WESTBOROUGH, MA October 9, 2018 Cognitive and emotional symptoms often occur when an athlete sustains a concussion. Individual sports have somewhat different trajectories when it comes to recovery – sometimes because of the nature of the sport and sometimes unique to the athlete and his or her emotional predisposition. Ice hockey is a high speed collision sport. Many athletes play the game on a year round basis chasing a dream of collegiate or professional status. Ice hockey has a high degree of collision-related concussions according to the National Council on Youth Sports.
Contrary to current beliefs, even currently healthy youth hockey players reported higher persisting psychological symptoms among those with a history of concussion. Psychological sequelae appeared unique to a history of concussion as athletes with a history of musculoskeletal injuries did not present with the same persisting psychological symptoms. A study in Pittsburgh looked at the incidence of concussion among younger and older adolescent players from elite hockey programs. They found a higher rate of concussion among younger players. In a post last month I presented the notion that size matters when it comes to elite (younger) athletes playing against older and more physically developed athletes. Concussions tend to be both more frequent and more long lasting.
As with any risk-reward scenario, decisions about physical risk must be considered when a player is invited to play up against older and more developed players. I have seen freshman football players competing at a varsity level and be severely harmed both physically and psychologically by the shear difference in size and strength. Younger athletes are often misinformed as to the physical demands of a varsity sport and wrongly believe they are athletic failures and weak unless they play through their injuries – including concussion according to Sefton, 2018.
In 2016 the majority college ice hockey player spend one to two years in junior hockey (ages 17-21) allowing them to continue their physical development prior to entering college hockey. This includes not only Division I scholarship programs but Division II and Division III programs as well. Very few natural freshmen play college hockey at 18 years of age unless they are highly gifted athletes. Even these players are coached and managed by trainers with ongoing development programs, weight training, and nutritional support to enhance upper body size and strength. Michael Sefton, 2016
Even though sport concussion is considered a unique subset of MTBI, results suggest that a smaller percentage of youth may be more prone to psychological sequelae following concussion. This means that not all concussions are created equal. Along with colleagues across the country I have been saying this for over 20 years. There is a literature on elite ice hockey players and a co-occurring mood disorder that needs to be addressed as they heal.
When I first started taking an interest in MTBI, also called concussion, physicians did not believe that someone sustained a brain injury unless there was a bonafide loss of consciousness. This remains one of the greatest myths in brain injury rehabilitation and I still hear from people that a son or daughter has a concussion “but he did not get knocked out” as if that minimizes the significance of the injury they sustained. Finally, I am still getting significant push back from the parents of children who are diagnosed with multiple concussions. The recovery from concussion two or three is not the same trajectory as the first. Many wonder why their child hasn’t bounced back like they did the first time around. And common to second concussion irritability and other mood-related changes are common.
I suggest to parents expect the unexpected and try not to attribute changes in school functioning to laziness alone. Plan on working with the school-based support team and athletic trainer as you return to learn and return to play. Most elite programs offer emotional support for athletes suffering with the effects of concussion. Many feel isolated or marginalized because they may appear normal and walk and talk just like other members of the team. Athletes recovering from concussion are at higher risk of second concussion if they return to play before their injuries heal. This takes 7-21 days on average.
The Pittsburgh study, published in Pediatrics in 2016, revealed that the population of ice hockey players they studied had a higher preponderance of players who had sustained one or more concussions. This is what I experienced in looking at junior level ice hockey (typically aged 16-20 years) teams a few years ago. I was surprised when I asked how many had sustained a prior concussion and most all the players raised their hands. Fighting is first allowed in this level of play and sometimes becomes a handicap for players with sites set on collegiate play. In many cities across the country junior hockey is the only show in town. Some cities in the mid-west actually televise games and report scores on local sports programs.
Remember no two concussions are the same. Sports all have their return to play protocol that begins with recognizing the importance of controlled exertion in the setting of concussion and recovery.
