Concussion: The Basics

Football helmet grants

Starting in 2012, helmet reconditioners will no longer accept helmets 10 years or older. Leagues that have depended on reconditioning their helmets every year and cannot afford replacement gear will be most affected. Although helmets do not prevent concussions, most experts agree that newer ones are preferable to used, and an older, unreconditioned helmet might increase the risk of injury. Many leagues ask their booster clubs for assistance with fundraising as this issue has now reached a critical phase. Limited grants for replacement helmets by leading manufacturers are now available for eligible youth leagues in several areas around the country. Applications are now being accepted for youth football programs seeking to replace their league's helmets before the start of the 2012 season. The Centers for Disease Control and Prevention, USA Football and partnering organizations have introduced a helmet replacement program for youth in underserved communities. It is estimated the program will provide almost 13,000 new helmets to athletes in low-income communities beginning in July 2012. To qualify a league must meet the following criteria: - Operate a youth football league (no middle or high school programs) - Live in one of the following areas: Cleveland, New Orleans, New York, or the San Francisco Bay area - Serve an economically disadvantaged area The application process requires registration at USA Football, the governing body for youth football under the NFL. The application is accessible only after viewing a concussion awareness video and pledging to utilize USA Football's resources to educate members of your league before the 2012 season. A visit from an official to verify the ages and number of helmets exceeding 10 years of age in your inventory will occur by mid-June, with new helmets arriving prior to the beginning of the 2012 season. Participating helmet manufacturers include Rawlings, Xenith, Riddell and Schutt. Questions/comments? contact Jean Rickerson at jean@SportsConcussions.org

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"Head Games" previews May 15

The first of three private screenings was held in Chicago on May 15th for "Head Games," a documentary on the sports concussion crisis. From acclaimed director Steve James (Hoop Dreams, The Interrupters) and award-winning producer Bruce Sheridan, Head Games takes a deeper look at the devastating and long-term effects of concussions in all sports. Inspired by events from the book Head Games written by Christopher Nowinski, the film offers eye-opening insight and cutting-edge science on head trauma from the nation’s leading medical experts. Additional screenings will be held June 6 at the Boston University School of Medicine Albany Street Auditorium and June 7 in Philadelphia at the Translational Research Center (TRC) Rubenstein Auditorium. Watch the trailer Questions/comments? contact Jean Rickerson at Jean@SportsConcussions.org

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Study takes closer look at athletes with CTE

New Findings Provide Important Data for Refining Diagnosis Postmortem analysis of the brains of ten professional athletes with chronic traumatic encephalopathy (CTE) provides new insights into the specific types of brain abnormalities associated with this diagnosis, reports a study in the July 2011 issue of Neurosurgery, official journal of the Congress of Neurological Surgeons. The journal is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health. The findings may help to refine the cellular criteria for making the postmortem diagnosis of CTE, provide initial clues as to some possible subytpes, and improve identification of cases. The study was led by Drs. Bennet I. Omalu and Julian Bailes of the Brain Injury Research Institute at West Virginia University.Detailed Information on Brain Abnormalities in CTE The researchers performed a detailed evaluation of autopsy brain specimens from 14 professional athletes and three high school football players who died unexpectedly. The goal was to take an in-depth looks at the cellular-level abnormalities associated with chronic traumatic encephalopathy (CTE)—a progressive neurodegenerative disease caused by repeated head trauma, seen especially in high-level competitive athletes. Patients with CTE develop mood disorders, cognitive dysfunction, and other psychiatric symptoms, typically occurring years after a history of repeated concussions. Drs. Omalu and Bailes have played a pivotal role in CTE research, having reported on the first three cases of CTE in American football players. Of the 14 professional athletes in the study, ten had autopsy brain findings consistent with a diagnosis of CTE. The CTE cases were seven football players, two wrestlers, and one boxer. Most died from non-natural causes—mainly suicide or trauma. The authors present a detailed analysis of the neuropathological findings in their cases of CTE. The main feature was "neurofibrillary tangles" (NFTs) and "neuritic threads" (NTs) scattered in different areas of the brain. The brains also show evidence of localized areas of brain trauma occurring amny years previously. Findings Suggest Possible 'Emerging' Subtypes None of the athletes with CTE had the characteristic brain atrophy (shrinkage) of Alzheimer's disease. None of the brains showed the widespread amyloid deposits typical of Alzheimer's disease, but some had scattered to frequent amyloid deposits. Although there are not yet enough cases to develop a true classification system, the authors identify some possible "emerging phenotypes" of CTE, based on the number and location of NFTs and NTs and amyloid deposits. The researchers also examined the brains of three high school football players who died of trauma sustained during competition. None of these young athletes met criteria for a diagnosis of CTE. However, one brain showed early, "incipient" abnormalities similar to those of CTE brains, likely related to repeated brain injury. Since the first reported case in 2002, there has been growing concern about CTE and other consequences of repeated head trauma and concussions in football players and other athletes. The findings have led to renewed discussion of the consequences of head trauma—not only in athletes, but also in other high-risk groups such as combat veterans. The Brain Injury Research Institute was created to study the short and long-term impact of brain injury and concussions and the development of CTE. Drs. Omalu and Bailes and colleagues hope their findings will contribute to further research into the neurological and psychosocial impact of CTE. In addition to proposing some possible subtypes of CTE, they suggest a set of pathological tests to be performed in diagnostic investigation of possible CTE. They believe that "CTE diagnosis and surveillance should become intrinsic components of routine patient care work-ups and routine hospital/medical examiner autopsies in high risk cohorts like athletes." Source: Study Takes a Closer Look at Brain Abnormalities in Athletes with CTE -- Lippincott Williams & Wilkins -- Newswise July 12, 2011 Questions/comments? Contact Jean Rickerson at Jean@SportsConcussions.org

