Brain Injuries in Sports

An evidence– based guideline from the AAN for evaluating and managing athletes with concussions recommends that athletes who are suspected of having a concussion be removed from the game immediately and not be returned until assessed by a licensed health care professional trained in diagnosing and managing concussion. The new guideline, which replaces a 1997 AAN guideline on the same topic, was published in Neurology® electronically ahead of print on March 18, 2013. It has been endorsed by several athletic, medical, and patient groups.  Click Here to read the guideline.

“Among the most important recommendations the Academy is making is that any athlete suspected of experiencing a concussion should immediately be removed from play,” said co– lead guideline author Christopher C. Giza, MD, with the David Geffen School of Medicine and Mattel Children’s Hospital at UCLA. “We’ve moved away from the concussion grading systems we first established in 1997 and are now recommending concussion and return to play be assessed in each athlete individually. There is no set timeline for safe return to play.”

The guideline also addresses sports with the highest risk of concussion, protection provided by helmets and headgear, increased risk after having a concussion, the relationship between multiple concussions and permanent or lasting impairments, and other issues.

Read the guideline, access clinician and patient resources, and download the new AAN Concussion Quick Check app. For more information, contact Julie Cox or (612) 928– 6069.

A new study published online at PLOS One found that “the brain degeneration observed among professional football players could result from an out-of-control immune response, similar to what multiple sclerosis patients experience. “Consequences of Repeated Blood-Brain Barrier Disruption in Football Players, Nicola Marchi, Jeffrey J. Bazarian, Vikram Puvenna, Mattia Janigro, Chaitali Ghosh, Jianhui Zhong, Tong Zhu, Eric Blackman, Desiree Stewart, Jasmina Ellis, Robert Butler, and Damir Janigro.

In its “preliminary” study, the researchers showed:  “That elevations of serum S100B indicating blood-brain barrier disruption occur in football players who experience sub-concussive head hits below the threshold for a diagnosis of concussion.  We have also shown that players who during a season experience the most significant repeated elevations of S100B are also those with the highest titer of serum S100B auto-antibodies.”

In an article published in Science Daily, Jeff Bazarian, one of the authors stated: “although the awareness of sports-related concussions is much higher, we still know very little about the long-term consequences and what happens inside the brain” ….Our theory is plausible as an explanation for how routine head hits that come with playing football can lead to severe neuro degeneration later in life.”  Click Here for a link to the story published in Science Daily.

Sports Illustrated also reported on the research.

The November 14, 2012 on-line issue of the Journal of the American Medical Association (JAMA) contained a research letter authored by Inga Coerte, M.D., Birgit Ertl-Wagner, M.D., Maximilian Reiser, M.D., Ross Zafonte, D.O., and Martha E. Shenton, Ph.D. from Harvard University.

The researchers, interested in whether frequent sub concussive blows to the head in soccer players could lead to traumatic brain injury, evaluated concussion-naïve soccer players using high resolution DTI, which “is highly sensitive for detecting alterations in white matter architecture.” The researchers utilized forty soccer players, all right handed males, from two training groups of an elite-level soccer club in Germany.  All had been trained since childhood for a career in professional soccer.  A comparison cohort of swimmers was recruited from competitive clubs to match on age, handedness, and sex.  Those with a prior history of concussion or any other neuropsychiatric disorders were excluded. 

The researchers utilized diffusion tensor imaging (DTI).  Wide differences between groups were found with increase radial diffusivity in soccer players.  The researchers commented that “this study found differences in white matter integrity in a small sample of soccer players compared with swimmers.  Although only participants without previous symptomatic concussion were included, advanced DTI revealed widespread increase in radial diffusivity in soccer players, consistent with findings observed in patients with mild traumatic brain injury and suggesting possible demyelination.” 

This demonstrates that DTI is being used in the diagnosis and research of persons with mild traumatic brain injury. This is further support for the use  and the admissibility of DTI in trial of patients with mTBI.

A recent article in WOUB Public Media talks about Ohio University’s attempt to determine ways to reduce the risk of injuries, including lessening the risk of sustaining a concussion.  Ohio University was one of the universities selected to work with the Datalys Center and USA football.  Licensed athletic trainers have been documenting player health and looking for ways to increase safety for youth football players.

Dr. Brian Ragan, assistant professor of athletic training at Ohio University, is collaborating with the US Department of Defense, National Institute of Health, and Centers for Disease Control and Prevention, to develop and improve a database to track personal injury information over long periods of time. 

A recent article in the New York Times highlights how researchers are working on a new, relatively inexpensive way to spot injuries and monitor brain diseases using magnetic sensors that can spot changes in brain waves.   This compact and portable detection device, part of the field of optical magnetometry, is constructed as a form of headgear roughly the size of a sugar cube, and works by having sensors measure changes in the brain’s magnetic field.  The device’s size, portability, and affordability allow for a wider range of applications that may someday be mass produced and used on athletes to monitor collisions and subsequent brain injuries in sports.
The compact magnetic sensors were developed by the Commerce Department’s National Institute of Standards and Technology, and they are working to offer an alternative to the costly and inflexible technology currently available, called superconducting quantum interference devices (“Squids”), which require cryogenic cooling which cannot be used at room temperature.  
Optical magnetometry has been used as an alternative to superconducting devices to monitor the magnetic fields of the heart rather than the brain.  The institute’s new compact technology, though still in prototype, has enormous potential for transforming the ways doctors and researchers can analyze the progression and status of diseases, as well as for the ability to control prosthetics using brain signals.  

Traumatic brain injury (TBI) is among the earliest illnesses described in human history and remains a major source of morbidity and mortality in the modern era. More than 2% of Americans currently lives with long-term disabilities as a result of a previous brain injury, and incidence and prevalence rates are even higher.

