Traumatic Brain Injury Induces Mental Impairments Using Mechanisms Linked with Alzheimer’s

Excerpted from EurekAlert
from the University of Texas Medical Branch at Galveston | Author Rakez Kayed

A new study from The University of Texas Medical Branch at Galveston fills an important gap in understanding the link between traumatic brain injury and neurodegenerative disorders such as Alzheimer’s disease.

Previously, UTMB researchers found a toxic form of tau protein that increases after a traumatic brain injury that may contribute to development of chronic traumatic encephalopathy, a condition experienced by many professional athletes and military personnel. What remained a mystery was if this protein could cause dementia symptoms.

To test this hunch, the group isolated this protein from animals that had experienced a TBI and then injected it into another group of animals to see if they would develop impairments. The animals developed the same type of mental impairments caused by Alzheimer’s disease and these new findings can be found in the Journal of Neurotrauma.

“These findings provide direct evidence supporting our hypothesis that this form of toxic tau induces many of the symptoms of TBI and may be responsible for the increased risk for neurodegenerative disease and spread of impairments throughout the brain following TBI,” said Rakez Kayed, associate professor in the department of neurology and the Mitchell Center for Neurodegenerative Diseases. “Because this form of tau plays an important role in the toxicity underlying TBI, it may be a viable therapeutic target. Further study is needed to explore this possibility.”

A TBI can happen after a sudden blow or jolt to the head or body and each year there are about 1.5 million new cases in the United States.

In some cases, TBI not only induces immediate mental difficulties, but can also lead to increased risk of dementia and other neurological disorders later in life. There are no currently available treatments for the long-term effects of TBI.

Brain cells depend on tau protein to form highways for the cell to receive nutrients and get rid of waste. In some neurodegenerative diseases, the tau protein changes into a toxic form. When this happens, molecular nutrients can no longer move to where they are needed and the brain cells eventually die.

In the current study, the UTMB team led by Kayed and Bridget Hawkins, assistant professor in the department of anesthesiology, found toxic forms of tau in the brains of animals in two different models of TBI.

Using a separate group of mice, the team injected the toxic tau molecules into the hippocampus, a brain region critical to memory. These mice underwent behavioral tests to assess their memory and thinking abilities. The mice that received the toxic tau had difficulties with these tests compared with similar mice that didn’t receive the injections. In the mice with the toxic protein, levels increased in the injection sites and the cerebellum, a brain region involved in motor control. This was similar to a previous Alzheimer’s animal model study that found toxic tau molecules spread damage from the injection site to other brain regions.

Kayed said that their results suggest that TBI may share a common mechanism with neurodegenerative tau-mediated diseases. These data also suggest that the increased prevalence of acquiring CTE and Alzheimer’s disease many years after the occurrence of TBI may be due to the seeding and spread of toxic tau released following brain injury. This has important implications for both the treatment of TBI and for the prevention of neurodegeneration later in life.

……

Other authors include Julia Gerson, Diana L. Castillo-Carranza, Urmi Sengupta, Riddhi Bodani, Donald Prough and Douglas DeWitt.

This work was supported in part by the Darrell K. Royal Research Fund for Alzheimer’s Disease, the Mitchell Center for Neurodegenerative Disease and the Sealy Center for Vaccine Development. Additionally, these studies were completed as part of an interdisciplinary research team funded by The Moody Project for Translational Traumatic Brain Injury Research.

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Women’s Hockey Grows Bigger, Faster and Dire

Excerpted from The New York Times | By SETH BERKMAN

The gold medal game at the Sochi Olympics last year represented the pinnacle of women’s hockey: a captivating 3-2 overtime victory by Canada over the United States that drew almost five million viewers on NBC.

But Amanda Kessel, a leading scorer for the Americans in Sochi and the college player of the year in 2013, has not played since, ending her career at Minnesota at 23 because of lingering symptoms from a concussion sustained before the Olympics. Her teammate Josephine Pucci retired over the summer at 24, cognizant of her concussion history.

A concussion kept Canada’s Haley Irwin out until the Olympic tournament’s semifinals. She assisted on the tying goal in the last minute of the final, but her symptoms returned after the Olympics. Another concussion, in January, has kept her from playing professionally in the Canadian Women’s Hockey League.

“You feel completely lost and completely broken as an athlete,” Irwin, 27, said in March after being left off Canada’s roster for the world championships.

