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Apps the way to go with brain injury rehab

posted by SK Brain Injury    |   June 28, 2011 12:26

Mobile assistance: Smart technology can help people overcome memory loss (iStockphoto)

Mobile assistance: Smart technology can help people overcome memory loss (iStockphoto)

Digital helper Portable touch-screen technology can help patients overcome the debilitating effects of memory loss due to brain injury, according to an Australian study.

Researchers at the Royal Rehabilitation Centre in Sydney have been using smartphones and electronic tablets to help patients remember daily tasks such as taking medication, remembering appointments and recalling names and faces.

Chief investigator Belinda Carr, professional leader of occupational therapy at the Royal Rehabilitation Centre, says many brain injury patients suffer problems with their memory.

"When patients experience a brain injury, some people can't remember information from one day to the next," she says.

The research team attempted to overcome this by using personal digital assistants (PDAs) to prompt memory.

Carr says the research, due to be presented at the Occupational Therapy Australia Conference starting tomorrow on the Gold Coast in Queensland, shows patients using the smart technology had "significant fewer memory failures".

"The number and seriousness of memory failures improved [and] importantly the client's caregivers reported lower frequency of forgetting," Carr says.

The study, undertaken between 2006 and 2009, involved 42 people with brain injuries ranging from severe memory problems to moderately severe memory impairment. The patients were predominantly men with an average age of 35 years.

While the control group used diaries to assist their memories, other participants in the trial were given PDAs to log information such as appointments and times for medication.

Participants were then given an hour of one-on-one training each week for eight weeks in using the PDA.

She says the training in the use of the gadgets is critical to the program's success and the participants are given small cue cards that stay with the technology to remember how to input information.

Greater gains

Carr says the study builds on previous research that shows the use of diaries helps people with brain injuries to improve their functional memory.

But she says the work shows modern touch-screen technology is an even better tool in helping people with brain injuries.

She says there are many contributing factors behind this, including the willingness of the patients to use the new technology.

"People with brain injuries are predominantly young males under 25 years and carrying around a diary now is not very cool," she says. "Having an iPhone doesn't make them look any different [to everyone else] so they want to use it."

Carr says the reduction in memory failures does not mean patients' memories are improving, rather the alarms on the new technology are prompting them to do something.

The technology allows the people with brain injuries to be more independent and, critically, reduces the amount of carer hours that need to be funded, she says.

It can also help in a return to work with the technology prompting them to remember tasks they are meant to perform.

Carr says the research suggests technology could also be useful in overcoming memory loss through diseases of ageing.

"Our study had an upper limit of 65 years," she says. "[But] this research has a follow-through for people with dementia and other age-related memory loss."

Since the original study the PDAs have been upgraded, with clients at the rehabilitation centre now using smartphones and electronic tablets, says Carr.

"We're finding many apps are very useful for our clients," she says, citing an app that can help locate a phone when it is lost.

Carr hopes apps will be developed "specifically to help people with brain injuries" but believes use of the technology as an aid for patients will grow.

"More and more we will see iPhones and iPads being used in a therapeutic setting," she says.





Concussions: What to Watch For

posted by SK Brain Injury    |   June 21, 2011 14:03


Posted: Feb 20, 2011 5:45 AM ET

Last Updated: Feb 21, 2011 11:00 PM ET

Concussions, head shots, cheap blows. There's been a lot of talk in pro sports lately of doing something to cut down on the number of injuries that occur in games played by very large, very strong and very talented athletes - especially in hockey and football.

Yet, in 2010, two of the highest profile athletes to miss significant chunks of the season were Canadians in a mostly-American game: baseball: Jason Bay of the New York Mets and Justin Morneau of the Minnesota Twins

Bay missed the last two months of the season after his head bashed into the left-field wall while he made a running catch at Dodger Stadium in Los Angeles in late July. Two weeks earlier, Morneau slid hard into second base during a game in Toronto, colliding with the shortstop.

