Lives Change When Symptoms Linger

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

Readmore
"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

Readmore
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

Readmore
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

Readmore
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/

Readmore
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.

Readmore
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

Readmore
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

Readmore
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

Readmore

Lives change when symptoms linger

Created on Monday, 22 August 2011 12:23

Last Updated on 17.05.2012

Published Date

Heather Ouimette was a popular cheerleader who didn't realize a concussion she suffered while sledding with some friends, would derail her. Hear from Dr. Joel Becker, Heather, and her mother as they describe her injury, prolonged recovery, and how it impacted her life...in their own words.

by Dr. Joel Becker

As a Clinical Neuropsychologist, I often have the opportunity to really “get to know” the individual I work with. Many of the student athletes I see, have follow-up with consultations over extended time periods; some weeks to a month, others months to a year or beyond.

Working with these resilient and determined young people has made me aware of the journey that many have to endure in order to reach their recovery goal.

This “case study” presentation is based on the study of one young woman who has sustained a long duration of persistent post concussion syndrome. Although her healing phase has been lengthy, she has and continues to have progressive recovery eighteen months after her initial injury. What follows is Heather’s story. I have integrated diagnostic and treatment knowledge through her vivid depiction of this frequent but elusive injury.

Brief History

Heather was 15 years old when she and several friends went sledding down a ski slope on an air mattress. Unfortunately, the mattress hit a point where Heather and her peers were catapulted off the fast moving object resulting in Heather flying a number of feet through the air with her head hitting the ground and the possibility of some body to body contact as well. There was likely a few seconds of loss of consciousness with substantial confusion subsequently. As with many of these types of injuries, the exact location of impact is often uncertain due to lack of palpable visible evidence on the outside and the nature of the individual’s sensorium being affected at the time of the injury. In Heather’s case, it did appear that the impact was focused to some degree toward the posterior right side and toward the back of her head on the right as well (parietal/occipital area). Despite this, the potentiality of other areas of the brain being involved due to the movement of the brain inside the cranium was certainly present. Heather experienced acute concussive symptoms immediately afterward. This included confusion, some memory loss of the injury and the events that happened immediately after the injury. Significant headaches, dizziness, concentration difficulty and sensitivity to light were also present. The information available indicated no observable lesion, bleed, swelling, fluid accumulation that could be detected by examination at a local ER.

Careful history taking is very important with this type of injury. The history of Heather’s neurological status indicated that at age 9 there was a concussive injury, which was diagnosed by a physician in an outpatient office. Heather apparently was swinging from a swing about three to four feet off the ground and was hanging by her legs when she fell and hit the hard ground resulting in some brief loss of consciousness. She was diagnosed with a concussion at that time but did not have any substantial residual difficulties

After the sledding accident, Heather was followed by her medical care providers over the subsequent months status post her injury. She was initially seen by me approximately five months later. Upon her initial consultation the following basic symptoms and challenges were identified: Cognitive difficulties consisted of difficulty with listening and trying to pay attention during conversations and class presentations, feeling sleepy or more tired even though she had a good rest the night before. There was also difficulty with intentional memory, (that is difficulty with remembering things that she wanted to do later on that day) there was difficulty with being distracted by outside stimuli in her environment and there were a couple of times a week where Heather felt she was “out of it” at times. In addition, as time went on, physical symptoms persisted including moderate to severe headaches, moderate to severe dizziness, severe fatigue, moderate to severe drowsiness, and notation of moderate to severe difficulty with concentration. On a mild to moderate level was difficulty with falling asleep. Symptoms on a minor level were nausea, balance problems, sensitivity to light, irritability, feeling slowed down.

Heather was an A/B student and had been participating as a high school cheerleader for two years. Her developmental history was largely unremarkable with the exception of the earlier concussion noted and history of frequent ear infections as a young child. All developmental milestones were met on time and there was no history of learning style difference nor any such history in the family.

As is often the case, the concussion injury was the most significant injury that the young healthy individual has incurred throughout their lifespan. When there is a history of learning style differences or neurocognitive difficulties often these pre-existing vulnerabilities are amplified at least during the initial recovery period.

The Role of Neurocognitive Diagnostic Assessment

With Heather sustaining new difficulties as noted throughout the first several months subsequent to her concussive injury, she, her family and healthcare providers continued to search for ways to manage and treat her ongoing symptom status. At this point, a Clinical Neuropsychologist is often consulted and this is what occurred in Heather’s case. She was administered a Neurocognitive Diagnostic Evaluation and a treatment plan was developed for her.

