Why Concussion Risks are Higher for Women

by Tony Doran, Psy.D.
HeadFirst Concussion Care Program Director
and Ann-Marie Sedor, HeadFirst Concussion Care Marketing

A number of research articles suggest that women are more susceptible to mild Traumatic Brain Injury. In fact, female college athletes have a higher rate of concussion compared to males when playing soccer (2.1 x greater risk), softball versus baseball (up to 3.2 x greater risk), and basketball (up to 1.7 x greater risk). So, why the difference? Research and anecdotal evidence has turned up three possible reasons: cultural differences; hormonal differences, or physiological differences.

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Canada forward Christine Sinclair (right) and USA midfielder Carli Lloyd head the ball during the 2016 CONCACAF women’s Olympic soccer tournament at BBVA Compass Stadium in Huston, Texas, on February 21. Soccer is also among those sports programs that produce a large share of concussions for female athletes. — Reuters

Some experts have said part of the reason for increased concussions in females may be due to the reporting rate — that women are more likely than men to notify a coach they are injured, whether due to a head injury or other concern. Cultural differences indeed indicate a reluctance among males to report any injuries for fear of being removed from play. However, because of the very nature of concussion being a clinical diagnosis that usually depends on self reporting, it is hard to say that the incidence differences between the genders is due to honesty.

Other research suggests that hormones including estrogen, oxytocin, progesterone, and testosterone, affect recovery times from concussion. Of course, men and women have vastly differing levels of these hormones. One published study from the University of Rochester (NY) has also shown that menstrual cycles play a part in healing from head trauma. The research showed that women in child-bearing years experience greater cognitive decline, delayed reaction times, extended periods of depression, more headaches, and longer hospital stays and return-to-work plans compared to men following head injury.

Other articles suggest that longer and weaker necks of female athletes influence the potential for greater cervical injury and flexibility of the cervical ligaments. During a 2013 Youth Sports Safety Summit presentation, recent findings from athletic trainers showed neck strength and rigidity could help lower the chance of concussion. For every one pound increase in neck strength, odds of brain injury fell by 5 percent. Consequently, some the nation’s foremost authorities on concussion suggest female athletes participate in daily neck strengthening exercises.

Other research suggest that there are different neuronal connections between the hemispheres and significant lobes within the cerebral cortex for men and women potentially influencing recovery time. A recent Georgetown University Medical Center study showed that mice with a single head injury temporarily lose 10 to 15 percent of the neuronal connections in their brains, which can be repaired when at least a week of rest is provided. The fact that male and female brains are “wired” differently could account for a higher incidence of and/or a longer healing period after brain injury in women.

Realistically, interplay of all of these factors could potentially influence the differences in concussions between the number of concussions of female athletes and their recovery.

Be Cautious of New Products or Research That Promise to Prevent or Heal Concussions

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

Periodically when I’m seeing patients in our HeadFirst concussion clinics, parents will ask me about a different brain trauma-related studies that they’ve heard about. These questions range from studies about concussion-healing chocolate milk to eye tracking devices to the effectiveness of helmets and different sports bands preventing head injuries. Presently, NO concussion treatments have been approved by the United States Food and Drug Administration (FDA). Likewise, the FDA has yet to approve of any devices that prevent concussions in the first place. No helmets, no mouth guards, no sports band or other piece of technology in any way shape or form has been demonstrated to completely prevent concussions.

I typically advise parents to be extremely cautious with new research or technology, or with the promises of concussion treatment. Instead, parents should seek out a concussion specialist who has years of experience treating these injuries and utilizes multiple methods in their assessment, diagnosis, and treatment planning.

Refreshing Delicious Chocolate Milk

Can chocolate milk heal concussions? Don’t count on it.

Concussion Awareness Spreads with News Headlines

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

Regardless of age and profession, motor vehicle accidents and falls are the most common ways that people can sustain traumatic brain injuries. Even first responders – police, fire, and ambulance crews – regularly go into harm’s way and risk personal injury that includes concussions, as recently happened when two firefighters in New Jersey slipped while jumping off their fire engine at a house fire.

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Even firefighters and other first responders are vulnerable to concussions (Photo: AP/Wide World)

Although sports like football, soccer, and lacrosse get a majority of the press about head traumas and traumatic brain injuries, most of the traumatic brain injuries that we see in HeadFirst Concussion clinics are due to everyday events such as slips and falls and motor vehicle accidents.

Some doctors tell me that the “concussion craze” is going to burn out soon. However, I think the way concussion specialists and medical providers diagnosis and treat traumatic brain injuries will continue to evolve. Other clinicians believe that education, evaluation and treatment of mTBIs will continue to grow in different directions.

