J.B. Bittner stared up at the team trainer kneeling over him. Bittner was sure he'd been knocked out, but had no idea how long he was unconscious on the ice.
That was during the 2007-08 ECHL season, when Bittner, now an assistant coach for the South Carolina Stingrays hockey team, was a member of the ECHL's Florida Everblades.
"It was during a fight and I got tangled up with a guy. I was grabbing for his jersey and lost my balance," Bittner recalled. "When I fell, my head kind of whiplashed when I hit the ice. I'd never blacked out on the ice like that before."
Bittner missed the final two months of the season with a severe concussion -- by his count the 10th such injury during a decade-long playing career that stretched from junior hockey to college and the professional ranks. He would not play again.
"That last concussion kind of scared me," said Bittner, who retired at the end of the 2008 season. "I didn't know what would happen the next time I took a hit like that."
Concussions in sports, particularly professional hockey and football, have become a major concern to league officials and the medical community.
The Pittsburgh Penguins' Sidney Crosby, arguably the NHL's biggest star, missed almost half of last season with a concussion. This season, Crosby has been out since Dec. 5 with concussion-like symptoms. The Philadelphia Flyers' Claude Giroux -- the league's leading scorer -- also missed several games with a concussion. While Giroux was out of the lineup, the Flyers announced that team captain Chris Pronger will miss the rest of the season with severe post-concussion syndrome.
"This isn't an issue that's going to go away," Bittner said. "They just started doing some long-term studies on concussions and how they affect you later in life, and I'm sure it's going to change the way players are treated."
In 1999-2000, the first full season concussion statistics were kept, 94 players missed at least one game with a concussion, according to STATS LLC. Two years ago, that number dropped to 33 players. Then last season the number jumped to 52. Through last week, 32 players had missed time with concussion-like symptoms. The ECHL and AHL, the two primary minor leagues in pro hockey, do not keep statistics on concussions.
"It tends to seem like an epidemic when in reality we're just better recognizing them," Mark Lovell, the founding director of UPMC Sports Medicine concussion program and CEO of ImPact, told The Associated Press.
The NHL has been at the forefront of the concussion issue, instituting a concussion program during the 1997 season.
The imPACT test is one way the league has been able to diagnose concussions. Developed by Lovell and Dr. Joseph Maroon, a neurosurgeon for the Pittsburgh Steelers, the imPACT test gives trainers and doctors a measuring stick for a player's brain activity. It's a computer-based test of fast-paced questions involving words, pictures and colors. Scores reflect how quickly and correctly a player answers the questions.
The NHL's policy has had a trickle-down effect on the ECHL. The Stingrays have been administering imPACT tests for six years.
"Before the season starts and before a guy steps on the ice, we give them an imPACT concussion test so we have a baseline of where they are," said Stingrays trainer D.J. Church. "So, if there's an incident on the ice, we can test them right away and compare the two tests. That's just a tool we use along with their symptoms to determine if they have a concussion."
While the Stingrays have voluntarily tested their players for six years, the ECHL only made preseason imPACT testing mandatory last year.
"Players are a lot smarter and a lot more versed on concussions," Church said. "A few years back, a guy gets hit and he tells the training staff he's OK, he probably just went back on the ice. Now, you've got protocol you have to follow, you have to get evaluated by a doctor before you can get back on the ice."
Church has had more than his share of experience with concussions in the past few seasons. Stingrays players Sasha Pokulak, Michael Dubuc, Nate Kiser, Josh Godrey and Sean Collins missed extended time with concussions over the past five seasons.
"Knock on wood, we haven't had any this year, and I hope we don't," Church said.
Life after hockey
Sean Collins, who played for the Stingrays during the 2007-08 season, recalls the frustration of sitting out two months of the season with a concussion.
"It looks like there's nothing wrong with you," said Collins, who plays for the Hershey Bears of the AHL. "You might feel great for two or three days straight, so you think you're getting better. But then you get your heart rate up and you get headaches and dizzy and you're back to square one.
"If you hurt your knee or wrist or just about any other injury, there's always a timetable for you to get back. You can live with that. But a concussion, there's no way to know how long it'll take."
Collins said most players never want to be out of the action and will say they are OK, even when they aren't.
"You have that warrior mentality that tells you to get back out there," said the Stingrays' Nate Kiser. "You don't want to let your teammates down. So you tell the trainer you're OK when you're really not."
Stingrays coach Spencer Carbery said it's up to the coaches and trainers to do what's best for the players.
"As a coach, you love a guy that wants to be on the ice and tells you he's fine and wants to get back out there," Carbery said. "But, at the same time, you've got to be smart about it. This guy is a human being. You want to win, you want the two points, but you've got to take the player's long term health into account."
Since there's no hard data to show the long-term effects of multiple concussions, former players like Bittner are concerned about his quality of life as he gets older. At 29, the cumulative effects of 10 concussions are unknown for Bittner.
"Sure, I'm worried about my long-term health a little bit," Bittner said. "I've noticed lately that my memory isn't that great. I don't remember things as well as I should. I can't say it's because I've had concussions, but because of the awareness now it makes you think about your life after hockey."