MS. DIANE REHMThanks for joining us, I'm Diane Rehm. Every year in the U.S., nearly two million people land in emergency room for concussions. Their symptoms are often confused with other minor ailments. The result, many undiagnosed brain injuries that can eventually cause long-term damage.

MS. DIANE REHMJoining me in the studio to talk about the overlooked epidemic of concussions, Dr. Gerard Gioia of the Children's National Medical Center, Linda Carroll and David Rosner, they're co-authors of the forthcoming book "The Concussion Crisis: Anatomy of a Silent Epidemic" and Jon Almquist of the Fairfax County Virginia Public Schools. Do join us, 800-433-8850. Send us your e-mail to drshow@wamu.org. Join us on Facebook or Twitter. Good morning to all of you and welcome.

MS. LINDA CARROLLGood morning.

MR. DAVID ROSNERGood morning.

DR. GERARD GIOIAGood morning.

MR. JON ALMQUISTGood morning.

REHMDr. Gioia, can you talk about the basics of concussions? How do they come about?

GIOIAWell, concussion is a type of brain injury where there's a force to the head or to the body that jerks the head rather violently then produces a change in the way that brain functions and we look at the signs and symptoms as our cardinal kinds of things to examine. We look at a change in your physical functioning. It may be that your balance is off. It may be that you have headaches. It may be that you can't tolerate sound and sight quite so well.

GIOIABut it also affects your cognitive functioning, your ability to maintain your attention, to remember things, to think clearly. It also changes your emotional functioning, more irritability, sometimes your moods can be affected and then it can affect your sleep as well.

REHMAnd does all of this happen right away or sometimes is there a delay in the process?

GIOIASo there can be a delay. Most times we see some type of sign or symptom initially, but the symptoms can continue to unfold over time based on what we think is happening in the brain.

REHMI have a dear friend out in Salt Lake City, Utah, who fell, hit her head, thought nothing of it, but then as time went on, she realized she was having all kinds of problems. Is that fairly typical?

GIOIAYes, it can be particularly as you continue to do your everyday activities...

REHMYeah...

GIOIA...that are demanding that brain's activity to be functioning normally. We start to see symptoms become much worse as you're trying to overwork the brain when it's not able to do so.

REHMTurning to you, Linda Carroll and David Rosner, tell me why you decided to focus on this problem, Linda?

CARROLLWell, I think we started out looking at severe brain injuries and we did that because of the war in Iraq. We had done a piece on severe brain injuries and while reporting the severe brain injury piece, you know, experts were saying, well, you know, it's not any different from what happens to people, civilians and so that led to talking to people with car accidents with severe brain injuries.

CARROLLAnd I have to say from my perspective as a health writer for almost 20 years I had never seen this. I mean, I guess I knew that people injured their brains, but I didn't know what it did to them.

REHMSo you were both surprised at how it happened and the number of people it happened to?

ROSNERCorrect. And at about that time concussions started to become a bigger issue in general and especially in the sports world where concussions are most visible. We see them most often so it kind of brought the spotlight on the danger of concussions.

REHMAnd especially in children. But you call this the silent epidemic Linda?

CARROLLRight. Well, it's because people don't recognize what's happening, you know, so many people can have a concussion or even a severe concussion and not recognize that something has happened to them. You know, they start having symptoms and they don't know it's from the jolt to the head and so their lives are maybe going down the drain and they don't know why. You know, suddenly they don't have memory, you know, I'm having trouble keeping my appointments and, you know, it's because you can go to an emergency room and not be diagnosed and you're sent on your merry way, you think you're fine.

REHMLinda Carroll and David Rosner, they're the co-authors of a new book. It's titled "The Concussion Crisis". Turning to you, Jon Almquist. Concussions, as David had said, do occur athletically. I can remember my own daughter at age 12 on the soccer field at school and all of a sudden, we hear she's being taken to a hospital because she's fallen on her head. How often does it occur in the school system, on the soccer field or any other kind of sports arena?

