Preventing Concussion whenever possible

WESTBOROUGH, MA March 20, 2018 I am frequently asked about helmets and those that claim to be protective against concussion.  As of this publication there are no helmets that unequivocally protect against the forces that impact the brain in the course of an athletic contest. The stunning Ted Talk video below reveals details about the protection offered by helmets today.  Concussion is described as occurring in lower brain centers not the surface of the brain as the CDC graphic describes.
“Players are rarely hit by a direct linear force.  They are struck from the side or oblique and the force causes the head to suddenly turn or twist a millisecond prior to the whiplash impact we see on television.”  Sefton, 2018
In fact, there is a newly designed mouth piece that has a built in gyroscope that is capable of measuring g-forces and rotation of the head resulting from head strikes.  Researchers now believe it is the rotational force that sends energy into the skull and brain that causes the greatest cognitive and behavioral changes in the event of a concussion. Players are rarely hit by a direct linear force.  They are struck from the side or oblique and the force causes the head to suddenly turn or twist a millisecond prior to the whiplash impact we see on television.

 

 

 

Link to Dr. Mike Evans Concussion 101 video

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TBI, concussion and headaches in females

headache-2-mbhi5p4ess5v9x1kbfpafgnr6lyhkdbydmq67h3pno.jpgWESTBOROUGH, MA March 15, 2018 Serious and chronic headaches are a frequent complaint of those recovering from mild traumatic brain injury.  “Headache is one of the most common symptoms after traumatic brain injury (often called “post-traumatic headache”). Over 30% of people report having headaches which continue long after injury.” (TBI and Headaches, 2010) They can be quite debilitating. The NCAA Headache Task force listed headaches as among the most debilitating symptoms in the aftermath of concussion.  Young women tend to have a higher incidence of post-concussive headaches than males.  There is treatment for post-concussive head pain.
Migraine headaches are three times more common in females than males.  Rates of emergency room visits related to traumatic brain injury (including concussions) among women almost doubled from 2001 to 2010, according to the Centers for Disease Control and Prevention (CDC). In my own practice here in Massachusetts I have seen more recurring headaches in females than in males. In addition, female athletes generally have a longer recovery course than some of the males I follow.  I will say that males are prone to abuse alcohol when recovering from concussion that may also be a confounding variable in the trajectory toward their normal baseline.
Individuals previously treated for headaches are at greater risk of both developing post-concussive headaches and for having chronic headaches following recovery from concussion.  These injuries can be caused by not only sports but also falls, car crashes, blunt trauma (getting hit on the head by an object), and assaults as noted in a 2016 Health.com report on women and concussion. I have worked with several high school athletes who had pre-injury headaches and received treatment for chronic headaches who went on to have an increased frequency of headaches after concussion. I worked with a tenured college professor who developed headaches from being hit with a basketball at her daughter’s middle school practice. This was shortly after being diagnosed with concussion from a prior head trauma.
American Olympian Lindsey Vonn suffered with the effects of concussion for months following a skiing accident in 2015  including chronic headaches.  The BBC recently featured 22-year old skier Rowan Cheshire who sustained a concussion 4 years ago that kept her from competing in the 2014 Olympic Games.  Cheshire had won the World Cup event one month prior to the Olympics in Sochi and suffered a severe concussion in a fall off the halfpipe. It was the first of two subsequent concussions over the next 3 years that caused severe side effects including migraine headaches and panic anxiety.  Cheshire worked closely with a sports psychologist during her recovery.
One reason for the difference between men and women in concussions is that women tend to have smaller neck and shoulder muscles allowing for greater whiplash from force striking the upper body.  Episodic headaches are usually set off by a single stressful situation or a build-up of stress. These are tension-related headaches which may be unrelated to concussion but whose frequency and intensity change following concussion or when under stressful life conditions. Nevertheless, unchecked stress and tension may contribute to an increased proclivity for head and neck pain and both respond very well to biofeedback and alternative interventions such as acupuncture and progressive relaxation. Daily strain can lead to chronic headaches. Coupled with concussion, stress can become inflammatory in terms of the frequency and intensity of headaches.
“Post traumatic headaches are seriously debilitating in terms of lost school and work days.  They are often a late symptom in the recovery from brain injury and concussion” Michael Sefton, 2018

