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

The results of postmortem examination of over 100 brains of NFL athletes are in

WESTBOROUGH,MA July 25, 2017 The laboratory at the Boston University School of Medicine has recently completed its initial examination of over 100 brains donated by the family members of those athletes who have died because of marked behavior and personality changes attributed to playing football.  The results confirm the presence of destructive proteins that have come to be known as chronic traumatic encephalopathy.  This was first reported over 10 years ago and was featured in the movie Concussion released in 2015 starring Will Smith as Bennet Omalu, M.D. who first reported on the syndrome.

Clock of the Week June 6

Westborough, MA June 6, 2017 The clock of the week is depicted below.  It was submitted this week by the Speech Language Pathology service at Whittier Rehabilitation Hospital.  I sometimes find it humorous that when I ask a patient to draw a clock they will have already drawn a clock for the speech pathologist. The drawing is used in all aspects of cognitive assessment by pracititioners of all types from neuropsychology to internal medicine to emergency medicine.  I typically begin an assessment with the clock drawing because it is nonthreatening and offers a great deal of interesting information about the cognitive capacity of the patient.  It was drawn by a 93-year old male with congestive heart

SLP_93 YOScan
Right handed 93-y/o male with probable dementia
failure and Paget’s disease. It is a disease affecting bone that interferes with the body’s normal recycling process, in which new bone tissue gradually replaces old bone tissue. Over time, the disease can cause affected bones to become fragile and misshapen (Mayo Clinic, 2017). In my experience there is no cognitive deficits associated with Paget’s.  This clock is suggestive of what seemed to be a great start – in terms of the initial placement of the numbers although as you can see the numbers 1-6 were drawn on both sides of the circle. This is an unusual finding suggesting decreased problem solving and self-monitoring on behalf of the patient.  The SLP drew the circle for the patient. I would suggest that the patient should be allowed to create his or her own circle as this can provide interesting data as well.  I once had a patient draw and elaborate grandfather clock fit for a castle.  The clock face became secondary and insignificant – for him.  The clock is a regular feature here at Concussion Assessment and Management.  
Anyone can submit a clock for consideration of the clock of the week.  Upload to my email address: – No identifying HIPPA protected information please but a brief overview is always helpful. 

Mayo Clinic. Taken June 6, 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.

Brain, Concussion and Stress: Health effects and post-concussion syndrome

Amygdala highlighted is over active when stress exists and raises the body’s threat level as shown in this BBC graphic
WESTBOROUGH, MA January 15, 2107 The human cost of stress has been well-studied and the effects of stress are a well-known cause of cardiovascular illness including heart attack and stoke.  It is now known that the brain plays a big role in all of this. The human stress response elevates heart functioning – especially blood pressure and normal heart rhythms in unhealthy ways.  Stress activates the amygdala in the brain by tricking it – as if some great threat exists.  People believe that the body’s autonomic nervous system can be thrown off after a concussion slowly becoming irregular resulting from an abnormal stress response. There is a deactivation of inhibitory neurons in the brain resulting in greater sympathetic activity. This involves progressive relaxation and guided imagery that can slowly lower the tension felt in the body.
Symptoms of concussion are known to elevate the sympathetic nervous system over time. Known as the fight-flight mechanism, stress activates the mechanism in the brain that prepares us each for battle.  This level of tension can only last for so long without needing a break. That is where the parasympathetic system comes in putting the brakes on the body allowing it to rest. The brain stem regulates heart rate and respiratory drive as well.  These functions are vital to survival and comprise the autonomic nervous system.
Study: Overactive system of emotional drive
Many believe that an overactive system in the brain results in the elevation of the autonomic nervous system. A Harvard study followed 300 patients for several years and found that those with an overactive amygdala were more likely to have cardiovascular disease and be at greater risk for stroke and heart attack. The amygdala is a tiny organ responsible for the emotions such as fear or pleasure.  It also plays a role in the systemic inflammatory response that may prolong the symptoms associated with concussion. “Heart experts said at-risk patients should be helped to manage stress” according to a BBC publication taken from Lancet.
The protocol I use involves paced breathing and heart rate entrainment as a way of putting the brakes on stress. But it takes time and American’s want instant fixes. Mindfulness requires self-monitoring and personal reflection.  If more people understood the health cost of stress and were able to identify high stress lifestyles then they might make behavioral changes that can lower the risk for cardiovascular disease later on.

The protocol quickly assists in helping patients find a balance or resonance between sympathetic and parasympathetic systems in the 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.

In several blog posts I have illustrated the potential negative health effects of high stress and physical functioning for which I am providing biofeedback at Whittier Rehabilitation Hospital in Massachusetts. This process helps put the brakes on the stress response and quiet the body.  The effects of concussion slowly elevate autonomic response adding to tension and physical malfunctioning. The biofeedback protocol helps lower the human cost of stress and the body’s inflammatory response and may lower feelings of tension and anxiety.  In doing so a rise in physical and emotional well-being may be expected.