Both players made what are considered good plays: Bay was able to hang on to the ball for the final out of the inning and Morneau's hard slide impeded Toronto's shortstop in his effort to throw out the runner going to first base. And in both incidents, the players - while apparently momentarily dazed - were able to get to their feet and walk off the field. "Always a good sign," as the announcer says at the end of the video of Morneau's incident posted on the official site of Major League Baseball.

Both players were out for the rest of the season because of ongoing symptoms of concussion.

What is a concussion?

A concussion is an injury to the brain resulting from a blow to the head. Your brain is protected from everyday bumps and jolts by the cerebrospinal fluid that it floats in, inside your skull. A hard enough jolt, though, causes your brain to smack into your skull.

Most people don't black out when they suffer a concussion. In fact, they may feel little more than a bit dazed at first and - like Jason Bay and Justin Morneau - be able to get up and walk away with little sign of injury.

A concussion is the mildest form of traumatic brain injury. In medical parlance, traumatic is used to indicate "sudden" as opposed to "chronic" which develops over a long period of time.

What are the symptoms of concussion?

Classic concussion symptoms include confusion and amnesia, especially of the event that caused the concussion.

Other immediate symptoms may include:

  • Headache.
  • Dizziness.
  • Ringing in the ears.
  • Nausea or vomiting.
  • Slurred speech.
  • Fatigue.

Other symptoms may show up in the days and weeks following the incident. They include:

  • Memory or concentration problems.
  • Sensitivity to light and noise.
  • Sleep disturbances.
  • Irritability.
  • Depression.

Like any head injury, it is important to watch the patient closely for 24 hours. If the patient loses consciousness often or has trouble waking up, you should seek immediate medical attention.

What should I look for if I suspect my child has suffered a concussion?

Kids can be particularly at risk for concussion - even if they're not involved in sports. Falling off a couch or bumping into a table could provide enough of a blow to cause a concussion. Watch for:

  • Listlessness, easy to tire.
  • Irritability, crankiness.
  • A change in eating or sleeping patterns.
  • A lack of interest in favourite toys.
  • A loss of balance or unsteady walking.

You should seek medical attention if your child loses consciousness, suffers a seizure, vomits repeatedly, has a headache that keeps getting worse, or has lasting or recurrent dizziness.

What is post-concussion syndrome?

It's when a combination of concussion symptoms persist for weeks or months after the injury that caused the concussion. They can persist for a year or more in some people.

It's unclear why the symptoms persist. Some experts believe the event that caused the concussion does structural damage to the brain or disrupts neurotransmitter systems. Others believe the syndrome is related to psychological factors, especially since the most common symptoms - including headache, dizziness and sleep difficulties - are similar to those of people suffering from depression.

When is it safe to resume activity after a concussion?

Definitely not on the same day the concussion is suffered. Beyond that, it depends.

The Second International Symposium on Sport Concussion, held in Prague in 2004, led to the creation of the Sport Concussion Assessment Tool (SCAT2). It's a standardized tool that medical professionals can use to diagnose athletes - and athlete can use to help determine if they're suffering from a concussion and whether they're ready to resume activity.


SCAT2 includes six steps to take before an athlete should return to play, with at least 24 hours for each stage. However, if symptoms recur, the athlete should return to the first stage. The New York Mets report that Jason Bay has been symptom-free since December, when he resumed working out. He's expected to be at full strength when the baseball season opens in April.

As for Justin Morneau? The Minnesota Twins say he continues to make good progress and has been hitting, fielding and throwing. But they won't know whether he's over his post-concussion issues until he starts playing in games during training camp later this month.





'Emotional roller-coaster' ahead for Giffords

posted by SK Brain Injury    |   June 20, 2011 09:13

In the long run, Rep. Gabrielle Giffords should flourish from returning to a home life with her husband. But in the days and weeks ahead, she and her family will have to make difficult adjustments to this new phase in her recovery.

While Giffords gets used to living outside a hospital for the first time in more than six months, her family — especially her astronaut husband, Mark Kelly — will learn to care for a person who still has significant cognitive and physical problems caused by a devastating gunshot wound to the head.

"It's really an emotional roller-coaster," said Dr. Richard Riggs, chairman of physical medicine and rehabilitation at Cedars-Sinai Medical Center in Los Angeles.