ALMQUISTWell, it definitely happens quite often. It is one of the injuries that we're dealing with on a daily basis. The numbers seems to have gone up over the past several years. We had done a paper a few years ago looking at an 11-year trend and the number of concussions reported to our certified athletic trainers in our school system. We have 27 different sports in 25 different high schools so we have a fairly decent collection of data of the injuries and they have definitely increased year after year after year. And I think part of that is recognizing that the symptoms and more people recognize the symptoms having the ability to then let the individuals who need to know, know about them.

ALMQUISTAnd also our education program has included the importance of recognizing the symptoms, what the symptoms are and doing the right thing and that's obviously getting them to rest and prevent another further injury.

REHMSure, if you're on the athletic field and you've got an athletic advisor, but suppose it's not on the athletic field. What about the other teachers?

ALMQUISTOne of the things that is very important is to recognize that it's not just athletes that get concussions when you're dealing with the school system. And one of the things that we're focusing on now is the importance of cognitive rest because when the brain works and then has a concussion, it takes a lot more energy for it to do the same tasks and that's where it really needs to rest otherwise you're going to prolong the overall burden. And so I think it's important that the teachers and the parents, everyone knows about the dangers and the concerns of concussions, the symptoms to look for and, again, bring it to someone's attention that can actually do something about it.

REHMJon Almquist, he's administrator in the Athletic Training Program for the Fairfax County Virginia Public Schools. Do join us, 800-433-8850. Dr. Gioia, is rest the key in helping a child and adult to heal from a concussion?

GIOIAYes, it is. And it's not as simple as it sounds especially for an active child being able to not physically go out and do all those fun recreational activities, certainly for an athlete that's playing sports. And then, of course, their job, which is school, shutting that down is very difficult.

GIOIAOne of the things that we're also trying to get across is that it's ultimately the managed rest. It's not shutting somebody down entirely except maybe in that first day or two if they're highly symptomatic, but how we then allow them to participate in activities that will not result in them taking another blow to the head, but where it does not worsen their symptoms. So it's a challenge both for kids in school and for adults at work.

REHMI'm sure keeping a child off the playing field when he or she seems to feel fine is difficult.

ALMQUISTIt is absolutely. We're trying to convince the coaches and the parents and the kids all, that this is the right thing to do then. And now, we're also adding the teachers into this equation.

REHMBut Linda Carroll, haven't helmets on bicycles or motorcycles or even football helmets, haven't they, to a certain extent, helped to lessen?

CARROLLWell they protect the skull and maybe you might get a minor, you know, protection from a concussion, but for the most part, the brain, you know, is floating around and, you know, your body and your head stop and your brain keeps going and that is the whole problem. You can't stop your brain from moving inside your skull. It's floating around in fluid and it's not anchored and so your body stops suddenly and your brain -- it's like if you didn't have a seatbelt on.

REHMRight.

CARROLLAnd your car slams to a halt and boom you go into the windshield. That's your brain hitting the front of your skull.

REHMAnd when that happens, Dr. Gioia?

GIOIAWell, that -- what it does is it stretches the brain. I mean, the brain is very pliable. It's probably the consistency of -- I've heard many different things, but mayonnaise. It's a pliable kind of material and so when you have that movement and that fast movement, it stretches that material which is the axons and the cells of the brain.

GIOIAIt then can affect how those brains respond and so it's -- I think Linda characterized it very nicely, particularly when you think about a motor vehicle moving and an occupant inside it is like the brain inside the skull, it moves as well.

REHMDr. Gerard Gioia, he's director of the Neuropsychology Program at Children's National Medical Center. We'll take a short break and when we come back, I see the lines are filled so many of you would like to hear more about concussions.

REHMAnd we're back talking about concussions. Now, that may be something that you're not worried about now, but you could confront yourself, someone in your family, a child perhaps. And concussions, believe me, have a long term impact. Here in the studio Dr. Gerard Gioia. He's at the Children's Hospital (sic) National Medical Center. Linda Carroll and David Rosner are coauthors of the forthcoming book "The Concussion Crisis: Anatomy of a Silent Epidemic." Jon Almquist is administrator of the Athletic Training Program for the Fairfax County, Va. Public Schools.