Women’s hockey is a growing sport, evolving through quicker and stronger players who are finally being rewarded for their talents as paid professional athletes. But concussions have kept some of the best players away from the ice for extended periods as the sport struggles to combat an issue that football and men’s hockey have failed at times to properly address. The N.H.L. is facing litigation, with former players accusing the league of glorifying violence and ignoring the dangers of repeated head injuries.

“The amount of players still getting concussions on the national level and college level, it’s too many,” said Pucci, whose sister’s hockey career was also ended by a concussion.

Women’s hockey penalizes body checking and does not have a history of fighting, creating a perception that the sport is safer than men’s hockey. But it is still a contact sport, particularly along the boards and around the goal. As the players grow faster and stronger, they create more powerful collisions, and enforcement of penalties can vary by level.

Despite increased public discussion, there is a dearth of information focused on concussions in women’s hockey. The few published studies available are unsettling.

An eight-year study released this year by the International Ice Hockey Federation analyzed women’s hockey injuries at the world championships and the Olympics. It found that concussions were the third-most-common injury (15.5 percent), behind contusions (28 percent) and sprains (20.8 percent).

A 2014 summary of self-reported concussions among N.C.A.A. student-athletes said that women’s hockey had the largest percentage of players who had experienced at least one concussion, at 20.9 percent.

In 2012, Dr. Paul Echlin, who helped develop a concussion curriculum in Canadian schools, led a small study of two Canadian college teams and found that female hockey players sustained concussions almost twice as frequently as men did.

The New York Times contacted every N.C.A.A. Division I women’s hockey program by email or telephone to ask about concussion tracking, training and protocol details. Almost two-thirds of colleges did not respond with any information, some citing confidentiality. Only Cornell and New Hampshire provided all of the requested data.

USA Hockey and Hockey Canada did not provide staff members for interviews to detail their concussion programs, instead referring to information on their websites.

“The problem is these organizations are dancing around the issue,” Echlin said, citing concerns about participation numbers as a reason that national federations might not be more forthcoming.

Limited Resources

Women’s hockey is not supported by the vast riches that back the N.H.L. and the N.F.L. After college, top players in North America can choose between two professional leagues: the Canadian Women’s Hockey League, which is in its ninth season and does not pay player salaries, and the National Women’s Hockey League, which began play in the fall and offers salaries.

The C.W.H.L.’s physician, Dr. Laura Cruz, recognizes that women’s professional hockey has limited resources. Every N.H.L. game has several doctors and spotters who can identify players exhibiting signs of concussions during games. The C.W.H.L. and the N.W.H.L. employ smaller medical staffs at games.

Despite limited means, the C.W.H.L. has made an effort to continually update concussion tracking methods in recent years, Cruz said, and the N.W.H.L. has a player safety department to monitor dangerous plays. It issued its first suspension this month.

Female professional hockey players are eligible for league health insurance, but it may not cover all concussion treatments, some of which can cost thousands of dollars. Professionals in North America make a maximum salary of $25,000; the average N.H.L. salary is about $2.5 million. In college, student-athletes are often covered under limited campus medical plans.

At the N.C.A.A. level, there can also be disparities in resources among larger and smaller institutions, said Dr. Jeffrey Kutcher, an associate professor of neurology at the University of Michigan.

“Every organization that touches the sport needs to be involved and working together,” said Kutcher, who is the director of the N.B.A.’s concussion program. “But that has to be coordinated and real.”

The N.C.A.A. advocates uniform concussion policies for all members, but some players said concussion information was often relayed in broad strokes and only in preseason training sessions that lasted under an hour.

Digit Murphy coached women’s hockey for almost 30 years. She said that with a growing platform, players had the ability to force change and initiate more dialogue with the sport’s governing bodies.

“I really believe someone is going to get killed,” Murphy said. “The sport has gone through so many iterations — N.H.L. and USA Hockey has increased awareness of it, but as you compete for higher stakes, you have this inability to care about the consequences of playing the sport because you’re so focused and intensely involved in the game.”

She added, “When athletics becomes a business, anything that becomes an elephant in the room is not discussed.”

Women with concussion histories described memory deficits and fears of chronic traumatic encephalopathy, a degenerative brain disease that has been diagnosed in dozens of former football and hockey players. Many share a familiar script of being holed up in dark rooms, sometimes having to abandon school, jobs and their playing careers.