The 41-year-old lawmaker left the hospital on Wednesday and moved to her husband's home in a Houston suburb not far from the Johnson Space Center.

Visitors came and went, including Kelly's brother Scott, also a NASA astronaut, and Giffords' mother, Gloria, who brought groceries.

It's a far cry from hospital life, where staff members monitor who visits, how long they stay, and even things like how much light is in a room. The rules help patients recovering from brain injuries by minimizing excess stimulation that they can find confusing and irritating.

Story: Giffords released from Houston hospital

Pets, children, phone calls, mail delivery, cooking — these are routine interruptions Giffords has lived without for nearly six months, Riggs said.

"There's going to be commotion, there's going to be activity," Riggs said.

In the long-term, it will help Giffords reintegrate into society, he said. In the short-term, the stimulation will likely be exhausting.

At the same time, the family will be torn between being caregivers and maintaining their normal relationship with Giffords. While Giffords will have a 24-hour home care assistant and will go to the hospital daily for intensive therapy, her family will still carry some of the burden.

"It's a hard balance," said Cara Camiolo Reddy, head of the brain injury program at UPMC Rehabilitation Institute in Pittsburgh. "You want to be there and care for them, but you also want to get back to your normal relationships with that person, so there's a lot of challenges there emotionally."

Some patients don't know, for example, that it's unsafe for them to drive or climb the stairs unassisted. Relatives are torn between wanting to give their family member freedom while also protecting them, Camiolo said.

"The patient will ask, when can I go back to work? When can I drive? Why do you keep following me?" Camiolo explained. "The patient can get angry at the family member for not letting them do things."

The benefits of being at home, though, can be great.

Giffords will get to try out the activities she's been practicing — things like getting into and out of a bathtub, walking on an uneven surface, like a sidewalk, or opening and closing the refrigerator, Riggs said.

"In the hospital you get rehab, but lose focus of why this is important," Riggs said. "When you put them at home, in the real-life situation, they do get motivated."

Giffords' husband acknowledged his wife didn't like being confined to the hospital she transferred to in late January, weeks after she was shot on Jan. 8 at a meeting with constituents in Tucson.

"Living and working in a rehab facility for five months straight has been especially challenging for her," he said.

Six people were killed in the rampage that injured Giffords and 12 others.

It will be months before doctors know what permanent impairments Giffords will have and whether the Democrat will be able to return to her job in the House of Representatives, or seek Arizona's open Senate seat. Chief of Staff Pia Carusone recently told the Arizona Republic that Giffords can speak, but struggles to put together complex thoughts and sentences. And while she can walk with assistance, she still sometimes needs a wheelchair — like when she was in Florida in May watching Kelly rocket into space as commander of space shuttle Endeavour.

Outside the hospital, a person's deficiencies also become more apparent, not only to the family but to the patient. Typically, after going home, the patient begins to comprehend the extent of their injuries and the long-term consequences, Riggs said.

It can be frightening and depressing, he said.

Ron Barber, a Giffords' staff member who was also shot in the rampage and is still recovering from gunshot wounds to the face and leg, said he and his wife were initially apprehensive when he was released from the hospital.

But within two days — after a nurse helped them rearrange furniture so he could get around and a home care assistant arrived — they realized how much better it was to be home.

"Being home, there's nothing like it," Barber said. "You're in familiar surroundings, with family."





Concussion-prone Berrick Barnes Takes Indefinite Break from Rugby

posted by SK Brain Injury    |   June 14, 2011 09:35


    Berrick Barnes
    The New South Wales Waratahs' Berrick Barnes has ruled himself out of the remainder of the domestic season. Photograph: Jason O'Brien/Action Images

    The Australia utility back Berrick Barnes has decided to take an indefinite break from rugby after seeking medical advice following repeated instances of concussion stemming from head knocks throughout the Super Rugby season.

    The 25-year-old, who can play fly-half and inside-centre, ruled himself out of the New South Wales Waratahs' lineup for the remainder of the season but hopes to be available for the Wallabies' squad in time for the World Cup in New Zealand, which starts in September.

