Wagner: The first time I am 100 percent positive I suffered from a concussion, in the early 2000s, I was working on triple flip [jumps] without my coach. I tapped in and just kind of automatically set myself up at an angle, and fell onto my butt, [got] whiplash and hit my head on the ice. I got up, I was really dizzy and I was seeing spots. Then for probably about three months after that, I would get these skull-crushing headaches, and I had tunnel vision. I was doing summer shows, I would be in front of all these spotlights, I couldn't see and it made me really dizzy. That was the first one that set everything off.

From there you have the typical falls, when you're working on jumps. I have never gone into the doctor [immediately] to be diagnosed. I've always suffered the consequences later and gone in and been [told], "OK, you have post-concussion syndrome."

Tetrick: I think I had at least two concussions prior to 2010, [when] I was involved in a crash at the Cascade Cycling Classic. While descending, another rider took out my front wheel, and I went from 45 mph to zero. My hip and head took the entire impact, and I fractured my pelvis and was in and out of consciousness for a few minutes with some seizures. I needed to get airlifted out of the mountainous terrain and was released from the hospital later that night. I suffered from a seizure the next morning, but so much focus [was] placed on my broken pelvis, not much was said about the brain injury. I was later diagnosed with a traumatic brain injury.

I was riding [six weeks later] while recovering, and I slipped out and crashed. Later, the doctor said that the whiplash from that crash could have caused much more damage. I never told anyone about this crash until several months later. I should not have been on my bike yet. I continued to race that year and arguably had one of my best seasons. It was easy to watch the progression of the bone healing, and I ignored any other side effects from the brain injury.

In October 2011, I crashed in a fluke over-the-handlebars crash at the Pan American Games while warming up. It was dark in the morning and we were unable to pre-ride the course, because it took place in downtown Guadalajara [Mexico]. I hit a storm grate that was angled the wrong way and my front tire slipped in.

Scurry: I've suffered three documented concussions. The first one [in 2007], I was in a training session and the ball came off the post and came back and hit me in my forehead. I went off the pitch that day and returned to play about two days later.

Second one [in 2008], Abby Wambach was coming in on me one versus one; we both went the same direction and, unfortunately, she collided into me. Fell on my head, and my head went into the ground. I was out of training maybe a day or two for that.

And then the most recent one, April 2010, playing in a [Women's Professional Soccer] game with the Washington Freedom against Philadelphia, coming out for a low ball, about to retrieve it and their forward came in across the side of me [and] clipped me in the side of my head with her knee. That's the one that ended my career and changed my life forever. I had no chance to brace, because I never saw it coming. I got hit about the 38th minute. The hit didn't really seem that bad, so I didn't come off the pitch until halftime. But I realized that things weren't right. As I'm walking off the pitch, I'm going sideways.

Ford: Describe your symptoms, both short term and long term, and how they affected your career and your life in general.

Wagner: I started getting these tremors [during the 2010-11 season]. It started in my hands; my hands would get really shaky. I thought, maybe it's stress, maybe I'm just tired. It started getting progressively worse, ridiculously fast. Every time I'd get on the ice and start jumping, my hands would start shaking, and then it would go to my arms, and then it got to the point where my entire body would be in this complete tremor. I'd have to go sit down and just wait it out. Sometimes it would be five minutes, sometimes it would be 40 minutes. It was totally out of my control.

Along with that came heart palpitations. My heart would go from a resting heart rate up to 170 after maybe one or two laps around the rink. So I went to a neurologist; they said, "Oh, everything looks fine." I went to a cardiologist; they couldn't explain anything. I kept on going to doctor after doctor, specialist after specialist, and they were all just like, "We don't know. It seems like it's stress-related."

Finally, I think it was Steve [Mathews, her chiropractor] that suggested I get my neck checked out. Got an X-ray and the vertebrae in my neck were literally at a full straight line. Usually there's a natural curve to it, and they were straight on, going into my spinal cord. I would get on the ice, start skating around, and they would shift and start putting pressure on my spinal cord.

When I was a kid, I was very much a numbers person, I loved math and science, I was really quick, memory was never a problem. Then I suffered the first concussion and the two after that. Along with headaches, I couldn't process numbers any more. I couldn't figure out science. People would start talking to me, and all of a sudden my brain wouldn't process it as English. I couldn't think of the words to respond, so I was trapped in this silent panic. Memory to this day is really difficult for me. I have trouble recalling words. I have trouble focusing on conversations. Oftentimes, I find I have to pause and really think about what I'm trying to say to be able to have a conversation.