Sefton, M. (2016). Body Checking in Hockey: When size matters. Blog post: https://concussionassessment.wordpress.com/2016/03/14/body-checking-in-ockey-size-matters/ Taken October 9, 2018
National Council on Youth Sports. Report on trends and participation in organized youth sports. Available at: www.ncys.org/publications/2008-sports-participation-study.php. Published 2008. Accessed March 17, 2015
Kontos, A. et.al. (2016) Incidence of Concussionin Youth Hockey Players http://pediatrics.aappublications.org/content/early/2016/01/07/peds.2015-1633#ref-5 PEDIATRICS Volume 137, number 2 , February 2016 :e 20151633 Taken October 9, 2018
WESTBOROUGH, MA September 7, 2018 Here is the Clock of the Week for the week of September 10, 2018. It is an interesting clock that illustrates both confusion and intrusion errors. The task is simple. It involves a 3- step process of drawing the circle, placing the numbers, and correctly placing the hands to read 11:10. I have espoused this task for several years now and publish interesting clocks. Last week, I was sent a clock that a speech pathologist here at the hospital was able to obtain from one of her patients. This clock was drawn by a 85-year old male diagnosed with Parkinson’s Disease (PD). He is right handed and has had PD for 15 years. He has also had a prior stroke which complicates the interpretation of this drawing.
What is interesting about this clock was the written language that appears in the middle of the clock face. This is an intrusion error from the prior task I had given him. He was asked to write a sentence. He completed the sentence and later, components of the same sentence showed up as a perseveration that intruded on the task at hand (the clock drawing). This is a sign of a lost cognitive “set”. He was drawing a clock and trying to place the numbers when just as quickly he began writing the prior sentence. Interestingly, the clock has no features in the lower quadrants of the drawing. He was able to roughly construct a circle but was stuck with the upper components of the clock. It looked to me that he understood that setting the clock for 11:10 meant that he needed to focus on the upper left and upper right sides of the drawing. As he drew the clock he seemed to get stuck drawing the hash marks of the numerals.
He has significant problems with both immediate and remote memory. PD has a life expectancy of 10-15 years. His case is complicated by a prior CVA and will likely result in a loss in his independence for going home.
Westborough, MA August 20, 2018 Athletes across the country are getting set for fall sports season. Both high school and university athletes have started their respective training camps and “try-outs” for football, soccer, field hockey, fall lacrosse, cross country, and even interscholastic ice hockey. I have already had calls to see young boys who are playing with varsity teams and may be outsized by 50 pounds or more. The allure of playing for the varsity team can be intoxicating to both student athletes and parents alike. The fantasy of popularity, physical dominance, and record setting success all add to the stress of playing high school or collegiate sports. Younger athletes are at higher risk of injury and for prolonged recovery from injury.
As with any risk-reward scenario, decisions about physical risk must be considered when a player is invited to play up. I have seen freshman football players competing at a varsity level and be severely harmed both physically and psychologically by the eventual outcome. Younger athletes are often misinformed as to the physical demands of a varsity sport and wrongly believe they are failures and weak unless they play through their injuries – including concussion.
With all the fan fare surrounding the NFL training camps varsity high school barely registers on the sports radar screen. It is a thrilling time for players who are invited to varsity practices when they may still be an underclassman or even still in middle school. Behind the scenes, there are coaches and parents colluding to allow younger players to suit up as varsity athletes all with the unspoken belief that starting earlier on the varsity team will better prepare the growing athlete for a Division 1 college experience – even a scholarship.
I provided on-field EMS coverage for a number of years in Massachusetts at youth and varsity high school level sports. I have also provided concussion management for university and AHL teams for several years. I have seen significant harm done to individual players when they are invited to play on varsity teams prior to having all the physical and emotional tools needed to understand a balance between school, competition, and injury – when these occur. Smaller, younger athletes pay a large price for playing up on varsity teams. The same goes for “walk on” freshman who try out for college football or other collegiate teams. They are asked to compete against athletes who are significantly stronger and heavier putting them in danger. Most are emotionally ill-equipped and physically unprepared for the difference in skill development and may be prone to serious injury. Sadly, when some walk on players become injured they are not afforded the first class rehabilitation afforded the varsity players. There is a great difference between a walk-on freshman at 18-years of age and a player who has been in the collegiate system for 2 or more years. The average high school athlete does not receive the expert weight training needed to be prepared to compete at the collegiate level and puts himself (or herself) at risk when positioned against their upperclass collegiate counterpart. Similarly, when a boy or girl in grade 7-8 is invited to “try out” for a varsity team a similar mismatch in size and skill set should be expected. Many school districts allow younger students to play varsity interscholastic sports if they qualify and have the skill sets.
Arguably some coaches encourage this competition as a rite of passage leaving the younger athlete vulnerable to serious injury including concussion. When this happens the player becomes marginalized and feels forgotten and unimportant which has a profound impact on his self-esteem and can derail his high school or collegiate playing career. I spend a fair amount of time teaching the re-exertion steps necessary for safe return-to-play and more importantly, for getting back to class. A specific return to play protocol outlining gradual increase in physical activity including management of concussion, headaches, decreased balance, dizziness, and emotional well-being. One particular protocol has been established by the Concussion in Sport Group (Aubry, Cantu, Dvorak, Graf-Baumann, Johnston, Kelly, Lovell, McCrory, Meeuwise, Schasmasch, 2001. Clinical J. Sports Med.).
