Neurological trauma and enduring change in survivors

Westborough, MA December 18, 2017 The British Medical Journal Lancet recently published a series of articles describing the long-term effects of brain trauma. The series is worth a serious read for those who are in the position to take care of trauma patients.

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There has been little change in our approach to handling the individual grind of caring for the TBI patient I must sadly admit.  Young and old it takes both patience and dedication to achieve the best outcomes with those we bring into our treatment continuum. “Survivors experience a substantial burden of physical, psychiatric, emotional, and cognitive disabilities, which disrupt the lives of individuals and their families, and pose huge costs to society” according the Lancet, 2017.  Many readers have read my post Updates in these pages where I have detailed well-known athletes like Formula 1 car driver Michael Schumacher and Mike Towell, the Irish boxer both of whom were seriously injured from TBI.  Towell died from injuries linked to second impact syndrome following a match in 2016.
Schumacher remains in a minimally conscious state in Switzerland.  He is conscious but does not speak or move about.  He requires 24 hour medical care and is living is a special suite adapted in his home that allows him to continue to receive the best care possible while being in his familiar setting surrounded by family and friends.  The cost of his care exceeds $ 100,000 per month.
Some reports suggest Mr. Trowell had sustained a brain injury in the early rounds of the fight.  “Essentially, “second impact syndrome” or SIS results from the brain’s inability to autoregulate cerebral perfusion pressure and swelling as a result of repeated cerebral trauma.” Sefton, 2016 on second impact syndrome and Mike Trowell
Autonomic regulation is the role of the brain stem that maintains the diurnal pattern of arousal for wakeful activity and sleep hygiene.  The brain stem regulates heart rate and respiratory drive as well.  These functions are vital to survival and comprise the autonomic nervous system.  The ANS functions as the brain and body’s alarm system signaling the need for fight-flight activation according to a Autonomic Storming post by Michael Sefton, Ph.D.
Lancet identifies the complexity of TBI and its multifactorial underpinning.  A growing number of patients are elderly that contribute to “heterogeneity of outcomes and consider ways forward for targeted management of severe TBI in the intensive care unit” as mentioned in the 2017 Lancet summary.  Improved management of TBI in the trauma centers and ICUs bring forth better rehabilitation candidates and better outcomes including return to home and eventually return to preinjury employment for many.  Surgical intervention crafted to decrease secondary injury to brain have been enhanced by improved diagnostic accumen, imaging and novel techniques such as radical craniectomy and cranioplasty for management of intracranial pressure and its associated edema.
The series also explains PSH or “autonomic storming” something that I have described in several posts and can be quite serious both in the trauma canter and later in the rehabilitation hospital   “Geert Meyfroidt and colleagues provide an overview of paroxysmal sympathetic hyperactivity, a consequence of acute brain injury, and discuss the promise of improved characterization and implications for management”. Damage to the system that regulates sympathetic and parasympathetic functioins due to traumatic brain injury can be unsettling for familiy members and clinicians alike. The recovering subject can have wild swings of autonomic arousal such as elevated heart rate – patients sometimes chug along at 140-160 while autonomic storming.  Paroxysmal changes in blood pressure may pose significant risk, respiratory rate may become tachypnic, patients frequent are febrile and may become excessively sweaty  as a consequence of autonomic dysfunction.  Patients in our rehabilitation frequently undergo repeated blood cultures and lab studies looking for a source of infection.  Many are returned to the trauma centers for additional brain imaging studies and cardiac monitoring that takes hours and is often unneccessary.  These procedures delay recovery and add confusion to the patient and his family.
The regulation of the secondary injuries such as paroxysmal sympathetic hyperactivity is essential for patient well-being and outcome measures including returning home and re-entering the work force. The Lancet series is a well written update on current brain injury treatment and management of this serious public health threat.

