High Incident of Concussion in Massachusetts

2012 Globe Article Focuses of Alarming Rate of Head Injury

New Braintree, MA November 9, 2012  An feature in the Boston Globe published in late October cited an incidence of over 3000 concussions in Massachusetts' athletes.  Public health records obtained by the Globe under the freedom of information act revealed the current state of head injury among athletes enrolled in sports for 2010 - the first year the data were collected.  Given the number of schools who did not report, this number is likely to be an underestimate of the true number of head injuries.  

Since Fall, 2009 Massachusetts has expected that all athletes, parents, coaches, and officials receive standardized training on the effects of concussion including signs and symptoms.  This may account for the large uptick in numbers reported in the Globe story.  The worrisome issue is why there is incomplete compliance with the laws mandate.  Arguably, the true concussion figures remain unknown.  

In Southbridge, MA a Pop Warner football game recently resulted in 5 concussions in a single contest.  Pop Warner is the youth football program for children from ages 5-14.  On this day 2 mismatched teams  squared off for a match in which the referees failed to regard the league mandated "mercy" rule that ends the contest when the score becomes one-sided such that the outcome is not in doubt.  This did not happen even though the team from Southbridge was more than 28 points ahead of the team from Tantasqua as per league rules.  Southbridge won the game 52-0.  The Tantasqua athletes sustained 5 concussions resulting in disciplinary action taken against the coaches and referees.  

These kinds of stories will continue to make news as long as we fail to take seriously the potential impact of head injuries.  Youth sports are vital for the development of physical skill, team discipline, and psychological well-being.  But nothing takes the place of protecting athletes from potentially lifelong injury now linked to repeated concussion.  Just as one would not permit an athlete to return to the field with a unhealed fracture to his/her leg, athletes with concussion must too be rested.

Baseline testing has been shown to provide a good starting point in getting a "snapshot" of the child's neurocognitive functioning.  Then, if an injury should occur post-injury testing can be initiated and will be used to determine when the child is fully healed from the concussion.  Websites like: www.concussionassessment.wordpress.com can offer baseline programs and consultation for teams who aren't sure of the new protocols for concussion management.

Deadspin Highlights Lack of Concern for QB

ASU Quarterback Sustains Concussion - Stays in Game

New Braintree, MA  November 2, 2012  Deadspin, the sports news website posted a story about Arizona State University QB Matt Scott who sustained a concussion while playing against conference rival University of Southern California this month.  Between plays he was seen vomiting - often a tell tale sign of concussion.  He did not miss a single set of downs and soon afterward led his team to a game winning touchdown.  Given the current state of knowledge about cerebral concussion, Deadspin.com raised a question about why the quarterback was not immediately replaced by his back-up leaving QB Matt Scott vulnerable for a far more serious and life threatening trauma were he to sustain another blow?  Arguably the ASU quarterback was the single handed game changer in the fourth quarter of the game against USC.  They raise the question about college athletes being exploited for their athletic gifts while "not caring" when the player can no longer contribute.  

The athletic department will undoubtedly deny that Scott was seriously injured and reiterate the schools aggressive policy on athlete injuries, concussion, and safe and protected return to play.   Shame on them.  No game is more important than the health an safety of a student athlete.

Michael Sefton, Ph.D.

"Will I be able to play in the next game?"

RETURN TO PLAY DIFFICULT TO PREDICT

New Braintree, MA October 30, 2012  Working with athletes is an incredible privilege.  They are motivated and eager to try the interventions you recommend as it pertains to recovery from sports-related brain injury.  Concussion in sports is bedeviling at times.  More so when an athlete is recovering from a second or third injury.  As a clinician I am asked frequently if I will clear an athlete to participate in his next game or the Thanksgiving Day match with an arch rival?  If you have read any of these published blogs then you know that recovery takes time and rest.  No player may anticipate being sidelined one day and being cleared for contact then next.  No player!  There is too much risk of second impact syndrome - a condition that results from the brain's inability to tolerate a second blow to the head while still recovering from the first.  While an infrequent affliction it can be fatal.

More frequently, during recovery an athlete may participate in light exercise, a ball toss, or shooting on the goalie which can create subtle delays in recovery from concussion.  Why?  The answer to this depends upon the extent of rest an athlete allows himself after injury.  Physical symptoms such as headaches, dizziness, and fatigue fade before the lingering neurocognitive effects such as decreased concentration and speed of processing.  Healing must be complete before returning to play in order to assure the athlete is not at an increased risk of re-injury.  In the past, I have worked with athletes who reported feeling "great and normal" who become re-injured their first time out.  Now these athletes must return to competition in a carefully controlled manner.

