Posted by Vanessa Fabrizio, MSIV Drexel University College of Medicine
FOOTBALL: the most popular sport in America. Little boys dream of growing up and playing in high school, then college, then hopefully the NFL. Even little girls dream of dating football players in school or marrying a NFL superstar.
Those who have never played football can pour money into the sport by simply watching it on TV or more drastically via sports betting. With advancements in the sport and the increasing athelticism of the players, the injury risk has drastically increased while the lifetime of a player in the NFL has decreased. More attention is being brought to the media about concussion and their long term sequelae in professional athletes, yet not enough people question how well the helmets are actually working.
What is a concussion?
Concussion: a mild traumatic brain injury that leads to a temporary loss of brain function. Symptoms of a concussion are commonly headaches, dizziness, nausea, vomiting, difficultly on ones feet and balancing, and loss of fine motor coordination. Other symptoms can include light sensitivity, blurry vision, tinnitus, and can even produce seizures. Most individuals who experience a concussion will also experience post-traumatic amnesia and experience difficulty paying attention and disorientation. Post concussive syndrome exists and these symptoms can linger for months affecting lifestyle in many ways.
Treatment for concussion is typically and simply rest. Avoiding head trauma is key to recovery.
Football is not the only sport where its players experience concussions. Boxing is an extremely dangerous sport and many of its victims experience neurological deficits due to their involvement. Soccer, basketball, volleyball, softball, and baseball to name a few all have increased risks of concussions greater than the general public.
This video demonstrates that not only professional players are at risk as it shows a 12yr old on the wrong end of a “hard hit”.
What do the studies say about helmet protection?
Recently an article in the LA times was published that talked about how the American Academy of Neurology is currently studying the effectiveness of different football helmets on the market today and how well they decrease concussion rates. The research that will be presented is showing that no helmet on the market today is actual effective in preventing concussions. However, it appears that the helmet this study rated as number 1, was rated last in a study at Virginia-Tech Wake Forest University School of Biomedical Engineering and Sciences. Obviously this shows that our testing of how effective helmets work isn’t standardized yet or up to par. As mentioned above, the sport of football itself has advanced so now helmets need to advance and the testing of the efficacy of these new helmets need to advance as well.
Should we encourage children to stop playing football to prevent them harm? As an avid football lover myself, I think that this is not the solution. We need to continue to raise media attention in order to expedite the process of creating these newer, safer helmets. Education about concussions need to be taught to young athletes as well as appropriate tackling measures to ensure safety. The NFL association has been good about updating the rules and regulations of the game to ensure player safety with fines and penalties for unnecessary roughness and hits. Lets hope they continue this way and it continues to trickle down all the way to the peewee leagues.
CLick here to link to the LA times article.
Posted by Dr Abhimanyu Kaura, PGYIII (Medicine), Monmouth Medical Center
Kuru disease is one of the five human spongioform encephalopathies caused by prions. This group also includes Creutzfeldt-Jakob disease (CJD), variant CJD, Gerstmann-Straussler Scheinker syndrome and fatal familial insomnia.
Bovine spongiform encephalopathy also known as “mad cow disease”, is another prion disease that affects cattle, and was responsible for bringing more attention to all of these disorders in the 1990s.
Kuru is confined the Fore tribes of Papua, New Guinea.
In the 1950s there were 2100 cases of Kuru in these tribes leading to about 1000 deaths per year.
As per the culture of the Fore tribe, if a person in a family dies his meat is eaten by his family members, especially the wife and children, as a mark of respect to him. 90% of people affected by the disease were women and children.
Between 1996 to 2004 only 11 new cases of Kuru were identified in the region. Currently with the ban of cannibalism in the Farah tribes the disease had become virtually non existent.
Kuru first presents with tremors, then unsteady gait and progresses to leg weakness, ataxia, incoherent speech, sporadic laughter finally. In later stages, affected patients become demented, bed bound and unable to swallow.
Death occurs most commonly from respiratory distress and pneumonia or infection of pressure sores. The disease is fatal within 1-2 years of the onset of symptoms and had no known cure.