 Lancet Neuology (2017) Jun;16(6):452-464. doi: 10.1016/S1474-4422(17)30118-7. Traumatic Brain Injury. Taken 12-18-2017.
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The state of knowledge and policy on concussion in Rugby Football Union

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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. https://www.nytimes.com/2014/04/06/sports/in-europe-echoes-of-america-as-concussions-spur-debate.html?_r=0  Taken June 13, 2017
Sefton, M. (2016) Second Impact Syndrome. https://concussionassessment.wordpress.com/2016/10/03/second-impact-syndrome-rare-but-often-fatal/ Taken August 7, 2017
Bandidi, P. (2016) Rugby, like NFL, doesnt have the conussion-issue figured out.  http://www.espn.com/espn/story/_/id/16029747/rugby-nfl-concussion-issue-figured-out Taken August 7, 2017
NCAA Concussion Concussion Safety Protocol. Guidelines https://www.ncaa.org/sites/default/files/2017SSI_ConcussionSafetyProtocolChecklist_20170322.pdf 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.

Return to school: Psychologists also working in the trenches after concussion

CONCUSSION-SCHOOL LIAISON 2017
WESTBOROUGH, MA May 1, 2017 The return to school following a brain injury should be carefully planned.  School nurses tend to be the point person for parents’ whose children are coming back to school after concussion.  But let’s not forget the school psychologist.  My wife, Mindy Sefton, Psy.D., is trained in concussion management and has crafted some of the best return-to-learn plans I have ever seen.  She works closely with the nurse and classroom teachers to be sure no student be placed at risk for failure. At her middle school there is a protocol for re-entry that is specific and tailored for individual students.
Students with acute concussion and those suffering with post concussion syndrome require assistance at school or risk falling behind their peers.  Some parents are not aware but it is true that when concussion sidelines and athlete he or she is highly vulnerable for school-related changes as well.  Schools or educational teams who are interested in offering a comprehensive concussion education program are encouraged to contact CAMP or Dr. Sefton directly for consultation. Student athletes often require support in school while recovering from concussion. Support protocols like reduced work, extra time for tests, and deferred projects are just three commonly prescribed accommodations.
 I am happy to help public schools with their protocols.  They are critically important for student success.  Individual programs can be integrated slowly on a team by team basis depending upon learning style, specific sport and unique student needs.  Dr. Sefton has specialized training in pediatric brain injury, concussion and neuropsychological assessment and is a member of the Academy of Brain Injury Specialists.  Training for coaches and trainers is available and recommended to identify updated return-to-play protocols and current standards of care.  Both web-based and individualized ImPACT testing is available for preseason and after injury assessment.  Return-to-play consultation is available with trainers and team physicians 24/7 at 508-579-0417 and email msefton@qmail.qcc.edu

School districts interested in using CAMP for supporting athletes injured while playing sports can contact Dr. Sefton at 508-579-0417.  Parents and physicians may call Dr. Sefton at any time to discuss individual injuries and school and sports  re-entry after injury. Post injury testing and neuropsychological consultation is also available. 

HeadacheReturn-to-Learn Care Plan
Some students who are injured playing in school sports may require a return to school care plan.  Dr. Sefton will consult with student, parents, and school personnel to assist with short-term accommodations in school that can assure for continued success in academic domains.  Not all children require changes in their educational programs but careful consideration of the child’s school functioning is essential.
Classroom teachers should be advised to monitor the student athlete for the following signs:
  • Increased problems paying attention/concentrating
  • Increased problems remembering/learning new information
  • Longer time required to complete tasks
  • Increase in physical symptoms (e.g., headache, fatigue) during schoolwork
  • Greater irritability, less tolerance for stressors

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

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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 http://www.bbc.com/news/health-38584975, taken January 14, 2017
WebMD post,  http://www.webmd.com/brain/news/20170111/stress-ball-in-your-brain-may-be-key-to-heart-risks#2, taken January 14, 2017
Sefton, M. (2016) Coincident stress may contribute to post concussion symptoms, blog post, https://concussionassessment.wordpress.com/2016/09/26/coincident-stress-may-contribute-to-pcs/, taken January 14, 2017

Concussion – Physicians once espoused a link to unresolved litigation

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Bennet Omalu, M.D. was first to recognize the impact of repetitive trauma and concussion PHOTO – The Trent
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