REHMHere's an e-mail from Mark who says, "Please ask your guests about the current thinking on recovery from a standard concussion. From a discussion on the soccer field sidelines this week, it seems that reducing stimulation of the brain, i.e. no reading, television, computers, homework for a week is the latest." What say you, Dr. Gioia?

GIOIAWell, this, again, is that managed rest idea that we really want to reduce the stimulation or the demand on that brain while it's recovering. First of all, we know that symptoms can worsen and the child is very uncomfortable during that time. And that what we're still studying is how it may, in fact, prolong -- and certainly the working hypothesis is this may prolong recovery if you continue to over stimulate it.

GIOIAIt's also important to recognize that every child, every adult manifests this injury differently. And it's really important that you have a good individualized evaluation of how that injury is playing out for you.

REHMBut you have to get to a doctor first, don't you?

GIOIAYes.

REHMAnd too often, David Rosner, don't these sports-related injuries go undiagnosed?

ROSNERYes, that's the biggest problem is that a lot of times athletes will not either recognize that what they've received is a head injury...

REHMBecause they don't want to get off the field.

ROSNERCorrect. And because of that, they won't report it to an athletic trainer or a coach.

REHMWhich is why it's so important, Jon Almquist, that an adult, a coach be present on the field at all times.

ALMQUISTI think the -- in organized sports, there will always be an adult coach there, but the important thing is that if they had a certified athletic trainer who's a medical professional actually there on the sideline each game or each day, that is -- raises the level because there's someone who is actually trained and educated to manage these concussions through -- recognize them to actually test for them and evaluate them. And then also work with the -- that athlete to get them back into sports appropriately and correctly.

REHMSo considering all these precautions, why do you think athletic injuries are on the rise?

ALMQUISTWell, I think the -- overall, we hope that the athletic participation is also on the rise. So with that, and also with the advent of more girls in sports as well, these are all good things. Sports is a great way to have so many benefits of having kids participate in sports of all different flavors and sizes and types. But the important thing is also to recognize that when there's an organization providing opportunity for kids to participate, there will be injuries. And that they should provide the appropriate care. And not just for concussions, but also for all the orthopedic injuries that may occur with sports participation.

REHMNow, Linda, you talk about hitting the windshield of a car. Here's an e-mail from Stephanie who said, "My four-year-old son was on bumper cars yesterday. When he was hit, at one point his head seemed to jerk quite violently. He seemed a little shaken at the time, but then fine shortly after. Is this something we should be concerned about? What should we keep an eye on?"

CARROLLWell, I do think that Dr. Gioia would be good for the symptoms and signs, you know, but I think we -- if it's our child, we have to be paying a lot of attention to whether they're different from the way they were before they had the accident or injury, you know. I mean, not every time you have a jolt something bad happens in your brain. But, you know, there are signs and symptoms in -- if you know your kid, you know if they're a little different. You know, maybe a little slower, maybe they're not focusing so good, maybe they're tired. I mean, you know, it's just something is off, you know.

REHMDr. Gioia.

GIOIAWell, the CDC website is a great starting point. And the signs and symptoms that Linda's mentioning, it's really the script that the parent wants to take a look at. So if you go to cdc.gov/concussion you will see a rich amount of information. And there are factsheets for parents, things they should be looking for.

GIOIAThe signs which are the observable problems they see in their youngster and the symptoms, the things that their youngster would tell them, mommy, my head's really hurting. Mommy, my vision is blurry or I can't see as well. Or mommy, I feel, you know, like the world is spinning when I stand up. All those kinds of things, it's a good cue. So those materials are available to everybody on that website.

REHMAnd here is a posting on Facebook. "Do childhood closed head injuries heal with age?" Dr. Gioia.

