Honoring Brain Injury Awareness Month

Since HeadFirst Sports Injury and Concussion Care launched just three years ago, we’ve already seen the tide turn about the public’s understanding of concussion (mild Traumatic Brain Injury or mTBI). We’ve gone from hearing “It’s a only a mild concussion,” and “You just got your bell rung a bit,” to an acknowledgment of the severity of this silent injury.

Locally here in the Capital region, HeadFirst has been extremely active in hosting educational seminars for coaches and parents, and participating in dozens of community outreach programs.

In 2014 alone, HeadFirst’s team of professionals participated in more than 80 community events reaching more than 180,000 people. These events included partnerships and sponsorships with the Brain Injury Association of Maryland, Hockey for Heroes (benefitting the Wounded Warrior Project, USA Warriors Ice Hockey Program and Disable Veterans of America), Sports Legacy Institute, Touchdown Club of Annapolis, as well as educational seminars for school and county recreational coaches and athletic directors, presentations for school nurses on concussions and mental health, and attendance at community health fairs.

These groups have welcomed our educators with open arms to help their coaches and athletic trainers understand the right protocol in managing a suspected head injury, from those critical first moments to long-term treatment for proper healing.

Our outreach programs are one of our cornerstones, we’d like to think they’ve helped change the traditional way of thinking about concussions.

HeadFirst is also a gathering point for professionals from around the region to share their expertise. Our monthly Concussion Consortium pulls together physicians, neurologists, neuropsychologists, physical and vision therapists, and other specialists, school administrators and nurses, athletic trainers and coaches, who discuss scientific research and resources for concussion treatment and protocols.

The Consortium often hosts a respected guest speaker who shares information about specific topics and issues related to concussion. Next week, we’re welcoming Sarah Loeffler, LCSW-C, of The Neuropsychiatry Program at Sheppard Pratt Health System in Baltimore, Md., who will discuss mTBI’s connection to anxiety and depression.

Also next week, HeadFirst Chief Executive Officer Robert G. Graw, Jr., M.D., and HeadFirst Program Director Tony Doran, Psy.D., are presenting their lecture, An Integrated Community Model for Concussion: Update, at the Brain Injury Association of Maryland’s annual conference.

Of course, all of this is in addition to our 11 clinics throughout the DC-Baltimore region, which is our reason for existence. From the thousands of neurocognitive ImPACT® tests we’ve administered to the patients for whom we have cared, we’ve heard amazing, heartfelt stories of the trials of living with a concussion and the willpower to overcome it. These serve as our inspiration to push ever forward.

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We continue to read emotional articles in the news about concussion awareness, including yesterday’s announcement of San Francisco 49er linebacker Chris Borland’s decision to retire due to the high potential of long-term brain injury from playing. Turning away from a lucrative career in the name of your health surely must be one of the most incredibly difficult decisions to make, and we applaud this young man for having the guts to make this choice.

HeadFirst Sports Injury and Concussion Care is proud to honor March’s designation as Brain Injury Awareness Month, as well as Brain Injury Awareness Day today, March 18. Looking back, it’s been a fulfilling journey, albeit a short one. The starting line is still in our sights and we know the finish line is a long way off—and very likely will continue to move even as we do.

Concussions can and do happen to anyone, anytime, anywhere. The non-discriminatory nature of this injury is what continues to motivate us to do our work.

What’s Missing in Youth Concussion Laws

by Tony Doran, Psy.D.
HeadFirst Concussion Care Program Director

A recent Fox Sports article discusses the youth concussion laws that have passed in all 50 states and the District of Columbia, but it also highlights some key elements that were missed.

Over the past five years, each state has modeled their laws after the State of Washington law in 2009, also known as “The Zackery Lystedt Law” after a high school athlete who suffered a life-changing concussion (pictured below, pre-injury and today, with his father).Zackery-Lystedt

Unfortunately, only 21 states have implemented all four key components of Washington’s law, which is considered the gold standard by many professionals:

1. REMOVAL FROM PLAY
This is pretty basic. The science and medical reasons for asking a child or athlete to leave a game or practice when a concussion is suspected is in place so a second and potentially more dangerous concussion does not occur. As of today’s writing, neither Illinois nor Wyoming requires the removal of an athlete from play in such a scenario. Arizona and South Carolina allow an athlete to return to play the same day if cleared by a physician.

When a child is suspected of having a concussion, it is a good idea to at least wait 24 to 48 hours after the injury to ensure that symptoms do not develop. Here at HeadFirst, as many as 40% of our patients develop symptoms one to two days after their injury.