One of the most common and devastating consequences of suffering from a brain injury is dementia. Studies have shown that suffering from a TBI early on in life, is associated with an increased risk of dementia later on in life.

Studies show that moderate and severe brain injuries increase the risk of dementia between 2- and 4-fold. It’s not as clear if mild traumatic brain injuries, like concussions, leads to dementia, mainly due to the fact that mild TBIs are often not well documented. However, studies have also shown that that multiple mild brain injuries, such as those sustained by professional boxers and football players, are associated with a high risk of chronic traumatic encephalopathy (CTE), a type of dementia with distinctive clinical and pathologic features.

The recent recognition that CTE is common in retired professional athletes, such as boxers, ice hockey and football players, has increased interest in this condition. Additionally, military personnel also experience extremely high rates of brain injuries due to combat blasts. These injuries may have a similar syndrome and long-term effect.

It is presently unknown whether dementia in TBI survivors is pathophysiologically similar to Alzheimer disease, CTE, or some other form of long-term brain damage. Such information is critical for developing preventive and treatment strategies for a common cause of acquired dementia.

As the number of females participating in youth soccer programs continues to increase, so does the number of sports-related concussions for females under the age of 18. Of the more than 3 million kids registered to play youth soccer in the US, girls make up 48% of that group.

A new report shows that girls are reporting nearly twice as many concussions as boys in the sports they both play, including soccer. The number of girls suffering concussions in soccer accounts for the second largest amount of all concussions reported by young athletes, according to the American Journal of Sports Medicine.  (Football tops the list.)

Though most people believe soccer is a relatively safe sport when discussing the chance of sustaining a concussion, “heading” has led to more concussions in the past few years than most would imagine. When heading, players attempt to use their foreheads to direct the ball, often jumping with opposing players. This move can lead to collisions between players, bumped heads and strained necks.  Heading is one of the most dangerous parts of soccer because players often collide.

Junior Seau, a 12-time Pro Bowl linebacker who led the San Diego Charges to a Super Bowl victory and played in a second Super Bowl with the New England Patriots, was found dead  from an apparent suicide earlier this week in his California home. Seau was only 43.

Seau’s death is the latest in a long line of professional football players who have suffered the most devastating effects of the sport: long-term, and often times deadly, results from too many hard hits and concussions sustained on the field.

Seau is the eighth member of the San Diego Chargers’ 1994 Super Bowl team to pass away. The other members of the team include defensive end Chris Mims, linebacker David Griggs, running back Rodney Culver, linebacker Lewis Bush, center Curtis Whitley, defensive tackle Shawn Lee and linebacker Doug Miller and Dave Duerson.

Duerson, a former defensive back, reportedly had brain damage common to chronic head trauma citing chronic traumatic encephalopathy (CTE), which had also been found in more than 20 other deceased players. In his last note to his family, Duerson had asked his brain be sent to researchers. He wanted the world to know what had enveloped him.

Duerson shot himself in the chest, an act which preserved his brain for study. Police say Seau apparently shot himself in the chest as well.

This is one more, devastating, example of why stricter limits need to be put in place in the NFL, as well as high school, college and recreational sporting leagues. A person’s life is not worth another hit on the field and one more ring.

The Athletic Trainers’ Society of New Jersey (ATSNJ) released a Concussion Policy Survey which states that although New Jersey has implemented the Concussion Law, some schools are delaying in their compliance with the new regulations. The survey examined 110 high school athletic trainers throughout the state of New Jersey and states that while most districts have a board approved policy, others do not and those without blame the Law stating that it is difficult to interpret certain provisions.

Some argue that terms included in the Law, such as “physician trained in concussion management,”  “academic modifications,” and “asymptomatic,” are not clearly defined in the context of the description.

The report states that:

  • Only 63% of team physicians are “trained in the management of concussions”
  • 9% of respondents do not have a board approved concussion policy.
  • 27% of schools adopted a generic policy.
  • 84% of districts do not defined “trained in the management of concussions” in their concussion policy.
  • 51% of districts do not define “asymptomatic” in their concussion policy.
  • 60% of districts do not define specific academic accommodations in their concussion policy.
  • 89% of school policies define “graduated return to play protocol”
  • 100% of districts utilized athletic trainers as the gatekeeper for the concussion management process

Sarah Burke, Canadian freestyle skier, four-time Winter X Games Gold Medalist and Olympic gold-medal contender, died yesterday at the age of 29 after complications from an accident at the Park City, Utah halfpipe January 10th.  Burke was considered a pioneer in her sport as she successfully lobbied to add superpipe skiing to the Olympic Winter Games.

The accident tore one of Burke’s major arteries supplying blood to her brain, causing her to go into cardiac arrest. She underwent surgery and spent nine days on life support at the University of Utah Hospital. Doctors state that Burke suffered irreversible brain damage after the fall because of a lack of oxygen and blood to the brain.

Members of the skiing community say Burke was a pioneer among freeskiers who inspired them to do greater things. "Sarah was the one who, in a very positive way, stood in the face of adversity and asked, `Why not?"’ said Peter Judge, the CEO of Canada’s freestyle team.

"She’s probably one of the nicest people I’ve known in my life, and that’s about the only thing I have to say about it," said American superpipe skier Simon Dumont, a multiple X Games medalist.

Burke’s death is a devastating blow to the skiing community. Every day, experienced and knowledgeable athletes suffer serious, life-threatening and even deadly brain injuries. I hope that Burke’s story will serve as a reminder for those who participate in such activities to use extreme caution while enjoying these sports.