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Ex-teammate: Seau suffered 1,500 concussions; donates brain

San Diego Chargers' linebacker Gary Plummer believes he suffered 1,000 concussions in his 15 years in the NFL, perhaps as many as five per game. His former teammate, Junior Seau, played for 20 years, leading Plummer to estimate Seau may have suffered about 1,500 concussions over the course of his career. Plummer told the San Jose Mercury News: "In the 1990s, I did a concussion seminar. They said a Grade 3 concussion meant you were knocked out, and a Grade 1 meant you were seeing stars after a hit, which made me burst out in laughter. As a middle linebacker in the NFL, if you don't have five of these (Grade 1 effects) each game, you were inactive the next game. "Junior played for 20 years. That's five concussions a game, easily. How many in his career then? That's over 1,500 concussions. I know that's startling, but I know it's true. I had over 1,000 in my 15 years. I felt the effects of it. I felt depression going on throughout my divorce. Junior went through it with his divorce." It is not known if concussions played a role in Seau's death. Junior Seau's death was ruled a suicide Thursday and his family made the decision to donate his brain to researchers who will be looking for evidence of brain disease brought on by repetitive head trauma. Chronic traumatic encephalopathy, or CTE, a degenerative brain disease that many believe is linked to concussions was found in Dave Duerson's brain. Duerson, who played for the Chicago Bears in the 1980s shot himself in the chest in February 2011. He left a note asking that his brain be donated for research. It is not known if former Atlanta Falcon Ray Easterling's family donated his brain for study. Easterling committed suicide April 19, 2012. His wife said he suffered from dementia. San Diego Chargers chaplain Shawn Mitchell said he didn't know where Seau's brain will be sent. "The Seau family really has, almost like Junior, a philanthropic approach, where they always desire to help others," Mitchell said in a phone interview Friday. "The purpose is not initially to discover anything about their son and what led to these tragic circumstances, but rather the betterment of other people and athletes down the road through anything that can be learned through the study," according to The AP. Source: Ex-teammate: Junior Seau had 1,500 concussions -- USA Today -- May 4, 2012 Chaplain: Seau's brain to be donated to research -- San Jose Mercury News -- May 4, 2012 Questions/comments? contact Jean Rickerson at Jean@SportsConcussions.org

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Former NFL player Coy Wire on concussions: create a new norm

