Impact of Concussions on High School Athletes
 

Came across this today and thought I would pass it along:

The Impact of Concussions on High School Athletes, Congressional testimony of Gerard Gioia, PhD

Very good article.

IT would be so good if all high schools could get a copy.

Donna

I am glad to see someone taking this issue to Congress. Unfortunately, Dr Gioia is repeating some of the same falsehoods that have been a big part of the problem.

He wrongly states <The length of time for a full recovery following
a concussion – and of functional impairment – varies from days to months. For most, it takes at least several weeks.>
Not only is there no evidence to support this statement, but there is long standing evidence to disprove it.

He also states from the CISC <be restricted from activities until they’re fully healed. The important roles of parents and the school were also highlighted>

There have never been any valid standards for return to activity. The ImPACT Test and CNS Vital Signs test are woefully inadequate. They are a good start as they help parents and students better understand the need for extended non-activity.

Fortunately, he acknowledges a serious lack of understanding as to the students with persistent symptoms.

<A portion of students have persisting problems with school learning and performance long after the acute effects of the concussion. We do not yet understand the reasons for these poor long-term outcomes, and must study them further. A high percentage of student-athletes with concussion/ mild TBI experience short- and medium term problems with school learning and performance. These academic problems, even if temporary, can have potential negative consequences for the student down the road. And, if unidentified and untreated, these problems can have significant long-term consequences for the student.>

He has this nailed this last issue. PSAT's, Merit Scholar Tests, SAT's ACT's and routine academic tests that effect the student's permanent GPA can forever change the opportunities available to the student.

He is unfortunately too vague about "if unidentified and untreated." For many, the only treatment available is accommodation by teachers in testing and other grade effecting evaluations. There needs to be a avenue to have academic failures due to symptoms deleted from the academic record allowing the student to retake or delay finishing a course until proper accommodations and assistance is made available.

He calls for federal involvement when he should instead be calling for local awareness. The feds will get in the way as they create ineffective bureaucracies. The local schools need to be aware of these issues with access to local services and diagnostics.

I have a hard time understanding why there is so much resistance to accepting the fact of concussions causing long term consequences. Do the schools worry about liability law suits? Here in Idaho, our state school athletic association objected to 'informed consent' and other informational requirements as presented by a concussion bill this past February. The gutted bill that resulted and was passed and signed by the governor is worthless.

I could go on but I think I have said enough for now.

I lived this exact same problem in high school from 1969 to 1973. Not much has changed in 35 years.

I'll have to disagree with you Mark. I think things have changed and continuing to evolve in terms of concussion management and high school athletes. It's not going to happen over night but steps are being taken in the right direction.

Dr. Gioia testimony is a great step towards raising the awareness of the cognitive struggles these kids face returning to school (or anyone for that matter). Much of the literature out there for schools/parents/coaches - place an emphasis on returning to play and don't spend much time talking about the return to school piece.

It is also true that everyone recovers at different rates. Some people do make full recovery. It is true that they don't understand why some people are lingering issues and other don't. This needs to be studied.

Actually, the research shows that nobody makes a full recovery. They may appear to make a full recovery but when the brain is put under stress, the lingering problems will become evident. When the medical and psychological industry start telling this truth, then things may start to change.

The problem is the threshold of "full recovery." It is expensive and or impossible to measure because there is a need for a before and after assessment of mental capabilities. A neuro-psych assessment is only done after a problem.

The ImPACT Test and CNS Vital Signs Test try to address this with baseline testing. It is not possible to get a complete baseline in just 30 minutes of computer testing. They are both a good start just as Dr Gioia's testimony is a good start.

Drs Gioia and Collins have created some evaluation protocols as a weak start. I have copies on my desk. The need for accurate self-reporting is a big problem, especially with athletes. The insurance companies and other responsible parties continue to fight against any recognition of long term problems. Only the worst and most obvious symptoms are recognized and even those are often attributed to somatic, malingering, and litigation issues.

The courts continue to rule that most diagnostic procedures that point to concussion are imprecise. The obvious brain injured get rehabilitated to levels that are considered a full recovery because they can live independently. They still have many limitations. It appears that full recovery means 'recovered as much as possible.'

