“]”]In the medical world, Chronic Traumatic Encephalopathy (CTE) is a rising star, sure to become a household name. And the turning point in CTE’s infamy may have just been reported this week, with the report that former hockey great Rick Martin had CTE at the time of his death. First, some background:

CTE is a kind of central nervous system damage that happens when people suffer repeated head injuries, typically soldiers or athletes in high impact sports, such as football or ice hockey. Early symptoms of CTE include memory problems, difficulty concentrating, and disorientation. As the disease progresses, people with CTE show behavioral problems—poor judgment, aggression, sexual compulsiveness, erratic behavior, and drug and alcohol abuse—as well as increasing nervous system symptoms, including tremors, staggering gait, deafness, and dementia. Unfortunately, the only way to definitely diagnose CTE is to examine the brain of the affected individual during an autopsy.

The organization that is at the forefront of research into CTE is the “brain bank” run by the Boston University Center for the Study of Traumatic Encephalopathy (CSTE). Some athletes who believe they may have CTE donate their brains to the brain bank for examination after their death. That was the case with former football pro Dave Duerson, who committed suicide by shooting himself in the chest to preserve his brain for examination and diagnosis. (To read more about Dave Duerson’s story, click here: Football Player Donates Brain to Research.)

WHAT’S NEW THIS WEEK

An article in The New York Times reported that former NHL star Rick Martin had CTE when he died last March of a heart attack at age 59. What makes this revelation a game-changer is that Martin was not known for being an on-ice fighter, and he only had one known concussion, way back in 1978. His head ht the ice, and he experienced immediate convulsions.

“Rick Martin’s case shows us that even hockey players who don’t engage in fighting are at risk for C.T.E., likely because of the repetitive brain trauma players receive throughout their career,” said Chris Nowinski, a director at the center and co-founder of the Sports Legacy Institute, which seeks to advance the study, treatment and prevention of brain trauma in athletes.

The thought is that although Martin had only one documented concussion, he had several more head impacts—trivial, but cumulatively damaging.

For everyone, the message is simple:  Protect your head!  This new information suggests that any blow to the head could contribute to long-term problems. You never know which blow with be the one to send your brain over the edge to permanent, progressive damage.

To read the full article in The New York Times, click here:  Former Star Had Disease Linked to Brain Trauma

On July 28, 2011, Northwestern Medicine in Chicago hosted a concussion symposium called “Playing It Safe: Changing the Mindset Around Concussion Safety.”  And a few top-notch physicians were on hand to talk about the effects of concussion.

Concussions are in the news every week these days. Former pro football players are suing the NFL, claiming that they were never warned of the dangerous, sometimes life-threatening effects of concussion. New helmets are being developed to protect brains better after hard hits. And coaches and players alike are receiving training in how to recognize and treat head injuries.

Concussions can happen anytime there is a blow to the head, causing a jarring or shaking that disturbs brain function.

“The brain is like jello, when jello is impacted it’s going to move within the bowl. The same thing applies for a brain; even if it’s the slightest impact the brain is affected,” said Carrie Jaworski, MD, head team physician for Northwestern University Athletics.

It’s easy to see why prevention and protection are so important—imagine trying to use a helmet to protect a bowl of Jell-O. Even the best helmet won’t keep the Jell-O from getting shaken up. And without a helmet, impacts can do even greater damage. Football players’ heads have at least some protection from those giant helmets; gymnasts’ and cheerleaders’ heads do not.

“Concussions aren’t discriminatory; they affect people of all ages and all activities, even in non-contact sports such as gymnastics or cheerleading,” said Hunt Batjer, MD, chair of the department of neurological surgery at Northwestern Memorial Hospital and Northwestern University Feinberg School of Medicine. “In fact, young girls may be at a higher risk than boys when it comes to concussions.”