Coy Wire was a team captain for the Buffalo Bills (2002-2007) and the Atlanta Falcons (2008-2011) during his nine years in the NFL. An All-American Honors athlete at Stanford University, Coy was the first player to lead the Cardinal in both rushing and tackles. He was a recipient of the NFL’s Ed Block Courage Award. Q: What would you tell athletes about concussions? The NFL is in a state of evolution and recent changes will only make it safer for younger athletes. The league and the NFLPA (National Football League Players’ Association) have made huge strides to address the concussion issue, while maintaining the excitement of the game for both fans and players. It’s important that all athletes remember that you only get one brain and as we learn more about the long-term and adverse effects of contact sports and repetitive head injury, we know that smaller hits over the course of a career- even a high school career- can accumulate. Learn to recognize the symptoms of head trauma. You can have headaches or you might be slightly dizzy …these are all bearable and many athletes mask these symptoms by taking a Tylenol and then they go out and play again. But a concussion is not an ankle or shoulder injury…later in life you can have surgery on that ankle or have knee replacement surgery but you only get one brain. You can’t get a brain replacement. If you mask head trauma you can be risking increased problems in the future for Alzheimer’s or dementia. Head trauma has to be looked at very differently. Yes, in a way it’s a body part like a shoulder, but your brain must be treated very differently. You can ice and elevate an ankle but can’t do that with your brain. Real damage may show up later in life …and it’s not just football, it can happen in any sport. We used to look at toughness and playing through injuries as a badge of honor. That you were tough both mentally and physically and that continuing to play while hurt brought you the respect of your peers. But we need to change the culture now, and that starts with you. You need to believe that it’s OK to miss a game or a week or longer. If you do have to sit out, it means you were playing hard and you took one for the team. You shouldn’t feel ashamed. And if you care about your friends and your teammates, keep them from harm. If you see a friend of yours doing something to hurt themselves, like playing with a concussion, step up and help them. You’re doing them a huge injustice by allowing them to continue to play. You are your brother’s keeper. Become a hero in their life and help them realize what they probably know deep down inside anyway. Someday they’ll look back and know what you did for them, and they’ll respect you more, later in their lives. Be a leader and help change the game. Help create a new norm. Coy Wire is the author of Change Your Mind; 10 Unconventional Secrets to Retrain Your Brain; March 2012. He is an inspirational speaker and mind coach. For more information contact him at http://www.coywire.com/

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CTE and Alzheimer's; different diseases

Alzheimer’s disease and Chronic Traumatic Encephalopathy (CTE) are both “neurodegenerative diseases.” That is, they are brain diseases that result in the progressive destruction of brain cells, eventually leading to cognitive, behavioral, and other impairments. Both diseases also lead to dementia. The distinction between Alzheimer’s and dementia is very often misunderstood, even by many doctors. “Dementia” is a clinical syndrome defined by memory and other cognitive impairments that are severe enough to cause difficulties in social and/or occupational functioning (i.e., reduced independence in functioning). Dementia is not an illness or a disease. Dementia is not a “mild” form of Alzheimer’s. Rather, it is analogous to “fever,” in that it tells you that you are sick, but doesn’t say what is causing the problem. Similarly, dementia means that there is something wrong with the brain’s functioning, but not what is causing it. Several illnesses and diseases can lead to dementia, including Alzheimer’s disease which accounts for approximately 75% of all cases of dementia. However, several other neurodegenerative diseases result in dementia, including CTE. Alzheimer’s and CTE are distinct diseases. Both Alzheimer’s and CTE can only be accurately diagnosed postmortem through a neuropathological examination of the brain. There have been several new scientific breakthroughs over the past few years that now allow doctors and scientists to be much more accurate in diagnosing Alzheimer’s during life. However, at this time, there is no method of diagnosing CTE during life, although our group at the Boston University Center for the Study of Traumatic Encephalopathy (CSTE) recently received a grant from the National Institutes of Health to begin developing these types of tests. One of the major differences between Alzheimer’s and CTE involves what causes each of the diseases. There is no known specific risk factor that leads to Alzheimer’s. For CTE, however, it is believed that repetitive brain trauma (including concussions and subconcussive blows to the head) is a necessary, but not sufficient risk factor. That is, everyone that has been found to have CTE in postmortem examination has had a history of repetitive brain trauma, including athletes (e.g., football and hockey players, boxers and wrestlers), as well as others, such as combat military personnel, developmentally disabled individuals who repeatedly bang their heads, and victims of domestic abuse. Boxers and football players (especially lineman) appear to be the most likely to get the disease because of the repetitive brain trauma exposure. But, it is important to note that not everyone with a history of repetitive brain trauma will develop CTE. Our center is currently conducting research into the other potential additive risk factors, such as genetics, age of initial brain trauma exposure, frequency and overall duration of exposure, etc. This research will hopefully lead us to understand why one person gets the disease and another person does not. This line of investigation, along with our new study to develop methods of diagnosing CTE during life, will eventually lead to effective treatments and prevention strategies. Robert A. Stern, Ph.D. is a Professor of Neurology and Neurosurgery; Co-Director, Center for the Study of Traumatic Encephalopathy; Director, Clinical Core, BU Alzheimer's Disease Center, Boston University School of Medicine.