Paige Decker sustained a career-ending concussion in November 2013 when she was playing for Yale and was blindsided by a check that sent her head crashing to the ice.

Decker has visited more than 40 physicians throughout North America, searching to alleviate the daily pains that saturate her nerves and muscles. She often leaves only with misdiagnoses and thousands of dollars in bills that her insurance does not cover. She compared her constant headaches to barbed wire constricting her brain.

Decker, 23, left a consulting job in Boston a year ago because of her health. She is largely confined to her parents’ house in Connecticut.

“That’s the worst feeling in the world, to not know how to get your life back,” Decker said. “I can’t even articulate — there’s no more raw, darker, deeper emotion of that helplessness.”

Decker’s injury has left no jarring scars, but two pink earplugs signal her discomfort. They reduce the chalkboard-scratching sensations that permeate her head whenever her Labrador retrievers bark or any high-pitched noise emanates nearby.

Decker said women’s hockey should explore more repercussions for illegal physical play. Suspensions and fines are rare.

The player who hit Decker was called for interference, her third infraction of the game. She returned to play after serving a two-minute penalty.

“That penalty didn’t have to happen,” Decker said. “I didn’t have to go through two years of suffering.”

Elusive Remedies

At the time of her injury, Decker said, Yale’s medical staff estimated that she would return from her injury within 10 days. When she did not, she sought alternative treatments through Internet searches and colleague recommendations, unaware of the dangers that some unproven cures carried.

Decker visited Dr. Ted Carrick, whose methods include using a GyroStim, or rotating chair, an alternative method with varying effectiveness. Pucci attributed part of her recovery to visits with Carrick, who also treated the Pittsburgh Penguins star Sidney Crosby. But Decker said she felt awful after the procedure.

Some players seek other untraditional cures like hyperbaric chambers. Decker eventually traveled to Vancouver, British Columbia, to receive prolotherapy, which included an injection of Novocain and dextrose in her neck. When her symptoms returned, she was referred to a local physician who could recreate the dosage.

Decker received 14 injections, causing her neck to swell like a balloon, she said.

“The most excruciating pain I ever experienced in my life,” she said.

Decker added that she knew six college teammates with long-term concussion symptoms. Two teammates, Ashley Dunbar and Lynn Kennedy, sustained career-ending concussions within weeks of Decker’s.
“You see it happening, you know it happens, but for whatever reason, I just never really thought that could be me,” Kennedy said.

Asked why there was a rash of concussions in women’s hockey, players, neurologists and physicians offered various reasons, including inconsistent refereeing, inadequate helmets and skill-level disparities.

Some players said they had not learned how to take a hit in youth hockey. Many do not experience more physical play, including checking, until reaching college or higher levels of competition.

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Body checking caused 30.8 percent of the concussions in the International Ice Hockey Federation study, but a penalty was called in only 25 percent of the episodes in which a concussion was caused by a body check.

Head injuries can also occur through unintended collisions, which were the leading cause of concussions in the I.I.H.F. study. During a practice drill in 2010, Minnesota goalie Alyssa Grogan dived for a poke check, and a player fell and kneed her in the forehead while another landed on the back of her head. It was her first concussion, but she was forced to retire and missed three semesters at the university.

Even after multiple concussions, leaving the game can be difficult. Despite new professional opportunities, options are limited after college. Participation in the Olympics can lead to thousands of dollars in performance bonuses. Some players hide symptoms to prolong their careers.

Against the advice of some doctors, Pucci, who had three diagnosed concussions in college and one in high school, worked her way back to make the 2014 Olympic roster. But in Sochi, she said, she knew that she would soon leave the game.

“I’ve put so much into hockey, and I’ve gotten so much in return, but it’s to the point where I feel like it’s time to walk away before I give hockey the opportunity to take too much away from me,” Pucci said.

Looking Ahead

Pucci has known Decker since youth hockey, and they have discussed creating a nonprofit organization to address concussions. Pucci works in clinical research at a cerebral vascular lab at NewYork-Presbyterian Hospital/Columbia University Medical Center and hopes to focus her work on concussions in the future.

For now, Decker occasionally posts on a blog she created in September, The Invisible Injury, while the hockey sticks in her garage gather dust.

She enrolled in a comprehensive concussion evaluation program with Kutcher at Michigan and said she was making “slow but steady progress.”