Cognitive Diagnostic Results

On assessment of attention focusing, Heather showed a tendency toward inattention and poor vigilance when having to sustain attention over extended periods of time. She also had moderately slow processing speed for nonverbal material that was given to her by a computerized program. Her working memory, as well as her visual scanning ability and being able to efficiently use the information from memory were attenuated. Other assessments found that there was loss of information for initial material that was learned and there was a trend toward left visual hemifield inattention. Motor skills were affected to some degree in that finger tapping speed in both hands was attenuated.

Despite some of these attenuated findings, there were also some definite indications of retained high levels of performance in that Heather performed well above average on a subtest that involved picking out essential details missing from pictures. Her ability to use abstract verbal conceptualization was well within normal limits and nonverbal reasoning ability was also well within normal limits. Qualitatively, she was highly motivated toward improving herself and maintaining consistent follow-up with her care providers.

The year that followed: The results of the Neurocognitive Diagnostic Assessment including information from the medical records that were available, pointed to an ongoing post concussion syndrome of a persistent type. Her age group, gender and nature of her injury may have correlated with this present finding. Her previous concussion earlier in her life may have some relationship to her present ongoing injury status. Her injury also likely involved more than one hit at the immediate time and there may have been rotation of the head due to the velocity and impact that she had sustained. Heather’s injury is likely due to multiple brain areas being involved. These areas of interest include frontal cortical areas, deep medial temporal lobe areas and the possibility of subcortical white matter as well as lower brain areas such as cerebellum. A number of recommendations were made for Heather, which were included in her IEP plan at school.

Current Progressive Status

When last seen in July of 2011, Heather had significantly progressed and her symptoms and difficulties had diminished. Although she does still have presence of some headache, (particularly on stressful days), mild dizziness, some fatigue and a number of other milder symptoms.

INTERVIEW WITH HEATHER 18 MONTHS AFTER HER CONCUSSION

Dr. Becker: Heather it has been approximately 18 months since your concussion of January 2010. There are a number of times when you experienced a return of symptoms or certainly when you experienced the symptoms more intensely. I was wondering if you could describe what it was like when those symptoms do come back? Could you correlate activities or events that were going on in your life at that time?

Heather: When I would move around a lot and become active it would come back stronger than doing anything else. My social life definitely took a turn for the worse. Right away I could tell that I wasn’t getting along with my friends as well and I couldn’t be around them as much as I used to. It would wear me out and I just couldn’t do it. With school, right away it affected my grades and just my attitude towards everything because it was harder to concentrate and remember stuff.

Dr. Becker: So even your social life was affected?

Heather: Yes, definitely.

Dr. Becker: You are about to return to school full time as a senior. I was wondering if you could describe the challenges that lie in front of you as you return to full time cognitive exertion in your academics ,personal activities, your physical exertion as well as social activities and others you will be involved in?

Heather: Ending off last year I was still behind in a lot of stuff, so I am kind of worried that I am going to fall behind again and not be caught up with the rest of the students and I am scared that it is going to be hard for my memory to remember stuff and to actually get stuff done on time. And as for social life I think it’s getting better now so I am not too worried about that.

Dr. Becker: What about other things you do, like physical activity, even just having fun going to a dance or similar leisure events?

Heather: That is fine right now.

Dr. Becker: Do you think it will be fine when you get into the whole gamut of things, the school environment and other related events?

Heather: Yes.

Dr. Becker: Of the experienced neurocognitive and physical symptoms that you may still be having, which are the ones that are the most troublesome for you? What are the top five that are current, still in play?

Heather: Definitely headaches, dizziness, concentrating, memory, drowsiness, and being tired.

Dr. Becker: Would you say that drowsiness is like the fatigue you experience after you’ve done a lot of things or do you wake up that way?

Heather: After I am out all day or doing stuff it wears me down really fast, so that effects me.

Dr. Becker: Now if I compared that to your baseline, (you know before the injury), would you become as fatigued as you are now or is it different?

Heather: No, it was never as bad as this.

Dr. Becker: So average active days that you would have had in the past are much more fatiguing now?

Heather: Yes.

Dr. Becker: What have you done that has been the most helpful to you as far as implementing treatment suggestions? Were there helpful changes or modifications in your home, your school, or your lifestyle? Have there been things you have been able to do or take on that have been suggested to you that make a difference?

