[nancys]

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

[Dmom3005]

Very good article.

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

Donna

[Mark in Idaho]

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.

[nancys]

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.

[Mark in Idaho]

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.

[erica21]

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....

[PCSLearner]

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.

[Mark in Idaho]

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.

[PCSLearner]

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

[Mark in Idaho]

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.