GIOIAWell, it depends on the type of closed head injury. So, you know, we use a variety of terms for brain injuries. And that's sometimes confusing. And different -- there can be different levels of severity of brain injury. We think of concussion along this -- what we refer to as the milder end of the spectrum, although that term is only useful relative to moderate and severe. It's not mild to the individual who has that injury.

GIOIAMany injuries that are in the concussion spectrum do recover over time. We still have some unanswered questions about what may or may not linger for some individuals. But generally speaking on the milder end they do. The -- but again, as I said before, every injury is very individual to that person and...

REHMAnd...

GIOIA...you can have lingering problems even in the milder injuries.

REHM...speaking of females on the playing fields, a former college soccer player from the Washington area, Linda, was charged with murder. And her defense is pleading insanity brought on by multiple concussions. Have you ever heard of this kind of defense? Does she have a case?

CARROLLWell, I'm not a lawyer and I don't know what's going on in the woman's brain, you know. I mean, I do know that having talked to a lot of people with brain injuries and concussions that people, at some point, have a little trouble controlling things like anger and rage. But...

REHMAfter concussions.

CARROLLAfter -- right, after a lot of concussions. But, you know, I've never run into anybody who needed to kill somebody because of, you know, concussion-induced rage. But...

REHMHow do you suppose...

CARROLL...I don't know.

REHM...this could play out, Dr. Gioia?

GIOIAWell, it's hard to say. That's obviously a complicated situation, no doubt with multiple factors. I mean, obviously there was the case a few years ago of that wrestler -- the professional wrestler who was found to have chronic traumatic encephalopathy and sadly killed his...

REHMWater on the brain?

GIOIAActually, no. That chronic traumatic encephalopathy is the deposit of these abnormal proteins in the brain due to multiple...

REHMI see.

GIOIA...injuries, multiple concussions. And he sadly killed his wife and his son and then himself and was later found to have this. You know, again, this would be a very complex situation that is going to require some pretty in-depth study of that individual's behavior and their injury history as well.

REHMAnd, Linda, in the book, you write about concussions resulting even when there's no head injury. Tell us about Angelica.

CARROLLWell, Angelica was a cheerleader that we met and she had a -- she was doing a cheerleading stunt that was called the helicopter where, you know, several of her teammates, you know, supported her legs and her arms. And then they threw her up in the air and twisted so she -- like a helicopter propeller. She would -- and somebody dropped her.

REHMWhoa.

CARROLLAnd she landed on her chin and her -- you know, she continued. Her coach had them continue to do the -- after she cleaned herself, you know, got the blood taken care of. And then she went home and she was off, you know. And her mom felt like, gee, this is...

REHMSomething's wrong.

CARROLL...really wrong.

REHMYeah.

CARROLLMy daughter's not herself. And she took her to a doctor and he said she had whiplash. And, you know -- and then, you know, time passed and she wasn't getting any better. And took her to another doctor and, you know, said the same thing. And finally she went to -- I think it was a jaw surgeon. And she said, you know, okay, you know, maybe she's got a fracture or something. There's something wrong with my daughter and she's not getting better. In fact, she's getting worse. What -- you know, what's going on?

CARROLLAnd amazingly, the man, after doing the x-rays, came in and said, look your daughter had a concussion, you know. And she should've been in an emergency room right away. And, you know, ultimately Angelica got better, but it took a year of, you know, therapy, you know.

REHMJon Almquist, are the cheerleaders also being watched carefully?

ALMQUISTAbsolutely, and we also do see a number of concussions in that sport. 'Cause right now, it is a sport and they are -- there's flyers, there's base people and there -- it's a very demanding sport and there are concussions in that sport as well.

REHMAnd so you've got to be very, very careful. When a young person or an older person gets to the hospital, Dr. Gioia, what's the first thing you do?

GIOIAWell, we hope that the hospital has a good protocol, that is a good set of procedures. I was one of the coauthors of the CDC's physician's toolkit and one of the things we wrote in there were what are the kind of trigger conditions that you as a physician are going to look for when an injury occurs? Anything obviously that contacts the head.

