What happens if I return to play too soon?

WESTBOROUGH, MA  April 20, 2017 Whenever I meet someone who comes to me because of a recent concussion they will inevitably ask “what happens if I return to play too soon?” If it isn’t the athlete asking that question it might be their parent.  Ever since the era of awareness of concussion began people have been more apprehensive about their return to activity.  I recently took care of a basketball coach who was feeling better when she was hit in the back of the head with an errant basketball during the shoot around. Her symptoms returned with intensity and left her on the sideline for over a month.  People now accept that the cumulative effects of concussion can have lasting impact.
The consensus currently indicates that some activity during recovery is beneficial rather than 100 % rest as once espoused.  That activity would consist of physical therapy, exertion and balance training along with controlled cognitive exercise.  It is still recommended that recovering patients not overuse their computers, tablets, game systems, etc. Sleep and rest also remain an important component of the recovery plan especially when re-integrating into school or work.  If symptoms persist or worsen than I often suggest lessening the work load.  Most schools will write off some work assignments when necessary. Some students get quite anxious about the make-up requirements for classrooms work if they have missed days or weeks of school.
 “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, US.

Concussion need not be the rite of spring

WESTBOROUGH, MA April 15, 2017 On March 15th across New England and most of the country high school spring sports take to the fields.  Well actually most of the lacrosse and softball teams start out in school gyms or field house.  Many actually rent out indoor playing fields to put in the hours needed to begin a rigorous new season.  The starting dates are closely watched by members of the Massachusetts Interscholastic Athletic Association – MIAA.  It is the same thing with football and fall sports – August 20th the ritual first day of Fall sports practice.  In spite of these rituals and scores of other idiosyncrasies that teams share, concussion should not be an expected rite of passage for contact sports.  Yet some people are still not taking it seriously.
Michael Sefton, Ph.D. in 2017 photograph

“The protocol about which I write comes in sequence to the athlete being symptom free.  When this happens he or she may begin a return to play protocol that consists of systematic activities designed to slowly stress the athlete in an effort to be certain that no symptoms will return as the athlete exerts himself over a 5-step sequence that ends in a full contact practice.”
Michael Sefton
I posted a short blog in January 2017 about the role of a stepwise return to play protocol. Most schools expect this protocol and are often surprised when the parent of an injured student marches in with a note authorizing return to full participation by the pediatrician – as if this trumps anything the CDC has implemented as the standard of care.  This may now be the standard of care but is not being followed.  In the past month I have been asked to write return to play protocols for athletes who had already been cleared to play by their pediatrician.  You cannot have it both ways – either a player is held out until he is fully healed or he is at risk of prolonged debility and postconcussion syndrome if injured again during recovery.  When it comes to middle or high school students the greater risk is missing days or weeks of school.

Case study – 2017
Just recently I saw a 12-year old middle school boy who had sustained a moderate injury while snowboarding.  He had 2-3 weeks of significant symptoms including sensitivity to light and sound, headaches, irritability and changes in sleep pattern.  He had taken one week off from school and returned 1-2 hours daily until fully reintegrated with his classmates. By outward appearances he was doing all the right things and had returned to his travel soccer team. Yet he was still having symptoms and should have taken a more focused approach to exerting himself. His school was beginning to push him to complete missing assignments that was adding to his anxiety and irritability.  The child had been seen at a local concussion clinic who had cleared him for step 1 of the 5-step protocol. They prescribed the CDC 5 step protocol I have mentioned here but there was no in-school trainer to manage each step. This frequently falls on coaches or the school nurse. But by allowing him to exert himself and practice with his teammates he missed out of steps 2 and 3. His brain had not fully healed and was struggling to keep up with energy demand of   school, homework, make-up tests and soccer.  Concussion is an energy crisis resulting in less efficient processing and it was clear to me that he had not fully recovered from his moderate injury. He needed to start over and his parents heard this to be a set-back. They were protective of his emotional well-being and wanted him to be with his class and team mates. These are important considerations and must be figured into the recovery equation.

“There should be an understanding that no student may be expected to take tests – even state mandated achievement tests until they are fully recovered from their injuries. The failure to allow full recovery to take place prior to exerting the athlete places him or herself at risk for additional injury from second impact. Some students require a formal 504 support plan for the duration of their symptoms.” Sefton, 2014

In another case from spring soccer that I previously illustrated, a young high school boy was recovering and had still been having headaches.  Their question was: could he travel to Portugal and play against an elite high school?  They had been planning the trip for nearly a year.  His anxiety over missing the trip was palpable but the risk of playing against older and more developed athletes was against my advice.  He could attend the trip but not play.  I am unsure what they decided to do but I did not see them again.  For readers of this post I ask: Does it make sense to have an athlete who is still recovering to play at the elite level where competition is fierce and risk of injury is real? The 5-step protocol should not begin until the athlete is symptom free.  Some believe the athlete should be symptom free for one week prior to beginning the return to play protocol.  To see the CDC protocol click here.

Sefton, M (2017) Understanding Concussion: People are still not getting it. https://concussionassessment.wordpress.com/2017/01/29/understanding-concussion-people-are-still-not-getting-it/ Blog post taken April 2, 2017
Sefton, M. (2014) Prolonged symptoms signal delayed healing. Blog post: https://wordpress.com/post/concussionassessment.wordpress.com/643 Taken April 2, 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


# 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!

Focused treatment depends on symptom profile

Prescribed rest—both physical and mental—is the standard treatment for concussion. But a growing body of evidence suggests that a more active, targeted approach might provide better outcomes for some patients, reports a special article in the December issue of Neurosurgery, official journal of the Congress of Neurological Surgeons (CNS). The journal is published by Wolters Kluwer.