“I have taken care of players who have been injured playing hockey but the recovery time is significantly longer for the young, smaller athlete.” Michael Sefton This is consistent with the findings published recently from the Hasbro Children’s Hospital study.
There is a risk to athletes who compete against players out of their weight class. Youth football organizations like Pop Warner and the American Youth Football Association require weekly weigh ins to avoid the physical mismatch and thereby reduce the risk to younger, less physically and emotionally developed athletes. Similarly,the sport of wrestling has had athletes compete in weight class for decades. Once injured with concussion, the return to play is now standardized with respect to the individual athlete’s symptom profile and history. This has changed across New England since 2009 when school sand colleges began requiring both pre-season screening and a systematic return-to-play protocol. Returning to play after concussion requires a stepwise process. Each step is monitored by a trainer, coach or volunteer with training in concussion. Athletes must remain asymptomatic at each phase of their return before they are released to 100 percent full contact at game speed. This is not always easy to arrange as many school districts have no athletic trainer or share the services of an athletic trainer among several sports.
Concussion occurs with and without a lapse in consciousness. Any force hitting the skull can induce the cascade of physiological effects of concussion. These symptoms generally last 3-21 days with the subtle cognitive consequences being most lingering. The Concussion Assessment and Management Program (CAMP) keeps track of patient’s who require support after concussion. CAMP is now located at Whittier Rehabilitation Hospital in Westborough, MA and offers a complete range of concussion assessment and management protocols. Many people wrongly believe that they may return to practice and then games without first being cleared by a physician or neuropsychologist specializing in concussion. Most states require this clearance before an athlete may return to play. Rhode Island was the first state in New England to require concussion education for all parents, athletes, coaches, and referees. Most states have followed suit. The state of Connecticut has an outstanding concussion training program for coaches.
P McCrory, K Johnston, W Meeuwisse, M Aubry, R Cantu, J Dvorak, T Graf-Baumann, J Kelly, M Lovell, P Schamasch. Br J Sports Med. 2005 Apr; 39(4): 196–204. doi: 10.1136/bjsm.2005.018614 PMCID: PMC1725173
Sefton, M. (2014) Post-concussion Syndrome. Blog post: https://concussionassessment.wordpress.com/consultation/post-concussion-syndrome-pcs/ Taken 8-15-2018
Westborough, MA August 15, 2018 The clock of the week is submitted by a Speech Language Pathologist working with patients here at Whittier Rehabilitation Hospital. The patient who constructed this weeks prize winner is a 64-year old male with bronchiolitis obliterans, a lung disease characterized by fixed airway obstruction. Inflammation and scarring occur in the airways of the lung, resulting in severe shortness of breath and dry cough according to Wikipedia (2018). Just looking at the clock it may be safe to say that there is significant cognitive decline and/or altered mental status depicted in the lack of appreciation for the task demand. It is not clear to what extent his lung disease may have left him vulnerable to the effects of hypoxia – the lack of oxygen in the blood. Depending upon how long the brain goes with depleted levels of oxygen and how low the oxygen saturation drops can have a great deal of impact on anoxic brain injury.
Anoxia has a profound impact on cognition and functional independence. I want to thank the astute speech language pathologist for obtaining this clock drawing in the course of her patient assessment. I am curious as to what treatment options and methods she may be using with this interesting patient. I would welcome other clock submissions.
WESTBOROUGH, MA August 2, 2018 Here is the clock of the week. It is drawn by Helen, an 84-year old right handed woman suffering from the affects of Dementia of the Alzheimer’s Type – DAT. I have published weekly or monthly clocks on these pages for the past 3 years. Recently I have added links to the video taken in our Neuropsychology service at Whittier Rehabilitation Hospital.
All HIPPA compliance rules are followed in terms of patient confidentiality. I encourage readers to send in clocks for me to publish. Helen had significant difficulty constructing this clock. Unlike some of the recent clocks I have published this clock was normal size. Helen had a resting tremor that closely resembled the movement pattern seen in patient’s with Parkinson’s Disease.