Heather: Definitely relaxing and staying calm and not getting stressed out and just taking it easy all together probably helped the most.

Dr. Becker: Do you find that knowing when to rest, knowing to carefully take those rest breaks help?

Heather: Yes. When I need them I definitely take them.

Dr. Becker: And people respect you?

Heather: Yes, absolutely.

Dr. Becker: And that’s at school too, right?

Heather: Yes.

Dr. Becker: So would you say that that’s an important component?

Heather: Yes. That is probably what has helped me the most.

Dr. Becker: Knowing when to take breaks?

Heather: Yes, and having the opportunity to.

Dr. Becker: Let’s say you have to take a break at school or you are at home doing homework or something like that. How long do the breaks have to be?

Heather: It could vary from like five minutes to half an hour. It depends on how bad the day is going. But usually about five to ten minutes. I just have to collect my thoughts and just relax.

Dr. Becker: And that resets you?

Heather: Yes.

Dr. Becker: And you can go back to what you were doing and it works?

Heather: Yes.

Dr. Becker: How has the awareness of your injury and what your injury has been like affected your general outlook on life?

Heather: I am definitely more careful. I don’t take as many risks. I know the effect of what could happen.

Dr. Becker: Do you think it makes you look at things differently? Do you look at other people differently? Do you see things that you didn’t see before about what people do or how to help people?

Heather: I think that I have grown personally from it. It has helped me that way. I do see people differently and I realize that they could be going through stuff that I don’t know about. It helps me look at it from a different angle.

Dr. Becker: So you are literally more insightful or empathetic toward what other people might be going through and what their issues might be?

Heather: Yes.

Dr. Becker: What things would you like to say that may be helpful to other young adults that might be experiencing the same type of injury? Is there any advice that you would like to offer them as a result of your personal experience?

Heather: Definitely have patience because this is something that takes time to heal and get over. So don’t rush and force yourself back into healing because it is not going to work.

Dr. Becker: So basically, what you are saying is that it’s going to take time and it is different for everybody.

Heather: Yes.

Dr. Becker: So just because your friend healed in three months or whatever, it doesn’t mean it is going to be the same for you.

Heather: Right. It’s different for everyone.

Dr. Becker: Heather do you have any questions that are still like happening in your life?

Heather: No.

Dr. Becker: So right now you have a pretty good perspective, feel pretty on top of it?

Heather: Yes.

Dr. Becker: Thank You.

Brief Interview with Mrs. Ouimette

Dr. Becker: Mrs. Ouimette, you have been helping support Heather through the past eighteen months. How has it effected you personally and other family members? What have you done to make it work and help yourself cope with this kind of thing since you have been so actively involved in all of this, (going to appointments and supporting Heather; how have you dealt with this?

Mrs. Ouimette: It has been hard to deal with it. It’s been very stressful constantly going to Dr.’s appointments and running around makes it a little stressful on the family because we are constantly going and constantly moving and doing things, constantly going to Dr.’s appointments here and there.

Dr. Becker: So it has been hard. How have you been able to stay healthy? What have you done?

Mrs. Ouimette: I just tell myself that this is for the best for Heather and the rest of things in life have to wait and she comes first. I know I have just really dealt with it and just knew that this is what needs to get done.

Dr Becker: Did you get help? Did you get other family members or friends to support you?

Mrs. Ouimette: My husband has been very helpful with doing things around the house, household chores and he is there to support us. Other family members have kicked in and done things to help out too.

Dr. Becker: Would you say that that is important?

Mrs. Ouimette: Absolutely. Outside family members for help is definitely important to have.

Dr. Becker: So they need to know what is going on and understand what you have to deal with so they can be available to help out?

Mrs. Ouimette: Yes, they need to know what is going on with Heather so when she is visiting at their house and she starts to get tired or worn down they need to know that she needs to relax and they can’t keep pushing her.

Dr. Becker: Have you noticed that when in social situations people may not always understand what Heather is dealing with?

Heather: Yes.

Mrs. Ouimette: They feel like she should be acting like a normal sixteen-year old and she can’t always.

Dr. Becker: Mrs. Ouimette, what are the things that you are most aware of that remain a concern or challenge for Heather?

Mrs. Ouimette: My main concern is her schoolwork. I know that it is still a challenge for her to complete and to follow along with everybody. She is getting better with it, but it is still a concern for me. Her social life is not as active as it should be for a sixteen year old. She still gets stressed out being in large groups and being with her friends too often.