It is those of us who never lost motor function who are considered 'fully recovered' because the rehab specialists can not help us recover any more. Most people consider me fully recovered from all outward observations. But ask my wife. She will tell you about how each concussion has led to less recovery wit more pronounced residual problems.

I used to think I was fully recovered until my concussion in 1996. When I asked others about how they observed me. They all saw changes that did not recover, dating back to 1965. When I charted my concussions and compared them to my academic record, I saw a direct correlation.

For some, the long term symptoms may just appear to be a greater level of symptoms from the next concussion. This is the only issue that many professionals agree on.

The same argument goes on regarding marijuana and alcohol. But the science shows that both increase the risk of later problems. Just a few "blotto" alcohol experiences in the teens will effect the person for a lifetime. Long term moderate use of marijuana greatly increases the risk of psychosis later in life.

But by listening to the mainstream both are considered to be benign as long as you avoid operating automobiles.

When there is a lnadmark decision that places liability on the entity that failed to provide proper informed consent, one will likely see a drastic change in how concussion is presented.

We have always had competitive sports but the intensity is getting much higher. Girls want to get sports scholarships. Guys compete for extremely competitive scholarship opportunities. The 'shake it off and play harder' mantra is still in the minds of most athletes and many coaches.

Our prisons are full of concussion caused brain injured people. The numbers are thought to be 60 percent or more with brain injuries.

We need the industry to stop saying "FULL RECOVERY." It enables athletes to continue to get injured. They then negatively impact a society that has very little tolerance for their struggles.

Well, it looks like rain and my soap box will get slippery. LOL.

Mark-

I have to disagree with you to a certain extent regarding the issue of "never recovering". From my experiences as an athlete, I know of quite a few who have sustained a concussion and fully recovered with in a couple of weeks. I even had a teammate collide with another person and was knocked out, having memory problems at the initial scene, who recovered two weeks later, and was completely back to her normal self.

I have had two concussions, and the first concussion I had I was out for three weeks with headaches. This second one has been far worse, but to date, I'm feeling significantly better and go days with out headaches now. The only lingering issue I'm having is a neck and back problem.

Naturally there are worse concussions than others, but just because you sustain a concussion- really bad or "not so bad"- surely doesn't mean that your brain will never fully recover? I think what is so hard, is there is no way to make generalizations about the brain- it is just way to complex.

I believe two components play into my lingering symptoms- the amount of impact and I was just one of the unlucky ones....

I keep returning to my daughter's psychologist's comparison of concussion to any other soft tissue injury. She said, "You know how if you jump hard on that ankle you sprained it still hurts, even years later?" Same thing...I think most people recover to a functioning point but may be more prone to stressors. The headache threshold may be lower, or the threshold for stress or confusion may be lower.

Repetitive injuries on any body part are going to eventually heal to a lower degree of healing. Just ask someone who has had two or three knee surgeries. It's all about supporting the injured area. In the case of the brain, I think it has to do with decreasing risk of future injury, reducing stress, increasing nutrition. Of course these are horrible deficits to deal with. I don't mean to minimize it.

As for school--in our experience the school district has been extremely supportive. They have offered informal accommodations and offered to help us through the 504 process to get more formal accommodations next year if necessary. They have not suggested that she drop out of her honors classes, rather they are looking for ways to help her succeed in those classes. If I suggested an accommodation they said "OK".

Unfortunately, I don't think this experience is typical. In my view this testimony is designed to help school districts understand how a concussion may impact a student and how schools may accommodate those students' learning needs. That is the extent of the school district's responsibility, in my opinion, and this is a step in the right direction.

As for athletics in school I think the Impact test is also a step in the right direction. It isn't perfect, but in our case it helped us realize that this wasn't "just" a bump on the head our daughter could fight through. There is no cheating your way through a properly administered Impact test. In our case the neuro who interpreted my daughter's results (after the 4th or 5th test) said, "Her cognitive tests say she is good to get back on the court, but her symptom level is too high. I won't clear her..take her to a neurologist".

Again, I'm not sure this is a typical result. The coaches and athletic director wanted my daughter back out there, and I suppose it would have been fairly easy for them to ignore her symptoms or somehow ignore the second half of the neuro's advice. Not every athletic department will have the same ethics as ours did in this case. Long story to say the Impact test is a step in the right direction, but there is room for improvement.