    "I'm not hiding from the fact that I've been a bit frustrated and anxious about things and that's probably causing some of the issues I'm having as well," Barnes said in Sydney. "So to get away from the environment just for a little bit is probably going to be pretty beneficial in that respect."

    Barnes, a veteran of 31 Tests, said earlier this month he wanted to be allowed to wear a boxing-style helmet to protect himself, after missing two matches for the Waratahs because of concussion and another with a migraine.

    The long-term effects of head injuries are a growing concern in all contact sports and the IRB issued new guidelines on the treatment of concussion last month.

    In Australia, the issue was brought into focus earlier this year when the former Australian Rules footballer Daniel Bell lodged a claim for compensation after being diagnosed with brain damage linked to concussions he sustained while playing.

    Barnes has previously expressed wariness about sacrificing his long-term health for his rugby career. "I want to play a bit longer and look after my own health too so I'm trying to work out the best way to do it," he said earlier this month. "I understand that footy is not a forever thing, I don't want to be affecting the forever part in any adverse sense."

    Barnes's loss comes as a further blow for the injury-hit Waratahs' post-season hopes. The Sydney-based side face a crunch match against the ACT Brumbies this weekend, needing victory in the regular season's last round to secure a top six play-off berth.





3D Technology Can Guide Brain Injury Treatment

posted by SK Brain Injury    |   June 14, 2011 09:32

Scientists are hoping that they can better understand the consequences of brain injury through loss of consciousness using 3D technology.

A 3D movie formed using sophisticated imaging equipment by researchers at Manchester University appears to show that loss of consciousness is caused by a change in electrical activity.

Lead researcher Brian Pollard, who presented findings to the European Anaesthesiology Congress in Amsterdam, suggested that it is caused by a change in activity among a group of cells which hinder communication between different parts of the brain.

He suggests that this functions more like a dimmer switch than a simple 'on-off'.

"We have been able to see a real time loss of consciousness in anatomically distinct regions of the brain for the first time," said Professor Pollard. "We are currently working on trying to interpret the changes that we have observed. We still do not know exactly what happens."

The findings and subsequent interpretations could be used to guide future treatment of brain injuries in emergency situations.

Serious Law, award winning traumatic brain injury law firm

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How the Brain Heals

posted by SK Brain Injury    |   June 14, 2011 09:27

Healing the human brain, one of the body’s great mysteries, is a much more complicated issue and oftentimes, there’s little a doctor can do to treat damage to the brain. However, breakthroughs in clinical neuroscience are teaching us that an injured brain often has an amazing potential to heal itself. In many cases, given the proper rest and rehabilitation, an injured brain can actually grow new neurons and form new connections, which scientists call “neurogenesis” and “neuroplasticity.”

Physical brain trauma can be broken into two categories -- internal and external. Internal brain injury, such as a stroke, can be caused by blood vessel blockages or from bleeding into the brain. Traumatic brain injury, such as a concussion, is caused by some kind of external trauma and causes more diffuse brain injury. Both internal and external brain injuries may be capable of healing to varying degrees, but the process can be frustrating.

Last year, for example, I saw a 20-year-old high-performing college student suffering from a concussion after a head-to-head soccer collision resulted in loss of consciousness for less than a minute. A week after this mild traumatic brain injury, he was still having trouble paying attention in class and retaining information. He tried studying more, but that stole time away from the sleep he needed to recover. His grades dropped. He was also short-tempered with friends, and when socializing, one drink of alcohol felt like three. All of these symptoms are typical signs of a concussion.

When he had unusual headaches, I had him see a neurologist. Though his MRI was normal, his parents sensed that he wasn’t quite himself.  In effect, some of his normal brain connections had short-circuited. We developed a plan and with support from his parents, he wisely decided to take the rest of the semester off to allow his brain the time to rest and recover. He entered a traumatic brain injury program in which they emphasized healing nutrition and adequate rest, gradually adding brain stimulation exercises to work on his memory, concentration and moods.