Post-traumatic headaches are commonplace in as many as 60 percent of cases.  Lingering headaches are a sign that healing is incomplete.  If they persist greater than 2 weeks.  I usually conduct an analysis of the athletes daily routine and discover they are not "resting" their brains as much as they should and may be prolonging their distress.

BMX RIDER DEFIES MEDICAL BELIEFS

ARE PEOPLE GETTING THE MESSAGE?

NEW BRAINTREE, MA June 30, 2012  I read an L.A. Times story featuring Kevin Robinson, a 40-year old athlete who rides BMX bicycles in the elite X-Games competition.  By his own admission he had has 50 concussions including one that rendered him near coma  and a second that resulted in 2 weeks of having limited language.  I would say his physician's would rather he not continue in the sport and save his brain for other things like taking care of his children and living a long healthy life.  But surprisingly Robinson says to retire form the sport would go against his principles and be inconsistent with his "personality".  

How can anyone hear that and expect that Mr. Robinson is anything but selfish and foolhardy?  At the same time he insists that athlete's should always wear helmets when they ride but admits he has sustained all of his injuries while wearing a helmet. He described himself as a BMX rider to the core and is unconvinced that he is in any substantive risk of long term consequence to his brain and overall health.  At the same time the L.A. Times reported that Robinson was a close friend with former San Diego Charger Junior Seau who committed suicide this spring.  Seau's death has been linked to concussion-related chronic traumatic encephalopathy.  Seau sustained dozens of concussions during his 20 year NFL career and suffered with depression.  Arguably Mr. Robinson thinks only of himself and remains stuck in an adolescent time warp when he espouses the belief that until he has proof that concussions are bad for you he will continue on riding as always. He even goes on to say that if his 6-year old son wants to follow in his footsteps than that is good enough for him.  Someone needs to wake this guy up.  Not only is he making a living riding a child's bicycle but he lacks adult judgment and has either been asleep for the last 10 years or already has cognitive impairment and lacks simple reasoning.  Robinson is waiting until the C-T scan he has had over 50 times results in an abnormal finding.  Someone needs to explain to Robinson that C-T and MRI never or rarely show evidence of structural brain injury and waiting any longer continues to put himself at risk for serious neurological deficits and psychopathology later in life.

Brain Injury and the Female Athlete

FEMALES HAVE SLOWER RECOVERY FROM CONCUSSION

NEW BRAINTREE, MA May 22, 2012 According to a Blog written by Prithvi Narayan, M.D. there are over 1.6 million sports-related concussions annually.  The recovery from concussion of female athletes has been shown to be different from their male counterparts.  Soccer has the highest rate of concussions among female athletes.  "The female players I have followed have been at greater risk for second injury and generally have a slower recovery than male athletes" according to Michael Sefton, Ph.D. This may result from an increase in competition among woman athletes at younger ages than ever.  "I have worked with students as young as 15 who are competing against woman in their late teens and early twenties who are trying to showcase their ability.  Truthfully, the difference in body mass is considerable leaving the younger athlete in a competitive disadvantage and at greater risk for concussion" said Michael Sefton.  In the last generation female athletes have had greater opportunity to compete for Division I scholarship money and increased brain injury due to concussion may be the trickle down effect.  After soccer, basketball and lacrosse have been identified as having the highest rate of concussions among high school athletic teams on which girls play.  Female lacrosse players do not wear helmets because checking is not permitted in woman's lacrosse.  

In an article published in the American Journal of Sports Medicine young female athletes are more vulnerable than males and even older female athletes.  The reason for this may be linked to higher force to body mass in the neck musculature and perhaps upper body that allows greater whiplash to the head of female athletes.  Another hypothesis includes better reporting accuracy among female athletes who may not be predisposed to hide symptoms of concussion as their male counterparts sometimes do.  


It is no less important to allow females to recover before returning to the field than males.  As a consultant in brain injury I recommend 1-2 weeks of rest - inactivity means no physical exertion, no texting, video games, even loud movies can put a tax on the recovering cognitive system.  The American Academy of Pediatrics suggests a 4 week recovery period after being diagnosed with concussion prior to returning to play.  The important issue becomes whether or not the athlete's brain has quieted and is working at it's baseline before the controlled 'start up' being recommended.  I have blogged about this in the past.  No player should return from concussion early simply because the team on which they are playing has a match against a division rival or an important tournament has been scheduled.  Readers may be surprised how often I am asked to allow an injured player to return to play early because of an "important league game" or to attend a distant tournament out of state.  In coming blogs I am going to write about the role of parents in recovery from concussion so please check back again soon.  Check the website for baseline testing opportunities at www.concussionassessment.com.  