GIOIASo in Angelica's case, obviously you're talking about a speed of dropping, hitting her jaw enough, it sounds like with rotation built in, as moving that body around. Anything that's high speed, and even if you don't touch your head, that jerks that head, all those kinda conditions we want to look for. Anything that involves injury to the neck is probably going to affect the head as well.

GIOIAAnd then we have the physicians go through their own medical signs and symptoms ruling in and ruling out the kinds of factors that they're looking for. We still need some greater standardization of these kinds of medical procedures in our emergency rooms and in our primary care offices.

REHMDr. Gerard Gioia of the Children's National Medical Center. You're listening to "The Diane Rehm Show." David Rosner, I'm thinking about all these professional athletes, the boxers, the jumpers, even the runners who might in fact suffer concussions.

ROSNERYes.

REHMAre there examples you can give us?

ROSNERWell, the high profile ones were, of course, the ones in the National Football League because you're talking about the most popular spectator sport. And this is where especially with the superstar quarter backs Troy Aikman and Steve Young suffering multiple concussions in the '90s it started to get on people's radar. They kind of became the poster boys for a concussion but it still was -- even when a few athletes were having to retire early with post-concussion syndrome, it still was easy to downplay.

ROSNERAnd it's really been, over the past, you know, five, six years or so when you've seen the chronic traumatic encephalopathy that Dr. Gioia mentioned in professional football players -- retired football players that, you know, when you start talking about dementia, that was kind of, we think, a big trigger to the awareness that's gone on within...

REHMWhat you're suggesting is that these multiple concussions out on the playing field can ultimately lead to dementia of a sort.

ROSNERRight. That's what -- and we're talking about, you know, only more than 20 football players have manifested with chronic traumatic encephalopathy, yeah. So it's not a big number.

REHMYeah.

ROSNERBut it's a scary number.

REHMSure.

ROSNERAnd what it portends for everyone who's...

REHMI wonder about Sugar Ray Leonard as a boxer. Are the boxers themselves subjected, I would think they are, to these kinds of multiple repetitive...

ROSNERRight.

REHM...head injuries?

ROSNERIt was almost -- you know, that was the shocking thing when you started to see that type of punch drunk syndrome that you'd seen in boxers and there everybody -- you know, it was expected. It was a fact of life. It had been in the medical literature going back to 1928. And, you know, it's -- there have been, you know, plenty of boxers suffering from dementia pugilistica. And then when you started to see that in footballs players that's when people said, whoa, this -- you know, this is serious.

REHMThis is serious and one thinks about Mohammad Ali who now has a severe case of Parkinson's disease, who is one of my heroes for the extent to which he has really tried to educate people about head injuries, Parkinson's disease and the like. Do you see any boxers, Dr. Gioia?

GIOIAI don't see boxers in our clinic largely because we see children. And...

REHMBut of course they're getting into...

GIOIA...there are...

REHM...boxing as well.

GIOIAThere are, yeah, kids that do that. You know, the issue here with this injury is that it's probably some combination of events. The amount of force, the number of times you're concussed, probably with some individual characteristics maybe genetically that we're still trying to understand.

REHMShort break, we'll be right back.

REHMWelcome back. It's time to open the phones. First to Kathy in Concord, N.H. You're on the air.

KATHYHi, Diane.

REHMHi.

KATHYI just had a couple of comments. I wanted to try to speak a little bit from the perspective of the actual injured parties. My daughter was a scholarship D2 athlete, playing basketball for St. Rios and was injured in her first tournament, pretty traumatically. The school stood by her. They did some -- they had done required baseline testing for all their athletes.

KATHYSo as soon as she was able to get home from Colorado, they did a follow-up test and realized how severe the damage was. She came home, we did the -- a lot of rest therapy. But one of the things she encountered was that brain victims look so normal. As an 18-year-old girl, she was pretty and she started to heal and had lapses of memory and was very anxious.

