“The NCAA said it doesn’t keep track of medical disqualifications or how many sidelined players have transferred to play football elsewhere. Most of the schools that make up the lucrative, upper echelon of college football refused to release even basic information about disqualifications.”
David Robinson – Boston Globe January 8, 2015
WESTBOROUGH, MA January 10, 2016 Can prior history of concussion be provided to the medical staff of a prospective team? Should an athlete be responsible in reporting the true incidence of concussion? At what point does healthcare privacy protect the student athlete from needing to report the history of brain trauma? What will the longterm implication be of repeated concussion in young athletes?
The fact is that student athletes who become disqualified due to concussion often make themselves available to other NCAA Division I schools. It seems impossible to believe that any medical staff of the highly regarded football program (or any contact sport) would disregard the pertinent facts of the athlete’s physical health and permit them to compete in football or any contact sport. This is as despicable as the NFL’s failure to speak out against concussion in defiance of those players who were badly damaged by the game – many who have died. Improved healthcare for student athletes and an NCAA concussion registry may reduce the chance of an athlete returning to football when medical opinion has removed them from competition because of the risk associated with repeat concussion. This is especially true when common sense fails and young players become enticed by the promise of fame and fortune.
The literature has now revealed the devastating impact of concussion and even the sub concussive head bumps on long term health and well-being of student athletes. Contact the Whittier Rehabilitation Hospital 508-871-2077 or Dr. Michael Sefton 508-579-0417 for pre-injury baseline testing or post-injury care.
WESTBOROUGH, MA March 15, 2016 In a published article headlining the BBC web pages the NFL has acknowledged that a link exists between repeated concussion and chronic traumatic encephalopathy – a deadly brain disease resulting in depression, memory loss, and erratic behavior. Only 50 days ago the NFL’s hired “expert” Mitch Berger, M.D., a neurosurgeon claimed that no link had been established between hits in football and the chronic brain disease leading to death.
This is the first time the NFL has acknowledged that such a link exists. Why are they now acknowledging what science has accepted years ago?
In Boston, neuropathologist Dr. Ann McKee unequivocally states that a correlation between concussive and subconcussive blows to the head has resulted in CTE in 90 of 94 brains she has examined – all from NFL players who have died and donated their brains to the Boston University Brain Bank. “The Boston Globe features this story as well today” according to Michael Sefton, Ph.D. “I have heard Dr. McKee and her colleagues report these findings since they examined the first series of brains including the brain of former N.E. Patriot Junior Seau who committed suicide shortly after his retirement from football.” The link has been well established for over 5 years but denied by NFL medical experts and league president Roger Goodell. The NFL Player’s Association sued Goodell and the NFL for hiding the dangers associated with concussion in 2014. The major motion picture Concussion starring Will Smith as real life physician Bennet Omalu was overlooked for an Oscar nomination in 2015. Nevertheless, the movie brought many of the NFL’s secrets about concussion out for all to see.
This link will take the reader to the BBC report.
The 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.
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: https://concussionassessment.wordpress.com/consultation/post-concussion-syndrome-pcs/. Taken December 26, 2015.
de Lench, B. (2015) Why I’m not a football apologist. Blog post: http://www.huffingtonpost.com/brooke-de-lench/why-im-not-a-football-apo_b_8855362.html. Taken 12-26-2015
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.
REPEAT CONCUSSION SHOULD BE AVOIDED
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.
REGRET, FEAR, AND HOPE
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.
WHITE HOUSE SYMPOSIUM
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.
Sefton, M. (2005). The Evil that Kid’s Do. Exlibris, Philadelphia.