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 August 3, 2015 Post-concussion Syndrome (PCS) effects about 5-10 percent of those who experience a concussion or mild traumatic brain injury. By definition it is diagnosed when patients fail to recover from their concussion in the expected 2-3 weeks or sometimes longer. This happens for a variety of reasons that are not always readily apparent. Sometimes the expectation of a quick recovery is thwarted by the return to full activity too soon, according to Michael Sefton, Ph.D Director of Neuropsychology at Whittier Rehabilitation Hospital in Westborough, MA. For example, when returning to work after 2-3 days of rest one should not expect the brain to be fully healed. As a result, a return-to-work plan is essential. Post concussion syndrome is not common but as many as 10-14 percent of cases exceed the usual 7-10 day recovery period.
There are biofeedback protocols for post-concussion syndrome (PCS) that have been shown to improved the autonomic nervous system mismatch that often accompanies PCS. Here at Whittier Rehabilitation Hospital I have been using HRV entrainment to activate, or entrain the parasympathetic “braking” system that may directly lower the arousal associated with concussion including muscle tension, anxiety, elevated pulse, and suboptimal breathing. The method uses paced breathing for greater autonomic resonance and has been shown effective with pain management, poorly deployed attention, ADHD, and peak performance training.
Heart rate variability is a measure of cardiovascular health (Conder and Conder, 2014). A link has been demonstrated between traumatic brain injury, even concussion, and multiple organs including the heart (Cernak and Noble-Haeusslein, 2009). The effects of brain trauma impact structures deep within the brain including the brain stem. These cerebral regions impact cardiac function and can lead to cardiac illness.
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. Thayer and Lane (2009) propose a right prefrontal cortex as having a direct role in cardiac modulation. This results in decreased heart rate variability and often increased heart rate and a host of other physiologic signs that prolong the recovery from concussion. Williams et al. (2013) proposed a white matter hypothesis highlighting the connection between white matter pathways in the brain and interaction between the amygdala and the sympathetic nervous system. Autonomic dysfunction is a well established underpinning of elevated stress. Hypertension is a leading cause of death around the world and may be attributed to the body’s abnormal response to external factors like stress.
“Traumatic brain injuries or TBI can occur at any time while working, playing, driving, or riding a bike! TBI is described as a public health problem that results from a sudden force being applied to the head and brain that results from high-speed acceleration-deceleration force coupled with secondary injuries from axonal shearing, cerebral edema, hypoxia, bleeding within the cranium, and autonomic dysfunction” (Sefton, 2014). In cases of brain injury one might see autonomic storming as just described that results from trauma to regions of the brain that control primitive bodily functions like respiration, heart rate, and emotional regulation.
“The brain stem regulates heart rate and respiratory drive as well. These functions are vital to survival and comprise the autonomic nervous system.” (Sefton, 2014) The human stress response drives a growing imbalance of the autonomic nervous system. Namely, the sympathetic nervous system, responsible for our innate fight-flight response is gradually accelerated adding to an influx of stress hormones like cortisol that can cause inflammation in the body. Cortisol can also have negative impact on sleep, memory, and acts as an appetite stimulant (APA). Scientists and physicians agree that chronic inflammation within the body can lead to failure in the affected systems like the heart.
Conder R. and Conder, A. (2014) Heart rate variability interventions for concussion and rehabilitation. Frontiers in Psychology, Review Article, August 2014, Volume 5.
American Psychological Association: cortisol. (n.d.). The American Heritage® Science Dictionary. Retrieved August 04, 2015, from Dictionary.com website: http://dictionary.reference.com/browse/cortisol
Sefton, M. (2014). Autonomic dysfunction: “Storming back from brain injury” Blog post. Retrieved August 6, 2015.
Thayer J. and Lane R. (2009). Claude Bernard and the heart-brain connection: further elaboration of a model of neurovisceral integration. Neuroscience Biobehavioral Review, 33, 81-88.
WESTBOROUGH, MA June 7, 2015 In response to questions I have received from visitors to the web site I have decided to add a wider genre of content to include neuropsychology in general. I have had a tab labeled neuropsychology since the beginning and it has been linked to topics of importance such as traumatic brain injury, cardiac arrhythmia, and dementia. These topics effect everyone at some point especially those people working in the medical field – brain injury, stroke, pain management, and more.
Neuropsychology is the study of the relationship between brain and behavior. When you think about it that includes just about everything from acquired injury, substance abuse to autism. The topics I will post are those in which I am involved here at Whittier and in my practice. I am adding to the content published here and will continue to work with those afflicted with concussion and post-concussion syndrome and their families. I am very excited to add biofeedback and EEG biofeedback to my practice. While I have limited assessment openings – biofeedback has been a demonstrated modality to enhance functioning.
On my other site I have included posts about domestic violence, the “active shooter”, juvenile fire setting and more that also effect many of us who work with people. That site may be reached at http://www.msefton.wordpress.com
“The days of playing after getting your bell rung is no longer a testament to toughness.” O.C.REGISTER 11-12-09