Dr. Becker: What about the fact that Heather is going to be entering college in about a year? Are you concerned about that certain things are in place so that the transition to college will be okay?

Mrs. Ouimette: I am a little concerned about the transition to college. I think that it will help her out that she is going to go to the community college to start with so that she is not thrown into such large classroom activities and hopefully by then she will start being able to handle the activity better.

Dr. Becker: Are you planning on doing the whole two years at MCC?

Mrs. Ouimette: For right now, yes. As the year goes on we will see what happens from there but as of right now yes, she will be doing two years at MCC.

Dr. Becker: With a transfer to UCONN or Eastern or something?

Heather: Yes.

Dr. Becker: I like that way of thinking. I agree that starting with a smaller environment will minimize being overwhelmed. Is that is a primary concern ? The level of intensity of the environment?

Mrs. Ouimette: Yes. You know in a bigger college setting I think it would be too much activity, too much movement and commotion and I am not sure she would be able to do it so well at this point right now.

Dr. Becker: At MCC would you be driving yourself, Heather?

Heather: Probably yes.

Mrs. . Ouimette: Yes.

Dr. Becker: Do you think you can get into the lifestyle of commuting back and forth?

Heather: Yes.

Dr. Becker: What are the things that you’re doing to work things out with Heather as she is returning to her full level of participation in her academic, social and functional activities, and in her home environment? Mrs. Ouimette, what are the things that you’re doing that seem to be working that are supporting Heather in her day to day activities?

Mrs. Ouimette: I push her along to do a little bit more, but I always watch her and I can see when the stress level is getting to be too much. I do push her along to get her to do a little more and more. I am there to support her and be there for her.

Dr. Becker: In your earlier comment, you sort of have a sense of a balance between not doing too much vs. wanting to do more.

Mrs. Ouimette: I push her to do more and more but not to overdo it. I am very aware of her personality and how she behaves and I can tell when she is starting to get too much.

Dr. Becker: How do you know?

Mrs. Ouimette: I can see it in her face, she gets tired. I am not really sure how I know but I can tell. Just the way she starts to behave, she might become a little bit more agitated. She might be a little bit more tired.

Dr. Becker: So, you can sense that this young person who is doing all this stuff is starting to wear down at times?

Mrs. Ouimette: I can tell, yes. I can sense by her behavior.

Dr. Becker: So that is your signal that it is time to back off, time to tone it down?

Mrs. Ouimette: Right.

Dr. Becker: Mrs. Ouimette, how is the awareness of what this injury has been like for Heather and what it has been like for you, affected how you look at life itself? Has it affected your general outlook on life? Do you see things differently now as a result of what you have been through?

Mrs. Ouimette: I realize how serious an injury like this is. Most people see it as oh, it’s just a little head injury, you’re just babying it, but I see how it has reacted to her, how it has affected her. I think more people need to be more aware of the seriousness of a head injury. I think personally that all students in school should have the ImPACT test whether they are in sports or not because it is very easy to have an injury, even in gym. It has brought more of an awareness of how serious a head injury can be.

Dr. Becker: In general you definitely understand that even young people that aren’t necessarily doing gymnastics or something like that can also be vulnerable?

Mrs. Ouimette: Yes.

Dr. Becker: Is there anything you can say out there that would be helpful to other parents, the injury and recovery of their young adult/child?

Mrs. Ouimette: Don’t ignore the symptoms and even if the child says, oh no it’s okay, it’s okay, keep an eye on them, push the treatments because it is not something to just take lightly.

Summary & Conclusions

The case study of Heather describes a number of clinical, social and interpersonal challenges that individuals with this injury have to sustain. They have continued their lives in academic and social environments despite the fact there are continuing symptoms sometimes quite formidable and sometimes on a more subtle level. A Neurocognitive Care Plan attempts to address these challenges in a coherent and consistent manner. As Heather has aptly pointed out in her interview, awareness of her injury, how it is affecting her and how to make modifications and changes in her environment are critical for her continued recovery.

This awareness can be compared to a central processing unit monitoring itself and attempting to compensate or make corrections. What is really being described, is the ability to be clearly aware of how the injury is manifesting itself through cognitive, sensory, perceptual and emotional areas and how to identify those injury manifestations, ultimately using the ability to make corrections. This identification awareness and ability to make corrections is not a simple manner and is one that challenges both the individual as well as their family. It also extends to professionals that are involved in their education, sport participation and health care.