Tips From the Concussion Symposium

Along with the usual academic discussions, the symposium provided some useful tips, too. Some of the information you may find helpful:

• Black outs. You don’t have to black out to have a serious concussion. In fact, most concussions don’t result in any black out, of any length.
• Game-specific signs of concussion. We know the general symptoms of dizziness, confusion, etc. But doctors at the symposium gave specific signs to watch for, which include appearing dazed or stunned; confusion about an assignment or position; forgetting a play; uncertainty of game, score, or opponent; moving clumsily; answering questions slowly; losing consciousness (even briefly); behavior or personality changes; and the inability to recall events before or after a hit or fall.

“If an outgoing and boisterous athlete on your team suddenly becomes quiet or withdrawn, this is a cue that the player needs to be taken out and evaluated. The signs can be very subtle, but if you feel like something is wrong, you need to assume it is,” said Adam Bennett, MD, sports medicine physician at Northwestern Memorial and assistant professor of family and community medicine at the Feinberg School.

• Second Impact Syndrome. Athletes who resume playing too soon after a concussion are at a greater risk for second impact syndrome, which can cause the brain to swell rapidly—a serious medical emergency. This occurs when a second head injury happens before the child recovers from the first concussion. Because the second hit happens when the brain is still injured, it is more vulnerable to additional injury…perhaps permanent, serious, irreversible injury.
• Encourage open dialog. Players need to know that talking about their symptoms is “safe”—that they will be respected for being open about their injury, and rewarded for taking time to heal. According to Dr. Batier:  “Players can shake off pain in the leg, but they should understand that they should never shake off a head injury.”
• Sidelining players. All players need to be sidelined until all symptoms have disappeared—that means not only the obvious physical symptoms of headache or blurred vision, but also normal concentration and resuming normal patterns of eating and sleeping. This could take three weeks…it could take three months or longer. For coaches and parents of youth athletes, this translates to a simple rule:  When in doubt, sit them out.

Also highlighted at the symposium were concussion war stories, such as this one from former football great Dan Hampton, from his years playing professional sports:

“I played during what I call the ‘crash-test for dummies’ period. Players would get hit so hard they wouldn’t even know how to walk off the field,” said Hampton. “I wish these discussions happened back when I played. Today most people are aware of the effects of a concussion, that wasn’t the case when I played.”

In an article on Branford.Patch.com, a Connecticut news site, Dr. Stephanie Arlis-Mayor provides information and advice about the best ways to handle sports-related concussions in children.

Dr. Arlis-Mayor is a physician at the Center for Orthopaedics, and on staff at Yale-New Haven Hospital in Connecticut. She has experience working with young athletes, including those in New Haven Public Schools and area youth ice hockey teams. Dr. Arlis-Mayor told the story of a young lacrosse player who recently sustained a concussion, but didn’t tell her parents about the injury:

Arlis-Mayor explained that on a Monday, this lacrosse player sustained a concussion but kept playing her game and attending school. By Thursday, the student-athlete was running the wrong way on the field during a game . By then, said Arlis-Mayor, her injury was exacerbated and her recovery could take longer than if she had been given attention for her concussion immediately after the incident.

Said over and over again, Arlis-Mayor could not emphasize enough: “It’s better to miss one game than the whole season.”

According to the doctor, the best way to ensure a successful recovery from concussion is to follow the “Five Rs”:

1. Recognize. Athletes, parents, and coaches should learn to recognize the symptoms of concussion so that the athletes can be treated as quickly as possible. (To learn the symptoms of concussion, watch our YouTube video here: HensonFuerst video on “Symptoms of Concussion”)
2. Remove. The injured athlete should be removed from play immediately, and not allowed to return until approved by a physician.
3. Refer. Coaches and parents should be referred to a trained healthcare professional who is experienced in treating concussion.
4. Rest. Concussion victims should have as much rest as possible. Arlis-Mayor said three days in a dark room, no matter the severity of concussion, can make a world of a difference in recovery time.  Arlis-Mayor said exposure to bright screens like televisions and video games should be avoided. If computer time is necessary, recovering athletes should have very limited access to screen time, with 15 to 30 minutes “on” and one hour off.
5. Return. The overall goal is to get the athlete back to playing—but not before all symptoms have resolved.