Symptom presentation
In early childhood there is similarity between boys and girls in symptoms profile. This changes as children enter their growth spurt. “Puberty, which marks a significant developmental fork in the road for males and females, also marks a divergence for concussions. With its onset, females increasingly experience higher incidence of concussions, different and more severe symptoms, and are often slower to recover from the injury.” Treatments for post-concussion range from complete rest to gradual re-exertion, to physical therapy and more. There is a growing trend to slowly increase physical activity once symptoms resolve and I have seen a return of symptoms in cases where physical activity is premature and in cases of second or subsequent concussion.
One clear intervention for post-concussion headaches involves a paced-breathing protocol and neurofeedback that I have been using.  I teach and practice stress management using biofeedback instruments that have demonstrated reducing duration of headaches, reducing stress, and lowering sympathetic abnormalities including heart rate.  The goal of treatment is to reduce the body’s reactivity and normalize the autonomic system. “Fortunately, even if post-concussion headaches don’t get better in the first few weeks after concussion, most are better within 3 months and almost all are better within a year after injury” according to Heidi Blume, M.D., at the American Migraine Foundation.

Sefton, M. (2018) Abnormal Stress response from mTBI often sometimes leads to headaches. Response comment in Emergency Medicine Journal, Volume 34, Issue 12, February 23, 2018
Levine, H. (2016) The Truth about concussions and women. http://www.health.com/headaches-and-migraines/women-concussions
Roehr, B. (2016). Concussions Affect Women More Adversely Than Men: Differences between how females and males experience concussions suggest the need for gender-specific prevention and treatment strategies. Scientific American posted March, 2016. https://www.scientificamerican.com/article/concussions-affect-women-more-adversely-than-men/ Taken February 28, 2018.
Lahz S, Bryant RA (1996). Incidence of chronic pain following
traumatic brain injury. Arch Phys Med Rehabil, 77(9),
889-891.
Blume, H. (2016). Headaches after Concussion. American Migraine Foundation.  https://americanmigrainefoundation.org/understanding-migraine/headaches-after-concussion/ Taken February 28, 2018

Despair and Self-destruction in elite athletes

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Washington State Tyler Hilinski ESPN photo
WESTBOROUGH, MA February 26, 2018 On January 16 the quarterback of the Washington State Cougars killed himself with a rifle he had taken from a friend.  So far a motive for his suicide has not been published.  Tyler Hilinski was 21-years old and a teammate of the son of former N.E. Patriots quarterback Drew Bledsoe.  One might not expect that an elite athlete is susceptible to depression and even suicidal behavior.  From the outside these athletes have the world by a string and are catered to from early an age.  Elite athletes are among the one percent who become Olympians or high level collegiate athletes, and those who go on to become professional athletes.  But there is a dark side of the business of elite sports when athletes become depressed and too often go without treatment. They suffer in silence sometimes marginalized from teammates and family members.
Much has been published about several high-profile NFL players who have killed themselves and later had their brains autopsied only to be found to have the tell-tale markers of chronic traumatic encephalopathy (CTE) only found post-mortem. Former San Diego Charger Junior Seau died in 2012, Dave Duerson a former Chicago Bear died in 2011, Mike Webster died in 2002 – all were found to have the post-mortem signs of CTE.  CTE is known to contribute to both wide mood swings and expressions of rage and violence as the disease progresses.  I published a post on Hernandez and other professional players earlier this year entitled CTE and its Violent Underpinning.  Recently, former N.E. Patriots player Aaron Hernandez, 27, killed himself in his jail cell and was diagnosed with CTE raising the specter of the role of CTE in the murders Hernandez was accused of committing.
 The case of Tyler Hilinski is different. Drew Bledsoe should be commended for his stand on mental illness and being strong enough to share his experience.  He is correct.  It is important for men to talk about feelings and they rarely do so.  In a Boston Globe interview Bledsoe unabashedly described his early experience with a sports psychologist when he needed someone to talk to.  He described it frankly “If you’ve got a sprained ankle, you go see the trainer. If you’ve got a cold, you go to the doctor. If you’re head’s not quite right, you need to go see someone.” Boston Globe February 4, 2018. An open-minded and resilient opinion in a time where stigma still exists about mental illness as character weakness.
In 2011, Tom Cavanaugh, a local player for the AHL Worcester Sharks ice hockey team jumped to his death after years of psychiatric torment that included several admissions to psychiatric hospitals for depression and ultimately schizophrenia. By outward appearances this Harvard graduate was on the fast track to NHL success.