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Junior Seau's former agent reflects on his death

The apparent self-inflicted death of legendary NFL linebacker Junior Seau has sent a shock wave throughout the world of sports. Seau played professional football for nineteen years for the Chargers, Dolphins and Patriots and was a 12 time Pro Bowl selection. His flamboyant playing style and jolting hits electrified fans for years. He was 43 years old. This is a time for grief and remembrance. Seau was an integral part of the San Diego community and dedicated time and effort to his charitable foundation. His family needs prayers and support. Normally, speculation as to causation would be premature, but these are not normal times. The spectre of head injury and the disastrous lifetime ramifications call for emphatic action. There is a largely undiagnosed health epidemic which has surrounded contact sports at the youth sports, high school, collegiate and professional level and it is a ticking time bomb. For many years a veil of denial has obscured the reality of what the long term impact of multiple concussions portend. I first became concerned in the late 80's and 90's when I represented half the starting quarterbacks in the National Football League. As I went with clients like Troy Aikman and Steve Young to post-concussion visits with neurologists there were too many unanswered questions. How many head injuries is too many? What are the long term ramifications? How long should a player sit out after suffering the hit? Physicians had few concrete answers, the brain was the last frontier of medical research. I finally decided that I could not in good conscience represent players in a sport that we intuitively knew could cause devestating consequences to the mental faculties of athletes, without becoming an active crusader to raise awareness of the danger. I felt like an "enabler" facilitating a "meat grinder" career. In the 90's we held three concussion conferences in Newport Beach with the leading neurologists, helmet manufacturers, and playing surface representatives talking to Steve, Troy, Warren Moon, Drew Bledsoe and many other clients. We issued a white paper calling for a standardized regimen of diagnosis and "return to play protocols." We urged better helmetry and protective devices. We asked for a neurologist to be put on the sideline and that the head and neck be banned from blocking and tackling. Not much changed. The players themselves were in a state of denial concerning physical health. They had been taught from Pop Warner on to ignore pain, hide injury so as to not lose their starting position or jeopardize their status on the team. They didn't want to be known as "training room" players and be stigmatized and isolated from their peers. They were young men and athletes, two categories that viewed long term health as an abstraction. The most critical priority for them was the next play. And retired athletes were stoic and didn't talk about impaired memory or depression to younger players. In some cases, because concussion is not visible like a leg injury, they may not have known. In conjunction with the Los Angeles based Concussion Institute we helped facilitate another series of Concussion Seminars seven years ago. This time there was concrete data presented by researchers like Dr. Julian Bailes, Dr. Robert Cantu, Dr. Kevin Guskiewicz and Dr. Robert Hovda that seemed to indicate that three was the "magic number." Three or more concussions apparently raised exponentially the post-career risk of dementia, Parkinson's and depression. Presentations were made about the existence of a genotype-an allele of which produced heightened risk of concussion and severe post-concussion consequences. A pattern developed in which the repetitive head injuries produced chronic traumatic encephalopathy, permanent brain damage. Player's like the Bears' Dave Duerson developed depression. Often loss of job and family would occur. And in some cases, suicide. To their credit, Commissioner Roger Goodell and the NFL responded by convening a physician's conference. They issued a whistleblower edict which urged players to report other impaired players. And they adopted baseline testing, developed by Dr. Mark Lovell. A cognivitive test is given prior to a season and in the case of concussion is followed by a second test. This is an objective way to measure the degree of damage and insure that players are asymptomatic at rest, on an excercise bike, and at practice before they are cleared to play. This is something that every parent should insist on for their "collision sport" children. Pro football may be most visible, but the risk is present in many other sports and at the collegiate, high school and youth levels. The adolescent brain may take three times as long to recover and it is still in formation. The physics of collision have changed -- bigger,stronger, faster athletes colliding with a stationary object. And so the problem will accelerate and not diminish. The simple act of offensive and defensive lineman colliding thousands of times produces low level concussive events. What will the cumulative effect of the injury mean for athletes in their forties and fifties? I knew Junior Seau since the day he and his massive Samoan friends partied back stage as he was drafted in New York City. He was only 43. I represented him for a time. I love sports, but love the individuals who play them more. As Peter, Paul and Mary sang, "How many deaths will it take 'till we know that too many people have died?" We need to find the answers, they can't just be "blowing in the wind." Leigh Steinberg was a sports agent for almost forty years. He represented many of the nation's most recognizable athletes including Troy Aikman, Steve Young, Drew Bledsoe, and Warren Moon. Leigh negotiated over $2 billion in contracts during his career. He was also the inspiration for the 1996 movie Jerry Maguire starring Tom Cruise. He is now CEO of Steinberg Sports and Entertainment located in Los Angeles, California. Leigh is a member of the SportsConcussions.org Advisory Board. Photo, above: (c) 2009 Dave Sizer@creativecommons.com Questions/comments? contact Jean Rickerson at Jean@SportsConcussions.org