Of course, treating concussion requires that the child actually report the injury. (Perhaps that should be the sixth R.) And another factor is lying by the athletes, parents, and coaches, all of whom want the athlete to return to play as soon as possible.

In order to ensure that athletes are ready to return to activity, Arlis-Mayor said baseline testing, like ImPACT, can help determine the cognitive ability of a concussion victim but is not the sole measure of recovery… Symptom observation through administering physical tests like balancing, help doctors and trainers determine if post-concussive athletes are ready to return to play. Returning too early, said Arlis-Mayor, places victims at a higher risk for a second concussion and at a higher risk of not recovering from the subsequent head injury.

Just about any sport can cause a concussion if the athlete’s head hits the ground in a fall, or if two players run head-first into each other. But some sports are more dangerous than others. Dr. Arlis-Mayor said it best:

“If you love your kids, don’t let them play football.”  [Dr. Arlis-Mayor, as quoted in the Branford Patch]

To read the full article, click here:  Heads Up! What You Should Know About Youth Sports Concussions

Decades ago, everyone knew that boxers had brain problems from taking too many hits to the head. The average person called it being punch drunk. Doctors called it dementia pugilistica, or dementia of fighters. Now, we understand that permanent brain injury can happen to anyone who takes a lot of hits to the head–people such as football, hockey, soccer, and rugby players. In fact, the problem has gotten so big that a new term has been coined: Athletes’ Dementia.

The medical term for Athletes’ Dementia is chronic traumatic encephalopathy, or CTE.

According to a Johns Hopkins Health Alert, the earliest symptoms of CTE are memory problems, disorientation and difficulty concentrating.

As chronic traumatic encephalopathy progresses, people begin to show poor judgment, erratic behavior, significant memory loss and some degree of Parkinson’s disease (impaired speech, difficulty with motor skills, slow movement and a loss of balance). In more advanced stages of CTE, patients experience tremors, full-blown Parkinsonism, a staggering gait, deafness and dementia.

Chronic traumatic encephalopathy is also commonly associated with psychological problems like depression, agitation, aggression and violence, loss of inhibitions, sexual compulsiveness, euphoria, drug and alcohol abuse and suicide.

Most of the time, the worst symptoms don’t appear until after the athlete has retired from professional play, and a 2009 study showed that the average lifespan of people with CTE is 51. Disturbingly young.

In February, we wrote about former football great Dave Duerson, who committed suicide. by shooting himself in the chest, not the head. That’s because Duerson’s final wish, expressed in his suicide note and in a voicemail message to his ex-wife, was that his brain would be given to the National Football League’s (NFL) brain bank.

The “brain bank” is the nickname of the Boston University Center for the Study of Traumatic Encephalopathy (CSTE). The CSTE was created in 2008 as a collaborative venture between Boston University School of Medicine and Sports Legacy Institute (SLI). Its is to conduct state-of-the-art research on chronic traumatic encephalopathy. Duerson shot himself in the chest so that his brain could be donated intact. (To read the full blog, click here:  Football Player Donates Brain to Research)

With a new name that is easier for the public to remember (and pronounce), Athletes’ Dementia will open the dialog about the long-term effects of sports on the brain–effects that previously had been underestimated. No doubt we’ll be hearing about dementia symptoms in players from a variety of sports. Let’s hope we hear about some real solutions and preventions before there are “brain banks” for all hard-hitting sports.

In a series of articles, The New York Times has been telling the story of Dave Duerson, a 50-year-old former Chicago Bear and father of four who killed himself earlier this month. Duerson’s final wish, expressed in his suicide note and in a voicemail message to his ex-wife, was that his brain would be given to the National Football League’s (NFL) brain bank.

Duerson’s death, and his final gift, will likely expand the national conversation about the effects of repeated concussion on football players’ brains…and what should be done to protect athletes of all ages.