Some considerations for the future may include:
– people who carry weapons, work with hazardous materials, or are employed in high-risk jobs could require baseline neurocognitive testing with their employment physical in the event they suffer a brain injury
– schoolchildren of all ages, including the elementary school level, may receive education, baseline testing, while training may be required for all parents and coaches about traumatic brain injuries (it is presently only required for high school kids)
– employers may insist employees to get baseline neurocognitive testing prior as a condition of employment

What we have found in HeadFirst Concussion clinics is that 60-70% of mTBIs are not sports related and more than 95% of our injured patients have not had baseline neurocognitive testing. While concussions continue to make the news and diagnosis increase as public awareness spreads, we encourage people of all ages to schedule a baseline neurocognitive test.

Significant Head Trauma Can Occur with Repeated Hits, Not Just Concussions

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

CTE’s connection to football has been in the news for five years now, with a debate centered around whether the number of concussions will affect long-term health and well-being of those playing the sport. Likewise, I’m constantly asked by patients and parents what the future effect of this or future concussions will be on their health. A recent study released by researchers at the Boston University School of Medicine (such as Dr. Robert Cantu, Dr. Ann McKee, Chris Nowinski and others) will probably give moms and dads across America a moment of pause before starting a collision sport like football or hockey.

An answer may lie in a concept developed by these researchers called the Cumulative Head Impact Index (CHII). They found individuals who had more hits to their heads—regardless of whether they had a concussion or not, were significantly (i.e., not even close…a large statistic margin) more likely to experience later-life cognitive problems, apathy and depression. The caution here is that the sample size was only 93 individuals and the exposure was only to football.

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A football helmet’s health warning sticker is pictured between a U.S. flag and the number 55, in memory of former NFL player Junior Seau; new research suggests that the accumulation of subconcussive hits may have more significant long-term effects than concussions. (© Mike Blake / Reuters/REUTERS)

The next step is for medical providers and concussion specialists to help families begin to connect the dots throughout the developmental hurdles of a child’s life. For example, the health outcomes for two 7th grade beginning hockey players if they have a different history. One student may have fallen off a changing table as an infant and suffered a skull fracture, have been in a motor vehicle accident, and have fallen multiple times during winter sports, while the other 7th grader may not have suffered any head injuries or significant head trauma. Baseline neurocognitive testing like the ImPACT® test might look different on these two young students, and the outcome and recovery time of any current injuries sustained by each of them could be considerably different.

I’ve often said that kids can’t live in a bubble as much as parents are sometimes inclined to want to wrap their kids in bubble wrap. Young people—really, people of all ages—are going to be in car accidents, bike accidents, and slip and fall just going through life. Parents need to make their own unique, informed decision about how much additional risk of physical injury to which they want to expose their child, given his or her medical history and athletic abilities.

The Connection Between Concussions and Suicide

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

The topic of mild traumatic brain injury and/or concussion has been in the news for several years. The release of a major motion picture, a concussion sustained by a professional sports star, or the passage of a law tends to rekindle interest in the topic. Recently, another issue was linked to concussion — the concern of suicide. But, I am optimistic. Why? By nature, I’m an optimist, but I’m also hopeful that parents, community leaders and politicians will pay attention to the epidemic of suicide in our country.

When I worked in the U.S. Navy, one of my careers was serving as their Suicide Prevention Program Coordinator. Every death by suicide crossed my desk. The number of Marines and Sailors who attempted and completed suicide staggered me.

In our country, the number of people — servicemembers or civilian — who die by suicide is almost too much to comprehend. Compared to 16,000 homicides each year in the U.S., the number of suicides is nearly double that at almost 32,000 a year, most due to untreated depression of some form.

Let’s put those numbers in another perspective: In the last decade of our troops fighting in Afghanistan and Iraq, just over 7,000 Americans have made the ultimate sacrifice and almost 50,000 have been wounded. During that same time, more than 300,000 have died by suicide and more than 50,000 have been children between the ages of 14 and 24. The number of suicide attempts is in the millions.

Researchers are also finding out that some of the consequences of concussion are linked to depression and suicide. Untreated brain injuries can lead to devastating consequences.

My optimism lies in the hope that coaches, parents, athletes, and community leaders understand that the physiology of a concussion caused by a blow to the head or body prompts the neurons to function ineffectively due to a disruption of their normal chemical process.

I’m optimistic that these same parents, coaches, athletes, and community leaders will make the connection that the neurological process of a concussion is to depression. That these neurons which govern our emotions and self-esteem for a variety of different reasons — the death of a loved one, loss of a job, bankruptcy, medical conditions — can lead to a disruption of the neurons and cause depression leading to suicide.

I’m optimistic that the people who form every individual’s support system, from parents and teachers to friends and fellow athletes, will ACT if something seems amiss:
A — ask an individual if he or she is thinking about suicide
C — let him or her know you care about them
T — get the individual to treatment with someone who specializes in suicide evaluations: a counselor, pastor or chaplain, family doctor or pediatrician, psychologist, or psychiatrist or local emergency room

Concussion-Suicide-Risk-March-2016-900x900I’m optimistic that people will realize that depression can be considered the “common cold” of psychiatric conditions and has a variety of effective treatment options.

I’m optimistic that people will pass on the suicide prevention hotline number and website to those in crisis: 1-800-273-TALK and www.suicidepreventionlifeline.org.