2. EDUCATION
Fortunately, this is not as opposed as it was just three or four years ago. Coaches now realize the importance of receiving education about how to evaluate and treat a head injury. New York law requires not only coaches but also nurses, athletic trainers, and teachers to receive training on concussion and concussion management.

But New York is the exception and there are many states that don’t require education about concussion. Researchers and scientists also still need to do much in this area. Studies have not been completed on what coaches and athletic trainers know prior to training and what type of training is effective.

3. PARENTAL CONSENT
This is quite a basic component of the law which requires student athletes and parents to sign an informed consent stating they understand the dangers of the sport and that a concussion or traumatic brain injury is one of the risks involved in the sport.

4. MEDICAL CLEARANCE
Only 30 states have this element as part of their laws requiring clearance by a trained concussion healthcare provider prior to injured athletes’ return to play. Many laws and training programs also do not specify what training a concussion specialist needs or requires.

Even though these elements are a good first step, they’re still not enough to protect our children. A carefully designed return-to-learn plan is just as important in concussion recovery since academic demands can slow brain healing. Unfortunately, only two states—Nebraska and Virginia—have return-to-learn elements within their concussion guidelines. These procedures require a school to be notified if a student has sustained a concussion and then to give that student accommodations due to the injury.

Some states have even made unsuccessful attempts to add supplementary requirements to their concussion laws.

Oklahoma tried to add a section to their law that would mandate suspensions and punishments on coaches and athletic trainers who didn’t follow concussion guidelines.

Massachusetts attempted to add required neurocognitive baseline testing for all high school students.

And, Maryland tried to add a requirement of helmet sensors on high schoolers’ helmets before basic scientific research had been completed on the sensors or the meaning of a positive or negative sensor result.

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A number research studies continue to suggest the negative effects of alcohol (and other recreational drug use) after brain injury.

Alcohol is a neurotoxin — meaning alcohol kills brain cells — exacerbating the effects of a concussion. There is no recommended safe amount of alcohol or recreational drug use after a concussion. Even moderate amounts of alcohol for people with a concussion have been associated with increased deficits in memory, attention and balance.

Additionally, heavy pre-injury alcohol consumption is associated with poorer health outcomes and substance abuse post-injury. Many concussion patients report they are more sensitive to the effects of alcohol after injury. Even a small amount of alcohol after a concussion can impair judgment and increase the risk of a fall (and subsequent head injury).

How Much “Strict Brain Rest” is Needed After a Concussion?

by Majid Fotuhi, M.D., Ph.D.
Founder & Chief Medical Officer, NeurExpand Brain Center
Guest Contributor

Guidelines by the American Academy of Neurology, American Academy of Pediatrics, and many sport organizations emphasize the importance of brain rest after a mild TBI. Now, a new study published in the January 5 issue of Pediatrics questions the validity of recommending 5 days of strict rest to all children who suffer a concussion.

Authors examined the difference between the outcomes of two groups of children (average age of 13-14 years old) who presented within 24 hours of a head injury to an emergency room. Half were told to rest for as long as needed, usually for 1-2 days, followed by stepwise return to the usual level of activity. The other half was told to rest for 5 days, without engaging in any school or work engagements, followed by stepwise return to activity. Participants had neurocognitive (ImPACT) and balance assessments at baseline and at their follow-up visits at 3 and 10 days. They also kept a diary of their activity level and how they felt.

In both groups, 60% of participants reported resolution of their symptoms. However, half of the “strict rest group” took 3 additional days to reach a full recovery. This strict rest group also tended to have a larger amount of emotional issues, as they were kept away from school and social settings. Children in the strict rest group who had headaches at the onset of their concussion tended to have lingering symptoms for a longer period of time than the control group. The one exception to better outcomes in the control group was for children who had immediate loss of consciousness or amnesia at the time of their injury. These children seemed to benefit from 5 days of strict brain rest.

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In general, it appears that not all children who experience a mild TBI should receive a prescription for strict 5-day brain rest. There may be benefits in treating each patient individually, depending on their initial symptoms, level of cognitive function, and severity of concussion. Some may need no rest, some may need 1-2 days of rest, and yet others may need 5 or more days of avoiding demanding brain stimulation.  More studies are needed before the current guidelines can change. The one recommendation that is gaining more support in recent years is to have patients engage in exercise early in their post-concussive period.  Increasing physical activity tends to do wonders for rehabilitation of patients who suffer from a stroke (which is a vascular brain injury) and it may be just as beneficial for kids or adults who have had a traumatic brain injury.

For now, if you have had a brain injury, please be sure to see your doctor or a sports medicine specialist who is familiar with concussion management issues. Your brain is a precious organ and it’s important to work with experts in the field  on controlling your symptoms and finding the best resolution for full recovery. Otherwise you may end up having lingering post-concussive symptoms for months, years, or decades.