The “brain bank” is the nickname of the Boston University Center for the Study of Traumatic Encephalopathy (CSTE). The CSTE was created in 2008 as a collaborative venture between Boston University School of Medicine and Sports Legacy Institute (SLI). Its is to conduct state-of-the-art research on chronic traumatic encephalopathy (CTE)—a form of progressive dementia—through the study of neuropathology, pathogenesis, clinical presentation, disease course, genetic and environmental risk factors and prevention. It’s research is done on donated brain and spinal cord tissue, with the hope that scientists can develop tests for diagnosing CTE in living people, and treatments for people who show signs of disease.

When Duerson took his own life, he shot himself in the chest, not the head, so that his brain could be donated intact.

According to The New York Times:

Players who began their careers knowing the likely costs to their knees and shoulders are only now learning about the cognitive risks, too. After years of denying or discrediting evidence of football’s impact on the brain — from C.T.E. in deceased players to an increasing number of retirees found to have dementia or other memory-related disease — the N.F.L. has spent the last year addressing the issue, mostly through changes in concussion management and playing rules.

Duerson was active in helping ex-footballers with disability. He served on a panel that helped administer the NFL’s disability plan and the 88 Plan, a care fund for families of players with dementia. There is no doubt that Duerson knew of the link between repeated head injury and dementia and neurologic disability…and it is likely that he believed he suffered from CTE. Friends say he had memory problems, and sometimes had a difficult time thinking of or writing the correct words.

Again, from The New York Times:

Duerson sent text messages to his family before he shot himself specifically requesting that his brain be examined for damage, two people aware of the messages said. Another person close to Duerson, who spoke on the condition of anonymity, said that Duerson had commented to him in recent months that he might have C.T.E., an incurable disease linked to depression, impaired impulse control and cognitive decline.

It will be awhile before we know whether Duerson suffered from CTE, or if he was suffering from depression without brain damage. Regardless of the outcome of the autopsy, Duerson’s death puts new focus on the effects of football on brain health and brain function. Pro athletes play under great risk, but some say the greatest risk is reserved for youth athletes, whose still-developing brains may suffer bigger consequences from smaller hits.

The conversation about how to prevent brain damage in athletes of all ages will be difficult. Fans love the raw aggression of the game, and those with money at stake may balk at taking the danger out of the game for fear of losing viewers and revenue. Will we see new safety equipment? New helmet designs? A change in the rules? This should be an interesting year for parents, coaches, football players, and the N.F.L.

Our hope is that Dave Duerson’s tragic death has meaning, that safety becomes the paramount concern, and that this is the last time a football player dies as the result—directly or indirectly— of what really is just a game.

Resources

Links for the two articles from The New York Times:

N.F.L. Players Shaken by Duerson’s Suicide Message (February 20, 2011)

A Suicide, a Last Request, a Family’s Questions (February 22, 2011)

To learn more about brain injury, check out the HensonFuerst website: http://www.lawmed.com/

The evolution of the “meaning” of concussion has just taken another step…and it’s a frightening step.

Back in the day, concussion was viewed as a mild bump on the head, getting your “bell rung.” No one paid it much mind; take the hit and get back in the game.

Recently, doctors have warned that concussion is more dangerous than that. In fact, pediatricians have been lobbying to have it renamed, from concussion to the more accurately descriptive “mild traumatic brain injury” (MTBI).

Earlier this year, scientists made the disturbing discovery that people who suffer repeated head injury (such as football players and soldiers) develop a type of brain damage that mimics amyotrophic lateral sclerosis (ALS), or Lou Gehrig’s disease. This was the discovery of a new disease syndrome that causes brain damage, central nervous system damage, dementia, and eventually death. It is called Chronic Traumatic Encephalopathy, or CTE, and it is only caused by repetitive brain trauma.