“We have to get over the stigma associated with asking for help. We need to get to the point where we treat emotional distress the same way we treat other ailments.” The NCAA reports that the incidence of college athlete suicide attempts is quite low.  “There are very few cases of completed suicide. However, we do know what kinds of factors and stressors might lead to an attempted suicide, and we do know that participation in sports can actually protect against some of those stressors.” as reported by David Lester for the NCAA.
“Reaching out for help when we need it is NOT a sign of weakness,” wrote Drew Bledsoe Wednesday on Instagram. “Trusting your friends and asking for help is the ultimate sign of STRENGTH!!”        Former N.E. Patriots Drew Bledsoe, 2018
Male athletes are not alone in their silent grief and torment. Johanna Nilsson, a Swedish born Northern Arizona University athlete killed herself in 2013 after a highly successful career in track and cross-country both at NAU and internationally. There was no specific explanation or warning given off by Johanna Nilsson who was just 30 at the time of her death.  In 2014, Madison Hallorin a 19-year old University of Pennsylvania athlete jumped to her death after a period of depression.
Jim and Stacy Holleran, have launched the Madison Holleran Foundation in an effort to help high school and college students who suffer from depression. The organization’s mission is to “prevent suicides and to assist those in a crisis situation with phone numbers and resources that will assist them during their time in crisis” — building resilience in athletes is important not only for confidence for winning but to help manage the down and out times when even a win can be a downer.

“Madison was the happiest kid, you know, when she was happy. And if that person would understand what they are doing to their family and their friends and their extended friends, they would not choose suicide if they really understood that they would be gone forever.”  Jim Hollerin, 2015

Elite athletes train for their sport every day of their lives and in some cases feel a vague great “missing piece” that can slowly erode their sense of resilience and emotional coping. Drew Bledsoe recognized this and asked a team trainer for a ‘name’ during a time of stress. But it would be important for athletes to become familiar with the routine cognitive behavioral strategies for stress management including HRV – Respiratory Sinus Arrhythmia and paced breathing for peak performance.

The Blaze (2015) Parents Release College Athlete’s Heartbreaking Suicide Note One Year After Her Shocking Death. Blog Post:  https://www.theblaze.com/news/2015/01/22/parents-release-college-athletes-heartbreaking-suicide-note-one-year-after-her-shocking-death Taken February 6, 2018
Lester, D. (2011) Mind, Body and Sport: Suicidal tendencies  An excerpt from the Sport Science Institute’s guide to understanding and supporting student-athlete mental wellness. http://www.ncaa.org/sport-science-institute/mind-body-and-sport-suicidal-tendencies Taken February 6, 2018

CTE found in teenage brains by B.U. team

WESTBROUGH, MA January 18, 2018 The scientists studying the damaged brains of older athletes have had the opportunity to study brain damage in athletes who died from other causes.  In 4 such cases, there was evidence of chronic traumatic encephalopathy (CTE) that was not commensurate with the degree of brain trauma that was observed during their athletic careers according to Felice Freyer of the Boston Globe. This recent study was published in the journal Brain illustrates that the onset of CTE may be closer to onset of brain injury than first thought not much later in life.
“The report, published Thursday in the journal Brain, also provides what Goldstein called “the best evidence to date” supporting the theory that CTE is caused not just by concussions, but rather by any blow to the head, including mild impacts. Instead of diagnosing and responding to concussions, he said, coaches would do better to protect children from all hits to the head.” Felice Freyer – Boston Globe 1-8-18
The possibility of younger athletes developing CTE and the symptoms associated with this progressive disease is quite worrisome especially to parents.  It was always thought that CTE would develop later in life if at all. With the prospects of the disease having a much earlier onset the cost of CTE over a lifetime is incalculable in terms of medical costs and neuropsychological sequelae that may evolve in time. The true impact of this and the consequence for repeated, subclinical blows to the head is only now becoming clear.
Like dementia of the Alzheimer’s type the build up of tau protein underlies the changes associated with CTE. “Chronic traumatic encephalopathy is a condition bringing forth progressive tauopathy that occurs as a consequence of repetitive mild traumatic brain injury. We analysed post-mortem brains obtained from a cohort of 85 subjects with histories of repetitive mild traumatic brain injury and found evidence of chronic traumatic encephalopathy in 68 subjects: all males, ranging in age from 17 to 98 years (mean 59.5 years), including 64 athletes, 21 military veterans (86% of whom were also athletes) and one individual who engaged in self-injurious head banging behavior” according to the journal Brain. McKee, A. et. al. 2017