SOURCE: Anderson, P. (2015, January 7). Strict Rest After Concussion Offers No Additional Benefit.

Concussions Can Affect Processing Time in Speech and Language

by Melissa D. Stockbridge, M.Sc.
Guest Contributor

Even a relatively minor head trauma can result in physical, cognitive, behavioral, and social consequences for a young patient. Specific effects of mild brain injury or concussion on language ability can include effects on the ability to think of the names for things, make sentences, and interact with others appropriately in social situations. Many studies have linked brain injury to difficulty reading and telling stories.

Anomia, or difficulty thinking of the names for objects or people (essentially, severe “tip-of-the-tongue” experiences), is the most common reported symptom that affects language. Problems with naming can have big impacts in the classroom. Imagine not being able to come up with the name of the main character in a novel or the particular term you need to name in your science class!

Not only is the accuracy of coming up with the names of objects affected (e.g., saying “dog” when viewing a picture of a dog), but also there is an increase in the time that it takes the patient to come up with the name.

This can be imagined by analogy to a computer connecting to the Internet that may eventually load a webpage correctly, but the connection is much slower than usual.

SpeakExamining differences in the “processing time” required to name an object may be useful in better understanding the cognitive changes that occur during the period of spontaneous recovery directly following a brain injury.

Researchers at the University of Maryland, College Park, are examining naming accuracy and processing time across the period of spontaneous
recovery from mild head trauma, in order to better understand the changes in young people with brain injuries.

Patients at HeadFirst Concussion Care between the ages of 10 to 20 years of age are being recruited to name rapidly presented images on a computer that measures how quickly they say the name of that image. It is predicted that adolescents with concussions will demonstrate a steep rate of recovery of naming accuracy to within normal range, with a slower recovery of processing time beyond that point.

It is our hope that this information will improve information available to clinicians and patients in making return-to-learning and return-to-play decisions and will add to what is known about how a minor injury may impact performance in language or in education.

Melissa D. Stockbridge is an M.A./Ph.D. student at the University of Maryland’s Department of Hearing and Speech Sciences

Giving Thanks for our Team, Plus Many Schools Lack in Return-to-Learn Guidelines

by Tony Doran, Psy.D.
HeadFirst Concussion Care Program Director

If this is your first time looking at our blog or visiting the HeadFirst website, we are one of the premier community-based concussion clinics in the country that provides education, evaluation, and treatment of traumatic brain injuries for children and adults ages 2 and up.

Our overall staff commitment to excellence is reflected in the teamwork and service to HeadFirst patients and their families.

Headfirst has seen thousands and thousands of patients this year, has conducted community outreach events with more than 180,000 attendees, provided thousands more ImPACT® concussion baseline tests, and is submitting our fifth research project for publication.

What we do in HeadFirst doesn’t happen by magic….

Providing care to this many patients requires an effort of our entire team: from the support of CEO Dr. Robert G. Graw, Jr., and Senior Medical Officers Dr. Stanford Coleman and Dr. Marc Weber, to Chief Creative Officer and Program Advisor Amy Knappen, to Director of Clinical Services and Training Lauren Burkhead, FNP, to all the medical providers and staff in our clinics. The collective effort of our entire team has lea HeadFirst Sports Injury and Concussion Care to experience tremendous success over the past year.

At this time of the year of giving thanks, I am truly blessed and thankful that I work with such a wonderful team of dedicated and motivated professionals.

I recently received this article from a fellow professional that highlights the widely varying policies of school preparedness for dealing with concussions.

The study was conducted at Nationwide Children’s Hospital in Columbus, Ohio, and surveyed 695 public high school principals about their knowledge of mild traumatic brain injury (mTBI). The findings highlight both good news as well as some opportunities for improvement.

For example:

  • Less than half of those surveyed had taken a concussion management training course
  • About a third of schools provide families with written plans
  • Less than a quarter provide potential academic accommodations to students
  • 80% had case managers assigned to students with concussions, who are usually a school nurse or athletic trainer
  • 86% could identify someone at their school who communicates with students’ health care providers after a concussion in an athlete, while only 79% could make that same identification if the injured student was a non-athlete

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Researchers also noted that preparedness plans shouldn’t concentrate only on school athletes. There is often a greater awareness of return-to-play guidelines than return-to-learn, although students should return to academics before returning to sports. Researchers felt that these findings highlight the need for guidelines governing return to academics.

It should be noted that, presently, only Nebraska and Virginia have return-to-learn laws in place, while all 50 states have return-to-play laws.