As for school liability for athletic injuries...this is nothing new, right? Go to any 10 year class reunion and watch the ex football stars hobbling around. I think parents bear the responsibility of any life-long risks their child might incur in playing sports. The missing piece is properly education parents.

There is a big difference between anecdotal observations and scientific research. Those 'fully recovered' people appear to be fully recovered. If their brain is put under stress, symptoms will become evident.

The symptomatic times may never be connected to the original concussion by the casual observer or even the subject. But the scientific data can demonstrate the connection.

The easiest stressor to trigger measurable symptoms is altitude. The study compared equally rated students in a university by testing them as sea level and again at 8000 feet altitude in an altitude chamber. Those with no concussion history did the same at both altitudes. Those with a concussion history did measurably worse at 8000 feet altitude.

In my anecdotal case, I found that I made mistakes flying my own personal airplane for any extended duration at high altitudes even though those altitudes were considered safe. I ended up quitting flying and selling my plane because of the mistakes I frequently made. Years later, I read about Dr Gronwall's research.

I also have problems with test taking. The stress of the testing environment would cause memory recall and other cognitive struggles. I could often remember all of my mistakes and the correct answers once I was out of the testing stress.

Much of the long term damage from a concussion is not as noticeable until the subject reaches the forty plus age group.

The simple fact that second and third concussions are far more damaging that the first demonstrates that the brain has been left in a weakened state.

After my first concussion in 1965, I would have said that I recovered fully within six months. After my concussion in 1970, I would have said I fully recovered by late 1972. In hind sight and by the observations of others, both concussions left me with lasting problems. My personality and other behavioral changes were discounted as just growing up. Hindsight shows that they were more drastic and centered on the concussion incident.

Erica, wait and tell me that concussions recover fully after you have lived a decade or two after a concussion or two.

Many doctors claim 'fully recovered' because their concussion patients stop complaining about their concussion symptoms. We stop complaining because nobody will listen to our complaints. Our symptoms and complaints get attributed to other causes.

btw, My first concussion caused me to miss 4 days of school. The first two days I was in the hospital being observed because of my slurred speech. There were no CT scans back in 1965. I never missed any school or work since then from my various concussions. I didn't even have to 'tough it out' to deal with them. Of 14 head impacts, only three would be considered concussions by main stream medical protocol. Yet, the last and least traumatic has caused the most permanent symptoms.

Only one doctor has agreed that my minor concussions were concussions based on my observation of a metallic taste in my mouth after the impact. The other doctors look at me as if I am crazy.

When the medical community finally accepts the permanence of concussion, hopefully there will be changes in how the public looks at concussions.

I am glad so many feel like they have recovered fully. The long term struggles are almost unbearable. To be able to return to normal life functions is great.

Just be careful to avoid another head impact and be willing to accept future return of symptoms as possibly caused by the 'healed' concussion. Otherwise, the later mental turmoil of 'what is wrong with my brain' can be overwhelming.

My best to all of you.

Here is a link to an abstract of an article comparing those who suffered from mTBI and their non-injured cohorts 23 years post-injury. Interesting stuff:

http://www.ncbi.nlm.nih.gov/pubmed/19205960

nancy, Thanks for this.

Very interesting study with a great article. This shows the long term effects of PCS in the very symptomatic concussion group using the MMPI II. The Minnesota Multiphasic Personality Inventory version 2 is a poor concussion diagnostic tool but still showed symptoms at 23 years post injury. As it said, <The most important predictors of poor outcome were a combination of post-traumatic amnesia >30 minutes and EEG pathology within 24 hours after TBI.>

The MMPI-2 can be a stronger indicator of concussion if it is analyzed with the Cripes Neurological Symptoms process. The CNS process is rarely used as it is not currently being published and the author is in private practice and no longer involved in a research setting.

The study in New Zealand did not need highly symptomatic concussion subjects to show the lasting effects. It just relied on the subject self report of a concussion versus no concussion for the control group.

fully recover?
 