Fortunately, this young man’s story had a good ending, as he returned the next semester and felt back to his normal functioning. But had he not taken time to properly heal, his concussion could have lingered weeks, even months, taking him on a roller coaster ride of feeling fine one day, fuzzy and disoriented the next. In any kind of TBI, the most important initial treatment is rest -- physical and cognitive -- until the brain recovers enough to start to repair itself. Common symptoms can include headaches, dizziness, nausea, fogginess, memory loss, fuzzy vision, stomachaches and mood swings. More severe head injuries involving coma or blast injuries as seen in veterans, can have more severe effects and require longer, more intensive rehabilitation.

Unlike externally acquired head injuries, strokes result in more localized neurological symptoms, and damage to the most severely injured stroke areas can be permanent. The stroke patient has an enormous challenge to try to overcome both loss of function and sometimes loss of dignity. 

However, stroke patients often have a zone of partial injury that is amenable to improvement through neurogenesis and neuroplasticity. That’s where aggressive and insightful rehab comes in. Adding a whole food diet rich in the phytonutrients found in a colorful variety of vegetables, along with adequate amounts of vitamin D, B vitamins and omega-3 fish oil, will support regenerating nerve cells, giving the brain its best chance to heal. Mental outlook is also an important factor; avoiding depression is essential to optimize stroke recovery.  The best stroke rehabilitation programs look at the whole person and help the patient cope with the physical, emotional, and social aspects of loss while helping the patient find the inner will to work hard on those functions that are capable of improvement.

And with any brain injury, whether minor or catastrophic, don’t discount the power of the human connection. Above all, the social interactions and support of loving family and friends have an immeasurable potential to heal. 




Connections: Summer 2011

posted by SK Brain Injury    |   June 9, 2011 14:43

Welcome to our summer edition of Connections - You can access the registration and pledge forms for the walk on the events page or by contacting your local chapter.


sbia-summer-2011.pdf (1.49 mb)



New Zealand University Targets Youth in Head Injury Awareness Campaign

posted by SK Brain Injury    |   June 7, 2011 08:34

It’s been called “the invisible epidemic”, but a group of researchers at the University of Waikato are conducting a series of studies to find out more about brain injury and impact it can have on people’s lifelong health and social interactions.

As part of Head Injury Awareness Week, Waikato University’s Dr Nicola Starkey and research officer Rosalind Case will join other agencies and organisations at Nawton shopping centre on Tuesday June 7 to get the message out about the symptoms and potential impact of brain injuries.

Dr Starkey says head injury – or traumatic brain injury (TBI) as it’s technically known - is very common.

“Brain injury can happen to anyone at any time – in a car crash or while playing sports, as well as through assaults and falls,” she says.

“Up to 95% of all TBIs are mild– what is often called concussion, affecting around 24,000 New Zealanders each year, but there’s very little information available on the social and healthcare implications of TBI for sufferers and their families.”

Typical signs of mild TBI are seeing stars, loss of consciousness and not remembering what happened. Mild TBI can lead to fatigue, poor memory, long-lasting headaches, irritability and inability to concentrate.

Over the past year, Dr Starkey with colleagues at AUT and Auckland University has collated information on every incident of head injury in the Waikato region in a study funded by the Health Research Council.

New funding totaling nearly $350,000 from the HRC and the Lotteries Grants Board means the researchers can now extend the study to focus on the impact of TBI on young people and their families.

“This will be the first longitudinal study of children with mild TBI,” says Dr Starkey. “Social behaviour is very complex, and deficits resulting from TBI can have a big impact on children and adolescents. They can end up in the wrong crowd, where they are more at risk from drugs, alcohol and crime.”

One study will focus on the 8- to 16-year-olds identified with mild TBI in the initial research. The researchers will focus on social behaviour and school-related functioning for up to two years after the initial injury.

“We’ll be looking at how these kids manage their emotions, how they cope with planning and organisation,” says Dr Starkey. “The injury may not alter their behaviour at the time, but it may have an impact further down the line.”

Another study will examine the impact of brain injury on school-related functioning in younger children, aged five to 11.

Research officer Rosalind Case, who has been awarded a $250,000 HRC clinical research fellowship to conduct the study with Dr Starkey, will work with local schools to follow the progress of children with mild TBI compared with a matched control group of unaffected children.

