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.

New Biofeedback protocol: Expanded Service for Brain Injury and Trauma

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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.

Childhood sports – When parents cross the line

 

20070202 - CATANIA - CALCIO: SCONTRI DOPO CATANIA-PALERMO, MORTO POLIZIOTTO - Nel fermo immagine tratto da sky sport un momento degli scontri tra tifosi e forze dell'ordine dopo Catania - Ascoli. ANSA /SKY SPORT / JI
2007 Hooliganism in Italy is nothing new to Europe     PHOTO: SKY SPORT

WESTBOROUGH,MA  January 7, 2016 Is the game time behavior of parents becoming a menace at some youth sports?  According to the Wichita (Kansas) Eagle, “the goal of youth participation in sports is to promote lifelong physical activity and healthy competition, officials said, but too often adults approach their kids’ games with their own goals, such as fame, money, Olympic medals and college scholarships.” This story was published in September 2014 after the wife of a football coach fired her pistol into the air to ward off angry parents who had attacked her husband over the amount of time their children were played in a previous game. According to the Wichita Eagle the coaches wife was not the only gun carrying youth football fan that day. This case was referred to local police to sort out.

Fan violence is a commonplace occurrence at many athletic events at venues around the world.  In arenas everywhere alcohol-fueled rivalries turn into violent mob scenes sometimes resulting in lawlessness and death.  The outrageous behavior of European football and rugby fans is notorious. In February 2007, the Italian professional football league was shut down for 2 weeks because of brutal hooliganism that took place in Catania in Italy leaving a police officer dead. In 2006,  2000 German police officers were needed to quell a disturbance after England’s soccer team was victorious in the World Cup of football.  “The passion of sport sometimes kindles mob-like behavior” according to Allyce Najimy at the center for the study of sports in society at Northeastern University in Boston. This passion may be seen on a daily basis here in the U.S. on the field of dreams at youth sports venues everywhere.  It is here that the parents of youth sports derive their greatest joy and heartfelt exaltation while watching their children play sports.  Passion is exuding from fans at little league baseball games to Pop Warner and American League youth football to U.S. sanctioned youth ice hockey and all those traveling teams.

 

In recent years, the behavior of parents has taken on a higher level of scrutiny at childhood sports across the country.  Parents are becoming just as fanatical toward players, coaches, and game officials sometimes resulting in physical assault – even homicide. As an ice hockey coach for nearly 10 years I was never surprised to be met at the locker room door by an angry father holding his notes from our last match.  “Mike, why did my son only play 11 minutes last week?” inquired a loving dad who was not interested in what I was selling.  I had parents who came to practice while under the influence of alcohol expecting to play along side the team as an assistant coach.  I have heard foul mouthed ranting from some of the most mild mannered parents all in the heat of battle brought on by the excitement of bantam ice hockey.

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Patrick O’Sullivan playing for Edmonton Oilers of the National Hockey League PHOTO NHL

“A parent’s greatest strength – their unwavering emotional support of their child and their willingness to make sacrifices for their child’s athletic advancement – is thus also their greatest weakness.”  This quote is never more true than when you read the story of Patrick O’Sullivan.

As recently as December 2015, retired NHL player Patrick O’Sullivan contributed his heart wrenching story of abuse while a youth ice hockey player growing up in rural Canada (The Players Tribute). “My father used to beat the shit out of me. I don’t say that to be shocking, or to get your attention. I say that because it’s just a simple fact. He would throw punches.” O’Sullivan described physical beatings that left him nearly unconscious from a ritual of choking and punching. After nearly every game, he routinely endured physical and emotional torment while riding home alone with his abusive father. People were witnesses – his father held nothing back often starting the physical harangue in the parking lot. And for what?  Finally at age 16, O’Sullivan had had enough and for once in his life stood up to a true bully – his father.  Ultimately, Patrick was drafted into the NHL and played in over 300 games with several NHL clubs.  In interviews after the publication of his story Patrick shared the desire to end parent abuse by encouraging witnesses to step forward and confront violent parents so that more children might not suffer. The road for him was a rocky one fraught with pain and embarrassment, and his father’s screed.

Mann, F. Plumlee, R. (2014) Passionate parents mean trouble for youth sports. Witchita Eagle, taken January 10, 2016.  http://www.kansas.com/news/local/crime/article2101296.html#storylink=cpy

Murphy, S. (2008) How to be a successful youth sports parent. Blog post , taken January 11, 2016. http://www.momsteam.com/team-of-experts/shane-murphy-phd/youth-sports-parenting/how-to-be-a-successful-youth-sports-parent#ixzz3wz8hqRC7

O’Sullivan, P. (2015) Black and Blue. Webb site: The Players Tribute. Taken January 18, 2015. http://www.theplayerstribune.com/?s=o%27sullivan

Spring sports yield bump in incidence of concussion

LAX
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.

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.

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.

http://ti.me/RC2mEP

http://www.sportsbusinessdaily.com/Daily/Issues/2014/05/30/Sports-in-Society/Concussion.aspx – Taken 7-4-2014

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

http://www.wric.com/story/25227470/concussions-affect-girls-more-than-boys