Decker said she did not know the best solution for curbing concussions in women’s hockey. Like many players, though, she said that more awareness would make a difference.

“You see left and right in doctors’ offices and wherever, your quick little synopsis of what a concussion is, what are symptoms,” she said. “Everyone knows those; it’s textbook. But when you get beyond the typical couple of weeks’ recovery, it’s like, then what happens? That was the challenge I faced.”

Decker added: “There wasn’t a clear-cut path for me or guidance as to what that next step should be. You can’t be running around like a chicken with its head cut off trying to get help. There’s a lot of room for improvement in terms of concussion awareness and what that actually means.”

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Concussions Can Occur in All Youth Sports

Excerpted from The New York Times | By JANE BRODY

Recent attention to long-term brain damage linked to multiple concussions among professional football players has prompted a much closer look at how children and adolescents who participate in sports can be protected from similar consequences.

And with good reason. The young brain is especially susceptible to concussion, and sports-related concussions account for more than half of all emergency room visits by children aged 8 through 13, according to the National Athletic Trainers’ Association. A child who suffers a concussion is one and a half times more likely to experience another, and those who have had two concussions have a threefold greater risk of the same injury happening again.

Many parents wonder if it is wise to let their children participate in sports like football and soccer, in which head injuries are most common. Concerns about concussion have been cited as a reason for a decline in enrollment in Pop Warner, the country’s largest youth football program.

At the same time, misconceptions among parents and coaches abound about the seriousness of concussions and how best to prevent them, especially for players who often think they are invincible and say they feel fine so they can get back in the game. Studies have found that more than 50 percent of high school athletes and 70 percent of college athletes failed to report concussions they had sustained while playing football.

But first, it is worth noting that almost no sport is free of a concussion hazard, and that participating in sports has “cognitive, physical, emotional and social benefits that outweigh everything,” said Steven P. Broglio, the director of the Neurotrauma Research Lab at the University of Michigan and the lead author of the National Athletic Trainers’ Association position statement on how best to deal with concussions among young athletes.

For far too long, concussions have been minimized, with youngsters who have sustained one often going back into the game much sooner than they should, sometimes on the very day they are injured. Experts say that even the language commonly used to describe a hit — like “ding” or “bell ringer” — minimizes the seriousness of the injury and should be abandoned.

Perhaps concussions would command greater respect if they were called by their proper medical term: mild traumatic brain injuries. A concussion is caused by a direct or indirect blow to the head. The brain is jostled against an unyielding skull, temporarily disrupting normal neurological and metabolic functions.

Contrary to popular belief, you don’t have to lose consciousness to have sustained a concussion. Ninety percent of concussions involve no loss of consciousness or only a brief disruption of mental alertness. You don’t even have to hit your head — a whiplash injury can cause one.

Furthermore, the usual five-minute assessment done on the sidelines to check an injured athlete’s ability to orient, remember, concentrate and recall words “misses about 40 percent of concussions,” Dr. Broglio said in an interview. “A single test is not diagnostic and should not be relied on. Multiple different tests taken together can increase the sensitivity to the mid- to upper 90s.”

However, the time allotted to assess an injured athlete on the sidelines is often inadequate to determine whether it is safe for a player to go back in the game, Dr. Broglio said. One of the most dangerous effects of failing to detect a concussion and allowing time for a young athlete to recover fully is second-impact syndrome — rapid, catastrophic swelling of the brain that can cause lifelong impairments, coma and even death — should the athlete have another concussion.

A growing number of parents now weigh the risks of concussion when helping their children decide which sport to pursue. The Institute of Medicine and the National Research Council of the National Academy of Sciences reported in 2012 that tackle football players sustained the most concussions among high-school-age athletes, with 11.2 reported among 10,000 “athletic exposures” — the number of practices and games in which an athlete participates. Lacrosse was the next riskiest, with 6.9 concussions per 10,000 athletic exposures, although one recent study found ice hockey and wrestling to be more hazardous than lacrosse.

Among girls, soccer is associated with the highest risk — 6.7 concussions per 10,000 athletic exposures, according to the academy study. Although many focus on the hazards of heading the ball, a new study of high school soccer players found that contact with another player was by far the most frequent cause of concussions among female and male players.

The study’s authors, from the University of Colorado School of Public Health, predicted that “banning heading is unlikely to eliminate athlete-athlete contact or the resultant injuries.” They noted that soccer had become a much more physical sport in recent years, resulting in more collisions between players.