“We’ll be asking teachers and parents for their impressions of the childrens’ classroom behaviour and academic achievement,” says Ms Case. “Previous research indicates that TBI can prevent children from reaching normal developmental milestones, so we hope this study will add to what we know about the long-term impact of TBI.”





High Tech Scan to Detect Brain Injury in Soldiers

posted by SK Brain Injury    |   June 6, 2011 08:46

An experimental high-tech brain scan is finding previously undetected traumatic brain injury in servicemen who sustain concussions in combat.

The research is considered a first step toward a better understanding of what happens in the brain after bomb blasts and what might be done about it, said Dr. David Brody of Washington University in St. Louis. He's senior author of the study in the June 2 issue of the New England Journal of Medicine.

Blast-related traumatic brain injuries have affected about 320,000 U.S. troops and are considered the "signature" injury of the wars in Iraq and Afghanistan, HealthDay reported. But because concussions alone cause no visible damage, experts have debated whether they actually damaged the brain.

The new "diffusion tensor imaging" scans seem to suggest that concussions can affect the "wiring" that connects parts of the brain. It's unclear what the new finding suggests for treatment, Brody said. Scientists are studying whether they reveal anything about a patient's future course, such as the risk of post-traumatic stress disorder.

The scans were done by adding software to an ordinary MRI machine.

The results suggest doctors may someday be able to use objective markers to help make a concussion diagnosis, said Katherine Helmick, deputy director for traumatic brain injury at the federally funded Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury.

Little can be done to reverse the initial brain damage that results from traumatic brain injury, which can cause changes in mood, behavior. But patients can often be helped with physical and occupational therapy and other forms of treatment.




Toronto Star Investigation - What "Really" Killed Bill Masterson?

posted by SK Brain Injury    |   May 30, 2011 10:10

It’s the most gruesome distinction in hockey: Only one player has ever died from injuries directly suffered in an NHL game.

When Bill Masterton’s limp body collapsed to the ice on Jan. 15, 1968, the Minnesota North Stars centre appeared to be the victim of an innocuous hit. Thirty hours later, he was dead in hospital.

Today his story is nearly forgotten, but for an annual NHL award that bears his name. It honours perseverance and dedication to hockey.

The irony is that perseverance probably killed Bill Masterton.

What happened in the days leading up to that fatal moment in Minneapolis, when Masterton played his 38th and final NHL game, has been largely a mystery.

But a Star investigation has uncovered evidence that an earlier, untreated concussion was likely responsible for Masterton’s death at the age of 29.

That injury was compounded by the age-old hockey code that preaches shake-it-off-and-get-back-out-there resilience in the face of pain, serious injury, even brain trauma.

“I’ve never said this to anyone before,” said Wren Blair, Masterton’s coach and general manager, now 85. “I’ve never thought that it had anything to do with that hit. I think he had a (pre-existing) cerebral brain hemorrhage.”

Those closest to Masterton concur he was suffering from a brain injury before he stepped on to the ice that night, as does a medical expert who reviewed an autopsy report obtained by the Star.

Minnesota goalie Cesare Maniago’s wife, Mavis, had a clear view of Masterton’s fall from her seat in the stands. She, too, believes something else was wrong with Masterton that night, something that explains why the routine bodycheck left him unconscious even before he hit the ice.

“I saw Bill’s head after he was just checked from behind and it just looked like his eyes were in the back of his head,” she said. “I thought he was out then and just went fast right down.”

While much in hockey has changed since Masterton died, one thing hasn’t: Playing hurt is a sacred principle.

“Billy” Masterton’s commitment to the game was bred in the bone.

A ritual unfolded every Saturday evening in the small Masterton home in Winnipeg’s East Kildonan neighbourhood: brothers Bill and Bob took a bath, slipped into pajamas and sat together in front of a tiny electric fireplace while listening to Foster Hewitt on the radio.

“We spent a lot of time dreaming,” said Bob. “But my brother was the worker and he had the ethic that you need to make the NHL.”

