Recently an article was published in JAMA by Mez, Daneshvar, and Kiernan et al that investigated the frequency of Chronic Traumatic Encephalopathy (CTE) in football players. It has become a topic of controversy because CTE has become a red flag for the public eye. It is now known to be correlated with repetitive trauma from popular impact sports such as hockey, football, and even soccer. While many hope to avoid or prevent the progression of this disease, there is currently no definitive causation and therefore no cure-all. CTE is a post mortem diagnosis that requires evidence of an accumulation of certain proteins along with other neurological criteria.
Mez, Daneshvar, and Kiernan et al used current classification systems to evaluate and assess 207 donated brains of football players. An overwhelming majority of them (87%) met the criteria for neuropathological diagnosis of CTE and the article detailed severity of symptoms (pre-mortem) associated with severity of CTE as well as mean age of death. While the article suggested a relationship between higher level of football participation (NFL) and worse disease presentation, the authors were definitely not stating a cause and effect relationship. The conveniance sample was for investigating possible relationships between activity levels and disease burden. This was an observational study with no constant or variables to compare.
Studies have shown that while living, a person with CTE may present with similar behaviors and cognitive impairments to that of a person with mood disorders, dementia, or Alzheimer’s disease. Mez, Daneshvar, and Kiernan et al outlined common characteristics and behaviors of the people that were diagnosed with CTE and therefore provided a foundation for future studies to help eventually determine causation, a sensitive and specific means of evaluation, and prevention. Until then, athletes of all levels must try their best to avoid repetitive and unecessary microtaumas. Playing smart and competitively, not aggresively, can help minimize repeated impact and trauma in every game.
Elizabeth Lamontagne PT, DPT, SCS, CKTP
We’ve all heard much about the dangers of football and the alarming incidence of concussions in the sport. Also about the NFL’s initial resistance to acknowledging the probable relationship of concussions to Chronic Traumatic Encephalopathy (CTE), which currently can only be diagnosed on autopsy.
CTE – as defined by the Boston University CTE Center16 – is “a progressive degenerative disease of the brain found in athletes (and others) with a history of repetitive brain trauma, including symptomatic concussions as well as asymptomatic subconcussive hits to the head… This trauma triggers progressive degeneration of the brain tissue, including the build-up of an abnormal protein called tau. These changes in the brain can begin months, years, or even decades after the last brain trauma or end of active athletic involvement. The brain degeneration is associated with memory loss, confusion, impaired judgment, impulse control problems, aggression, depression, and, eventually, progressive dementia.”
The concern many have is not only for the health and safety of the athletes. Others who have suffered mild traumatic brain injury want to know if they are susceptible to CTE as well. No one really has that answer yet. However, lets look carefully at the information that is out there and how it can be interpreted.
First, scary as it may be, recognize that the high incidence of CTE reported in studies reflects several biases. The most significant of these is self-selection. The brains that have been examined on autopsy are primarily those of athletes who have donated their brains for research due to symptoms they’ve experienced, or those whose family has suspected the diagnosis. This clearly inflates the percentages of athletes diagnosed with the condition.
One such study done by Boston University and the US Department of Veteran’s Affairs17 established that 87 of 91 football players had signs of CTE on autopsy, while Boston University also found the condition in 79% (131 of 165) of football players across all levels.17
These frightening results are mildly contrasted by another study18 that looked at 60+ former NFL players – all aged 60-69 – to try to identify symptoms of CTE in living people. Their age range indicates that these were players who played before heightened concussion awareness and before protocols were initiated by the NFL. The results showed that 60% had completely normal age-appropriate cognitive decline. Of the remaining 40%, 6% met the criteria for dementia. It would be interesting – and possibly revealing – to be able to correlate the findings on these men with how their brains subsequently present on autopsy.
Though this group also played before helmets were improved, the sturdier helmets may even have encouraged harder hitting. The NFL’s response has included recent rule changes to modulate direct hits to the head, though the game will likely see an even greater proportion of debilitating but less threatening lower body injuries as a result. The players of today are also typically stronger, bigger and faster than those in the era of those tested in this study. This too likely influences the frequency and outcomes of traumas that they experience.
Though the brain has the ability to recover from one injury, long-term effects are more likely after multiple incidents.
However, keep in mind that football players sustain blows to the head (direct and/or indirect) on almost every play. This cumulative subconcussive microtrauma may be as much or more of a factor in causing CTE than one or few isolated incidents of concussive trauma. Not at all good for football or soccer players, but an encouraging note for others who fear the long term effects of having sustained a concussion, or even several of them.