Michael Sefton, Ph.D.

What is Concussion?

WHAT IS CONCUSSION?

This blog was first published in September 2011.  Yet every day I speak with people who are unsure whether or not symptoms they are seeing is sign of a concussion or something else.  Earlier this month a parent called me to ask whether frontal head pain could simply be early spring allergies or is it the concussion?  And, she went on, if it is allergy than her son can play in the upcoming lacrosse jamboree. Yes?  I have written a blog about post-injury head aches and I assume she did not read it.  My answer to the question was carefully worded but amounted to "even if your son had an outbreak of his seasonal allergy symptoms the fact is that he sustained a blow to his head resulting in confusion, poor short term memory, and head pain suggesting that he should not participate in the jamboree."  When my words fall on deaf ears I remind parents that the physician has the final say on return to play.  Generally, I speak with physicians and educate them as best I can about the need to be symptom free before exertion.  The American Academy of Pediatrics recently published a consensus statement on concussion that has updated pediatricians about current return to play protocols.

There is a myth among many people that believes that in order to be diagnosed with a concussion the athlete must be knocked unconscious.  You can't believe how many people I interview who say "it wasn't a concussion because he wasn't knocked out."  The truth is that cerebral concussion can occur whenever there is sufficient force applied to the skull to cause a disruption in cogntive functioning.  The lapse in functioning may be quite subtle or it can be dramatic such as frank confusion and disorientation.  Recovery often takes 1-2 weeks but symptoms can remain longer in complex cases. 


The Concussion Assessment and Management Program (CAMP) offers consultation to schools and individual teams about concussion management and return-to-play protocols.  It is very important to rest after concussion and be completely symptom free before trying to get back on the field.  When an athlete is cleared to play by his or her physician he should return slowly in a step-by-step way to assure that symptoms do not return.  In coming blogs Dr. Sefton will provide education about concussion and the impact it has on a student's functioning in school.


The website below offers more detail about returning to play after concussion. 

www.concussionassessment.com

RETURN TO SCHOOL AFTER CONCUSSION

 

People are getting the message about the need to rest after sustaining a serious concussion.  They are also learning that students should not practice or appear in games until being symptom free and being cleared by their physician.  The message is getting out. What I keep encountering is that students are struggling to maintain their academic focus after injury.  This is frequently quite difficult and may actually prolong their recovery curve.  How is that possible?

 

The primary issue after a student sustains a concussion is decreased mental and cognitive efficiency.  The metabolic activity in the brain is changed during post-injury time.  This takes one to two weeks to resume the normal cascade of cerebral perfusion and neurotransmission.  This is the cause of the cognitive slowing that takes place and poor focus.  The key to recovery is rest - physical and cognitive.  That means that if a student is out of sports because of a head injury (concussion) he or she should not be studying 3 or more hours a day for mid-term exams.  Every year I get calls from frantic students (and their parents) about whether they can take the SAT exam a week after they sustained a concussion.  They should not OR if they do they can expect a significantly different score than they might otherwise have attained having not been concussed. 

 

SCHOOL NURSES A SUPPORT

 

It is important that parents notify the school nurse once a student returns to school after injury.  That is fairly intuitive if the student is using crutches or needs someone to carry his backpack.  But concussionis often considered an invisible injury and some prefer not to say anything to nurses.  I can tell you that school nurses are awesome to work with and I would not hesitate to use them for support.  Most nurses I work with are well informed about concussion and the need for rest.  They allow students to check-in when they need to decompress from the travails of class work sometimes permitting a 20 minute power nap when needed.  Yes, inform the nurse.

 

Rest is invariably the key ingredient to healing.  But in many cases students need not be kept home for days upon days.  I recommend a partial day immediately following the injury with gradually longer times in class.  Try not to miss the same class every day e.g. math or science because these require ongoing repetition and build from one topic to the next.  However, parents and school counselors can  be quite creative about the return to school schedule until the student athlete is fully healed. 

 

MIDTERMS AND SAT TESTS

 

Students are expected to take standardized tests during their time in class.  Bigger tests evoke bigger stress for athletes recovering form concussion.  Whenever possible school administrators have allowed athletes to make up tests when they are ready.  Most teachers are willing to modify an exam schedule for someone in need.