Tetrick: It was hard for me to recognize the changes in personality and the adaptations I was making to compensate for these. It wasn't until a physical from my team doctor that she began to uncover some of my symptoms. I was complaining of moodiness, depression, insomnia, and inability to emotionally respond. I couldn't read [at] length and had [trouble] focusing when reading and processing the information. When racing [in 2010], there were a few instances I would get lost in airports or not remember where I was.

I flew home [after the 2011 crash] and had my parents pick me up from the airport. I couldn't drive. I couldn't focus. My head felt like it was going to explode. Then it was total darkness. Depression. Lights out. Lying in bed for days straight. Unable to cry. Can't stop crying. The team doctor then said I shouldn't race any mass -tart races or ride in dangerous situations, such as the rain or in groups, until I was cleared by a neuropsychologist.

At the time, I was going through a divorce, and I think this additional emotional/mental stress added to the complications from the head injury. It is an already very complicated and subjective injury to monitor, and even more so when adding an additional life-altering event. Short term was the headaches, darkness and extreme sensitivity to noise and light. Longer term, [there were] more emotional side effects. I raced one year on antidepressants.

I felt like I would get "flooded" when in emotional conversations or arguments. It would be like someone turned on the water faucet in my head, and once the water went over my ears, I couldn't respond anymore. After hard efforts on the bike or when I was fatigued, I would have numb lips. I couldn't read long emails or books for at least a year after. I went to graduate school to not only study neuropsychology but to also force myself to learn how to learn again. Almost try to program my brain. My brain fatigues much quicker than it used to, and I can't focus as long, but I can still learn and grow and adapt.

Scurry: My initial symptoms were the usual suspects: dizziness, headache, sensitivities to light, sound and movement, insomnia that developed over time, balance issues, dizziness. I also had an overall detachment from other people. Depression started to set in. And panic and anxiety started to set in. And these are things I never experienced at all before the hit. I also had issues learning, retrieving information, remembering where things were. I had intense headaches that originated from behind my left ear, because I ended up having occipital nerve damage.

A lot of times what happens to people who have concussions is that you not only have damage to your brain, you can also have skeletal damage to your neck and head area. And a lot of times that's not seen or talked about.

I knew nothing about anxiety. I can get in front of 90,000 people and save a [penalty kick], no problem. And then I was worried about missing my turn on my way to the grocery store. All of a sudden, I couldn't focus on anything for a minute. I knew my career was over, and I think a lot of people thought, well, she's just upset and sad and depressed because her career is over. But I knew it was more than that.


Ford: How would you rate on-site concussion diagnosis protocol in your sport? What would you do to improve that protocol?

Wagner: I think we have come very far in skating; if you're at a major event, absolutely, that is one of the first things they go to, to make sure they can rule it out. But I think there's still an environment within skating and coaches where it's like tough love, "shake it off, you'll be fine," and it's a vicious cycle. It trains the athletes to not really think of that as a priority. Usually, you have a bad fall and you think, "Is my foot OK. Did I hurt my hand?" [Concussion] is not the first thing we're thinking about.

Generally speaking, these athletes are going to have a couple sessions by themselves where they're not supervised. Skating caters to a Type A aggressive personality -- "I'm gonna work, put in the extra hours. I'm exhausted. I'm losing technique, but I'm gonna keep on pushing" -- and that's where the injuries happen.

We need to introduce coaches to some kind of general protocol when your athlete takes a hard fall and hits their head. I think people are getting better with falls, but it's not always physical contact that results in a concussion. The whiplash and snapping your neck can just as easily cause a concussion. Getting the coaches on board a little more, [with] an easy test they can do rinkside to make sure their athlete is OK, would be helpful.

Tetrick: It was seven minutes before race start [after crashing in warm-ups at the 2011 Pan American Games] and the doctor shined a flashlight into my eyes and asked if I wanted to race. I said I had a [traumatic brain injury] past and to make sure I was OK. I didn't want my brain to swell with the effort, and I knew I had a history of head injuries. Of course, I wanted to race, so I did. I missed a turn on the course, and I remember nothing from that day.

It would be hard to have a different protocol unless you change the nature of the sport. You have to finish the stage if it's a stage race, and there's no sideline. I am noticing more awareness of head injuries, but I would like to see a more standardized protocol. If you lose consciousness, you should not get back on the bike or race the next day. It's not about smelling salts at that point. You have to pull the plug.

