Philadelphia Eagles News

Head Athletic Trainer Rick Burkholder

Opening Remarks:"In light of the [RB Brian] Westbrook injury and also, I'm not sure if you're realize it or not, the Commissioner of the National Football League spoke with Congress today about concussions in our game, I thought I would give you guys a little update on concussions and Westbrook's situation. First of all, I know that there were some articles put out there and certain people that claim they were experts and had some misinformation. In 2001 in Vienna and then follow up in 2004 in Prague and then 2008 in Zurich a group of physicians and clinicians worldwide got together to put to rest some of the myths and some of the different grading systems, return to play, that kind of thing to make it easier for parents, coaches, athletic trainers, therapists physicians to come up with universal treatment plan for concussions. We follow that. We follow their guidelines.

"Also, I am one of two athletic trainers in the National Football League that sits on the NFL's committee on concussions. I see it two or three times a year in those meetings and I take that part of my job as one of the highest levels of concern for our players and for me as a clinician. That injury has a lot of focus within the media and within the players union and within the players' safety group, but it's a big issue with their livelihood and that's one of the things that I concern myself with as their healthcare provider. We've gone to great lengths to make sure that we know what we're dealing with.

"As far as our physicians are concerned, [team internist] Dr. Gary Dorshimer out of Pennsylvania hospital is my go-to guy and if you noticed on Monday night after we determined that he had a concussion, and that he didn't have a neck injury, I immediately turned the case to Dr. Dorshimer as I walked off the field. Dr. Dorshimer spent time in the locker room evaluating him. He has been on the phone with myself and with Brian the last couple of days. We will evaluate him again tomorrow. He is our guy that does it. Our [orthopedists] have never handled concussions here and that will not be the case as long as I am the athletic trainer here. Dr. Dorshimer is the guy and he is very versed in all the concussion terminology, nomenclature, diagnosis, all of that kind of stuff.

"Some of the basic stuff that I think should be out there that you guys should know about is that concussions come from a direct blow. In Brian's case it came from a direct blow from a knee to the head, but it could come from a blow to the face, to the neck, to the body, anything that transmits into the brain. In most cases, there is no anatomical disruption. There is nothing to find in their brain that causes this. It's just a loss of function. There is nothing torn. You don't see damage on an MRI. You don't see damage on a CT scan. That's why often times with these concussions we don't do testing like that because they don't mean anything. It is really based on the symptoms. They have rapid onset. As you saw with Brian's case, he was hit in the back of the head and instantly had symptoms. They are usually short-lived symptoms. A guy sprains his knee, it is four to six weeks of symptoms. These guys that get concussions, it's short lived. There is usually no structural damage, just a loss of function.

"Originally, a lot of the literature that you guys have seen and a lot of literature that was talked about, it graded concussions first degree, second degree, third degree. At one time there were twenty different standards out there which really confused the athletes, confused the medical community, that kind of thing. When they went to Vienna in 2001, they classified it as simple and complex. They had two classifications. They've since even dropped that. That's what led me up here today, somebody asked Andy, 'What was the grade of the concussion?' We don't know. We don't know because we don't grade the concussions until after we've run the whole course of how they've responded to their symptoms and how quickly they return to normal function. That's been the recommendation of this committee to make sure that automatically when he is knocked out he's a grade two, grade three.

"Brian did lose consciousness on the field. We think it was less than a minute. That does not play into the grading. What that does is the loss of consciousness often times gives you an indicator that it's going to be a little bit longer for him to return from symptoms then a guy who is not knocked unconscious. We don't use it as a grade, but we use it as an indicator that he may take a little bit longer. That is not always the case either. The 'loss of consciousness' thing is just one thing for us. We look at a lot of symptoms and we look at how he responds to those symptoms and I will tell you that immediately once he woke up on the field he knew everything. He knew where he was. He knew his brother was in front of him. He knew Coach Reid was behind me. He knew everything. He has a very short interval between breaking the huddle and the play that he doesn't remember. That's called retrograde amnesia. It's not a big indicator for us when we look at recovery. When we look for amnesia, and you'll see some of this as you guys research it, the amnesia that we worry about is that he can't remember things that happened after he was hit. He has none of that. He remembers waking up. He actually remembers that he was dreaming. He remembered a lot of things about the event, but he doesn't have any time in there where he says, 'I don't remember you guys walking me off the field. I don't remember how I got to the locker room. I don't remember the second half of the game being out on the field talking to Andy and the team.' He knew all of that so those are all good indicators for us.

"We look at his symptoms as he goes along here over the next couple of days. We look obviously at headache, his fatigue factor, how he's responding in meetings, whether watching film or studying the playbook affects him, whether he's irritable, whether he's nervous, whether he appears to be depressed, that kind of thing. I'm talking to Brian all day. Every time that he comes out of a meeting and takes a break, I talk to him. [Eagles assistant athletic trainer] Chris Peduzzi talks to him. Dr. Dorshimer calls me to check on him. We've already spoken twice today about it. This is a constant, ongoing thing with him.