Where Do We Go From Here?

Heather has decided not to attempt to return to cheerleading as she enters her senior year in high school. She will be attending school on a full-time basis and have an active and interpersonal lifestyle. Specific modifications will remain in place for Heather during this academic year. These will include: Availability of rest breaks as she needs them, particularly if she feels mentally fatigued or any onset of symptoms. PowerPoint or lecture notes are to be provided to her at the beginning of each class so she that she can maintain her attention and focus on the material being presented and not worry about getting everything recorded while she is trying to pay attention at the same time. No more than one examination a day. Extended time on examinations as needed. Heather also has an academic advisor who is particularly aware of her injury status and what her IEP is. Most importantly, Heather is aware of her own need to personally observe and let people know if anything occurring in her environment is increasing or bringing on additional symptoms.

Conclusion & Concluding Comments

Heather is expected to continue to recover as she progresses through this academic year. She has chosen to go to a community college with smaller classes for the first two academic years and then transfer to a larger four year college subsequent to this. This is ideal in that it continues to challenge Heather while minimizing the overwhelming potential of being in a new environment that would be large and potentially having an extreme amount of sensory stimuli, which might be deleterious to Heather’s recovery. The understanding of why Heather’s injury persisted for such a length of time is still not fully understood. Some working hypotheses are offered:

It is possible that individuals with a history of multiple concussive injuries may have a somewhat more complicated or longer duration of recovery status.
Young women in her age group may be at higher risk of a more prolonged recovery compared to young men in their age group. The basis for this finding is not fully understood.

Further diagnostic assessment was done with Heather including a reassessment of her memory functions which showed recovery in a number of areas and some continued difficulty with memory functions, which may be related also to attention and concentration. In addition, given her long-term symptom status an MRI of the brain was done and this was found to be without significance. Given that Heather has had periods of “spacing out” and it is at this duration since her injury, an EEG was ordered to see if there would be any identification of electrophysiological activity in her cortex. Heather will continue to follow-up with her sports medicine physician and will continue follow-up with myself. Neurocognitive monitoring and treatment suggestions as she progresses through the summer into her academic environment will be tried. Pragmatic functions such as driving, physical involvement and intense environmental stressful conditions will be evaluated and monitored as she progresses along in her functional life as a young 16-year old woman. These pragmatic and day to day functional involvements are not to be underestimated in that it is important that healthy recovery involve as much of the normalcy of the young adults’ life.

While it is absolutely a truism that no two concussive injuries are alike, there are some stable constancies found. It is largely a fact that ongoing post concussion symptoms often involve concentration and attention, aspects of memory, (particularly working memory), potentially perspective memory as well as some executive functions including multitasking, goal planning and monitoring. Further, mood factors such as anxiety, despondent mood, low threshold for irritability and high anxiety levels can persist. Cognitively, there may be episodes of confusion, a feeling of less certainty about what one is doing, and reduced proficient skills previously mastered.

Awareness of these concerns and the ability to work with them will be critical in order to maximally improve from the injury. Ultimately, with the awareness of her challenges and strengths further recovery is expected.

Joel Becker, Ph.D. is the Director, Neurocognitive Diagnostic and Treatment Clinic, LLC, in Danielson, Connecticut. He is an ImPACT consultant who works with athletes from a wide number of schools and collaborates with sports medicine professionals throughout New England. NDTC manages the Sports Concussion Program at the Pomfret School, Salve Regina University and Bryant University. Dr. Becker was an Instructor of Physiological Psychology at the University of Rhode Island in Kingston RI. He is a member of the Connecticut Concussion Task Force. and a medical staff affiliate at Day Kimball Hospital. Contact Dr. Becker through his website sportsconcussionndtc.com or This email address is being protected from spambots. You need JavaScript enabled to view it. .

Upcoming Presentation: Dr. Becker is a Faculty Presenter at the North American Brain Injury Society's (NABIS) Annual Conference in New Orleans, Louisiana on September 16, 2011. He will be discussing case studies representing Persistent Post Concussion Syndrome.

Health

Study: some have more symptoms and they last longer

EAST LANSING, Mich. — New research out of Michigan State University reveals female athletes and younger athletes take longer to recover from concussions, findings that call for physicians and ...

Neuroscience

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 ...

Resources

CDC: Return-to-school guide for school ...

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.
Some ...