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NFL draft highlights concussion issues

Concern over longevity issues stemming from a string of injuries including back-to-back concussions, may have contributed to Chris Owusu's omission from the first seven rounds of the NFL draft this weekend. But Stanford's talented receiver, who turned in one of the fastest times in the 40-yard dash at the NFL Combine in February and was considered a possible top 100 prospect during his senior year, was signed by the San Francisco 49ers shortly after the draft concluded on Saturday. Owusu, one of Andrew Luck's go-to receivers missed the end of his senior season including two Bowl games after suffering two concussions in three weeks, his third in a little more than a year. Admitting to frustration because his symptoms cleared rapidly after each injury, he was not authorized by Cardinal physicians to return. Considered a third-round talent, Sports Illustrated's Jim Trotter spoke to several general managers about Owusu. "He's off our board," says one general manager. "He was from the start. It wouldn't matter if he was RG3, he'd still be off our board. With that kind of history it's not worth the risk of him being seriously injured, especially with all the attention you're going to receive. If you draft him you're going to be under the microscope the whole time. Every time he gets hit it's going to be magnified tenfold." For the 49ers, Owusu was too good to pass up. "Chris wasn't wiped off our board," 49ers general manager Trent Baalke said Saturday when he met the media at the conclusion of the draft. "You've got to remember, he was cleared to play by the same group of doctors that work with us on a regular basis. He certainly was not off our board," according to NBC SportsGroup. Owusu was taking part in a Stanford School of Medicine research project when he suffered at least one of his concussions. Researchers recorded impact data from players wearing high-tech mouthguards in an effort to gain a better understanding of the forces that cause the injury. Source: Read more: http://sportsillustrated.cnn.com/2012/writers/jim_trotter/04/25/draft.concussions/index.html#ixzz1tSyGvhE8 Questions/comments? contact Jean Rickerson at Jean@SportsConcussions.org Photo: (c) Maveric2003@creativecommons

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Brain wiring a no-brainer? (video)