What worries me most is a secondary impact. There's so much that's out of our control -- you blow a tire or there's oil on the road or a deer runs in front of you or something happens to someone in front of you. Then again, I'm getting a Ph.D. in [neuropsychology] and I'd still want to race.

Scurry: It has definitely evolved. Back when I was playing, it was, "Where are you, how many fingers," that sort of thing. Take the player to the sideline, really quick three- or four-minute assessment. Now we know that is very inadequate in terms of whether a concussion has occurred, because these symptoms take a little bit of time to come on.

A player can get knocked out, be on the pitch, laid out, and they're allowed to resume that game. I think that is absolutely ridiculous. There's no way that a doctor or trainer should be asking the person who just got knocked out how they're doing. If they're an athlete, they want to get back out there. It needs to change. I've been talking about a head-injury substitute. Part of the problem has always been, "Do we burn this sub?" A head-injury substitution [that would not] count against the three [allowable subs]. I think that's vital.

Especially at the Olympic level, you have to have a neutral person assessing each player suspected of a head injury. I also think there needs to be a spotter, somebody in the stands, in the media box.

Ford: What kind of support did you receive from your professional team and/or national federation?

Wagner: I received a lot of support from my national federation. They've stepped up to the plate, and they really recognize the importance of recovery from these concussions. My professional team is Russian and old school. So if anyone's gonna tell me, "You're fine, push through the pain, get over it," it's going to be my coach. But he also respects that I'm an adult and if I say I can't handle this today, he will respect that.

Tetrick: Absolutely none from the national federation. When I crashed with them, I still had to travel home from a foreign country with no assistance, and it was a very scary time. There was more disappointment in the loss of a medal opportunity than for the safety of the athlete.

My professional teams completed baseline testing at the beginning of the year. Apps [such as Sway and Impact] are used to see if an athlete can race after crashing. Unfortunately with these very subjective apps, the team will see if you pass that and clear you immediately. I think some concussions, or many, cannot be measured using these apps.

The team also shouldn't have the complete say if this athlete is clear or not. Of course, the athlete will want to race, most likely, and I have seen directors have riders keep racing because it is good for the team. I think there should be a third party or doctor that will stand up for the better outcome of health. Although I think those simple apps for baseline testing are better than nothing, I don't think they provide a very accurate measure. I think the whole neuropsych assessment is much more comprehensive, and I wish teams/national federation would do this. I passed Sway when I had a concussion.

Scurry: I was under the insurance of the Washington Freedom. The league folded shortly after that, and it became a worker's comp situation. Then you have to go to court to fight for everything. Eventually, we found Dr. [Kevin] Crutchfield in Baltimore, who had been working with concussion patients at the pro level. Unfortunately, it took eight or nine months to get to see him -- between the time we found him and we could actually see him -- because I had to go to court to get permission even to get a second opinion.

I want people to understand that the concussion journey that I was on was incredibly long anyway, but it was made longer by that. It was extended probably about a year longer than it should have been.

Ford: What were the keys to your diagnosis and recovery?

Wagner: I think I'm still in the thick of it. I think it really has altered the way my brain processes information, and I think it's probably going to be that way forever, since I waited so long to actually do something about it. Steve [Mathews, the chiropractor who diagnosed and treated the neck issues causing her tremors] was a huge part in the recovery process.

Beyond that, it was so late in the game and so long since I had suffered from the concussions that I didn't do much active recovery for the concussions, I just tried to look forward into more preventive measures. I worked on strengthening my neck so that when I do fall, I at least can support my head a little bit better. I was literally like a bobblehead when I was younger. I do everything I can to help with my memory. I learned a new language. I tried to learn to play the guitar. Something I've tried to change over the years is finding that balance where I'm satisfied I've pushed myself enough, but not training to the point of exhaustion.

For me, learning choreography is next to impossible. I have to go over steps over and over and over again. I have certain ways I work with my choreographer now so that it's manageable. I've accepted that I'm only good at doing one thing at a time now. School and skating is very overwhelming for me. As soon as I retire from skating, I'm going to dive in.

Tetrick: I think that a brain injury may be a lifetime of recovery and changing and adapting to your new reality. It is hard to predict. I have to learn about the things that I like now and the things I can't handle. I need to learn how I respond now to stress, noises, relationships and pressure. It is a process that I am not sure will ever be over. Especially as we age with these brain injuries and the plethora of other symptoms that are only just beginning to be discovered.