Vulnerability differs amongst athletes on the field. Dr. Steven Erickson noted that offensive linemen face forces “that are generally linear and the players know they are coming. Consequently, the head doesn’t move very much, so the brain doesn’t move very much. This may still represent brain trauma, but less often to the degree of causing concussion.”
He contrasted this with receivers. Though the “magnitude of the forces they sustain may be lower, the rotational component to the trauma, the player not being able to anticipate the nature of the hit and the degree of subsequent brain motion all make it more likely they will sustain a clinical concussion.”
A study by the Mayo Clinic, published in December 2015, found that one in three amateur athletes who participated in contact sports while in school developed CTE. 19 That statistic will likely cause even more scrutiny of the games and cause some to weigh the risk-reward of participation differently than before. Again though, this study also reflected issues of self-selection.
I asked Dr. Erickson about the cheating (underperforming) on baseline screening that we have read about occurring in the NFL, and whether this effort by some players to lessen the likelihood that a subsequent concussion will be diagnosed can be detected.
His response was that “though it may be possible, there are internal checks with ImPACT™ whereby validity scores can generally identify when an individual is cheating.”
Dr. Erickson commented that “this is another advantage of the vestibular test (see Part 2 of this series) advocated at the Banner Concussion Center, because a non-physiologic response is detected with intentional underperformance or anxiety responses to testing, We benefit from the fact that athletes don’t know how to cheat to underperform on the test.”
He added that “of course, best medicine is for an athlete to put in best effort at baseline as well as post injury. The motivation factor is very real. Sometimes those not particularly motivated in baseline testing are very motivated to achieve in order to return to play,”
Hopefully more athletes and their coaches are acknowledging that playing through will not serve them well either in the short or long term.
So, does the Banner Concussion team advocate keeping kids from playing sports? Most definitely not… Each member acknowledges the many benefits of sport, such as exercise, physical development and emotional growth. Developing mental toughness and learning life lessons such as teamwork and how to deal with adversity while enjoying a healthy social outlet that is fun, challenging and productive trumps fear.
They stress that concussion can happen almost any time – even to those who don’t play sports – and that sports can be made safe. The key to addressing concussion is education and diligence. It is important to be able to identify concussion if/when it happens and seek appropriate assessment and care. By managing the symptoms, recovery is accelerated and the likelihood of recurrence minimized. The value of baseline testing cannot be stressed enough nor can the importance of not allowing an athlete of any age to return to play after sustaining a head trauma resulting in symptoms without undergoing an evaluation.
Though most who suffer a concussion recover fully and within a four-week period, the caution is to understand that symptoms left untreated – can result in long lasting consequences.
As for those who sustain multiple head traumas and, quite possibly – or especially – those who have also suffered repeated microtrauma, the long term effects are coming into better focus with the further study of CTE.
References for Parts 1-3 of the Concussion Series:
- Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control. Report to Congress on mild traumatic brain injury in the United States: steps to prevent a serious public health problem. Atlanta (GA): Centers for Disease Control and Prevention; 2003.
- Lescohier I, DiScala C. Blunt trauma in children: causes and outcomes of head versus intracranial injury. Pediatrics 1993;91(4):721-5.
- Langlois JA, Rutland-Brown W, Wald M. The epidemiology and impact of traumatic brain injury: a brief overview. Journal of Head Trauma Rehabilitation 2006;21(5):375-8
- Finkelstein E, Corso P, Miller T and associates. The Incidence and Economic Burden of Injuries in the United States. New York (NY): Oxford University Press; 2006.
- Fung M, Willer B, Moreland D, Leddy J. A proposal for an evidence-based emergency department discharge form for mild traumatic brain injury. Brain Injury 2006;20(9):889-94.
- Alexander, Andrew L., Lee, Jee Eun, Lazar, Mariana, Field, Aaron, S.
Diffusion Tensor Imaging of the Brain. Neurotherapeutics. 2007 Jul; 4(3): 316–329.doi: 10.1016/j.nurt.2007.05.011
- Field M, Collins M, Lovell M, Maroon J. Does age play a role in recovery from sports-related concussion? A comparison of high school and collegiate athletes. The Journal of Pediatrics 2003;142(5):546-53.