He didn’t just work on the ice. He was a rarity in the way he prepared for a life outside the game. He starred at the University of Denver from 1957-61, helping the Pioneers win three national collegiate titles and earning tournament MVP honours his senior year. More importantly, he earned a degree.

Masterton left pro hockey after two seasons when it appeared he’d never make the NHL. He pursued a master’s degree in business engineering, eventually joining technology giant Honeywell, where he worked on the financial end of the Apollo project. He settled in Minneapolis with his high school sweetheart, Carol, and they adopted two children, Scott and Sally.

In 1967, Masterton’s nearly forgotten hope of playing in the NHL re-emerged with the league’s expansion from six to 12 teams. The Montreal Canadiens, which owned his rights, traded them to Minnesota. Blair, in charge of the North Stars, came calling.

Bob Masterton remembers his brother telling him about the NHL offer over dinner. “I looked at him and said, ‘What are you going to do?’ because he was just starting a young family,” said Bob. “It was kind of one of those things where I asked the question but I knew what he was going to do. It was always in the back of his mind.”

The season started with promise: Masterton scored the first goal in North Stars history. But 37 games later, in the days leading up to the hit that would kill him, there were signs all was not right.

The night before the fatal game against Oakland, Masterton was at Maniago’s house with his family — Scott was 3 and Sally, 1 — helping the genial goaltender celebrate his 29th birthday with teammates.

In a quiet moment, Masterton made a rare admission to Maniago: He was struggling with the effects of a head check into the glass during a recent game.

“He had been complaining of headaches,” said Maniago. “He’d got hit and even that night he said ‘Gee, I’ve really been getting these migraines and they’ve been with me for about a week.’”

In several games prior to the tragedy, Blair had also noticed something strange.

“I’d said to our trainer, ‘Do you ever look at Billy when the game’s on?’” Blair recalled. “His face is blood red, almost purple. (The trainer) said, ‘Yeah, I notice that too.’ I said, ‘I wonder if we could have him checked. There’s something wrong.’”

Masterton, who was always quick to dismiss concerns, was never sent to a doctor.

“I’m fine,” he’d say, the mantra of a thousand hockey players.

Carl Johnson, assistant general manager of Minnesota’s farm team in Memphis, said he was told Masterton had blacked out while on line rushes during practice.

Former Edmonton Oilers coach John Muckler, who coached the North Stars’ farm club in Memphis that season, said he saw signs of trouble with Masterton in training camp.

“I really believe he was injured before the fatal blow. I know that in our training camp he got hit hard a couple of times. And he got hit a few games very hard at the NHL level. His aggressiveness got him.”

Masterton wasn’t big. But he played as though he was, said Muckler.

“He wasn’t the most talented guy in the world but he really wanted to play. . . . He wanted it badly. I’ve never seen a person work so hard. He’d never show when he got hurt. He never laid down.”

When he suffered the final hit of his career, Masterton was making his patented move — crossing the opposing blueline and cutting to one side before passing the puck to a teammate.

Oakland defencemen Larry Cahan and Ron Harris moved in to check Masterton, who wound up falling on the back of his head. One account holds that Masterton regained consciousness for a few moments and repeated the words, “Never again, never again,” before closing his eyes for the final time.

Neatly typed on Masterton’s 1968 autopsy report are the words, “Likely Cause of Death: Cerebral contusions” sustained from a “fall on ice.”

After reviewing the document, Dr. Charles Tator, a Toronto neurosurgeon and concussion expert, believes Masterton suffered “second impact syndrome,” a rare occurrence where a second concussion happens on the heels of a first concussion that never healed, causing rapid and severe brain swelling.

“We know the second hit can be fatal. The usual story is just as has unfolded here, that they can even talk a bit after that final hit and then they lapse into a coma,” Tator said. “There is evidence of massive brain swelling . . . that is out of proportion to the blow that he got. My interpretation is that the seeds of this catastrophic injury were sown days before.”

What makes hockey players hide their injuries and re-enter games knowing the next hit could spell ruin?

Fear, plain and simple, said Mike Walton, a Maple Leafs rookie when Masterton died.