McKee, A. et. al. (2017) The spectrum of disease in chronic traumatic encephalopathy. Brain, Volume 136, Issue 1, 1 January 2013, Pages 43–64, https://doi.org/10.1093/brain/aws307

The state of knowledge and policy on concussion in Rugby Football Union

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Westborough, MA  August 15, 2017 Just as American’s have begun to understand the true impact of concussion and the risk associated with repeat concussion and other blows to the head, the Rugby Football Union has started to take a serious look at the problem with respect to the long-term consequence of brain injury.  According to the New York Times in April 2014 “a tidal wave of earnings” may confound the rightful medical response to concussion injuries and dominate the return to play decisions on behalf of athletes who are found to have concussion. The remove-from-competition protocol has not taken hold in European rugby where players are routinely returned to play after a 5 minute time out during which they are examined by team medical personnel. Most are back on the pitch within 5 minutes. I have seen college Rugby games where this precise “recovery” was the norm.  The NCAA has protocols for managing concussion but in some club sports these protocols are not followed.
In 2011, Ben Robinson, a 14-year old boy in Northern Ireland, died from second impact syndrome resulting from playing through a concussion. He returned to the game three times after first being injured in a high school rugby match.  Ultimately he died after collapsing on the rugby pitch. Second impact syndrome results from a repeat brain injury resulting in a metabolic “energy crisis” that interferes with brain function including maintaining homeostasis on a cellular level. I  have documented it in several published Word Press Human Behavior posts.
More recently Irish Boxer Mike Towell died from second impact syndrome hours after his fight much the same way as 14-year old Ben Robinson.  He was seriously injured early in the bout and knocked down.  His toughness and tenacity along with unacceptable referee decision making allowed him to return to the fight. “The assumption that rugby had a better handle on concussions than football, however, might have been flawed from the get-go. The most recent injury audit performed by England’s Rugby Football Union (RFU) established that concussions in elite-level professional games were occurring at a rate of 13.4 per 1,000 player hours.” Bandidi, 2016
The NCAA protocol is cited here.  “Medical personnel with training in the diagnosis, treatment and initial management of acute concussion must be “available” at all NCAA varsity practices in the following contact/collision sports: basketball; equestrian; field hockey; football; ice hockey; lacrosse; pole vault; rugby; skiing; soccer; wrestling.” Female athletes are particularly vulnerable to concussion and tend to have longer recover times. Concussion is sometimes considered an invisible injury largely due to the absence of frank signs of injury on the outside of the head.
According to the BBC, Towell was knocked to the mat in the first round of a 10 round bout.  He was given a standing 8 count and continued the fight.  Some said he dominated the next two rounds when finally in the fifth round he was again knocked down and the fight was ended.  Michael Sefton blog 2016

Burns, J. NY Times, In Europe, Echoes of America as Concussions Spur Debate, April 5, 2014. https://www.nytimes.com/2014/04/06/sports/in-europe-echoes-of-america-as-concussions-spur-debate.html?_r=0  Taken June 13, 2017
Sefton, M. (2016) Second Impact Syndrome. https://concussionassessment.wordpress.com/2016/10/03/second-impact-syndrome-rare-but-often-fatal/ Taken August 7, 2017
Bandidi, P. (2016) Rugby, like NFL, doesnt have the conussion-issue figured out.  http://www.espn.com/espn/story/_/id/16029747/rugby-nfl-concussion-issue-figured-out Taken August 7, 2017
NCAA Concussion Concussion Safety Protocol. Guidelines https://www.ncaa.org/sites/default/files/2017SSI_ConcussionSafetyProtocolChecklist_20170322.pdf Taken August 8, 2017