Girls’ basketball is not far behind, with 5.6 concussions per 10,000 exposures, a rate twice that of boys’ basketball.

Gymnastics has seen a sharp rise in concussions in recent years. As the USA Gymnastics organization pointed out last year, “a concussion can be caused by a hit to the body, not just the head. A gymnast could fall, have a whiplash type movement and sustain a concussion even though they didn’t hit their head.”

The lowest concussion rate is associated with swimming, with only 0.2 such injuries per 10,000 exposures among girls and 0.1 among boys who swim competitively, according to a 2012 study in The American Journal of Sports Medicine.

Every athlete, parent and coach should be familiar with the signs and symptoms of concussion, some of which may show up hours or days after the injury. The athletic trainers’ report includes these:

■ Difficulty thinking clearly, concentrating or remembering new information.

■ Headache, blurry vision, queasiness or vomiting, dizziness or balance problems or sensitivity to noise or light.

■ Irritability, moodiness, sadness or nervousness.

■ Excessive sleepiness or difficulty falling asleep or remaining asleep.

Any of these should be reported without delay to a coach, athletic trainer, parent or school nurse. Especially worrisome is a symptom that gets worse with time.

All 50 states and the District of Columbia have laws to protect young athletes suspected of having sustained a head injury. Most important, the laws stipulate that no one with even a slight concussion should return to play the day of injury. The athlete should be evaluated and cleared by a health care provider trained to do so before returning.

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Effective Concussion Treatment Remains Frustratingly Elusive, Despite a Booming Industry

Excerpted from The New York Times | By BARRY MEIER & DANIELLE IVORYposted July 3, 2015

In a small brick building across the street from a Taco Bell in Marrero, La., patients enter a clear plastic capsule and breathe pure oxygen.

The procedure, known as hyperbaric oxygen therapy, uses a pressurized chamber to help scuba divers overcome the bends and to aid people sickened by toxic gases. But Dr. Paul G. Harch, who operates the clinic there on the outskirts of New Orleans, offers it as a concussion treatment.

One patient, Rashada Parks, said that she had struggled with neck pain, mood swings and concentration problems ever since she fell and hit her head more than three years ago. Narcotic painkillers hadn’t helped her, nor had antidepressants. But after 40 hourlong treatments, or dives, in a hyperbaric chamber, her symptoms have subsided.

“I have hope now,” Ms. Parks said. “It’s amazing.”

Three studies run at a taxpayer cost of about $70 million have all come to a far different conclusion. They found that the benefits of hyperbaric oxygen reported by patients like Ms. Parks may have resulted from a placebolike effect, not the therapy’s supposed ability to repair and regenerate brain cells.

But undeterred, advocates of the treatment recently persuaded lawmakers to spend even more public money investigating whether the three studies were flawed.

A growing industry has developed around concussions, with entrepreneurs, academic institutions and doctors scrambling to find ways to detect, prevent and treat head injuries. An estimated 1.7 million Americans are treated every year after suffering concussions from falls, car accidents, sports injuries and other causes.

While the vast majority quickly recover with rest, a small percentage of patients experience lingering effects a year or longer afterward. Along with memory issues, symptoms can include headaches, dizziness and vision and balance problems.

Over the last decade, the Defense Department has spent more than $800 million on brain injury research, with organizations and companies like the National Football League and General Electric spending tens of millions more. And as people become more aware of the debilitating long-term consequences of repeated concussions, businesses have been chasing salable solutions.

The search for ways to treat and prevent concussions has spawned screening tools, helmet sensors, electronic mouthpieces, diagnostic blood tests and brain imaging devices. Start-ups are marketing their products to the military, schools, hospitals, sports teams and parents, and controversial therapies like hyperbaric oxygen are being promoted to patients.

But as the industry booms, medical experts are raising concerns that it is a business where much of the science is sketchy, belief frequently outruns fact, and claims of technological breakthroughs evaporate soon after they are made.

Michael Singer, the chief executive of BrainScope, a company that makes a hand-held brain-wave measuring device cleared by the Food and Drug Administration to help assess injuries, says that while some companies are studying their products before selling them, others are selling untested products or marketing them without seeking regulatory approval.

“It is a Wild West out there,” he said.