- Bryan Kolb, PhDand Robbin Gibb, PhD: Brain Plasticity and Behaviour in the Developing Brain . J Can Acad Child Adolesc Psychiatry. 2011 Nov; 20(4): 265–276.
- Guskiewicz K, et al. Cumulative effects associated with recurrent concussion in collegiate football players: the NCAA Concussion Study. JAMA 2003;290(19):2549-55.
- Pellman EJ, Lovell MR, Viano DC, Casson IR. Concussion in professional football: recovery of NFL and high school athletes assessed by computerized neuropsychological testing–Part 12. Neurosurgery 2006;58(2):263-74;discussion 263-74
- Kashluba S, Casey JE, Paniak C. Evaluating the utility of ICD-10 diagnostic criteria for postconcussion syndrome following mild traumatic brain injury. Journal of the International Neuropsychological Society 2006;12(1):111-8.
- Dean PJ, O’Neill D, Sterr A. Post-concussion syndrome: prevalence after mild traumatic brain injury in comparison with a sample without head injury. Brain Inj. 2012;26(1):14-26. doi: 10.3109/02699052.2011.635354.Epub 2011 Nov 22
- McManus, C. Stress-Induced Hyperalgesia: Clinical Implications for the Physical Therapist Orthopedic Physical Therapy Practice. 2012;24(3):165-168. (http://carolynmcmanus.com/publications/mcmanus-stress-induced-hyperalgesia.pdf)
- UPMC Sports Medicine Website
- Boston University CTE Center: http://www.bu.edu/cte/about/what-is-cte/
- Hart, J.J., JAMA Neurology 2013
- Mayo Clinic Press Release: Mayo Clinic: Evidence suggests contact sports played by amateurs increase risk of degenerative disorder http://newsletter.carehubs.com/t/ViewEmail/j/2B6E3073A3AD413C/59F3204D88C0AFA89A8E73400EDACAB4
- Aubry M, et al. Summary and agreement statement of the first International Conference on Concussion in Sport, Vienna 2001. Clinical Journal of Sports Medicine 2002 Jan;12(1):6-11
Though the media has bombarded us with articles, news reports and even a film on concussions, the confounding thing is that so little of the information geared to the general public has served to really educate and inform. There is so much more to this story than football and chronic traumatic encephalopathy (CTE). For instance, how do you know if you’ve suffered a concussion? If you have, what should you expect? Where should you go to receive optimal care, and what should that entail? How scared should you be? Buckle up, take a deep breath and relax… there is a wealth of information to share.
The mild traumatic brain injury (MTBI) that is a concussion happens to countless ordinary people every day. You or someone you love may even have been one of them. The injury might have resulted from a simple fall or a tumble taken in sports like skiing or cycling. Trauma sustained in a car accident or in a war zone blast might be to blame, or maybe you sustained a contact injury in a heated game of just about any team sport. Regardless of the mechanism of injury, the course of care should follow a very specific process. A thorough assessment is step one, in order to identify any cognitive, visual or vestibular and balance dysfunctions (all of which will be explained later) as well as a myriad of possible symptoms that must be addressed. This should be followed by highly personalized treatment focused on restoring symptom free and full function.
Concussion care is a fairly new specialty because for so long little was understood about the injury itself as well as the appropriate course of treatment. There remains much to learn. The medical management of concussions is a specialty that requires post-graduate education regardless of the professional discipline involved (neuropsychology, vestibular/physical therapy (PT), neuro-optometry, occupational/visual therapy and sports medicine (physicians, orthopedic PTs & athletic trainers). Experience counts for a lot and, as with professionals in any field, not all are created equal. Educated consumers have to know what to look for in order to best advocate for themselves and their loved ones.
The important thing to emphasize, however, is that with accurate diagnosis and appropriate treatment, the overwhelming majority of people with MTBI recover fully, even those with post concussion syndrome; More on that to follow.
The CDC (Center for Disease Control) literature1 reports “that an estimated 75%-90% of the 1.4 million traumatic brain injury (TBI)-related deaths, hospitalizations, and emergency department visits that occur each year are concussions or other forms of MTBI. 2,3 In addition, approximately 1.6 – 3.8 million sports and recreation-related TBIs occur in the United States each year”, 4 and many “of these are MTBIs that are not treated in a hospital or emergency department.” There are many other places to go for care.
