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

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.  Taken June 13, 2017
Sefton, M. (2016) Second Impact Syndrome. Taken August 7, 2017
Bandidi, P. (2016) Rugby, like NFL, doesnt have the conussion-issue figured out. Taken August 7, 2017
NCAA Concussion Concussion Safety Protocol. Guidelines Taken August 8, 2017

Worthwhile educational video brings concussion to life


WESTBOROUGH, MA These educational videos are posted by the National Academy of Neuropsychology and offer viewers the personal stories of elite athletes – many of them are nationally

Dr Sefton
Michael Sefton (right) with former Boston Bruins player teaching young hockey players about concussion

known.  In my practice I have learned that concussion impacts the younger athlete with more unpredictable outcomes and a longer recovery.  I have worked with professional and college athletes and have come to know that management of these players is important.  Light exertion should be part of their recovery.  Individualized return to play protocols are designed for those who suffer a second or third concussion.  If this occurs within a single season most athletes are encouraged to shut it down allowing time for complete recovery before competing at 100 percent.

See these videos and Concussion 101 – Dr. Mike Evans interesting take of this injury.



National Academy of Neuropsychology posts educational video


New Biofeedback protocol: Expanded Service for Brain Injury and Trauma

Biograph instrument showing paced breathing protocol by Thought Technologies

WESTBOROUGH, MA April 1, 2016  The Neuropsychology Service at WRH has added both physiologic and EEG biofeedback to the service for those afflicted with concussion, TBI, and trauma. The protocol involves heart rate variability and controlled or paced breathing as a means of gaining enhanced resonance in the autonomic nervous system.  Autonomic storming is a common reaction to traumatic brain injury and can be debilitating over and above the structural changes that impact condition and behavior. It is not new and has utility in treating anxiety and other stress-related conditions.  The protocol is designed to activate the body’s parasympathetic function as a “quieting mechanism” – to put the brakes on for relief and a variety of physical symptoms including pain, irritability, and depression.  The “protocol quickly assists in helping patients find a balance or resonance between sympathetic and parasympathetic systems in their body using controlled, paced, breathing and prototypic progressive relaxation” according to Michael Sefton, Ph.D., Director of Psychological and Neuropsychological services at Whittier Rehabilitation Hospital in Westborough, MA.  Patients are urged to have at least 10 sessions of HRV biofeedback and may practice at home between sessions.  Diet and exercise are important parts of recovery from TBI, concussion, and other pain-related syndromes. Dr. Sefton is certified in biofeedback including neurofeedback and is a Certified Brain Injury Specialist.  Contact Dr. Sefton for more information of this protocol or an appointment 508-871-2077.

What to expect with first concussion?

WESTBOROUGH, MA March 21, 2016 Here is a blog that I first published in September 2013 when I first started to write this blog.  I occasionally am asked to “put up” a blog post that was previously published.  I resist this out of fear of growing irrelevant.  In any case, this blog cites some of the concerns people have when a child is diagnosed with concussion for the first time.  What can you expect?  I think it is a reasonable post that I will update with the current standard of care. Here are some of my early thoughts and those that are new.

Student athletes experience fatigue and decreased mental endurance

“I remember when my son was playing ice hockey.  He was 12 or 13 years old.  He was hit at center ice near the bench.  The opposing playing went low hitting Casey – toppling him head over heels.  He managed to get right up but had rubber legs and skated away from the bench not toward the bench and the safety of his coaches.”  Michael Sefton, Ph.D.


The first concussion results in a wide range of responses from players, parents, and coaches.  Some result in an ambulance ride to the local trauma center.  Whenever an athlete is suspected to have sustained a head or neck injury his spinal cord needs to be held at midline so that he may be immobilized.  This results in the placement of a cervical collar and usually being strapped to a long board and can be a scary process for a young athlete.  Yet most concussions do not require advanced life support for their management. While working in the ambulance I have taken care of many players with concussion – all of whom did just fine.

Shortly after injury and usually prior to EMS arrival someone may assess the injured athlete at rink side or in the locker room.  It is commonplace to use an assessment tool like the SCAT to measure the athlete’s orientation, awareness, concentration, and short-term memory.  A concussion does not require that an athlete be knocked unconscious to signal an event has occurred – most concussions do not result in unconsciousness.  Remember this if you ever have a son or daughter with a concussion.