KATHYIt was very difficult for her to communicate though and people couldn't see broken bones or blood or the damage so they treated her very strangely, which made for an increasingly frustrating situation for her. And then, the other thing that I wanted to emphasize, especially for colleges and universities or programs, is to provide that health and support. They rallied around her. They did not revoke her scholarship.

KATHYThey allowed her to do online classes when she was strong enough and I'm very proud to say that due to familial support, she's back down in Tampa and will graduate as a senior this year.

REHMCongratulations. Kathy, that's a good news story. Linda, what about the fact that in the recovery process, people don’t really see the concussion. It's not as though your arm is in a sling.

CARROLLRight, well even with severe brain injuries, you know, people who recover, it was the thing that originally struck us, was you would meet someone and you would talk to them and they seemed perfectly normal until you would talk to them long enough where they had to use a part of their brain that didn't work. You know, their short term memory was bad or maybe you had an appointment to meet them some place and they just couldn't make the appointment because their organization wasn't as good as it used to be or they couldn't focus or lost track of time.

REHMInteresting.

CARROLLAnd we all do that, a little bit, but people with brain injuries do it so much more. And -- but to all intensive purposed a lot of these people, you first meet them, they seem fine and then it's hard to accept that there's something wrong.

REHMYes. And she -- Kathy, talked about the support of the school system.

ROSNERYeah, I think, that's why it's so important to have the school system really -- have an athletic trainer there to be able to develop a concussion management program that basically educates the parents, the staff, the teachers and the kids and the coaches. That, you know, the minimizing the systems is a real big problem we have. And you can always get another reason for why this kid is acting funny.

ROSNERWe're dealing with teenagers here, a normal teenager occasionally is foggy once in a while without a head injury. So it's a lot of minimizing to the symptoms...

REHMYeah.

ROSNER...and that's very important, that when this does happen, you really look very closely and deeply and dig for those symptoms and then accommodate and have the classroom accommodations as well as the physical accommodations.

REHMAll right, to St. Louis, Mo. Good morning, Katherine. Katherine, are you there?

KATHERINEHello.

REHMYes. Go right ahead, please.

KATHERINEI have a 21-year-old son who suffered a concussion when he was three. We took him to the emergency room and part of his face was drooping. They couldn't really find any skull fractures or anything. But we knew it was a pretty serious concussion. By the time he got into school, he was really having a challenging time. He was very popular, very physically gifted, they called him.

KATHERINEBut he struggles with school. So eventually, by the time he hit 7th grade, he hit a wall and they said "Oh, he's an adolescent. Oh, this --" they wanted to come up with every reason for his inability to do well in academics. And finally, the counselor said something's up and we went to a neuropsychologist that the school paid for and he did extensive testing. It took, like, a month. And they figured out, he did have a brain injury that affected his executive functions.

KATHERINEBut it took me all of those years to get the schools -- they thought I was nuts, they came up with any kind of excuse not to deal with this kid. "He's a bad kid." Finally, he's 21 years old, he is a very active athlete, as far as, you know, extreme sports and that is because his executive function isn't working as well as it should. So you have this gifted kid that's physically -- who is taking these risks and doing really well at it.

KATHERINEI guess, my question is, two parts, why aren't we training these teachers to recognize brain injury? And, number two, I've heard that Arnica immediately taken after a concussion or brain injury can help. And I make my kids carry Arnica in their cars and in their backpacks.

REHMWhat do you think about Arnica, Dr. Gioia?

GIOIAWell, I'll be very honest with you, I'm not clear on what Arnica is. But, you know, right now we are still doing a lot of research on how to treat these injuries. You know, the brain is a complex, complex organ. And there is, unfortunately, no simple and single way that we can, at this point, treat it, certainly, in terms of medicines.

GIOIAThere's a lot of research going on right now to try to come up with various kinds of, both, acute medications and then long term medications. But also, other kinds of strategies, as well which sounds like, in this particular case with this young man, fortunately when the injury and it's dysfunction was defined, things really started to open up for him.

REHMBut when you say, Katherine, number one, what is Arnica? Why are you using it?