Today, The New York Times reports that the autopsy of a 21-year-old college football player who died of suicide revealed that he had the early stages of CTE. This young man, Owen Thomas, had no history of depression, but suffered what was called a “sudden and uncharacteristic emotional collapse” before taking his life in April 2010. Thomas is the youngest football player, and first amateur football player, to be found with clear CTE. If he hadn’t killed himself, the brain injury wouldn’t have been discovered for years, if ever. But the circumstances of his death demanded autopsy.

Although there is no way to definitively link his suicide to the brain damage, the connection is certainly possible, if not probable:

“It’s not unreasonable that aspects of his behavior were related to the underlying brain disease that was detected,” said Dr. Perl [Daniel Perl, professor of pathology at Uniformed Services University of the Health Sciences], adding that he was speaking as an experienced neuropathologist and not on behalf of his organization. “This is real.”

Dr. Perl added that this finding showed that CTE is possible earlier, and at impact levels lower than those experienced by professional football players.

Right now, no one knows how many hits…how frequent the hits…or how hard the hits have to be before “several concussions” becomes “irreversible brain damage.”  The only thing that is clear is that we need to do more to protect the brains of young athletes. If CTE was found in the brain of an otherwise healthy 21-year-old man, when did it start? In high school? Junior high? Pop Warner Youth Football?

Just last month, we reported about the virtual explosion in the number of head injuries experienced by children while playing sports: In just 10 years, kids ages 8-13 had double the number of concussion-related hospital emergency visits. Kids ages 14-19 had quadruple the number. Unless we take action now, some of these children may end up with permanent, debilitating brain injury.

What can we do? We wrote about that, too…just last week. (Click here to read that entry: The Head Game of Youth Sports.)  And you know what? We’ll continue to write about concussion and brain injury until there is nothing left to write about. Football season is here…let’s keep all players safe.

If you want to read the full article from The New York Times, click here: Penn Football Player Had Brain Disease, Autopsy Shows

In late April 2010, an NCAA panel recommended that all schools have a clear plan for what to do when a student athlete receives a head injury. The main issues are recognizing signs of mild traumatic brain injury (MTBI, also known as concussion), understanding the potential severity of every head injury, and deciding when the athlete is fit to resume playing. (Sports Illustrated/CNN)

The first week of May, it was announced that athletes at all Big Ten colleges will be required to undergo education about the symptoms of MTBI.

On May 9, 2010, Dylan Steigers died of a football-related head injury. He walked off the field after a scrimmage, vomited–a sign of concussion–then taken to the hospital. He died of subdural hematoma (bleeding on the brain). His death will surely be remembered and cited often as yet another reminder of how serious every head injury can be. (OregonLive)

At HensonFuerst, we are highly attuned to the dangers of brain trauma.  Every day we see clients whose lives have been changed forever after an accident. We support the principle of brain injury education for athletes, coaches, parents, and college administration officials.  The more we all understand about the signs and symptoms of brain injury, the more we respect the seriousness of even “mild” concussions, the more we encourage wellness over performance, the fewer disabled athletes will require a lifetime of special care.

We hope that the responsibility for recognizing when an athlete may be unfit to play is given to those who have the appropriate medical training. We say this because it was reported that “students will sign a waiver acknowledging their responsibility to be an active participant in their care.” (Dr. Jeffrey Kutcher, as reported on AnnArbor.com.)

Yes, it is important that athletes report their symptoms honestly–without fear of mockery or reprisals–but people who have a brain injury can be confused, forgetful, and disoriented. If the intention of this waiver is to get athletes to become more aware, that’s wonderful, but we hope that it is not used as a way to shield the colleges from their responsibility to protect the students.

HensonFuerst is a proud supporter of the Brain Injury Association of North Carolina (BIANC).

One of the world’s leading brain injury researchers recommends that children under age 18 should sit out of sports participation for three months after suffering a concussion. This statement was made by Dr. Bennet Omalu, co-founder of the Brain Injury Research Institute at West Virginia University, on February 1, 2010, while testifying at a House Judiciary Committee hearing on the impact of injuries in collegiate and youth football. (See AP story here.)