What is most common is post-injury confusion, irregular balance, inattention, and decreased short-term memory.  Some athletes become emotional and cry.  This usually results from confusion and not understanding what has happened.  This may be limited if a parent or coach is with the player in the ambulance or hospital.

Once the ambulance hands of your son or daughter to the emergency department nurses he or she is likely going to have an x-ray of the head and neck and probably a C-T scan of the brain to rule out fracture and intracranial injury.  Sometimes lab studies are undertaken.  These tests are frequently negative in spite of active concussion.  Some parents leave with the false sense that nothing has happened to their child.  Why?

The answer to concussion lies in the metabolic cascade – a shift in neural transmission and the onset of reduced efficiency between centers of the brain.  Structurally the brain is uninjured but its intracellular transport system may be temporarily corrupt. This hallmark injury is difficult to document in the ED but clinically results in cognitive slowing and some physical signs like sensitivity to sound and light, headache, fatigue, irritability, and often poor balance and memory.  The symptoms frequently can be measured for 7-10 days before they are fully healed.  Athletes should not return to play before they are fully healed and cleared by a physician.

My first personal experience turned out well thankfully.  Casey underwent the million dollar work-up at the hospital and each test was normal.  We were given written instruction for what to watch in the unlikely event he was bleeding into his brain, somnolence, seizure, vomiting followed by unresponsiveness.  None of this occurred.  Our son was held off the ice for 2 weeks before he returned to practice.  He had about 3 days where he was not himself – a normally talkative, curious boy.  During his recovery he rested and was not permitted to use the many video game systems we own.  He needed to rest.  Slowly as we could see he was more himself he was given back a wide range of activities like attending the full school day.

Parents can expect a comprehensive evaluation when student athletes are injured from concussion.  Post-injury neurocognitive testing is sometimes recommended.  My son took 2 post-injury ImPACT tests until he reached his baseline.  By then he was feeling fine and beginning step one of the return-to -play protocol.  Some athletes require a few physical therapy sessions for balance, vestibular functions and proprioception.  These can be arranged by the pediatrician or brain injury specialist.  Consultation with school nurses and teachers should be considered given the reduction in cognitive functions like: attention.  Some athletes return to school for half days during the acute recovery from concussion.  I have written education plans for recovering students to have reduced homework load, delay all tests until recovery, early release, and well-timed rest breaks.  A small subset of injured players require more prolonged care and go on to develop post-concussion syndrome.  This results when symptoms persist beyond the normal trajectory of recovery.  In most cases, when an athlete has symptoms lasting over 6 months one can begin to think about post-concussion syndrome.  With effectice management and planning most athletes heal and recover from concussion without complication.  They should not be rushed and post-injury return-to-play plans should be addressed.  No player should go from zero play to tournament play without first undergoing a step-by-step protocol to make certain symptoms do not recur with exertion.

Concussion night 2016 at Bruin’s game

206982_1037539872681_50_nThe Children’s Hospital of Boston is participating in the special night at the Boston Bruin’s game on March 10, 2016.  The Bruins welcome Rebekah Mannix, M.D. a physician spokesperson at Children’s Hospital.  She acknowledge that brain injury is a silent injury often overlooked.  She described the importance of brain injury awareness including concussion prevention. Dr. Mannix talked about the silent injury that is concussion.  As an emergency room physician she noted that most injuries do not show up in the computerized tomography (C-T scan).  Athletes should rest following injury but recovery is different with all athletes – especially the younger players. Treatment options were discussed with Dale Arnold – NESN Sport Bruins Face-Off Live host.