KATHERINEIt's supposed to reduce the internal swelling, any kind of internal swelling or bruising.

REHMOK. Well, Dr. Gioia has not heard of it. Linda? David...

CARROLLNo.

REHM...how about you?

ROSNERNo.

REHMNobody here has heard of it. I'm -- you know...

KATHERINEMaybe you should do a show on Arnica.

REHMWell, I don't know about that. I'd want to know a lot more about Arnica before I did a show on it. But as far as training teachers, Jon Almquist, that seems to be exactly what's happening.

ALMQUISTYes. We are definitely ramping up that whole process of educating the teachers and working with them for cognitive and academic accommodations. And, I think, this book "The Concussion Crisis" is a great read for -- if, you know -- what you need to do is go to your school and ask your administrators about what their concussion management policy is. And if it doesn't have a fairly extensive component with regard to academic accommodations, this should be a must read for the administration and hopefully then they will get things in the works.

REHMYou have to spend a great deal of time, I would think, integrating the concussion victim back into the school system.

ALMQUISTYes. And it's, like Dr. Gioia said, it's a working with appropriate rest. It's not eliminating, it's not putting them in a dark room and closing the door for two weeks. It's, basically, working with -- knowing what they can deal with, how different things affect their brains ability to function and then adapting so you can minimize those risks or that stress.

ALMQUISTAnd by still keeping these very zealous athlete -- young kids that like to socialize and like to be active, from getting depressed, as well. Because if you take everything away from them, that can actually work the brain harder with regard to just their depression.

REHMTo Cleveland, Ohio. Good morning, Vicky.

VICKYHi, I was wondering if one has an accident or takes a fall, loses consciousness and temporarily consciousness and memory, does that necessarily mean it's a concussion or brain damage?

REHMDr. Gioia.

GIOIAThat does define a concussion, any blow to the head, any force, any jolt that then produces loss of consciousness which is one of the signs or loss of memory which would be the amnesia as either before or after the injury. It would definitely define that. Now, that -- you use the term brain damage and often times we reserve that term, more so for when there's been a permanent, kind of, problem to the brain. Certainly, that injury or that force will impair the brains function. The question is whether it becomes permanent or not.

REHMAll right. And to Jean in Vienna, Va. Hi there.

JEANHi, Diane, thanks for taking my call.

REHMSurely.

JEANI'd like to address a question to Dr. Gioia. I'm concerned about the little kids, the real little ones. For example, I have an 18-month-old grandson who loves the water and his father often has him jumping off the diving board with him. And I really am concerned that the impact on the water, could jostle and have a, you know, an effect on this babies brain. And everyone says "Oh, you know, he loves it." Well, yeah, but, you know, I am concerned, what's the possible repercussions could be to this...

GIOIAWell, you know, I think it's important, obviously, to use just, you know, good judgment in how we, you know, what sort of forces we apply to any youngsters head. Hard for me to speak specifically to how your grandson is entering the water but again, I think, the key here is that, with any activity, if a parent is concerned that they've taken a blow, it's very useful to have the signs and symptoms available to you.

GIOIAI often times tell parents that, just, you know, especially if you have somebody who's in a sport, clip the signs and symptoms card from the CDC on the refrigerator. You know, we've developed even a little app that goes along with our CDC...

REHMRight.

GIOIA...materials.

REHMRight.

GIOIAThings that you can just -- help you, guide you, for whether there's a problem or not.

REHMBut, you know, if you're going into the water, jumping, you're going in feet first. If you're taking an 18-month-old off a diving board and diving head first, that doesn’t make too much sense to me. Does it to you, Jon Almquist?

ALMQUISTWell, again, I think, you'd really like to see what the actual situation is but again, I think, common sense would be a very appropriate way to handle that.

REHMWould you do that?

GIOIAI don't know that I would take my grandson in, head first, that way, no.

ALMQUISTNo.

REHMExactly. All right, thank you very much. And to Gainesville, Fla. Good morning, Keith.

