Concussion’s Axis of Evil

The term concussion is derived from the Latin word “concutere” which means “to shake violently”:

This term is used to describe a head injury associated with a temporary loss of brain function, including impaired consciousness, cognitive dysfunction and/or emotional problems.

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To fully understand Concussion’s Axis of Evil, one need look no further than the brutal world of professional boxing and it’s neurological complications.

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One of the most savage beatings any fighter every received occurred on July 4, 1919 in Toledo, Ohio, when 24 year old Jack Dempsey destroyed 37 year old Jess Willard to become the Heavyweight Champion of the World.

One can easily spot the effects of concussion in Willard as he sustains blow after blow to the head, and he develops unsteady gait, erratic behavior (failing to avoid punches and protect himself) and ultimately unconsciousness.

New Jersey’s own Harrison S. Martland MD (1883-1954) was the first to report in 1928 that repeated beatings of this kind could lead to a delayed permanent neurologic syndrome referred to as punch drunk syndrome.

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His observations went largely unheeded.

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Muhammad Ali (born as Cassius Marcellus Clay in 1942) was only 22 when he became word heavyweight champion in 1964, almost 40 years after Martland’s paper was published.

Here is with Liberace in 1964:

Almost 10 years after that performance, Prof Corsellis reported further clinical and pathological features of punch drunk syndrome in his 1973 paper “The Aftermath of Boxing”.
Here’s data from one of his cases:

By the 1980s, reports of abnormal brain CT scans in professional boxers had reached the popular media (Sports Illustrated, 1983):

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By 1983, Muhammad Ali was retired from professional boxing,

and soon to be diagnosed with “Parkinson’s disease”.

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Here he is on the Today show with Bryant Gumbel in 1991:

Here he is in 2009:

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Obviously, repeated head trauma, and it’s consequences, is not unique to boxing:

John Grimsley (1962-2008) was a linebacker for the Houston Oilers.  He retired in 1993.  In 2008, aged 45, he was killed by an accidental gun shout wound to the chest.

His brain was examined as part of an ongoing study by Boston University’s Study of Traumatic Encephalopathy.

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His brain showed the same pathologic changes as the Punch Drunk boxers.

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This syndrome, more commonly referred to as Chronic Traumatic Encephalopathy, is now known to have occurred as a consequence of repeated head trauma in many other sports, including soccer, hockey, horse-racing and wrestling.

College football and amateur soccer players have been shown to have impaired performance on neuropsychologic testing, worse with increasing number of concussions.

Then, there’s the Second Impact Syndrome (SIS).

SIS is said to be a rare, often fatal, traumatic brain injury that occurs when a repeat injury is sustained before symptoms of a previous head injury have resolved.
Although limited to single case reports, and disputed as a discrete syndrome in the scientific literature, SIS cases are young athletes and have become high profile in the media:

Click here to find out more about this case.

It has become clear that it takes athletes longer to recover from repeated that single concussions:

This data, as well as SIS cases, has led to a concern that the presence of ongoing concussive symptoms are a significant risk factor for further injury to occur, and that any residual symptoms should mandate restriction for further contact sport in young athletes.

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Finally, it is know that concussions are under-reported by high school players.

A 2004 survey of 1500 varsity football payers in Milwaukee disclosed that although 15% had sustained a concussion during the season only 50% reported it to their coach or trainer.

So there we have it, Concussion’s Axis of Evil:

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And the solution?

The Allies Against Concussion:

Click here to read more about how we have put these measures into effect at Monmouth Neuroscience Institute.

Click here to find out more about the Matthew J. Morahan III Health Assessment Center for athletes at Barnabas Heath.

A Simple Device to Detect Concussions

Preventing, evaluating and managing sports related concussions is a hot topic right now.

For example, Monmouth Neuroscience Institute, in association with the  Matthew J. Morahan III Health Assessment Program, offers baseline cognitive screening events and concussion evaluations for local school and college athletes.

Like most programs around the country, we use the ImPACT computerized testing to measure reaction times and assess concussions.  However, this type of computer testing requires specialized equipment and staff training.

Investigators are still looking for a more simple and cost effective assessment tool that can be used to asses athletes’ reaction times right on the side lines, to allow immediate return to play decisions during the actual game.

Sports medicine physicians from the University of Michigan have developed a homemade device that could be used in this way.

They stuck a hockey puck to then end of a long wooden dowel marked with centimeter spaced lines along its length.

The evaluator holds it in front of the athlete who is seated with one arm resting on a table. The evaluator lines up the puck with the bottom of the athlete’s hand and lets go.  Once the athlete has caught the falling stick, the evaluator marks where his hand lands, which gives a quantitative measure of reaction time.

A concussed athlete will have a slower reaction time and take longer to catch the stick (catching it further down) than a healthy athlete.

In a study published last year these investigators first used their homemade device to measure pre-season reaction times of football, soccer and hockey players.  Then they waited for these same athletes to get injured with concussions, and had them to re-take the test within at least 48 hours of the head injury.  They found that the concussed athletes took significantly longer (sometimes as much as a full second) to catch the rod than before the head trauma.

The catch?  You still need a baseline measure for each athlete – but it might be easier to get high school and college kids to do this simple 5min test before the first game of the season than have them go to specialized testing center for a computer based test.  Then, with those baseline test results recorded, any coach can repeat the test on the side-lines after an injury and decide if they should be worried.

I am sure the use of a hockey puck was no accident!

Read more about the study here.

Read more about concussion and concussion screening.

Find out more about the Matthew J. Morahan III Health Assessment Program at Barnabas Health.