Not long ago, the field of brain injury research was small. Numerous attempts to develop drugs to treat patients with significant head injuries failed as researchers struggled to understand the brain’s complexity. Little attention was paid to concussion, which is also called mild traumatic brain injury

“The number of neurologists interested in traumatic brain injury could have held a convention in a phone booth,” said Dr. Ramon Diaz-Arrastia, an expert at the Uniformed Services University of the Health Sciences in Bethesda, Md. That changed a decade ago after reports showed that hundreds of thousands of service members were returning from Iraq and Afghanistan impaired by concussions caused by battlefield blasts and accidents. In 2007, Congress, facing criticism that the military had ignored the psychological and physical toll of the conflicts, allocated $600 million for research and treatment, splitting the funds between traumatic brain injury and post-traumatic stress disorder, or PTSD.

The Defense Department went on a spending spree. It funded dozens of studies to find a concussion treatment. Some studies examined supplements, others looked at drugs like Lipitor, the cholesterol medication, and still more trials tested medical devices. Research was also underwritten to develop blood tests to better identify soldiers with concussions and to create improved imaging tools to map a concussion’s impact on the brain.

Dr. David X. Cifu, a professor at Virginia Commonwealth University in Richmond who also works for the Veterans Affairs Department, said that the hundreds of millions of dollars in government funds spawned a research feeding frenzy that led to dubious claims.

“It was a small field that got amazingly large because a lot of people were making stuff up and claiming things,” Dr. Cifu said.

Some specialists said they believed the military’s approach to concussions suffered from a basic problem.

While agreement exists on the symptoms that define a concussion at the time when one occurs, a similar definition did not — and still does not — exist to describe what happens after a concussion, including how the injury’s symptoms change over time.

In addition, many soldiers who are diagnosed with a mild brain injury also have PTSD, a defined condition with symptoms similar to those associated with a concussion. Some critics within the military argued it was overestimating the concussion problem and channeling patients into the wrong type of treatment.

“They would get the message they had a serious brain injury,” said one of these critics, Dr. Charles Hoge, a psychiatrist at Walter Reed Army Institute of Research.

Whatever the case, the inability to separate PTSD from concussion turned the government’s research program into a scientific hodgepodge. A 2013 Veterans Affairs review of studies of mild traumatic brain injury, or M.T.B.I., in soldiers and veterans found that the studies’ overall quality was poor, and it was impossible to separate long-term impacts unique to concussion from those attributable to PTSD.

Col. Dallas Hack, a doctor who oversees the Army’s research program, said officials realized several years ago that the military’s efforts had gone off-course and a lot of money had been spent on studies that produced little in the way of tangible results. Since then, the Defense Department has refocused its efforts on basic questions, such as developing a better definition of concussion.

We were naïve” at the start, Colonel Hack said.

A few years ago, a major producer of football helmets, Riddell, announced that it was on the trail of the concussion chase’s Holy Grail: a way to reduce injuries by using electronic impact sensors to monitor head blows. The National Football League was so enthusiastic about the technology’s potential that it studied the performance of impact sensors in the Riddell helmet in eight N.F.L. games.

But the league ended the experiment, saying the data produced by the sensors was too crude to be of value. “You couldn’t fully appreciate the magnitude and the location of a hit,” said Jeff Miller, the senior vice president for health and safety policy for the N.F.L.

The end of the N.F.L’s field test, however, hasn’t dimmed enthusiasm for sensors among coaches and parents. In the fall, players on several college football teams, including the University of South Carolina and the University of Texas, will take the field wearing mouth guards equipped with sensors made by a small company, i1 Biometrics.

As with much in the concussion business, experts are still uncertain whether the data produced by impact sensors will result in fewer concussions or simply create statistical noise that adds to parents’ anxiety. Sensors “can serve as a second set of eyes, but they cannot diagnose concussions,” said Blaine Hoshizaki, a professor at the School of Human Kinetics at the University of Ottawa.

Impact sensors vary in design, but they are intended to serve as early warning systems that may help reduce concussions. A sensor records the movement of a player’s head and can be set to light up or send a signal to a cellphone or monitoring station when that movement is very abrupt, such as when a player is tackled hard. At that point, the player can be examined and, if needed, taken out of a game.

With growing demand, the cost of sensors, which are mass produced in Asia, has dropped sharply. Helmet makers can easily charge double for a helmet containing them, and such products are available not only in football, but also hockey, lacrosse, cycling and other sports.