"We'll look at his symptoms and once his headache clears, because that's his big symptom because he has a very mild headache, mild to me is okay but he still has a headache. When that clears, the next step is you take him through an exercise program so you get his heart rate up. Does that make his symptoms worse? If it doesn't make his symptoms worse, then you go to the next step, which is you start to do some football-type drills where you get balance and footwork and change in direction. If that goes well, then you return him to practice. Then, if that goes well you return him to a game. The question has been asked to me, 'Have you had anyone knocked unconscious here and then play the next week?' Yes. I've had guys not knocked unconscious here and not play the next week because the grading scale to us doesn't matter. It's all symptoms and it's how do they return from their symptoms [and] when they do, can they take the next challenge? Can they take the next challenge? Can they take the next challenge? Where are we game-time wise? And that's exactly what we'll do with Brian."

"I've had guys here who had very mild concussions that played in a game that we didn't even know it until after the game. They came to us after the game and said, 'I got my bell rung.' We took them through our process. They had symptoms through Thursday, Friday. We didn't let them exercise. [We] put them on a bike on Friday, they got worse symptoms, we backed them down and they didn't play Sunday. Every time they get increased symptoms, we back them to their next step and then we move forward. Some guys it takes 10 days, some guys it takes three days. I think we are very up to speed on our assessment. I think we are very up to speed on our treatment, and I think that we have had a very good record here at the Eagles, at least in the 11 years I've been here and searching back.

"I think as the education on concussions has increased so has our awareness and it will continue to be that way. I invite the opportunity to be able to speak on the subject, and I spoke at the 2007 conference for the NFL and I think it's something that our league needs to notice. I think the Commissioner has done a phenomenal job of bringing this to light, and I think our players are protected better now than ever before. One thing that the Concussion Committee and the National Football League has determined is that, for the most part, the physicians for the NFL teams are doing a great job of managing these things on the sideline. I think that Brian's is just another case of something that we see every year. He just happens to be a star running back here and it was on national TV. He was knocked unconscious clearly on TV. He'll go through the course as other guys here have gone through and I think he'll do fine."

On what Westbrook doesn't remember: "I'm on the sideline, I don't know exactly what goes on in that huddle and I don't know what goes on when they break the huddle, how many calls [C] Jamaal [Jackson] makes and how many calls [QB] Donovan [McNabb] makes and all that, but Brian doesn't remember that stuff. He remembers being in the huddle, he remembers the playing being called and then he doesn't remember until he wakes up. How long is that? I'm not sure, 20 seconds in there that's he's lost that he may never get back. From the international committee, you'll find out that in all their research, and all their stuff was research based, the retrograde stuff is not nearly as important a factor in long-term care as the anterograde stuff, which is the stuff after the fact like if he didn't remember his brother being out there and his mom, all that kind of stuff. He remembers all that, so we're not too worried about his loss of consciousness and we're not worried about that little window of retrograde amnesia that he had, so now we're just controlling his symptoms."

On whether he will be more susceptible to concussions in the future:"If he's handled poorly. Occupationally, I think that depending on what you do for a living, yes. If you're asking me about Brian, he plays in a sport where concussions happen, so he's got a better chance than I do of having one. But is it greater because he's had this one? We don't think so as long as we manage it correctly."

On whether Westbrook is being ultra cautious knowing how serious concussions are: "Brian is one of our smartest football players. He is one of the smartest guys on our team. He understands what is going on. He does a lot of research. He has a lot of faith in us and a lot of faith in our medical staff. He's had some significant injuries while he's been here, so he's built a relationship with us. He and I have talked extensively about this and he understands it.

"One thing that I should have mentioned back in the beginning of this is that the National Football League has put in a situation where, if you lose consciousness in a game you have to come out of the game. That's one of the standards that we put in. Not because of grading, but because we know that when they lose consciousness they have a chance to have more severe symptoms in the next couple of days. It's too hard for the physicians and it's too hard for the athletic trainers to make a decision on the field, in the heat of battle if a guy loses consciousness. It's a great rule that's put in, then you can survey them over the next 24 or 48 hours to figure out what direction they are going to take. As soon as we got up to walk I said, 'Hey listen now, you know I'm not going to let you play tonight because you lost consciousness.' And he said, 'I totally understand.' He's got a grasp of it. He didn't fight me to play. He's not fighting me right now to play. We've laid out the course of treatment, he's been super compliant with it, he wants to know a lot about it, he's in great communication with my [doctors], he's in great communication with me, and as a group we'll make a great decision on it."

On whether players that lose consciousness in a game are not allowed to return: "Exactly, I guess I didn't state that very well. If they are knocked unconscious, they cannot return in the same game."

On how long that rule has been in place: "It's been in place for, probably two years I think. I have a little retrograde amnesia myself. [In] 2007, when we did all the upgrades in concussion standards is when we put it in. I know it's at least been in since [NFL] Commissioner [Roger] Goodell has been the commissioner."