The numbers reveal an economic factor at play as well – even outside of the NFL. A study done in the US in 2000 found that direct as well as indirect costs – such as lost productivity from MTBI – totaled an estimated 12 billion dollars 5
A little background information on concussions:
It is important to recognize that not every head blow causes a concussion. This was the first thing Dr. Steven Erickson, emphasized when we spoke. Dr. Erickson, who, in addition to being a co-founder and the Medical Director of the Banner Concussion Center in Phoenix, AZ, is a consultant for MLB umpires.
Any head trauma that results in the onset of temporary neurologic symptoms (be it from a direct or indirect blow) is considered to be a concussion. The injury is due to the brain moving quickly within the skull and may or may not entail a loss of consciousness; Typically, a collection of cognitive, physical, emotional and/or sleep-related symptoms results.
This includes some of the 22 common symptoms specifically listed and rated on a 0-6 scale on a form that each Banner client completes both prior to and following every treatment (See the list in Figure 1 below), as well as neck pain and ringing in the ears (tinnitus). It also includes any less typical symptoms a patient might report, such as “seeing the color green”.
Figure 1: Banner Concussion Center’s In-Office Symptom Score Sheet
Clients rate each symptom on a 0-6 scale prior to and following every treatment session.
- Headache 12. Sensitivity to noise
- Nausea 13. Irritability
- Vomiting 14. Sadness
- Balance Problems 15. Nervousness
- Dizziness 16. Feeling more emotional
- Fatigue 17. Numbness or tingling
- Trouble falling asleep 18. Feeling slowed down
- Sleeping more than usual 19. Feeling mentally foggy
- Sleeping less than usual 20. Difficulty concentrating
- Drowsiness 21. Difficulty remembering
- Sensitivity to light 22. Visual problems
Patients are also questioned regarding these additional common symptoms:
- Neck Pain
- Ringing in your ears
The most common symptoms after concussion include: visual disturbances, sensitivity to light or noise, headaches, nausea or vomiting, difficulties concentrating or remembering, balance problems, emotional changes and alterations in sleep pattern.
While more severe traumatic brain injuries cause structural damage, the clinical signs and symptoms of altered brain function after MTBI can be attributed more to dysfunction of brain metabolism. This entails “a complex cascade of ionic, metabolic and physiologic events.” 6
Making the Diagnosis:
A thorough initial evaluation is of paramount importance to determine whether the injured person has something even more serious. Concussion is a diagnosis of exclusion – emergent conditions such as skull fracture or an acute subdural hematoma (a bleed between the covering of brain – the dura – and the brain itself) must first be ruled out.
Dr. Erickson stressed that the best place to start is at the Emergency Room, where greater awareness and improved training has resulted in movement away from automatic CT scans for mild head trauma.
Tests such as Magnetic Resonance Imaging (MRI) or Computerized Tomography (CT) are not able to diagnose the disturbance of brain function typical after concussion because there are generally no associated abnormalities on structural neuroimaging. Mild concussive trauma is unlikely to cause tearing of the tissues in the brain and so no bleeding results. It is the collection of blood that would otherwise be evident on imaging.
Dr. John DenBoer, Clinical Neuropsychologist/Sports Psychologist at Banner, whose outside private practice affiliation is with Mental Edge Neuropsychology in Scottsdale, emphasized that with “almost any other injury or illness, you do a scan or run a blood test and you can define it… whereas the testing after concussion focuses on function.” He commented that though “diffusion tensor imaging (DTI) 7 shows how the white matter tracks in the brain are disrupted by concussion, this is not widely used due to cost and availability. They have it in only ten clinics around the country and currently use it largely for legal cases or research studies.”
Diagnosis can sometimes prove tricky because symptoms can mimic those of other diagnoses (such as headache syndromes, PTSD…) and may have a delayed onset. However, once concussion is diagnosed, it is best to seek care within the first week.
When examining a patient after head trauma, gaining an understanding of the nature of the force sustained can be helpful; was it a direct blow to the head or a body (indirect) blow? A body blow may cause a whiplash injury where the head moves forward then backward rapidly. If the impact was a direct one, where was the hit absorbed? Different symptom patterns may emerge depending on the specific mechanism of injury.1
In addition, the severity of symptoms may relate to the degree of impact. Those who have sustained multiple concussions may exhibit more involved symptoms than expected, a reflection of their vulnerability and/or a psychological overlay whereby increased anxiety about the consequences of sustaining another blow can amplify symptoms.