Hi, I am new to the forum and will try to give a quick history...I was hit in the back of the head with a softball in July 09 and did not know I had a concussion right away...I was riding rollercoasters three days after the injury because I didnt know and just felt tired. Severe symptoms started about a week later...headaches, fatigue, foggy, noise, light, etc. These severe symptoms lasted until about february 2010. I am still symptomatic today with the above, just to a lesser degree. I am upset because I was told I would make a "full recovery" by the UPMC Concussion center in pittsburgh and I have not. I consider a full recovery to mean back to my normal self...my normal way of thinking, feeling, and behaving...The symptoms have a significant effect on my life right now....lost my job, moved back home with parents, still not working....I am still looking for help/answers and struggling. My big question now is "full recovery". I am young 27 and have hope that I will get better and maybe fully recover, but am starting to have my doubts. This is my only concussion and I have been trying to heal from it ever since. I have seen my brother get hit in the head and act confused for about 15 min. but then return to normal the next couple days and I mean return to normal...no symptoms...like it never happpened. I think the word "concussion" can be misleading. I would say that my brother showed signs of a mild concussion and recovered fully. Now they called my injury a "concussion" but at this point I think "a mild brain injury with the possibility of permanent symptoms" would be more appropriate...I understand they tell everyone initially that they will recover fully because who wants to hear the opposite right after a head injury? All I can say is that I know I haven't recovered fully yet and if I do it will be Gods miracle. Any advice is welcome.

Andy,

Your doctor likely said you would fully recover because he is misinformed. I have addressed this in previous posts on this thread:

<There is a big difference between anecdotal observations and scientific research. Those 'fully recovered' people appear to be fully recovered. If their brain is put under stress, symptoms will become evident.

The symptomatic times may never be connected to the original concussion by the casual observer or even the subject. But the scientific data can demonstrate the connection. >

Your brother will likely exhibit symptoms when the stress to his brain is increased. He may show a tendency to outbursts during stressful events, etc, that are not connected to his concussion.

There are many issues to consider about your attempt at recovery. Consuming the good stuff and not consuming the bad stuff is a big one. Alcohol needs to be severely limited. Maybe an occasional beer. No getting buzzed.

There are no drugs that speed up or help with recovery. there are nutritional regimens that will help your brain heal to the extent that it can. Do a search on this forum for nutrition or vitamins. The improvements will be very slow, even under the best circumstances.

As some have mentioned, structured exercise that does not reach a level that triggers symptoms is beneficial. Reduce the stress in your living environment. This means sounds, arguing, visual stimulation/clutter, etc.

Learning to relax and not get excited about the many things that frustrate you will be a big help. We all have similar symptoms. Those that learn to not react to their symptoms do much better. This means those around you need to also not cause you stress when your symptoms frustrate them.

Get Dr Glen Johnson's TBI Survival Guide at www.tbiguide.com Download and print it out. Have your family and friends read it so they can help you.

Do not get caught up with the medical industry's terminology. You have a cluster of symptoms that result for your head impact, regardless of what the doctors call it. Concussion, TBI, mTBI, Post Concussion Syndrome, all can mean the same thing.

Also, everybody's brain responds differently to the impact they have suffered. Comparing one person to another is of no value. Even doctors use large groups to arrive at statistical models.

As I have said earlier in this thread, everybody has long term symptoms from their concussion. Some are just less obvious that others. Your brothers are less obvious. Your are much more obvious.

You have a disabling concussion. Learn what you can do. then figure out how to deal with the things you can't do. Often, you can learn a new way of doing those difficult things.

I have many work-arounds and accommodations for my permanent and on and off again symptoms.

My best to you.

recover
 

thanks Mark,

I am on vitamins, no meds other than alieve for headache, and no beer. I do llimit stressors, but am struggling with the stress of starting to work again...I am gonna try part time cleaning for now with a family friend so...as for exercise all I can really do is walk. Ya family does not understand and think that I am depressed. These forums are a great source of hope.

andy

recover
 

Mark,

I would hope my doctor is not misinformed...I see doctor Collins the

well-known expert on concussions in pittsburgh...although the last time I

went he said I had a conversion disorder which I dont think is true...I think it

is just the concussion effects...I am just still hung up with stories like that

of people who seem to make a full recovery and live successfully like brian

boyle who was in a coma and then competed in the iron man like three years

later and today is attending college and seems to be living a normal life...is

that a full recovery??? how can I still be having all these problems when I

was not even knocked out? I cannot exercise and I sleep about 12 hours

every night. I don't mean to complain but I want my life back and my brain.