Updated – Concussion Management

NEW Updated Concussion Guidelines

from the American Academy of Neurology

Background information:

Concussion is a mild traumatic brain injury that occurs when a blow or jolt to the head disrupts the normal functioning of the brain.

Symptoms include persistent headache, problems with memory and communication, personality changes, and depression.

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Concussion can occur from a blow to the head/body, such as helmet to helmet contact, or contact with the ground or another object.

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More than a million Americans sustain a concussion each year.

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A concussion does not always “knock you out”.

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Symptoms of a concussion can last, hours, days, weeks, or even months.

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Why is this important?

Repeated concussion can lead to permanent brain damage, affecting academics, internships, social interactions, and athletics.

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Athletes who continue to play after sustaining a concussion, may take longer to recover and are at an increased risk for developing Second Impact Syndrome or a more prolonged Post-Concussion Syndrome.

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Numerous studies in professional boxers have shown that repeated brain injury can lead to permanent brain damage (dementia), sometimes referred to as “punch drunk” syndrome or dementia pugilistica.

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Autopsy studies have shown similar brain changes in former professional football players who experienced multiple concussions.

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Recent studies of college football players showed an association between multiple concussions and reduced cognitive performance.

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Guidelines for concussion evaluation and management

New American Academy of Neurology guidelines suggest the following management of concussion:

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Suspected Concussion:

Any athlete with suspected concussion should be closely observed and undergo repeated “side line assessments” for at least 30 minutes:

The presence of one or more of these symptoms and signs indicates concussion, that athlete should be removed from play, and referred to an emergency room or experienced concussion program for more detailed assessment.

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Brain Imaging Studies

Any athlete who sustains a head injury who has unconsciousness, persistently altered mentation, or progressive deterioration on the screening tool (above) over time should be sent to the emergency room for a brain imaging study to rule out a skull fracture or intracerberbral hemorrhage.

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Follow-up Care at a Concussion Center

All athletes with concussion, whether they did not need to go the emergency room, or whether seen in the emergency room and sent home, should be evaluated by a health care provider experienced in managing concussion or a concussion center.  They should be prohibited from return to play or practice (contact risk activity) until the concussion has resolved and they are asymptomatic off medications.

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The concussion center uses clinical assessment of symptoms, computerized cognitive testing and balance testing to follow an athlete’s concussion, and determine when it has resolved.

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Computerized testing:

Immediate Post-Concussion Assessment and Cognitive Testing (or ImPACT ) is used at many centers to help assess the severity of concussive brain injury and determine when it safe for athletes to resume sporting activities.

The test is computerized and lasts approximately twenty minutes.

Ideally, athletes should take a baseline test at the beginning of the season.

The test should then be repeated within 24-72 hrs after a concussion. The scores are compared to that athlete’s baseline to identify any residual change in verbal and visual memory, processing speed, and reaction time.

ImPACT testing can then be repeated to look for improvement, once the symptoms have cleared, or 7-10 days after the first post-concussion test.

This information can assist with decisions regarding when a player may return to action.

It should be noted that the widespread application of ImPACT testing has been criticized by some authorities.

ImPACT testing can be helpful, but is only part of the neurologic evaluation of athletes with concussion, and should not be the only factor used to determine when that athlete can return to sporting activities.

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Balance Testing:

The Balance error scoring system (BESS) is a clinical assessment of postural stability that is administered in the concussion center and contributes to the diagnosis of concussion.

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Recovery from concussion

Most athletes recover fully from a concussion, but it can take weeks, months, and even years.

School attendance, student work load and other activities may need to be modified according to the individual’s symptoms.

The athlete’s symptoms should be closely monitored until they feel symptom free.

Once the athlete is symptom free, and they have been cleared through ImPACT, they may begin a progressive return to their sport.

A progressive return involves gradually increasing the level and intensity of the activity, while closely monitoring the athlete for any return of symptoms

Day 1: Walking or easy biking for 20-30 min.

Day 2: Jogging or moderate biking for 20-30 min.

Day 3: Running or heavy biking for 20-30 min.

Day 4: Sport specific drills/practice (non-contact)

Day 5: Return to contact sports

If symptoms return at any point during the progression the activity should be stopped. The athlete should return to rest and must be symptom free for at least 24 hrs before starting the progression again.

Recovery may take longer in those with a previous history of concussion, learning disability, or attention disorder.

It must be stressed to athletes, parents and athletic trainers that these guideline are important, and must be followed to minimize the risk of permanent brain injury.

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Retirement from play

Health care professionals in a concussion center may suggest that athletes who have experienced multiple concussions and have persistent neurobehavioral problems permanently retire from contact sports.

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Download the AAN Concussion App

Download a concussion quick check app specially developed for coaches and parents directly to your ipad or droid device.

Concussion Assessments at Monmouth

The Matthew J. Morahan, III Memorial Health Assessment Center for Athletes is now available at Monmouth Medical Center.

Concussion

What does this mean?

1. Monmouth will be offering baseline IMPACT screening and cardiac screening to high school and college athletes, either at a free screening event or by appointment.

2. Athletes who sustain a sports related concussion and require immediate medical attention will be evaluated in the Monmouth Medical Center Emergency Room.  If they are felt to be suffering from ongoing symptoms of concussion, they can be referred to the Monmouth Concussion Center for same or next day evaluation by a neurologist and return to play determination.

3. Evaluation in the Monmouth Concussion Center will typically include a physician assessment, simple balance testing and IMPACT (R) cognitive testing.

4. The results of these evaluations with be forwarded to the athlete’s primary physician and athletic trainer, and arrangements will be made for appropriate follow-up.

Click here for more information about concussion.

Click here for directions to the Monmouth Neuroscience Out-Patient Area.