WESTBOROUGH, MA July 24, 2018 Some people believe that the simple task of drawing a clock is like a window into the brain (Eknoyan,et al. (2012). I have posted reviews of clock drawing over several years. Edith Kaplan, Ph.D. is credited with teaching me the importance of these neurocognitive protocols in 1985 while I was training at Boston City Hospital. Dr Kaplan saw the clock drawing as a parietal lobe test (Kaplan, 1988) but many debate that focal attribution of the clock drawing may under represent the clinical utility of this perfunctory task. Tranel and collegues (2008) found that the clock drawing has several potential neuropsychological correlates represent the neuroanatomic underpinnings of the individual clocks scored and rated in their research.
“Documenting the type of clock-drawing errors can contribute to the clinical evaluation of patients with suspected neuropsychiatric disorders and syndromes” Eknoyan, et al.
Watch the video below and enjoy a complete assessment of a single patient undergoing neuropsychological assessment. Post your thoughts and let me know what your observations say to the underpinnings of cognition we are seeing. This patient was cooperative and friendly. He is only 82 years of age and was undergoing treatment for a recent mechanical fall.
Eknoyan, D. et al. (2012) Journal of Neuropsychiatry Clin Neuroscience, 24:3 Summer.
Kaplan, E. (1988) The Process Approach. In Boll T, Bryant, BK, editors. Clinical Neuropsychology and Brain Function. Washington DC, APA.
Tranel, D, et al. (2008) Does the Clock Drawing Test have Focal Neuroanatomical Correlates? Neuropsychology, 22(5) 553-562.
WESTBOROUGH, MA July 16, 2018 I have recently been taking care of a couple of men who have experienced significant hearing loss as they aged. The loss of any sensory system contributes to a significant change in independence and satisfaction in life. In this systematic review and meta-analysis of 36 epidemiologic studies and 20 264 unique participants, age-related hearing loss was significantly associated with decline in all main cognitive domains and with increased risk for cognitive impairment and incident dementia. Increased risks for Alzheimer disease and vascular dementia were not statistically significant.
“Hearing loss may have a profoundly detrimental effect on older people’s physical and mental well-being, and even health care resources,” says senior study investigator and Johns Hopkins otologist and epidemiologist Frank Lin, M.D., Ph.D.
“Our results underscore why hearing loss should not be considered an inconsequential part of aging, but an important issue for public health,” says Lin, an assistant professor at the Johns Hopkins University School of Medicine and the university’s Bloomberg School of Public Health. According to Lin, as many as 27 million Americans over age 50, including two-thirds of men and women aged 70 years and older, suffer from some form of hearing loss.
“Dr Frank Lin says social isolation resulting from hearing loss may explain the physical and mental declines – as well as the cognitive deficits – that afflict older adults. This, in turn, may lead to more illness and hospitalization, he says. His team already has further research under way to see if treating hearing loss with counseling and hearing aids can reduce people’s risk of cognitive decline and dementia”.
Tinnitus is sometimes associated with hearing loss. Tinnitus is also known as ringing in the ears and is described by many as a constant high pitched sound or whistling noise. It is sometimes attributed to “trauma” from years of employment or working in an industry that required no hearing protection.
I have begun using a new protocol in my biofeedback session for those most bothered by tinnitus. Neurofeedback is a non- invasive neuromodulation technique which records a subject’s neuronal activity, extracts relevant aspects of brain processes by means of real time signal processing and returns feedback to the subject as visual or auditory stimuli. The aim of neurofeedback is to change behavioral traits or medical conditions associated with altered neural activity as demonstrated for chronic tinnitus.”
“Subjective tinnitus has been described as the constant perception of an auditory sensation that does not correlate to any external acoustic stimulus (Stouffer and Tyler, 1990). It can be perceived as either pitch or noise-like sound and its perception may be unilateral, bilateral or spread out in the whole head (De Ridder et al., 2014b).”
Loughrey DG, Kelly ME, Kelley GA, Brennan S, Lawlor BA. Association of Age-Related Hearing Loss With Cognitive Function, Cognitive Impairment, and Dementia A Systematic Review and Meta-analysis. JAMA Otolaryngol Head Neck Surg. 2018;144(2):115–126. doi:10.1001/jamaoto.2017.2513
Güntensperger D, Thüring C, Meyer M, Neff P and Kleinjung T (2017) Neurofeedback for Tinnitus Treatment – Review and Current Concepts. Front. Aging Neurosci. 9:386. doi: 10.3389/fnagi.2017.00386
De Ridder, D., Fransen, H., Francois, O., Sunaert, S., Kovacs, S., and van de Heyning, P. (2006). Amygdalohippocampal involvement in tinnitus and auditory memory. Acta Otolaryngol. 126, 50–53. doi: 10.1080/03655230600895580