“Injury wasn’t really of any importance in the sense that you didn’t want to lose your job and if you couldn’t play, obviously they had to fill their roster,” said Walton, now a real estate agent in Toronto. “It was a dictatorship. They had total control.”

While knowledge of concussions has increased dramatically since Masterton died, the warrior-like mindset of professional hockey players is everlasting, he said.

“It goes on today, there’s no question about it. The general public doesn’t understand the adrenaline, the passion, the dedication the players have to get out there and perform.”

Throughout his college career, right through to his training camp in Memphis, Masterton wore a helmet, a rarity in an age when head protection was dismissed by players and management alike. It disappeared during his 38-game career as an NHLer.

“I’ve always thought of this after, that when he complained (of headaches) at least he could have put on a helmet for a couple of days,” said teammate Wayne Connolly. “But it was frowned on, really.”

Only Andre Boudrias had the temerity to challenge it on Minnesota. He was traded the following season to Chicago.

“We were not allowed to wear helmets,” said J.P. Parise. “You would get traded if you did. It was a no-no in no uncertain terms. You were a yellow belly if you wore a helmet.”

Bill’s son Scott Masterton, now 46 with four children of his own, also believes that his father’s fate was sealed long before the night when the final blow was dealt.

“My mother, before she died, talked about it. He was having some headaches. My feeling is that he may have gotten a minor concussion playing or practising on some other day . . . and when he got hit the second time, he had that head whip and when that happens, you can go unconscious in that split second before you fall.”

He speaks with the authority of an athlete accustomed to putting his body at risk.

As a 29-year-old professional U.S. kickboxing champion, the younger Masterton’s career ended with a slip and fall in the ring against the then British champion on the very date — Jan. 15th — of his father’s death, also at the age of 29.

Their professional athletic careers may have ended with eerie similarity exactly 25 years apart. But from that moment forward, the echoes of his father’s life stopped. With a blown knee and broken bones, Scott stepped away from his sport.

“I knew it was time to stop.”

How much has changed in the NHL since Masterton’s limp body was removed from the Minnesota ice? What distant early warning does his death serve to the league and to the growing ranks of players suffering from the contemporary concussion epidemic in hockey?

Philadelphia forward Ian Laperriere is one of three final nominees for this year’s Masterton Trophy — despite not playing a single game in 2010-11 as he deals with post-concussion syndrome.

Like Masterton, Laperriere earned an unlikely place in the pros with grit. Twice last season, Laperriere took slapshots in the face. Still, he returned to play following lost teeth, hundreds of stitches and even the discovery of a spot on his brain visible on a CAT scan.

Laperriere’s brain was bleeding. But four neurologists cleared him to play after the spot disappeared.

“People said I was crazy, but I’m like, ‘They brought me here to show the young guys the right way,’” said the 37-year-old Laperriere, who had signed with Philly before the 2009-10 season.

His playing style has endeared him to hockey fans. Nowhere was that more apparent than during a standing ovation for Laperriere during Game 3 of the Eastern Conference semifinals against Boston last year. The scoreboard showed a video of Laperriere getting nailed in face with a puck in the opening series against New Jersey, blood pouring from a gash over his right eye.

As dramatic music replaced a play-by-play call of the incident, the video moved backwards in slow motion until just before Laperriere’s face absorbed the slapshot. The question flashed up on the big screen: “What if Ian didn’t believe in sacrifice?”

Laperriere acknowledged his career may be over, though he can’t bring himself to retire. He admits he lied to team doctors about his post-concussion issues in order to return for a shot at the Stanley Cup.

“If I had a slim chance to play, I’m going to play.”

That’s a philosophy that Scott Masterton views with the ambivalence of both a former competitive athlete and a man left fatherless at the age of 3.

He sees both nobility and short-sightedness in the demands placed on hockey’s most devoted players. He understands how passion and perseverance can deliver both glory and death.

“The idea that you persevere goes back to time immemorial. It’s a badge of honour,” he said. “It’s also the mindset that will shorten their lives and destroy their bodies. Men are the way men are.”

The Bill Masterton Memorial Trophy, for perseverance, sportsmanship and dedication to hockey, will be awarded June 22.