What happens to the brain when concussed? See for yourself in CDC video just published

WESTBOROUGH, MA April 21, 2017  There has been a great deal of research published recently about the cumulative impact of concussion.  Every athlete who experiences a concussion has a unique trajectory toward recovery.  It is well-known that athlete’s who experience  a second or third concussion may be at risk for long-term cognitive symptoms unless they rest until the symptoms are fully resolved. It is now expected that each recovery is different and should be tailored for the presenting symptom profile and the athlete’s medical history. A combination of rest and controlled exertion seems to work best for recovery.  Balance and vestibular changes from concussion require physical therapy in the days after injury. We offer these services at Whittier Rehabilitation Hospital. In cases of second or third concussion the recovery can be very different and often prolonged.
There are dozens of You Tube videos that I have posted in these pages illustrating the brain as it becomes concussed. On my first website nearly 20 years ago I purchased a .gif program to illustrate the movement of the brain during a concussion – like the one below.  It cost me nearly $100 to download and post on my website.  Now they are available free of cost and easily posted to social media.
A concussion is a traumatic brain injury resulting from force causing energy to pass through the brain resulting in the brain shaking within the skull.  A study published in January 2016 in the Journal of Pediatrics suggests that preadolescent boys are at higher risk of concussion when playing on varsity ice hockey teams.  The study at Hasbro Children’s Hospital in Providence, RI also suggested that girls playing ice hockey who are heavier may be at greater risk for concussion.  On average, the preadolescent boys in the study took 54 days to become symptom free.
Here is a link to another very useful video produced by a Canadian physician Dr. Mike Evans. I often have families watch this 10 minute video before initiating our conversation.  The point is that the brain is seriously impacted by energy pulsating through the skull from whatever cause.  I have seen several snow boarders this winter. Spring sports usually see an uptick of concussions in lacrosse and girl’s softball.  Concussion can be expected to effect all cognitive functioning including concentration, speed of mental processing, problem solving, memory, and behavior.

Why play sports ? – Ask Morgan William

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# 2 Morgan William    Toptwitter.com photo

 

WESTBOROUGH, MA April 1, 2017 In my family playing sports has been a lifelong commitment.  There were plenty of times things did not go as hoped which can be heart breaking for student athletes and heart wrenching for supportive mom’s, dad’s and superfans everywhere.  The physical and psychological benefit of playing sports is well-known just ask any member of the Mississippi State Women’s Basketball team who knocked off the goliath UConn women who had won 111 games without a loss.  In fact, UConn defeated this same Mississippi State team by over 60 points in 2016.  Not so fast.
Congratulations go to 5-foot-5 Morgan William whose winning shot in overtime sealed the win and punched their ticket to the Women’s Division I Semifinal game next week. As exciting as the win may have been, the UConn women will go down in history as having the longest unbeaten streak in history.  The basketball program will be fine going forward – but it stings really bad right now in Storrs, CT.  Why play sports?  The highs and lows of competition teach us about success and failure.  Whether we win or not does not matter as long as we work together and leave nothing on the court – or ice.  Team work builds relationships and discipline – things needed for the real world. Even in Storrs, CT – home the the University of Connecticut amidst the tears and disbelief there is a lesson to be learned.  In this case no team should be taken for granted and no single player can do it all. But last night against UConn it was Mississippi State’s Morgan William’ turn to shine and put on a clinic.


“The training fosters both physical and psychological resilience to stress.”



Women’s sport has grown exponentially since Title IX was introduced that leveled the playing field for female athletes. The physical benefits include improved cardiovascular health and stress-endorphine responses are immeasurable. Psychological benefits include reducing distress, enhancing confidence in abilities and recognizing psychological responses that need the attention of a mental health professional. These benefits have positive implications for long-term health and the prevention of OSI.
Ask any member of the Mississippi State Women’s basketball why they play sports and they will tell you it is for all these reasons and for the chance to end an 111 game winning streak that no one would believe could happen. But it did!