On what symptoms Westbrook exhibited during the game and what symptoms he is exhibiting now: "During the game he was unconscious when we got out there and he had, if you notice, his arms up right away. That's a little defense mechanism for concussed individuals, it's called decerebrate rigidity, it's just a reaction. We noticed that he was unconscious and he had a little bit of snoring to him and when I woke him up, he immediately knew everything.

On how he woke Westbrook up:"One of the standards that I have out there is that I am the only guy that gets to talk when they are knocked out, because what happens is, players start yelling their name and we don't know whether he has a neck injury yet. We don't want him moving his head too fast. That's why my assistant, Chris [Peduzzi], had a hold of his head firmly. If you notice, when he was coming out of the unconsciousness he was a little bit combative. That's not unusual. He was trying to push us away, but he was still unconscious. As he came out of it, as soon as he was awake and as soon as he recognized me, I said, 'Brian who are you talking to?' He said, 'It's Rick.' I said, 'Where are we?' He said, 'FedEx Field.'

He immediately, as soon as he woke up, he knew everything. He knew his brother was there, he knew Coach Reid was behind me, he knew Chris was holding his head, he knew exactly what happened, so his symptoms there cleared quickly. He didn't even really have a headache until after the game. I think it was about the second quarter, I ran inside to check on everybody and make sure he was doing alright, because I knew some of the coaches on the bench wanted to know how he was doing. When I went in he was fine. He was absolutely fine. He was actually laughing a little bit about how good he felt. His symptoms cleared within minutes and he felt fine. Now, he didn't have a great night of sleep, but none of us really did. He slept a little bit on the train then got home and tried to sleep yesterday a little bit, was up and down, and we made him come in here at 12:00 to be tested. He's a little fatigued, but I think most of our guys are that play on Monday nights. The only symptom he has right now really is the headache and that's enough for me. It doesn't matter if he has seven symptoms or one symptom, I'm not going to let him progress to the next level until he gets rid of the headache."

On how you treat a headache that is the result of a concussion: "It's interesting treatment-wise. There's not medication or anything like that that you really work on these guys. You may give them a little Tylenol to assist with their headache. The big treatment for us, we have one thing that some of the other clinicians aren't using that we believe in is called frequency specific microcurrent, which kind of takes care of some of the brain fog for you and clears you up a little bit quicker. There is not a whole lot of treatment. You just let time take its course and then once he gets rid of the symptoms, then we'll start the exercise stuff."

On when Commissioner Goodell met with experts to talk about concussions: "That was in '07, in Chicago. I'm pretty sure it was in '07. It was in Chicago. He had people from the concussion committee speak, or what they call MTBI, mild traumatic brain injury committee speak, he had people outside the committee like doctor [Robert] Cantu [Chief of Neurosurgery and Director of Sports Medicine at Emerson Hospital in MA] and doctor Kevin Guskiewicz [Research Director for the Center for the Study of Retired Athletes] speak. He invited the players union there, he had union reps there, he had the union's physician there and he had media there. It was a big deal. It was in Chicago and it lasted a day or two, and then we formulated guidelines out of that."

On whether the Commissioner's concern with concussions and his standing on the committee makes him more cautious dealing with Westbrook's recovery: "You know what makes me cautious with Brian is that it is Brian and it is one of our team guys. It's always been that way here. We don't try to put people out there hurt and we try to do the best medical job we can to get guys healthy as quickly as possible. It's not an exact science and we've made mistakes and we've had successes. It will continue to be that way. I worry about Brian and then if I can carry the torch for my profession a little bit because I've been fortunate enough to have been named to that committee by the commissioner and able to work with the commissioner, I will. I'll carry the torch, but first and foremost, this week, I have to take care of Brian Westbrook."

On how much of a role impact testing will play in his recovery: "Impact testing is a big buzz word right now. Neuropsychological testing is what it is. The league has mandated that everybody does that. We have baselines on all of our guys, meaning that we've tested guys before they start contact. Every rookie that comes in here gets it and then we have a baseline on those guys so we can go back and compare the tests after they've been injured to that previous test and that's what we use as our guide. Brian is one of those guys and he was tested yesterday and he'll be tested again today. We'll continue to look at his [tests] until he gets back to baseline. Once we get that back and the symptoms calm down then we'll do the exercise challenge. Right now we are in that period, which is normal for him to have a headache and his scores aren't quite high enough yet. They will come back. This is a normal course for almost every one of our players that has a concussion."

On how having a short week will affect Westbrook's recovery and availability: "One of the things that I emphasized to management and to the coaching staff on Monday night was, 'Listen, we have a short week. That may play into it.' It doesn't matter to me that it's a short week because I'm going day to day with his symptoms. If he's not better until next Wednesday, it doesn't matter that we play Sunday. If he is better on Thursday it doesn't matter if we play Sunday or Monday. If he's better, the short week, yes it matters because he's got less time to recover, which is okay. It doesn't affect me in the least. When Brian Westbrook is ready to play again we'll have him out there. Until then we are going to be very cautious with him, like we are with every one of our guys that has a concussion."

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