Dr. Omalu was the expert who discovered the condition called chronic traumatic encephalaopathy (CTE), a form of degenerative, permanent brain damage which can be caused by repeated concussions.

In an earlier committee meeting (January 2009), Dr. Omalu explained that concussions cause damage to brain structures at the cellular and sub-cellular levels. After concussion, some genes get “turned on” and cause a type of protein (APP, or amyloid precursor protein) to accumulate in brain cells and nerve fibers. APP is strongly associated with Alzheimers disease and other degenerative brain disorders.

So concussion increases APP. And APP is related to brain degeneration.

Here’s the kicker:  After a concussion, it take 3 months for all the extra APP to disappear. That’s why Dr. Omalu recommends that children stay out of sports (and other vigorous activities that could reinjure the brain) for 3 months. Adults should probably also be sidelined for that long, but it would be next to impossible to regulate when a 250-pound star football player can run back out onto the field.

Logical, right?

Except that the sports most likely to result in concussion are the same ones that value toughness and a certain degree of violence. According a report in the New York TImes (12/10/2009),

“…one day after the N.F.L. decided that no player showing any significant sign of concussion could return to a game, several players at Tustin High School in California admitted they still wouldn’t tell a trainer if they got hurt.”

And, from the DailyMe…

In the immortal words of U.S. Representative Ted Poe, R-Texas, “I mean if Congress gets involved, it would be the end of football as we know it…. We would all be playing touch football out there.”

It’s one thing to voluntarily damage your brain if you’re an adult, but we need to protect kids from activities that could cause them a lifetime of misery…or even a premature death. A single concussion can have devastating consequences. A Bellevue, Washington boy, Zachery Lystedt, is still learning to walk again after a severe concussion he got playing football when he was 13.

It is imperative that doctors, schools, coaches, and parents all cooperate for the health of our children. Concussions need to be diagnosed properly–as mild traumatic brain damage–and treated with the same care, respect, and time we give to other serious injuries. A broken collarbone means 3 months of down-time from sports. A child’s brain deserves at least the same amount of time to heal.

(For more info on APP and neurodegeneration, click here.)

Reducing the number of sports-related head injuries remains a goal and a passion for the lawyers at HensonFuerst. I recently ran across this list of the sports with the highest number of head injuries treated in U.S. hospital emergency rooms in 2008 (as reported by the U.S. Consumer Product Safety Commission).
We urge all parents and participants of sporting activities to take proper precautions to prevent brain injuries. If you do sustain an injury, make sure you receive prompt medical attention.

The Top 15 Sports for Head Injury

• Cycling: 70,802
• Football: 40,825
• Basketball: 27,583
• Baseball/Softball: 26,964
• Powered Recreational Vehicles (ATVs, Go-Carts, Mini bikes, Off-road): 25,970
• Soccer: 19,252
• Skateboards/Scooters: 18,324
• Fitness/Exercise/Health Club: 14,713
• Horseback Riding: 11,749
• Winter Sports (Skiing, Sledding, Snowboarding, Snowmobiling): 11,723
• Water Sports (Diving, Scuba Diving, Surfing, Swimming, Water Polo, Water Skiing): 11,239
• Golf: 8,420
• Gymnastics/Dance/Cheerleading: 6,364
• Trampolines: 5,971
• Hockey: 5,272

NFL football legend Scot Brantley took a lot of hard hits in his eight seasons as a star linebacker for the Tampa Bay Buccaneers in the 1980s. Brantley is 51 now, and the hits are still coming—he believes his two strokes are the result of the concussion he suffered as a college senior.

The NFL is just coming around to the idea that a “mere” concussion is categorized as traumatic brain injury (TBI), and can cause long-lasting effects.

In a segment titled “Hard Hits,” Scot Brantley spoke with NPR’s Dick Gordon today (January 20, 2010) about his medical journey, and how he hopes the NFL will respond to TBI in today’s players. You can hear the interview on iTunes (search for APM: The Story).

The interview is also available at: http://www.thestory.org/archive/podcast.xml