First, Dr Collins is a neuro-psychologist, not a medical doctor. His research is far from conclusive. He and his colleague, Dr. Lovell, focus on 'return to play' issues. Dr Lovell designed the ImPACT system for baseline and post sports related concussion. Neither have any research that shows that their return to play criteria are valid as an indicator of when it is SAFE for the brain for the athlete to return to play.

Their strength is in keeping athletes out of the game. They have an objective system that can be used to convince athletes to stay out of the game. This compares to the previous system of vague symptom observations or even a set number of days before returning to play. It will be years before their protocol is able to be substantiated.

It may reduce the seriousness of Second Impact Syndrome but I believe the Multiple Impact Syndrome statistics will not change. It will likely save lives but there will still be many lives changed by returning to play.

I have stated for a long time that there is no test that can determine when the brain is healed enough to tolerate another concussion. I challenge the 'experts' to show me otherwise.

The value of their protocol is it reduces the chance of injury due to the lack of coordination or slowed responses that accompany many concussions. It can measure response times and other motor skills. The neuro-psychometrics have no bearing on the brain's ability to tolerate another impact.

They are experts in that they have done some research, published it, and even sold a product based on their research.

To put it simply, They can tell you when statistics show that it is definitely NOT safe to return to play. They cannot tell you when it definitely IS safe to return to play. There is a big difference between the two concepts.

I would like to see the liability release they use when they advise that it is safe to return to play.

I just reviewed my ImPACT baseline report of December 2008, almost 8 years after my last concussion. It includes a statement that it should be interpreted by a medical professional.

More important are the scales.
Memory composite (verbal) 81 49%
Memory composite (visual) 60 27%
Vis. motor speed composite 34.2 58%
Reaction time composite 0.97 5%

There is also a subjective scale of symptoms. My score was 73.

This baseline did not include any reference to whether I should be allowed to play contact sports. If I did suffer another concussion, I would likely drop even further in the scales.

btw, The percentage means where I am in the population.
My reaction time is at the bottom of the population.
5 out of 100 people have a better reaction time than me.
51 out of 100 people have a better verbal memory than me.
Yet, my intelligence is better than 90 to 99 percent of the population, depending on the type of intelligence measured. I have this score from two other neuro-psych assessments.

The failure of the ImPACT Test to measure intelligence is a shortcoming. Research shows that memory scores that are far out of sync with intelligence scores are indicative of a brain injury.

As I stated to start this discussion, your doctor is misinformed. It is very common for a psychologist to diagnose conversion disorder. This is usually based on their belief that concussions heal fully within a year so any lingering symptoms are conversion disorder. I have had two different neuro-psychs say the same thing about me.

They even discounted my scores based on their belief that I should be fully healed by the time they evaluated me. They refused to report some of the scores that contradicted their diagnosis of conversion/malingering/depression.

They discounted the validity of the scores even when the validity scores were 49 and 48 out of 50. 50 would be a NO Malingering/ 100 % valid score. The usual validity score that demonstrates malingering/conversion is below 35.

A true expert in sports concussion is Dr Julian Bailes at University of Virginia Medical Center. There are a few others like him. Some have spoken at the Howard Hughes Medical Institute broadcast on The Research Channel. There is a very good CME course available online for free at http://www.btflearning.org/go/ActivityFrontPage?id=58

The experts have one thing in common. They strongly acknowledge how much we do not understand about concussion. They also agree that this lack of understanding leads to life-long struggles with getting adequate medical care for concussion.

If the needed understanding of concussion was scaled from 0 to 100. I would put the Ph.D. 'experts' like Gioia, Collins, Lovell, etc. at about 15. Some medical doctors like Dr Bailes would be at about 30. Most primary care physicians are at 1 to 3 with some emergency physicians at 5 t0 10.

There is a neurosurgeon at Mass General who is also very good.