Concussion – Physicians once espoused a link to unresolved litigation

Bennet Omalu, M.D. was first to recognize the impact of repetitive trauma and concussion PHOTO – The Trent
I am reading Concussion – the novel by Jeanne Marie Laskas upon which the film starring Will Smith is based – released on Christmas day 2015.  Smith portrays Dr. Bennet Omalu – forensic pathologist who first published the startling details of changes in the brains of those who suffer repeat head trauma. I am struck by the David and Goliath nature of the task – bringing medical discovery to the mainstream marketplace and the adversarial response of the medical establishment and the corporate giant National Football League.
There are still people in the brain injury field who attempt to discredit Dr. Omalu and the discovery of chronic traumatic encephalopathy.  Indeed, the affliction did not begin with NFL football.  I am sure over the years people with repeated concussions and subclinical injuries exhibited similar pathology when their autopsied brains were studied.  Aging boxers have been known to exhibit soft neurological signs even Parkinson’s disease.  An early study may have chronicled their symptoms as a common sequelae of boxers who experienced a career of getting blows to the head.  Dr. Omalu implored the medical establishment to take notice of the incidence of depression, substance abuse and suicide among retired NFL players that may be correlated with the findings from autopsy studies of players who died as middle-aged men.
I have observed first hand just how difficult it has been selling concussion management to schools, coaches, and athletic directors for over 15 years. In 1993, my interest in mild traumatic brain injury was first set in motion by a series of cases that were referred to me by a group of physicians with whom I was associated. I collected data for several months using emergency department statistics to come up with numbers of persons who were treated for mild traumatic brain injury. I was interested in pediatric patients. What I found in review of months of emergency department visits was that many cases were not coded for ‘brain injury’ because of other afflictions like lacerations, fractures, and more.
What’s more unless someone were brought into the emergency department with altered mental status or unconscious from head trauma the true incidence of injuries to the brain were not carefully recorded. Arguably, the reason for this was a tendency to wrongly believe that in the absence of a documented loss of consciousness there was no reason to think brain injury nor was there any real concern for those few cases who were seen for concussion – as long as there was no loss of consciousness. Yet I was seeing cases from car crashes, falls, and football injuries that were having prolonged recovery times who were never diagnosed with mild TBI.
The squeaky wheel – gets a referral
For those patients who managed to get referred to the neurologist or neuropsychologist the symptoms they experienced were debilitating and often quite severe. It was not always linked back to their concussion – sometimes addressed as psychological or even psychosomatic in etiology.  We began to see that a subset of concussion or Mild TBI cases went on to have a very unexpected set of symptoms including headaches, sound/light sensitivity, poor concentration, mood changes, and more that lasted for weeks and months. 5-10 % of cases of concussion remain symptomatic 8 weeks after first becoming injured and require supportive therapy.
What is now diagnosed post-concussion syndrome or PCS was frankly dismissed as a psychiatric illness like depression or anxiety or even an attempt at malingering as an intentional attempt to gain compensation years ago.  PCS has no visual markers on computer brain scans or currently available lab tests.  Like concussion it is an invisible injury that renders many people unable to work. Headaches, neck pain, fatigue, visual changes, irritability, sensitivity to sound and light, depression, and poor sleep hygiene were common.
Some physicians even stated “the symptoms would likely get better once the law suits were settled” when making a referral to me.  Over 20 years later, I sometimes meet with same misattribution but in general there is greater understanding of the potential long-term effects of concussion. Omalu warns us that repeated injuries have a cumulative impact on aging brains. His serendipitous findings has raised awareness of the neurologic malfunctioning that may take place when athletes are exposed to repeated blows to the head while playing football.  Many have gone on to commit suicide.
I was fortunate enough to be invited to the prescreening debut of the film Concussion a few days before it opened in Boston.  It was sponsored by MomsTEAM.  I was introduced to Brooke de Lench, Executive Director of MomsTEAM, Institute of Youth Sports Safety. He blog post was published in the Huffington Post the week before the film’s release. I enjoyed the film and found it a compelling caveat to my current knowledge and what I know to be true.
Sefton, M. (2014). Postconcusive Symptoms: Lingering symptoms following concussion. Blog post: Taken December 26, 2015.
de Lench, B. (2015) Why I’m not a football apologist. Blog post: Taken 12-26-2015

Presidential interest in brain injury

Michael Sefton, Ph.D. 2014 photograph
Michael Sefton, Ph.D. 2014 photograph

WESTBOROUGH, MA June 1, 2014  On May 29th President Barack Obama held the first summit for concussion and its management.  Mr. Obama convened a group of plenty to discuss the true impact of concussive brain injury and who is at risk and why.  President Obama hosted the Healthy Kids and Safe Sports Concussion Summit in May at the White House to address the growing risk of concussions in youth.  The president believes that concussion is a growing theat to public health – especially to children.  He is correct especially among athletes whose brains may continue to develop for years to come.  “Concussive injury has the potential to derail the trajectory of normal development and is fully preventable,” according to Michael Sefton, Ph.D., Director of Neuropsychology at Whittier Rehabilitation Hospital in Westborough, MA.  At a conference for public school nurses, Sefton espoused the importance of cognitive and physical rest in the days following a concussion.  “For this reason alone no athlete should return to the field of play until they are fully healed from concussion” according to Sefton.  The return to school must be carefully controlled as well to avoid the exaccerbation and prolongation of symptoms.