And finally, I’m optimistic that people will pass this blog and information onto at least FIVE other people and in doing so, might just save a life.

“Concussion” Movie is Just the Beginning of the Brain Injury Conversation

by Ann-Marie Sedor, HeadFirst Concussion Care Marketing

The much-anticipated movie “Concussion” is scheduled for release this year on Christmas Day, and already there is Oscar Award talk for Will Smith, who plays the role of Dr. Bennet Omalu. It was Dr. Omalu who discovered the tragic progressive degenerative effects of years of multiple concussions in NFL players, which he named CTE (chronic traumatic encephalopathy).

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Bennet Omalu, M.D., (L) and actor Will Smith attend the screening of the major motion film, “Concussion,” on November 23, 2015. (VALERIE MACON/AFP/Getty Images)

The film highlights the NFL’s initial response of anger and denial. Indeed, since Dr. Omalu’s discovery in 2002, the NFL has experienced lawsuits, exposés, and finger-pointing in general. Now, 13 years later, bystanders have watched the NFL’s reaction to this scientific research unfold in a manner not unlike many stages of grief – first denial, then anger, on to bargaining and, finally, acceptance. (Although, the League is still working on fully coming to terms with this last step.)

For their part, the NFL hasn’t had much reaction to the movie, preferring to keep the controversy at arm’s length. While Dr. Omalu has vocalized his opposition to children playing football until they are legally and emotionally old enough to understand the danger of putting their brains at risk, the NFL can’t afford to lose any of their reported $7+ billion in annual revenue.

Yet, while the debate rages on, two points are patently clear from years of scientific research: that children repeatedly hitting their heads during developmental years is potentially very harmful, and that college and professional football players can face significant health consequences from playing the sport.

But just how serious are families going to be about keeping their children from playing football? Indeed, this is just the beginning of the conversation about brain injuries.

As a community-based concussion clinic that has treated more than 30,000 traumatic brain injury patients over the past three years, HeadFirst Concussion Care has seen multiple reasons for why people sustain concussions. And while football is a violent sport, soccer, lacrosse and hockey also put our youth at risk for head trauma.

And again, this is just half of the dialogue. HeadFirst’s data shows that traumatic brain injuries sustained while playing organized sports with a concussion protocol in place (high school or college sports) account for a relatively small percentage of our patients. In fact, in as many as 80 percent of our patients, concussions are sustained by other mechanisms of injury. These include non-organized sports-related injuries (bike riding, skateboarding, trampolining, skiing, pick-up or other informal recreational games), slips and falls, motor vehicle accidents, and assaults.

The key message is that the people must understand that traumatic brain injuries can happen to anyone, anywhere, at any time. Not just kids. Not just athletes. And certainly, not just NFL players. And since anyone is at risk, everyone must understand the proper protocols for healing an injured brain.

On a final note to end the year, my holiday wish is that families, schools, and employers begin to talk about head injuries and follow traumatic brain injury protocols to keep all children and adults safe.

Honoring Brain Injury Awareness Month

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

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.

brain-injury-awareness-month

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.

HeadFirst-Doc-is-In

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.

How Well Do Football Helmets Protect Players from Concussions?

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

One of the most common questions that I get from parents is “How well will my child’s helmet protect against concussion?”

The elusive answer appears to have been provided at the 2014 American Academy of Neurology’s annual meeting. In a study co-authored by Frank Conidi, MD, DO, MS, director of the Florida Center for Headache and Sports Neurology, Assistant Clinical Professor of Neurology at Florida State University College of Medicine, the standard drop test was modified to measure linear and rotational responses in crash test dummies to repeated 12 mile-per-hour impacts.

Conidi, who is also the vice chair of the American Academy of Neurology’s Sports Neurology Section, and his colleagues conducted 330 tests to measure how well 10 popular football helmet designs protected against traumatic brain injury, including: Adams a2000, Rawlings Quantum, Riddell 360, Riddell Revolution, Riddell Revolution Speed, Riddell VSR4, Schutt Air Advantage, Schutt DNA Pro+, Xenith X1 and Xenith X2.

They found that helmets do protect the player from massive injuries like skull fractures in the range of 70 to 80 percent but provide little to no protection against concussion in the range of 10 to 15 percent.

Why is that? While the helmet does its job in disbursing the impact of a hard hit across the helmet to greatly reduce the risk of a skull fracture at one specific site, a helmet cannot stop the brain from shaking inside the skull, thus providing little to no protection against a concussion.

In fact, the team of scientists found that football helmets, on average, reduce the risk of traumatic brain injury by only 20 percent compared to not wearing a helmet. Added to these statistics, Conidi says, “Alarmingly, those that offered the least protection are among the most popular on the field.”

One of the best tools we have available is neurocognitive baseline testing. With the beginning of the school year upon us, please remember to get your child baseline tested. Headfirst Concussion Care offers free ImPACT® baseline testing. Please call 1-855-748-4868 (SIT-IT-OUT) or visit us online to arrange your child’s appointment.

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