BBC report, taken January 14, 2017
WebMD post,, taken January 14, 2017
Sefton, M. (2016) Coincident stress may contribute to post concussion symptoms, blog post,, taken January 14, 2017

Welcome back student athletes – Fall sports 2015!

MIAA requires that all schools report prevalence of concussion on an annual basis

Westborough, MA August 18, 2015 Schools across the country are preparing student athletes to return to the fall sports gridiron.  This week each year I visit several public and private high schools to inform the parents’ of student athletes about the individual concussion programs that each school offers.  Most schools have policies that require physician guided return to play.  As a neuropsychologist and certified school psychologist I want to point out that there is so much more to recovery than just getting back on the field of play.  A school re-entry plan should be put in place after a student athlete sustains a concussion.  This usually means one to three days off from school to allow the brain to heal.

Since July 2010 the MIAA – Massachusetts Interscholastic Athletic Association – the governing body for pubic school athletics has required concussion education for coaches, parents, referees, and athletes themselves.  The idea is to inform everyone about the signs and symptoms of concussion.  Emphasis is now being placed on the athletes themselves to report a concussion before they risk greater injury by returning to play while still experiencing the symptoms of concussion.  The symptoms of concussion have been well described elsewhere including on this website and most parents have taken the online test that is mandated by the MIAA.

As a neuropsychologist in practice in Westborough I have been fortunate to work with excellent athletic trainers, school nurses, and pediatricians as a team providing baseline ImPACT testing, assessment of post-injury concussion, and carefully designed return-to-learn programs, and clearance for return-to-play.  I have assisted several Massachusetts and Rhode Island school districts with writing individual concussion policies that have addressed current “best practice” for dealing with student athletes who suffer head injuries in sport.

MIAA-1024x535The MIAA has begun to allow non-physicians to play a larger role in the return-to-play decisions.  The MIAA website has all of its concussion policies that are here on this link.  This will permit other practitioners with specialized training in concussion management the opportunity to develop return-to-learn plans and to clear an athlete for competition when they are ready.  Physician Assistants, Neuropsychologists, Nurse Practitioners, and some ATC Trainers can now write return to play plans with the appropriate training and careful consideration of each student’s needs.

Congratulations for all those student athletes who worked all summer at captain’s practices – running, skating, playing summer soccer, etc.  Good luck and be safe.  Contact me at Whittier Rehabilitation Hospital for consultation after injury. My policy is to have injured players seen within 72 hours for updated neurocognitive testing and post-injury planning.  When symptoms exceed 7-10 days further assessment and consultation may be needed.  I encourage everyone to see Dr. Evans video posted below to learn more about recovery from concussion.  It takes a care team to help a student athlete get back to school and back to play in a safe way.  Stay in touch with team trainers, physicians, and your school nurse.

Concussion Video released August, 2014 that is interesting and funny by Dr. Mike Evans, a Canadian Internist

Check out Dr. Mike Evans Concussion 101 video – click here

Spring sports yield bump in incidence of concussion

H.S. lacrosse

Westborough, MA April 5, 2015  The spring try-out has all but been completed.  Most varsity teams have their rosters set and the games have begun.  In terms of collision sports men’s lacrosse and women’s softball both have high incidence of concussion. As seasons have gone by, I have seen an elevated rate of girls being injured during softball while sliding into their base or from player on player collisions.  Arguably, fast pitch softball has a high incidence of batters being hit by pitch resulting in concussion.  Men’s baseball also has a high incidence of concussion from wild pitches hitting batter helmets to outfield collisions.

Every spring I mail out reminder cards to the schools I take care of reminding athletic director’s to have their athlete’s sign on and take the pre-season baseline test – if they have not done so in the fall.  Most of the time I try and encourage trainers to refer cases of concussion for neuropsychological assessment early rather than later when symptoms have become chronic.  Early referral to a trained neuropsychologist can have a positive impact on successful return to play – including providing support for a step-by-step return to play plan.  I have said over and over that no player should go from zero play to game play without first going through a supervised return to play protocol.  No matter what you might think, the return to play protocol is the safest way to introduce an athlete back to sport and offers the least likely chance of an athlete being diagnosed with post-concussion syndrome – a chronic set of symptoms that can include headaches, poor attention, decreased short-term memory, depression, and more.  Yet I am still seeing physician’s who release student athletes for “game” play with only 5-7 days of rest.  Many believe this is inadequate.

Here in Massachusetts the MIAA has required that athletes be cleared by their primary physician before they are eligible to return to play.  Since the inception of the MIAA requirements the MIAA has broadened the definition of clinician that may clear an athlete for play to include clinical neuropsychologists and nurse practitioners with documented training in concussion management.  I am finding that some schools have allowed athletes to return to play prior to being officially cleared by their doctors – sometimes by the team trainer with some training in concussion.  This falls outside of the letter of the law set forth in the MIAA mandate and places athletes at risk.

It is prudent to have student athletes see a primary care physician and or another practitioner who can set forth a comprehensive return to play plan that allows for 7-10 days of rest followed by an active plan to return the athlete to the field of play as soon as safely possible.  Early referral to a specialist may be warranted whenever recovery takes an unexpected turn.