KEITHGood morning. I'm bringing the other end of the age perspective here. I took four concussions over the age of 40, starting in 2006 as a law enforcement officer. The first was a training -- a fight training situation. I had $20,000 a surgery to repair bones in my face. The other concussions from car crashes with a result of the symptoms from that, not being able to rest properly, headaches, disorientation.

KEITHMy career ended over that. But I'm still here which is a good thing. Some of my symptoms, I was treated or assessed properly. I didn't even go on that -- the one with the -- required the surgery. I didn't even get transported to the emergency room appropriately because everybody just said "Oh, well, you just got a fracture." So the accumulative effects in those of us on the other end of the age spectrum are what I'd like your guests to speak to and encourage everyone to take this seriously.

REHMAbsolutely. Dr. Gioia.

GIOIAYeah, all these principles apply across the age spectrum whether your 40 or actually even with senior citizens. There's been a particular push within the CDC to look at senior citizens. We often times worry about those falls and how they affect the hip, well, they also can affect the head. And so all of these issues, from a public health and a medical perspective, apply throughout the age span.

GIOIAOne of the things that is being done now -- and, you know, unfortunately, things take time. But the medical field, both public health and clinical medicine, is really trying to update all their policies, their procedures, their training to start to recognize these problems. It's taking some time and as we know that can happen sometimes in a spotty way across the country.

GIOIABut, as Jon has said, in the same way that we want our schools to have good concussion management programs, we want our medical system to have good brain injury recognition...

REHMExactly.

GIOIA...diagnosis and management...

REHMYeah.

GIOIA...systems as well.

REHMWell and, of course, we've talked lots about schools. But Linda, lots of times these things happen right in the home.

CARROLLRight, or, you know, driving or whatever. You -- you know, people have accidents and they think that it's no big deal because they can walk away from it, you know, or if they have a fall, you know. If you can get up and walk away, it's kind of the American way, you're fine. Just dust yourself off and go on. And it's very easy to do that and not realize that you've done something to your brain.

CARROLLAnd to not recognize that, well, and now your memory is not quite as good as it used to be, why is that? You know, you're a little forgetful, you're a having trouble focusing on things.

REHMYeah.

CARROLLYou know, it's very easy to miss that.

REHMRight.

CARROLLBut if you don't understand that concussions are serious.

REHMAnd just to update on Arnica, our producer, Lisa Dunn, Googled it and it has been used medicinally for centuries, there are no scientific studies that prove its medical effectiveness. It is a plant. And let's go to Trevor City, Mich., very quickly, Eileen, please.

EILEENHi, this is Dr. Eileen Swigert, I'm medical director with a women's flat track roller derby team up in Northern Michigan. And we see concussions frequently in our sport. The questions that I have, is how critical is it for -- to get that scan that's recommended? I believe CAT scan, when you do have loss of consciousness, immediately.

REHMAll right, Dr. Gioia?

GIOIAWell, the, you know, the emergency medical world has really tried to define, sort of, the key critical indicators for scanning. And we probably don't have time to go into that in detail but certainly, anytime and certainly when we look at our, what we call our red flags for neurologic deterioration, someone who has extended loss of consciousness, who's wavering in and out of consciousness, who may have some indications of other neurologic signs. You want to get them into emergency medical care and possibly scanning.

REHMAnd Mary Beth writes an e-mail, she says "Just this year, our school system is requiring each student athlete to go online with the Cleveland clinic and complete a baseline concussion test before the session starts. If the athlete does not complete the test, they're not allowed to play." Does that make sense to you?

GIOIAIt does, but to remember that the online testing is not the only answer really to have a complete concussion management program. And the certified athletic trainer at the school to be able to recognize and diagnose these symptoms is essential.

REHMJon Almquist, Linda Carroll and David Rosner and Dr. Gerard Gioia, thank you all so much.

GIOIAThank you.

CARROLLThank you.

ROSNERThank you.

REHMAnd thanks for listening all, I'm Diane Rehm.