The brain appears to be wired more like the checkerboard streets of New York City than the curvy lanes of Columbia, Md., suggests a new brain imaging study. The most detailed images, to date, reveal a pervasive 3D grid structure with no diagonals, say scientists funded by the National Institutes of Health. “Far from being just a tangle of wires, the brain’s connections turn out to be more like ribbon cables -- folding 2D sheets of parallel neuronal fibers that cross paths at right angles, like the warp and weft of a fabric,” explained Van Wedeen, M.D., of Massachusetts General Hospital (MGH), A.A. Martinos Center for Biomedical Imaging and the Harvard Medical School. “This grid structure is continuous and consistent at all scales and across humans and other primate species." Wedeen and colleagues report new evidence of the brain’s elegant simplicity March 30, 2012 in the journal Science. The study was funded, in part, by the NIH’s National Institute of Mental Health (NIMH), the Human Connectome Project of the NIH Blueprint for Neuroscience Research, and other NIH components. “Getting a high resolution wiring diagram of our brains is a landmark in human neuroanatomy,” said NIMH Director Thomas R. Insel, M.D. “This new technology may reveal individual differences in brain connections that could aid diagnosis and treatment of brain disorders.” Knowledge gained from the study helped shape design specifications for the most powerful brain scanner of its kind, which was installed at MGH’s Martinos Center last fall. The new Connectom diffusion magnetic resonance imaging (MRI) scanner can visualize the networks of crisscrossing fibers – by which different parts of the brain communicate with each other – in 10-fold higher detail than conventional scanners, said Wedeen. “This one-of-a-kind instrument is bringing into sharper focus an astonishingly simple architecture that makes sense in light of how the brain grows,” he explained. “The wiring of the mature brain appears to mirror three primal pathways established in embryonic development.” As the brain gets wired up in early development, its connections form along perpendicular pathways, running horizontally, vertically and transversely. This grid structure appears to guide connectivity like lane markers on a highway, which would limit options for growing nerve fibers to change direction during development. If they can turn in just four directions: left, right, up or down, this may enforce a more efficient, orderly way for the fibers to find their proper connections – and for the structure to adapt through evolution, suggest the researchers. Obtaining detailed images of these pathways in human brain has long eluded researchers, in part, because the human cortex, or outer mantle, develops many folds, nooks and crannies that obscure the structure of its connections. Although studies using chemical tracers in neural tracts of animal brains yielded hints of a grid structure, such invasive techniques could not be used in humans. Wedeen’s team is part of a Human Connectome Project Harvard/MGH-UCLA consortiumExternal Link: Please review our disclaimer. that is optimizing MRI technology to more accurately to image the pathways. In diffusion imaging, the scanner detects movement of water inside the fibers to reveal their locations. A high resolution technique called diffusion spectrum imaging (DSI) makes it possible to see the different orientations of multiple fibers that cross at a single location – the key to seeing the grid structure. In the current study, researchers performed DSI scans on postmortem brains of four types of monkeys – rhesus, owl, marmoset and galago – and in living humans. They saw the same 2D sheet structure containing parallel fibers crossing paths everywhere in all of the brains – even in local path neighborhoods. The grid structure of cortex pathways was continuous with those of lower brain structures, including memory and emotion centers. The more complex human and rhesus brains showed more differentiation between pathways than simpler species. Among immediate implications, the findings suggest a simplifying framework for understanding the brain’s structure, pathways and connectivity. The technology used in the current study was able to see only about 25 percent of the grid structure in human brain. It was only apparent in large central circuitry, not in outlying areas where the folding obscures it. But lessons learned were incorporated into the design of the newly installed Connectom scanner, which can see 75 percent of it, according to Wedeen. Much as a telescope with a larger mirror or lens provides a clearer image, the new scanner markedly boosts resolving power by magnifying magnetic fields with magnetically stronger copper coils, called gradients. Gradients make it possible to vary the magnetic field and get a precise fix on locations in the brain. The Connectom scanner’s gradients are seven times stronger than those of conventional scanners. Scans that would have previously taken hours – and, thus would have been impractical with living human subjects – can now be performed in minutes. “Before, we had just driving directions. Now, we have a map showing how all the highways and byways are interconnected,” said Wedeen. “Brain wiring is not like the wiring in your basement, where it just needs to connect the right endpoints. Rather, the grid is the language of the brain and wiring and re-wiring work by modifying it.” Curvature in this DSI image of a whole human brain turns out to be folding of 2D sheets of parallel neuronal fibers that cross paths at right angles. This picture came from the new Connectom scanner.Source: Van Wedeen, M.D., Martinos Center and Dept. of Radiology, Massachusetts General Hospital and Harvard University Medical School Reference Wedeen VJ, Rosene DL, Ruopeng W, Guangping D, Mortazavi F, Hagmann P, Kass JH, Tseng W-YI. The Geometric Structure of the Brain Fiber Pathways: A Continuous Orthogonal Grid. March 30, 2012 Science. ### The mission of the NIMH is to transform the understanding and treatment of mental illnesses through basic and clinical research, paving the way for prevention, recovery and cure. For more information, visit the NIMH website. The NIH Blueprint for Neuroscience Research is a cooperative effort among the NIH Office of the Director and the 15 NIH Institutes and Centers that support research on the nervous system. By pooling resources and expertise, the Blueprint supports transformative neuroscience research, and the development of new tools, training opportunities, and other resources to assist neuroscientists. About the National Institutes of Health (NIH): NIH, the nation's medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit the NIH website. Questions/comments? contact Jean Rickerson at jean@SportsConcussions.org

