Female Athletes Head for Trouble

March 27, 2009 — -- UPDATE: Jill Brooks, the neuropsychologist who treated Melissa Wester Inzitari, now runs Head 2 Head Consultants, a practice in Gladstone, N.J., and is a member of the New Jersey State Interscholastic Association's Medical Advisory Committee.

Like all great athletes, she slows the game down. She soars in the air and, for a moment, sees every angle. Teammates flashing grins as they cut toward the goal. The ball spinning as it sails over -- no, as it lines off the side of her head when she nails it. Again.

This is Melissa Wester, this is her sport and this is her move. It's fall 1996, and she's a sophomore at The College of New Jersey. She is a tiny 4'11"; as a freshman, she was shorter than the girl nicknamed "Midget," so Melissa became "Toy." But height doesn't measure stature: She was All-America and captain of her high school squads in Bridgewater, N.J. Sometimes height doesn't even measure altitude. Skying and heading the ball lets her triumph over taller players; she even runs up opponents' backs to get as much height as she can.

When her feet touch earth again, even before she starts running, Melissa gets a rush nothing else delivers. She feels her adrenaline-jacked heart beating in her skull. Breathing this hard tells her she's as alive as she can be.

The ball is back in the air. She closes in on it, times her jump, aims her shoulders -- but another player rockets into the same space. Their heads collide.

Happens all the time: Melissa has played through midair crashes and getting kicked on the ground, through broken ribs and busted ankles. But after this hit, she feels like she's watching herself run, not telling her body how to move. "I feel like I don't know where I am," she says to an assistant coach at halftime. Bizarrely, Melissa asks teammates for milkshakes, then begs them not to tell the head coach. She just wants to play. She always wants to play.

In the second half, Melissa starts walking in circles, staring at the lights. Yanked from the game, she heads for the wrong team's bench.

Her coaches call an ambulance. "You can't take me," she yells. Then she snaps, "Let's just go."

She babbles all the way to the Trenton hospital. But once there, a CT scan shows nothing wrong, and she's cleared to play. I wasn't knocked out, she thinks. It can't be that bad.

Next day, she's back at practice and into her usual routine. Except things aren't normal anymore. During her days, she has practices and games, but she's weirdly sensitive to light and sound. She wears sunglasses inside movie theaters. At night, there are team parties -- and pressurizing headaches, migraines bad enough to keep her home while her friends go clubbing. Her roommate plays soccer. Her boyfriend plays soccer. Her three sisters play soccer. When there's nobody to play with, and she feels happy, Melissa likes to kick a ball against a wall. When there's nobody to play with, and she feels unhappy, she likes to kick a ball against a wall. But as the season winds down, there are a lot more unhappy days.

Junior year, Melissa is voted team captain. But her game is off, and her grades drop. She fails tests and gets the first D of her life. She loses her car in parking lots. Once, on the way to class, she looks for the third floor of a two-story building. Another morning, she leans back in the shower and closes her eyes to let the water cascade down her face. She falls over. She never used to cry but finds herself weeping at McDonald's commercials. She's impatient, even nasty, when she doesn't mean to be. Her family notices her personality changes. Her younger brother says, She's such a bitch.

There's a day during senior year when Melissa realizes she can't see out of her left eye, although her vision soon returns. She's scared but doesn't want to say anything. Is she supposed to tell the world she can't find her classrooms? Melissa starts to wonder if she has a brain tumor.

During halftime of a game, it happens again -- she's zoning in and out, her eyes blurry. The familiar rush has become her enemy. Her adrenaline-fueled heart still pushes her to play, but now, as the blood rushes through her skull, her head pounds with pain. Her hands find her knees. She vomits, again and again.

Her boyfriend, Joe, waits outside the bathroom. "Enough is enough," he says. He tells Melissa's coach, too. That week, Melissa's grandmother drives her to see Jill Brooks, a clinical neuropsychologist at Robert Wood Johnson Medical School in New Brunswick, N.J. She stays for six hours.

"Is light bothering you?" Brooks asks. "Have you noticed changes in your personality?"

For the first time in two years, someone has noticed that Melissa has a range of postconcussion symptoms. She's not out of her mind, she doesn't have a brain tumor. But she does have brain damage.

A neurologist hands Melissa a paper filled with squiggles from an electroencephalogram. The left side of her brain is abnormal and probably has been since that sophomore-year concussion. She realizes that most of what she thought she knew about concussions was wrong. They often don't appear on CT scans or MRIs. You don't even need to be knocked out to get one. But if you return to play before the brain heals from the initial trauma, every subsequent blow adds to its injury. Melissa's head was like an egg that scrambled without ever cracking.