Chronic Stress – The unbridled malignancy that effects us all

WESTBOROUGH, MA January 31, 2017 There is no way to avoid a stressful life it seems.  Some people are better than others at reducing the impact of stress.  Excercise, healthy eating, regular sleep, and mindfulness reduce the impact of the stress and tension we all experience in our lives.  These behaviors are being taught to children who experience stress just like their parents in many schools. Meanwhile, concussion and more serious brain injuries result in changes in the autonomic nervous system that are sometimes life threatening.  The behavioral response of these afflictions include marked restlessness, anxiety, changes in sleep hygiene, abnormal pain response, and pervasive tension.
In cases of severe brain injury one might see autonomic storming as described in a prior blog. Autonomic storming results from trauma to regions of the brain that control primitive bodily functions like respiration, heart rate, and emotional regulation. This includes profuse sweating, elevated heart rate, rapid changes in body temperature and motor restlessness. These functions are comprised in the autonomic nervous system and are known as the fight-flight mechanism.  The sympathetic nervous system elevates blood pressure, respiratory drive, and gets us ready to fight or run.  Meanwhile, the parasympathetic system puts the brakes on these functions allowing the body to return to its normal resting rate.

“Eventually, chronic stress could be treated as an important risk factor for cardiovascular disease, which is routinely screened for and effectively managed like other major cardiovascular disease risk factors.” Ahmed Tawakol, Harvard Medical School

Ostensibly, stress has the capacity to change this normal resting heart rate and slowly raise our levels making it difficult to truly relax. In the long term, external stress can change our heart functioning including hypertension and cardiac arrhythmia and put us at risk for cardiovascular illness including heart attack and stroke. Lifestyle changes are necessary to avoid long-term health problems from stress. Mindfulness includes deep, regular breathing, guided imagery, and progressive relaxation. It is being introduced in some public schools so that it may become part of the coping mechanisms used by kids when stress sets them off – as it undeniably will do.

Sefton, M. (2015). Heart rate variability: Biofeedback options for post-concussion syndrome,  https://concussionassessment.wordpress.com/2015/08/03/heart-rate-variability-biofeedback-options-for-post-concussion-syndrome/
WebMD (2017) Brain ‘stress ball’ may be key to heart risks. http://www.webmd.com/brain/news/20170111/stress-ball-in-your-brain-may-be-key-to-heart-risks#2, taken January 14, 2017

The stress and frustration at not being ‘well’ – and not knowing why?

WESTBOROUGH, MA February 5, 2017 There is growing frustration in my practice about the lack of “treatment” for concussion and postconcussion syndrome or PCS.  There are many people whose lives have been changed because of one or more than one concussion occurring in close succession.  I am currently seeing a number of cases of individuals who suffer with the symptoms of PCS and are miserable. Over time they have grown hypervigilant about every sign or symptom they experience attributing them to the concussion from long ago. Long term symptoms include headaches, poor memory, low endurance, neck and body pain, tinnitis, feeling like being in a mental fog. I might add that the stress of PCS diectly contributes to changes in mood including: depression and anxiety. People with PCS are at higher risk of substance abuse while recovering.
5-15 percent of peple who sustain a concussion can expect to have symptoms that excede the normal 7-10 day window.  Those who report symptoms greater that 3-6 months are diagnosed with PCS.  I’ve been reading the blog of one PCS sufferer who is eloquent in her description of the impact of concussion on her young adult life. She shares her frustration and fear over not getting better and just as importantly no being understood.  I hear that to many times – nobody listens and nobody understands just how much they suffer. Many grow accusatory and suspicious that the primary physician is denying them the medical care or diagnostic tests they need to find answers and utlimately to recover.
Sometimes vague physical symptoms create an overwhelming emotional response that may come from lingering resentment felt when seeing doctors who seem unable to understand their needs. I always recommend that patients practice a script so that when seeing the specialist they are able to present themselves and their suffering, including all symptoms, in a cohesive understandable manner. Strangely the outward appearance of lingering concussion may appear to be solely a psychiatric condition rather than someone who is recovering from a brain injury. Some physicians unfairly believe prolonged symptoms may be linked to ongoing litigation and are magnified as a way of deriving greater compensation.
In a published blog from September 2016 I have addressed secondary trauma that may confound the recovery from brain injury when it occurs concurrently. Coincident acute stress may exacerbate the physical symptoms and duration of symptoms following concussion and make healing an arduous process.
“A history of migraine headaches may be a predictor of post concussive headaches. Other stressors like divorce, loss, financial problems, motor vehicle crash and others may change the trajectory of recovery.” Sefton, 2016
If someone you know suffers from PCS the effects to a family system can be dramatic too especially when the head of household can no longer go to work.  Whether it is a professional, elite student athlete or a salesman injured in a car crash there is an experience of stigma associated with the invisible injury of concussion. It is increasingly understood that concussion interferes with the efficiency of central nervous system functioning slowing it down.  This is why cognitive rest is recommended so automatically for those newly diagnosed. When the cognitive demand excedes the mental resources available there is a “energy mismatch” that puts a stall on the recovery.
Evidently, there’s no monolithic prescription for treating PCS, which results in much of the work, research, and accountability for getting better being placed onto the patient. It’s a process of trial and error, albeit a very long, frustrating one” according to one blogger who has had PCS for over 2 years. Hockey gal blog