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by Réjean M. Guerriero, DO^*^† and William P. Meehan III, MD^*^‡§║

*Brain Injury Center, †Department of Neurology, ‡Sports Concussion Clinic, Division of Sports Medicine and §Division of Emergency Medicine, Children’s Hospital Boston, Harvard Medical School, Boston, MA; ║The Micheli Center for Injury Prevention and Health Promotion of the Young Athlete, Waltham, MA

Introduction

Concussion is type of traumatic brain injury. While many concussions resolve quickly, in some cases the effects of concussion can last for months. Furthermore, the long-term consequences from sustaining repeated concussions can be substantial. In this overview we will define concussion and discuss how frequently it occurs. Additionally, we will explain the body mechanics that can lead to a concussion and the process by which brain cells are injured. We will walk through many of the common symptoms of concussion, as well as the appropriate management and steps needed to return to normal activities.

Definition of Concussion and How Commonly It Occurs

Simply put, a concussion is: “temporary, trauma-induced brain dysfunction.” In other words, the brain stops working properly, as a result of injury. A concussion is a complex brain injury that results from direct or indirect head trauma. While previously referred to in athletics as a “ding” or “getting your bell rung,” efforts are being made to use more appropriate terms, such as “concussion” or “traumatic brain injury” that underscore the potential seriousness of concussion. Concussion causes temporary symptoms, such as headaches, confusion, nausea, loss of consciousness, or amnesia. It is a problem of brain function, as opposed to structure – meaning concussion by itself does not cause bleeding, bruising or swelling of the brain. Therefore, a concussion cannot be seen on medical pictures of the brain such as “MRIs” or “cat scans,” also known as “CTs.”

Concussions have received a significant amount of attention in the media in the last several years, particularly those that occur in amateur and professional sports. Recognizing the potential for serious long-term problems for athletes who sustain multiple concussions, The National Football League (NFL) and National Hockey League (NHL) have begun instituting policies designed to protect athletes from concussion and to ensure that players recover adequately following this injury. Many states now have laws in place to protect younger athletes from returning to play too soon following a concussion. It is appropriate to ask your coaches, athletic trainers, or other school officials what these policies are in your area.

The CDC estimates that there are as many as 3.8 million sport-related concussions in children and adults per year. Each year, 144,000 children are taken to the emergency department after sustaining a concussion. The highest rates of concussion in athletics occur in collision sports such as football, rugby, boys’/men’s ice hockey and boys’/men’s lacrosse. However, the rates in contact sports such as soccer and basketball, both male and female, are substantial.

Mechanism of Concussion and Brain Injury

A concussion may occur from a direct blow to the head and neck or a hit to the body with an indirect force that shakes the head, such as occurs in “whiplash” injuries. Concussion is caused by a rapid spinning (or rotational acceleration) of the head. This often occurs in sports when an athlete’s chin or head is struck by an opponent or a piece of athletic equipment. Similarly, if the athletes chin or head strikes the playing surface (field or ice) the head can be spun rapidly causing a concussion. When the skull and the brain within it are spun rapidly, the nerves or brain cells temporarily stop working properly. This interruption in normal brain cell activity leads to headaches, confusion, and other symptoms described below.

Symptoms

A symptom is something that an injured person feels or experiences. Some common symptoms of concussion include: headache, dizziness, balance problems, confusion, visual disturbances, sensitivity to light and noise, nausea, fatigue, excessive sleepiness or difficulty sleeping, loss of consciousness, convulsions, vomiting, disorientation, memory loss, attention problems, difficulty concentrating, and feeling in a “fog” or “dazed.” After a concussion, emotional symptoms can also appear including: irritability, sadness, anxiety, and rapid changes in emotion. These symptoms may change over time. Often, the more dramatic symptoms such as memory loss, confusion, vomiting, and loss of consciousness will immediately follow the concussion, while less obvious symptoms such as irritability or problems with attention and concentrating are revealed minutes, hours or a day or two later, when the more dramatic symptoms start to resolve. Regardless of how many symptoms one experiences or how severe the symptoms are, they are all characteristics of brain injury and should be discussed with your doctor or other medical professional.