She tells her family, and her father sobs, wishing he'd done more. She redshirts but will never play competitive soccer again. She accepts note-taking help from classmates and attends extra study sessions to deal with her short-term memory problems. Working with Brooks, she develops methods to associate words with pictures -- new ways of retaining information.

Most important, Melissa learns that she is not alone. In sports played by both women and men, women sustain more concussions. The girls' concussion rate in high school soccer is 68 percent higher than for boys. And it's nearly triple the boys' rate in high school basketball, according to research by scientists at Ohio State, Nationwide Children's Hospital in Columbus, Ohio, and the NCAA. Other studies reveal similar differences between softball and baseball, in college sports as well as high school. Yet researchers, including Brooks, find that female athletes get less information than males about concussions from all sources, including coaches, trainers and the media. Generally, women athletes don't consider concussions a serious phenomenon.

Melissa reads studies showing female athletes suffer more symptoms and recover more slowly than males. But nobody can scientifically explain to her why girls' and boys' experiences are different.

There are theories, though. In addition to receiving different levels of education about concussions, women and men have different hormones protecting their brains and different levels of neck strength. They also have different styles of play, and none of the return-to-play guidelines used by teams to evaluate injured athletes take gender into account. Research shows that doctors and trainers don't conduct follow-up exams with female athletes as quickly as they do with males, either. Adding to the confusion, young women frequently get menstrual headaches -- migraines, even -- as hormones flood their changing bodies, making it all too easy to dismiss concussion symptoms.

Melissa graduates in 1999, still yearning to get back on the field. At one point she charges into Brooks' office waving a contract from a local semipro club, shouting, "I know you're going to clear me." But she also knows by now that the only way to recover from a concussion is complete rest, both physical and mental. And after her hours with Brooks, Melissa has discovered that although she's played soccer since she was 5, she also wants to take care of herself, and she wants other athletes to do the same. Slowly, she starts to realize that she's moving from a player's mind-set to a coach's.

Upon leaving school, Melissa starts coaching a Bridgewater club team she once played for. She marries Joe and becomes Melissa Inzitari. In 2002, they have a daughter, Alyssa, who loves to play soccer from the time she first kicks a ball. Melissa still gets headaches and still has to think really hard about where her car is parked. But in 2003, after an EEG shows that her brain is functioning better, she returns to school for a nursing degree.

She also begins training teams of 8-year-old girls whom she will coach until they are teens, teaching them to head balls properly, to avoid collisions, to report injuries fully and honestly. She feels the kids idolizing her, realizes she has a chance to fill their brains with the knowledge she's gained.

She coaches a girl named Lindsay who, by age 12, reminds her of herself: flat-out speed, an iron will to win -- and repeated head injuries. Considering whether to bench Lindsay, Melissa realizes for the first time the relentless pressure her coaches must have felt, from athletes and parents. She tells Lindsay and her family about the big picture, about how too many young athletes with concussions -- fully 50 percent -- return to sports while they still have symptoms, before their brains are ready. Just like she did. Lindsay agrees to sit.

When Melissa's son, Joey, is born with Down syndrome in 2004, she resolves to spend less time on soccer. She walks off the field but can't walk away: Melissa becomes technical director for the Bridgewater Soccer Association, responsible for tryouts, evaluations and getting all 32 teams trainers. That makes 32 groups of players, parents, coaches and trainers who now learn about concussions.

She and Brooks speak at conferences held by groups such as the Brain Injury Association of New Jersey and the New Jersey State Interscholastic Athletic Association. "We can't wait for research to catch up with the question of why women are at risk," Brooks says. "These young athletes need prevention and education now." Brooks establishes a pilot prevention program in her home school district of Bernardsville and becomes a memeber of the Traumatic Brain Injury Fund, which receives 50 cents from every car-registration fee in New Jersey. Among other things, it pays for baseline neuropsychological testing in high schools. Across the state, doctors and trainers can now compare pre- and post-injury test performances to help them decide when athletes can return to play.

When she feels they're ready, Brooks introduces her female patients to one another, connecting young women who have reforged their identities and rechanneled their energies after experiencing brain injury. "You have a choice," Melissa tells a former Rutgers field hockey player who has suffered 17 concussions and been through headaches, seizures and depression. "You can keep playing, or you can read to your kids someday."

It's the winter of 2009, and she still sees every angle.