Patients should be screened for amnesia, which may result after sustaining concussion. This sometimes affects recall of events prior to the injury (retrograde amnesia), or may affect memory of event that followed (anterograde amnesia). In addition, the examining physician generally relies on bystanders to determine whether the individual suffered seizures (an atypical occurrence). Family members can also contribute valuable information regarding signs of mild brain trauma that they may have observed since the injury was sustained.
The immediate post injury period:
If concussion is suspected, it is important to avoid physical activity and mental exertion (stimulation such as watching television, using a computer or reading), get plenty of rest, stay well hydrated and avoid caffeine or alcohol (information on brain foods that boost cognitive function can be found here). This initial protective phase after injury is key. A medical provider should be consulted and, in the event of severe symptoms, going to the ER immediately is crucial.
The Recovery Process:
An uncomplicated course of recovery is generally seven to 14 days for adults and 14 to 21 days (for children and adolescents). This is interesting because – though younger people have increased plasticity of the nervous system8 – the immature brain takes longer to recover from trauma. 9,10,11
If you’ve had one concussion are you more likely to sustain another?
Dr. Erickson, noted that his “guess is that at least 10% of those with full symptomatic recovery and complete cognitive recovery may still have vestibular dysfunction that predisposes to other injury.” This actually represents an incomplete recovery. In other words, even if you think you are better, you may not be. Inadequate care may leave you with residual vestibular or visual dysfunction, creating an otherwise avoidable susceptibility to additional head trauma.
Dr. Erickson’s experience has also shown that there is what he refers to as “a concussion threshold that is lowered even after a complete visual, cognitive and vestibular recovery and when an individual is symptom free. Individuals are more likely to have a subsequent concussion for a period of several weeks to months even with less impact involved. There is no definitive formula.
At the most extreme end of the spectrum is what is referred to as Second Impact Syndrome. Dr. Erickson noted that this condition is preventable. “An emphasis must be placed on kids reporting injury, and then getting them off the field immediately thereafter. Many play through, and every year a few kids die of this syndrome. Another big head blow very shortly after an untreated concussion can result in a loss of control of the auto-regulation of blood flow. This results in swelling and death. Second Impact Syndrome has been seen only in kids. There have been no reports in the literature of this occurring in adults.
This can’t be researched for obvious reasons – it would entail intentionally delivering a second blow and monitoring the outcome.”
Post Concussion Syndrome:
According to Dr. Erickson, approximately 70% of concussions follow an uncomplicated course. Recovery that occurs outside the normative recovery curve (longer than what is expected) is referred to as post concussion syndrome. Here, the literature is confusing, with some publications saying that symptoms persisting for three or more months constitute post concussion syndrome 12, while others note that it begins after four weeks (Banner), and still others only after a year.13
I believe the discrepancy in these definitions is due in part to the fact that clients at the Banner Center receive care that identifies and addresses any and all deficits across the various systems. Because of this, the typical patient has an uncomplicated course of recovery within the expected time period.
A prolonged recovery is generally due to persistent vestibular, visual or cognitive deficits, usually with some emotional or psychological stress or anxiety. The psychological component – which is a biological response that may also include depression – is “completely understandable for those with delayed recovery and persistent debilitating symptoms, such as headaches.”
Sherry Massingale, MPT, Senior Clinical Manager at the Banner Concussion Center, noted that with post concussion syndrome, “the overarching concern – and the fear of further trauma or setbacks that often accompanies delayed recovery – can serve to worsen or perpetuate physical symptoms or symptoms of depression. It may also result in self-limiting behavior due a fear of returning to the activity that resulted in injury or any activity that subsequently exacerbates symptoms”
Though post concussion syndrome is more likely after each successive concussion, 10 there is no definitive generic pattern. The higher incidence is more likely due to alterations neurochemically or psychologically, especially if the sufferer/athlete has had prior longer-term recoveries. Persistent symptoms are also more common after mild brain injury to those with a history of anxiety/depression, or those who have previously exhibited neurologic hypersensitivity. This population typically has a heightened somatic response to psychological stress – whereby pain is more readily elicited or amplified. Dr. DenBoer stressed that this type of pain – though very real and not at all imagined – can be effectively modulated or resolved via strategies such as mindfulness or other behavioral modification techniques.
The biologic responses that occur with these techniques provide strong scientific evidence of their benefits in the prevention and treatment of chronic pain as well as in effectively boosting mood.14
Part 2 of this article will focus on Assessment, and Part 3 on Football and CTE. Articles referenced and footnoted will appear at the conclusion.