Seeking Medical Attention

Anyone who sustains a head injury and is “knocked out,” has a convulsion, loses consciousness, is confused or disoriented, has persistent vomiting, or appears concerning in any other way should seek medical attention as soon as possible. If the athlete appears well and medical attention is not readily available, then it is reasonable to monitor the person closely at home. If the physician examining a patient with a concussion is concerned that there may be another injury, such as a skull fracture, bleeding in the brain, or swelling of the brain, he or she may consider getting an image of the head, such as a CT or MRI. The decision whether to do one of these tests is individualized and depends on the how the injury occurred and the patient’s physical examination. The decision is best left up to the physician managing the athlete.

Recovery, Treatment and Return to normal activities

Most concussions will heal on their own within a few days to a few weeks. In fact, 98% of high school athletes recover from their concussions within a month of the injury. The most important aspect of treatment and recovery is REST. There are 2 types of rest: physical and cognitive. Physical rest means avoiding vigorous exercise – avoiding activities that increase the heart rate. Cognitive rest is equally important and often overlooked. The word “cognitive” is used to describe activities that involve thinking, concentrating, remembering, or other intellectual activities. Cognitive rest means avoiding or at least minimizing cognitive activities. Common cognitive activities include schoolwork, reading, playing card or board games, playing video or computer games, and text messaging. Typically the more dedicated one is about rest and recovery; the quicker one can return to normal activities.

Returning to sports should be done in progressive stages. The following recovery plan was adapted from the most recent International Conference on Concussion in Sport. Typically, each step occurs over a 24-hour period monitored by medical personnel, such as a doctor or athletic trainer. An individual must remain symptom free in order to progress to the next stage. If symptoms return at an activity level, the athlete should return to the prior symptom-free step for at least 24 hours.

Step:

1. Complete physical rest

2. Light aerobic exercise, such as walking or easy (low effort) stationary cycling.

3. Sport-specific exercise, such as ice skating, swimming, or running.

4. Non-contact training drills and progressive resistance training

5. Medical clearance

6. Full contact practice

7. Return to play

Conclusion

A concussion is temporary, trauma-induced brain dysfunction. It is a complex form of traumatic brain injury. This injury can result in headaches and functional disturbances that lead to the symptoms discussed above. Concussion is not bleeding, bruising, or swelling of the brain. Typically, the brain is able to recover from a sport-related concussion within a few days or weeks; however, some individuals may experience symptoms for several weeks or months. Regardless, the most important aspect of recovery from concussion is physical and cognitive rest. If you think that you or someone you know has sustained a concussion, be sure to talk with a medical professional.

Further Reading and Resources

Website sponsored by the Centers for Disease Control and Prevention:

www.cdc.gov/concussion

Website sponsored by the American Academy of Pediatrics. Search “Concussion”:

www.healthychildren.org

Website sponsored by the National Federation of State High School Association. Search “Concussion”:

www.nfhs.org

Meehan, W. P. (2011) Kids, Sports, and Concussion: A Guide for Coaches and Parents.

Satan Barbara, CA: Praeger

McCrory, P., Meeuwisse, W., Johnston, K., Dvorak, J., Aubry, M., Molloy, M., & Cantu, R. (2009). Consensus statement on concussion in sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008 Journal of athletic training, 44(4), 434–448.

Current research

Concussion research has increased dramatically over the past several years, particularly at the youth level. However, studies take time. Much of the data that's been accumulated so far applies to adults and does not extrapolate directly to youth athletes. Therefore, it is important to remember that adult remedies may not be suitable for student-athletes. For instance, tests performed on adult helmets, with adult-sized forces and dimensions, do not apply to youth helmets. Human brains are not fully developed until around age 25.

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School professionals play an important role in the health of all students. Recognizing the signs and symptoms of concussion is important, as is managing their return to school post-injury.
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