The growing base of knowledge about the cumulative effects of brain injury has people worried. It is an intuitive notion that concussion should be avoided and more is not better.  Data are being presented almost weekly about the long term impact of repeat concussive injury.  The Boston University School of Medicine now has a collection of brains that were donated by athletes with a known history of concussion.  They have exposed damatic changes in the pathophysiology of brain tissue and hypothesize a correlated change in functional viability that evolve from the forces of sport.  Until recently, chronic traumatic encephalopathy or CTE could be diagnosed in postmortem analysis brain tissue only.  It shows a marked change in morphology, atrophy or shrinkage, and tell-tale sign of Tau proteins consistent with progressive cellular degradation and programmed cell death as seen in the brains of Alzheimer’s patients after death.  There is a blood test currently being studied to measure the antemortem amount of this protein in patients.  The published data has been dramatic.  The stories associated with each brain is a testament to the substantive change is behavior and affective stability that may utlimately be attributed to concussion and other brain injuries.  Athletes everywhere suddenly realize they may not have seen the last of the effects of concussion.


During one parent information session – held at a local high school, a gentleman pushing the floor mop volunteered his own story.  During high school he played on the school football team.  In one game, a particularly violent contest he was knocked out cold for a few moments.  The symptoms quickly evaporated and he was put back into the game.  This happened 3 more times and 3 more times the player was allowed to return to the game as a lineman.  It was an important game and during his time it was a testament to toughness to return to the field of play after injury.  Only now, he lives with regret, fear, and hope that he will not develop a debilitating brain disease as he gets older.  But he knows this could happen.  These days, players are taught to recognize the symptoms of concussion and are designated mandated reporters.  If they know of someone playing through an injury like a concussion they must notify a coach or trainer.  In 2014, parents for their part are being educated about the risks of not resting after being diagnosed with concussion and planning for the return to school once healed.  In 2010, the Massachusetts Interscholastic Athletic Association or MIAA has mandated education and training for all athletes, parents, coaches, and trainers about the potential long term consequence of concussion.  Schools were responsible for concussion protocols and policies for injured student athletes.  School nurses were cast into the role of managing student symptoms by providing tylenol, ice, and rest breaks on Monday mornings following a weekend injury – sometimes with little or no warning.  They are on the front line for intervention with students struggling with this invisible injury.


The May 29, 2014 Symposium on concussion undoubtedly included nationally known experts like Mickey Collins, Ph.D., ImPACT Testing  – University of Pittsburgh, Gerry Gioia, Ph.D. from the Children’s National Medical Center and perhaps Bob Cantu, M.D., internationally known neurosurgeon and concussion expert from the B.U. Medical Center in Boston. Dr. Cantu published Concussion and our Kids in 2012 and often is heard to say that young children should not be playing contact sport.  These three experts are both knowledgeable, approachable and kind.  I respect their work greatly.  The goal of the symposium was to raise awareness about the dangers of concussion and generate initiatives to minimize the long term consequence of this public health problem.  The AP’s Darlene Superville wrote the summit “signaled an effort by Obama to use the power of the presidency to elevate a national conversation over youth concussions.”

President Obama, like presidents before him, takes particular interest in certain topics – in this case concussion and recently the scurge of elder abuse.  There was a previous White House symposium on school safety in the wake of the spate of school shootings in the mid 2000’s.  Like this one, I had made an attempt to get on that guest list so that I might add my viewpoint.  Arguably, The Evil that Kid’s Do (Sefton, 2005) was a book written to address the issue of childhood violence from the clinical point of view may have made a worthy discussion point and added to the collective conversation.

President Obama suffered a concussion while playing youth football.  Then, Secretary of State Hillary Clinton sustained a concussion as a result of a fall while serving in 2012. – Taken 7-4-2014

Sefton, M. (2005). The Evil that Kid’s Do. Exlibris, Philadelphia.