I worked with a general medical practitioner, a neuropsychologist and a clinical therapist. I went to specialists to get the CT scans and such, but that is only showing bleeding, bruising or swelling. It paints a very small picture of what lies inside. I think the team of medical professionals was imperative. The doctor understood what I was going through and could discuss with the psychologist to prescribe medication and treatment accordingly. The neuropsych was the first person I could describe my symptoms to without having them be shocked. The therapist helped work out some of the emotional ramifications of the injury. My team thought I needed a sports psychologist, and this was not the case. It wasn't about sport. It was about life.

Scurry: I went and had a lot of different testing, MRI, CT scan, structural stuff to see if they could see something in my brain. All those tests came out negative. I ended up going to see a psychologist to help me with the emotional issues. I was doing Impact tests and failing them. I would take one every week, 10 days. Nobody could figure out what was happening; a lot of times, the doctor and the trainer were like, "Well, you should be fine by now. It's been a month or two or three." And I'm like, "Well, I'm not fine."

[The psychologist] had experience with neurological issues in her practice. She understood better than most some of the stuff I was dealing with. I think a lot of people thought, well she's just upset and sad and depressed because her career is over. But I knew it was more than that. When I went to Dr. Crutchfield [in January 2013], he diagnosed me within 15 minutes. I told him where my pain was, and the first thing he did was touch me behind my ear at the base of my skull, and I almost kicked him. As soon as he diagnosed me, I started to cry.

It took [until] October before I actually got the [occipital nerve] surgery. Took that much time of [insurance] tug-of-war. I consider myself 95 percent recovered. All my nerves have grown back, and I have feeling in the back of my head. But that was only the first step for my case. Then I had to do the balance therapy and the cognitive rehabilitation, basically had to retrain my brain. That took from January to October of 2014. Now we're a year past that and I've been doing phenomenally well.

Ford: Have you told your story publicly before?

Wagner: It's come up, but not in full detail. It's really hard to recognize and talk about an injury you don't really see. The last thing you want to do going into the Olympics is, "Oh, there's this one defective thing about me. There's something wrong, there's something that's not 100 percent," in this sport when there are so many people breathing down your neck to replace you. There is a little bit of a fear against reporting an injury. You know that just like that, you can be replaced on the world team, they can switch you out for someone else going into whatever competition you're signed up for. I didn't want to talk about anything that would paint me in a different light from what I wanted to be.

Tetrick: I have shared my story some, and each time I tell it, it gets easier. At first, I hid my story, because it was too close to my heart. I didn't want to show vulnerability or admit that I was suffering. I actually had an article written for Marie Claire magazine about this process, but I had them pull the article at the last minute. I was not prepared to show such a raw and horrible part of my life. I cried the first time I told it to a group of UC Davis cycling club members. I worry that the further I distance myself from it, the less I will remember the changes and the gravity of the situation. It was one of those things where you think, "Oh, now I am better ... look how far I have come!"

Many athletes, both male and female, will reach out to me about their own experiences with concussions or teammates and their concerns. At first, this was a very heavy burden, because I didn't want to admit how much my own head injury had changed and continues to change my life. I didn't want the responsibility to understand other people's struggles. I didn't feel qualified. This encouraged me to go to graduate school. I wanted to become the expert in this. The amount of Twitter and Facebook messages I get from other professional athletes regarding their symptoms and concussion questions is actually astounding, which shows there is a need for a place to go for safe information from someone that has been there.

Scurry: You go into a cocoon or a cave, and a lot of NFL players can probably attest, you don't really tell people how bad it really is. Because if you admit how bad it is, then it's that way. But if you don't talk about it, it'll stop. I think a journalist should know that somebody with an athlete's heart, if they [don't] realize how bad off they are, they may not even be able to understand and give you an accurate depiction of where they're at. Or they may, in fact, be embarrassed about it. If an athlete is wiiling to tell you it's bad, it's probably quite a bit worse. And if they're telling you they're fine, it's a 50-50 shot that they are.

I started to decide I was gonna tell my story based on a couple of things. One, I realized how many concussions there were in women's soccer. Two, it was therapeutic for me to do it. I had basically gone underground because I was in such a bad way for so long. I just was not in the world. And when I finally got the help, I started to come out of it. I opened the kimono and started telling people about what had happened. I figured, if a two-time Olympic gold medalist, World Cup champion, who has a clear head injury can't get the treatment I need, can't get the right diagnosis, can't get to the right people in a timely manner, then I can only imagine what a U-15 girl or U-13 boy must be going through.