Here’s a video introduction
Watch the full story here:
The causative organism is a prion, a mutated protein which replicates itself like a virus, and is spread by eating the neuronal tissue of infected people.
The precise incubation period of the disease is unknown, but can be up to fifty years.
The detailed studies of theses cases of Kuru has helped us understand other prion diseases such as variant CJD, sporadic CJD whose clinical features and course is similar to this condition.
And maybe another link between Zombies and neurology?
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.
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.
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.
His observations went largely unheeded.
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 1983, Muhammad Ali was retired from professional boxing,
Obviously, repeated head trauma, and it’s consequences, is not unique to boxing:
His brain was examined as part of an ongoing study by Boston University’s Study of Traumatic Encephalopathy.
His brain showed the same pathologic changes as the Punch Drunk boxers.
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.
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.
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.
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:
And the solution?
The Allies Against Concussion:
Click here to find out more about the Matthew J. Morahan III Health Assessment Center for athletes at Barnabas Heath.
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!
While ImPACT is useful for evaluating concussion overall, some parts of the rest can mistake normal controls as impaired almost half of the time.
This underscores the importance of using multiple assessments when evaluating concussion patients.
Another recent study shows that professional athletes are more likely to seek medical evaluation after sports concussion that university athletes. Research published earlier this year already showed that high school athletes are least likely to be aware of the danger of concussions, and most likely to return to play too quickly.
NEW Updated Concussion Guidelines
from the American Academy of Neurology
Symptoms include persistent headache, problems with memory and communication, personality changes, and depression.
Concussion can occur from a blow to the head/body, such as helmet to helmet contact, or contact with the ground or another object.
More than a million Americans sustain a concussion each year.
A concussion does not always “knock you out”.
Symptoms of a concussion can last, hours, days, weeks, or even months.
Why is this important?
Repeated concussion can lead to permanent brain damage, affecting academics, internships, social interactions, and athletics.
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.
Autopsy studies have shown similar brain changes in former professional football players who experienced multiple concussions.
Recent studies of college football players showed an association between multiple concussions and reduced cognitive performance.
Guidelines for concussion evaluation and management
New American Academy of Neurology guidelines suggest the following management of 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.
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.
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.
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.
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.
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.
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.
Download the AAN Concussion App
When people of think of amnesia, they usually first think of the mysterious stranger in a soap opera, who shows up in town after an accident or traumatic experience, having forgotten their own identity, and the efforts that ensue to uncover the missing information.
Actually, in medical practice this type of “soap opera” amnesia is psychogenic, a so-called psychogenic fugue state, very different from the amnesia seen with organic neurologic disorders like head trauma or stroke.
The character Dory in the 2003 Pixar Movie Finding Nemo is a better representation of organic neurologic amnesia – she has anteriorgrade amnesia and cannot retain new information, but remembers her name and other details of her own identity.
It is thought that new memories are formed by a structure of the brain known as the Papez ciruit or limbic system, which includes the hippocampus, (subiculum), fornix, mammillary bodies, anterior thalamic nucleus, cingulum, and entorhinal cortex.
Any lesion or process which interrupts this circuit will prevent the formation of new memories, leading to anteriograde amnesia.
Temporary Anteriograde amnesia can be caused by:
zzzzhead trauma – post-traumatic amnesia or PTA,
zzzzand from Transient Global Amnesia (TGA).
TGA is a sudden onset of temporary anteriograde amnesia usually lasting lasting 4-12 hours. It is often triggered by an emotional event or sexual intercourse. During the episode, the affected patient is alert and lucid, cognizant of their own identity, but appears perplexed and may ask the same questions repeatedly. The exact cause is unknown. The recurrence rate is low.
More permanent anteriograde amnesia can be caused by:
zzzzbrain damage resulting from herpes encephalitis,
zzzzor from hemorrhage into the mamillary bodies – “Korsakoff’s psychosis”.
Korsakoff’s psychosis is caused by thiamine deficiency, usually related to chronic alcoholism. Affected patients have permanent anteriograde amnesia, and so they live in the past, and confabulate (make up details) to fill in the gaps in their memory.