The current state of the experts is a good start if they understand that they still have a long way to go. The next few years will be interesting as the blast related concussion in vets returning from Iraq is hitting a critical mass. These vets are often now many years post injury yet still very symptomatic. The NFL is beginning to release information about their research too.

A big concern with some is the impact of Obama Care on concussion. Concussions can be very expensive to fully diagnose and attempt to treat. Some are concerned that there will be concussion grades established to limit care for those below the set threshold.

Thanks for all the info Mark,

do you have any suggestions for proper diagnosis? treatments? meds?

andy

Hey, Andy! Sorry to hear of your injury. PCS really, really stinks.

My daughter's injury happened in August '09, just after yours. She is still having a lot of nausea, headaches with stress or too much exercise. Her cognitive skills and fatigue are much improved. Still light sensitive.

I am certainly not an expert in PCS, so take my advice with a grain of salt for sure. My strategy for my daughter the last few months is to track down symptoms one at a time and see if any therapies might help each one.

In her case, once things sort of started to calm down it became obvious that her eyes were the source of many of her problems. I kept researching, calling doctors, calling state agencies who help coordinate care, etc., until I finally found someone to do some vision therapy for her. We are hopeful it will help.

The uber-specialist neuro opthamologists said, "her vision is 20/20, but there is some optic nerve trauma that will get better with time". Our hometown optomitrist said, "yeah, there might be some therapies to help...I don't know". So I took to finding a therapy like a dog with a bone.

All this to say that there are so many problems that can come from a head injury (vestibular, eyes, hormones, pituitary, thyroid, neck). For whatever reason, neurologists don't seem to usually encourage their patients to track down these issues. You sort of need to do it all yourself.

Keep in mind, too, that it's possible you could spend your energies tracking down each of these and end up just needing more time to heal. None of these suggestions is a magic cure, but I would rather spend time tracking them down now rather than figure it out by accident six months from now. Right? If somthing might relieve some suffering I'm all about finding it sooner rather than later.

OH...as for your question about meds...our neuro put my daughter on Elavil. I think it really helped with pain prevention during the acute stage.

After a few months, though, she felt like it was making her feel worse than the concussion. Plus it caused heart palpitations, which was scary. Once she got over the withdrawal symptoms she didn't really feel much different without it.

It is supposed to act as a "neuro-generator" and help the brain re-establish pathways. IDK...just what I've read. It's wicked strong, though, so if you don't feel you need it I would steer clear.

Mark: I think we disagree on the main point of the Norway study. I think it's important to point out that there were no differences between the head injured group and the non-head injured group in terms of education, income, and other "quality of life" indicators except for those who had those two specific symptoms.

In other words, people who did not have memory loss over 30 minutes and those who did not have EEG abnormalities can expect to be on a fairly even par with their non-head-injured cohorts in 23 years.

So, according to this one study, those on this forum who might still be experiencing some symptoms for several months, but don't have those other two factors, can expect to recover to a very functional level.

PCSLearner,

I agree with your statement:

<So, according to this one study, those on this forum who might still be experiencing some symptoms for several months, but don't have those other two factors, can expect to recover to a very functional level.>

The important comment is 'very functional level.' This is often misinterpreted to be a full recovery.

Although, I do not think the two factors have as much impact on long term symptoms. They may have the most statistical impact but there were likely many without these symptoms post-injury who have long term symptoms.

It would have been much more interesting and informative if some of the Weschsler tests were included in the study. They are more objective where-as the MMPI-2 is more subjective. The MMPI-2 is more about the subject answering about how they feel where-as the Weschsler tests function.

Andy,

I would suggest that you have Post Concussion Syndrome. There is very little in the way of treatment/meds. Individual symptoms are treated, but not the cluster of symptoms know as Post Concussion Syndrome. i e, Treat the head aches, learn work-arounds for the memory problems.

The Buffalo protocol sounds like an effective treatment for those with athletic ambitions. Just remember that there is no way of knowing how sensitive the brain is to a second impact/multiple impacts.

There are brain training games and exercises that may help regain some lost cognitive functions. The value of these exercises is specific to the individual. There is no broad brush for treating PCS symptoms other than rest, avoid stress, and get good nutrition. .