Concussion cases hard to figure

BOSTON -- Dr. Mark Lovell is considered a concussion expert internationally and is the founding director of the University of Pittsburgh Medical Center Sports Medicine Concussion Program. He's the co-founder of ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing).

He also works in conjunction with the National Hockey League and the National Football League. He spent Wednesday afternoon examining 15 patients suffering from concussions.

He knows what he's talking about when it comes to injuries of the brain.

While Lovell has no immediate knowledge of the case of Boston Bruins forward Marc Savard, whose preparations for this season have been put on hold because of post-concussion syndrome, he spoke in general terms with ESPNBoston.com about the long-term effects concussions can have on athletes.

"You're always worried about it when you have an athlete who has lingering symptoms," Lovell said in a phone interview. "Everybody is different in terms of their recovery rate, and while most people recover from concussions, some people take longer than others. It's really a highly individualized thing, which is what makes it so challenging.

"Certainly, if people are having ongoing symptoms, they need to be very careful and they need to be thoroughly evaluated."

Savard suffered a Grade 2 concussion in March and missed nearly two months before returning to the ice briefly in the Stanley Cup playoffs. A team source told ESPN Boston on Tuesday that Savard could miss the entire season, although general manager Peter Chiarelli downplayed that possibility.

Lovell is on the medical staff for the Pittsburgh Penguins, and developed a testing program for concussion and post-concussion syndrome for the NHL in the 1990s. He no longer runs the program, but he's still a consultant for the league.

The variance in individuals' recovery time from concussions has made it impossible to set guidelines for when an athlete should be ready to return to action, Lovell said.

For the past 25 years, he has conducted research to determine how medical personnel can make better decisions about when someone is indeed back to normal and can return to competition without risking further damage.

The Bruins did everything by the book with Savard and were extremely cautious before giving him medical clearance to return to game action this past spring. After finally passing all the testing and examinations, Savard was on the ice for the Bruins' Eastern Conference semifinal matchup against the Philadelphia Flyers in May.

He played all seven games and felt no ill effects at the time. When that series ended in defeat for the Bruins, Savard went about a normal offseason. Like many hockey players in the summer, Savard played golf but otherwise took it easy. When it was time to start his offseason workouts, he did so at an intense pace (as Chiarelli noted last week) with his personal trainer.

Toward the end of the summer, according to Chiarelli, Savard began to have symptoms related to post-concussion syndrome. Chiarelli would not disclose the exact symptoms.

Lovell, who stressed that he does not have any information about Savard's case, explained how, why and what type of symptoms are generally present in such cases.

The symptoms include headaches, dizziness, balance problems, grogginess, and concentration and memory problems, along with the feeling of not being in sync.

"People can have symptoms, in general, that are provoked when they start heavily working out again. That's not unheard of," Lovell said. "If someone were relaxing for a significant period of time, and then they went back and really started pushing it, the symptoms can come back. It's related.

"The symptoms with concussions can be provoked by strenuous physical activity. It has to do with heart rate and also with sports-specific things, like rapidly having to look side to side, and those types of things. You can get flare-up symptoms when someone has to increase their level of physical exertion or mental exertion."

The Grade 2 concussion Savard suffered March 7, when he was on the receiving end of a blindside hit by the Penguins' Matt Cooke, was the third of his career. The number of brain injuries and the effect they can have on athletes differs from case to case, Lovell said.

"The tolerance of players is hugely variable," Lovell said. "First of all, there's no magic number. It would be really easy if there were, if you knew that once you've had three concussions you needed to retire. But it doesn't work that way.

"I've seen athletes who have had multiple concussions that were spaced out over time, who we can't find anything wrong with. And I've seen players who have had one concussion who had to retire. So it really is that variable. There are a lot of factors we don't understand yet."

Such is the case with Savard. According to the Bruins source ESPN Boston spoke with Tuesday, there still are a lot of unknowns, although the source said it is "possible" Savard could miss the season. Efforts by ESPNBoston.com to speak with Chiarelli about Savard over the past two days have been unsuccessful.

When asked whether a player would be at risk if he were to play while experiencing post-concussion syndrome, Lovell's answer was simple and understandable.

"We recommend that players not play as long as they are having post-concussion symptoms," he said. "We want them to be clear of symptoms before they go back."

The amount of testing in both the NHL and NFL has increased and become more "provocative" in the past 15 years to assure "people are normal" before returning to action, Lovell said.

"That has become the standard and the standard in collegiate athletics, too," Lovell said. "It has changed a great deal from the way it was when I first started doing this when, basically, there was no systematic standard program."

Each case is different, but the general timeline for an athlete to return to competition depends on the type of symptoms the player is experiencing.

Athletes need to be symptom-free for several days in a row (usually seven) before beginning a gradual physical exertion program. Normally that takes the form of riding a stationary exercise bike or walking on a treadmill.

"These are international guidelines I helped put together years ago that are now pretty much followed by everyone," Lovell said. "The idea is to not push the player while they are still having symptoms and wait until they are completely symptom-free at rest before you start pushing them to do more physical activity. That's the generally accepted protocol for managing the injuries."

The Bruins followed all of these steps with Savard last spring, and it seems they'll do the same this time around.

"Realistically, the more problems someone has with an injury, the more careful you're going to be the next time," Lovell said. "That's just human nature."

Recently, the agent for Paul Kariya announced his client would miss the entire 2010-11 season due to post-concussion syndrome. The veteran forward missed six games last season with the St. Louis Blues after suffering a concussion, the second of his career.

Kariya decided it was best to sit out the entire season because of the medical advice he received from Lovell.

In light of Kariya's situation, Lovell was asked whether he thought it would be best for Savard to sit out for an extended amount of time. Lovell again stressed that each case is different.

"I certainly can't comment specifically on his case because I honestly don't know and it would be improper for me to comment," he said.

The Bruins' medical and training staffs have always been careful when it comes to serious injuries. They are cautious and never rush a player back, including Savard.

His situation is serious, and the Bruins are treating it as such for obvious reasons.

"[Hockey] is a contact sport, a collision sport, actually, and every year we [the medical community] become more careful in terms of handling these injuries," Lovell said. "Unfortunately, some people do develop ongoing problems that just don't go away that easily."

Joe McDonald covers the Bruins and Red Sox for ESPNBoston.com.