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Parents need to be their child’s best advocate and ensure that they get accommodations from their doctor for continued school success.  mTBI is the only injury that affects a child’s ability to continue to be successful at school. This injury requires the collective effort of those working closely with the child to be in constant communication, which include the parents, nurse, teachers, and health care providers treating the child’s mTBI.

How Much Do Athletes Know About Concussion Symptoms?

by Tony Doran, Psy.D.
HeadFirst Concussion Care Program Director

Only a few studies have ever been conducted to examine the efforts that hospitals, universities and communities are making to educate children about the symptoms of a traumatic brain injury. Fortunately, the University of Florida is one of the few institutions who has done some work in this area. Their recent survey of 334 varsity high school football players from 11 Florida high schools uncovered some interesting, yet unsurprising, results.

Footballs - Question Mark

The conclusion that University of Florida researchers drew was that most of the high schoolers did not know or could not associate some of the symptoms that they might experience with a concussion, including nausea, neck pain, and trouble concentrating.

In fact, even with parents or guardians signing a consent form indicating they discussed concussion awareness with their child, nearly half of the study’s athletes suggested they had not.

At HeadFirst Concussion Care, our own research team recently conducted a brief survey at a local high school during the athletes’ annual sports physicals.

Our team asked high schoolers if they knew the difference between various medical injuries, including orthopedic injuries, cardiac emergencies, mTBI’s, and dehydration.

We found that these youth athletes had some knowledge of mTBI but we also learned that many of the teenagers in our sample were uninformed about dehydration and cardiac emergencies.

Conducting this research is so important because it shapes the ways we can improve our education and training.  Knowledge is the most important key to reducing the number of concussions, especially multiple traumas.

Monitoring educational programs in high schools, middle schools and recreation programs is extremely important to HeadFirst so we can find out where to direct our educational efforts to keep children, parents and coaches informed.

HeadFirst-Doc-is-InIs it OK to drink alcohol or smoke a joint ever now and then with a mTBI?

As a former military guy, I’m nearly duty-bound to remind others that using cannabis is still illegal in Maryland. This, in itself, should provide additional motivation for avoiding the drug.

As a dad, I’m stunned that more private schools in the area don’t conduct mandatory random drug tests.

Research is still ongoing, but adding chemicals to the brain, including cannabis, when it is injured and recovering would most likely add to one’s recovery time. I recommend staying away from all brain stimulants and depressants while recovering from an mTBI. This includes not only cannabis and alcohol, but also caffeine products.  — Dr. D.

What Are We Teaching Our Kids?

by Tony Doran, Psy.D.
HeadFirst Concussion Care Program Director

Former pro football player Jim McMahon and pro hockey player Jeremy Roenick (below), both of whom suffered concussions during their careers, are joining up to raise awareness about the dangers of concussions at all levels of sports. Their foundation, Players Against Concussions, is planning event sponsorships and has already launched three advisory boards that include leaders in youth sports, research and medicine, and current and former pro athletes.

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Roenick acknowledged that, as long as kids are going to play sports, concussions are not going to go away, but the duo is hoping to educate everyone in sports – from the athletes, to the parents, to the coaches – that early treatment is the best approach.

As Roenick says, “It’s the lack of education that causes people to have problems later in life.” And he’s absolutely right. After all, education is a cornerstone of the HeadFirst program.

As a parent, doctor and scientist, I have several thoughts both after reading this article and, coincidentally, watching a Pop Warner football game over the weekend that left me realizing how far we need to go with the educational process.

More doctors and researchers and educators need to go to Pop Warner football games. While watching 8-year-olds play this past weekend, parents were high-fiving and jumping up and down like they were watching older, more advanced kids at a high school state final or NCAA playoff game.

There were the cheerleader parents, the sideline coach parents, and the parents living vicariously through their kids. But, I’m not sure any of them had safety as their top priority.

As a parent, I wondered, “What are you folks thinking and what’s the point of this game? What are you teaching your kids because they’re watching you jump around!”

As a doctor and coach, I silently asked, “How is your emotional yelling toward these young children affecting them?”

As a scientist, I wonder about our educational efforts for concussion awareness going and also how states compare to one another? I was just traveling not too long ago to another state (I won’t say where but I have extended family in New Jersey) and considered how we could use different states’ “best practices” to help all of us improve our educational programs. This is certainly something to consider.

Be sure to check out next week’s blog when I’ll review some of our results from educational surveys of high school athletes here in Maryland regarding mTBI.

HeadFirst-Doc-is-InAt the Pop Warner game last weekend, I did witness one hard hit. The player was flagged for “targeting” another player and helmet-to-helmet contact. Prior to high school youth players, should be flagged for “improper tackling technique” – helmet-to-helmet contact. Refs, coaches and parents can then instruct the child on the proper football technique.   — Dr. D.