In March, nearly 100 corporate executives, entrepreneurs and researchers crammed into a conference room at Virginia Tech, in Blacksburg, Va., for a one-day seminar “Head Acceleration Measurement Sensors.” Some two dozen companies make such sensors, and the March meeting was attended by companies with names like Triax Technologies and Brain Sentry, as well as helmet producers like Schutt Sports, which makes football gear, and Trek, the bicycle maker. One presenter at the meeting discussed an earpiece with a sensor inside it, while i1 Biometrics demonstrated its sensor-containing mouth guard.

Jesse Harper, the company’s president, said in an interview that i1 Biometrics first tested the device in laboratories and then on cadavers, whose skulls were struck to record the device’s ability to detect motion.

“It’s not the most cocktail-friendly conversation,” Mr. Harper said of the cadaver tests.
After tests on players proved successful, the company started selling the device last year to high schools and a number of colleges. The mouth-guard system costs $199 a player, Mr. Harper said.

Currently, however, there is no consensus among coaches about the strength of a sensor reading that would lead to pulling a player out of a game. While one player might absorb a strong head blow without ill effect, the same force would stagger another one.

Mr. Harper added that the schools and colleges buying his company’s mouthpiece could also use it as a training tool to study the position of a player’s head when struck and potentially work on ways to reduce the most harmful impacts. But some experts say they believe that sensors are still not ready for widespread use.

Mr. Miller, the N.F.L. executive, says he thinks the sensors are likely to improve. But last year, when the league, General Electric and Under Armour announced the award of $8.5 million in competitive grants to companies developing promising concussion-related technologies, not a single sensor producer was among the recipients.

Dr. Harch, the New Orleans-area physician, is a true believer in the benefits of hyperbaric oxygen. In his book, “The Oxygen Revolution,” he claims the treatment not only helps treat post-concussion syndrome, but also autism and Alzheimer’s disease.

One major professional medical group, the Undersea and Hyperbaric Medical Society, has said there is no evidence showing the technique is effective in resolving concussion symptoms. “I don’t offer this treatment in my facility for mild traumatic brain injury because I’m not convinced it works,” said Dr. Enoch T. Huang, an official at the society and a specialist at the Adventist Medical Center in Portland, Ore.

Dr. Harch acknowledges that he is in the minority. “My generation of doctors thinks this is a fraudulent theory,” he said. Many years ago, he and other advocates formed a competing professional group, the International Hyperbaric Medical Association, which has lobbied to get coverage for the treatment.

The military has also been skeptical and for a time refused to fund hyperbaric oxygen research. But facing intense lobbying from lawmakers and veterans groups, the military agreed to start several trials.

“We just had to do the study and put it to rest,” said Carl Castro, a professor at the University of Southern California and a retired Army colonel once involved in overseeing military concussion research.

Conducting those studies posed a challenge. Researchers were concerned that because hyperbaric oxygen therapy is so intense — a patient typically takes five dives a week over two months — the benefits patients experienced were more psychological than physical.

To address that issue, researchers divided patients into groups. One got hyperbaric oxygen therapy. Another got so-called sham procedures, in which patients sat in a chamber pressurized slightly to create the feeling of treatment, but instead of pure oxygen received room air, which is about 20 percent oxygen.

“We had no idea what we’d find,” said Dr. Lindell K. Weaver, a hyperbaric expert at the LDS Hospital in Salt Lake City who worked on the studies.

Those trials found that patients who had a real treatment or a sham treatment reported similar benefits, pointing to a placebo effect. But if Defense Department officials hoped the results would end the debate, they were wrong.

Late last year, hyperbaric oxygen proponents started a new lobbying campaign, arguing to lawmakers that the studies’ conclusions were misleading because patients who had received sham procedures were still getting the treatment, though at a lower dose. They pointed to other studies with positive findings and claimed the government did not want to pay for the hyperbaric oxygen because of its cost. Dr. Harch estimated that, depending on location, the price of a series of 40 dives typically ranged from $5,000 to $12,000.

Sympathetic lawmakers responded by putting language in the most recent congressional budget bill requiring the Government Accountability Office to review whether the military trials had been run properly. Many of those lawmakers were the same ones who had lobbied the military to run the trials in the first place.

Representative Walter B. Jones Jr., Republican of North Carolina, said he supported the accountability office review. He has introduced a bill that would require Veterans Affairs to pay for the treatment if prescribed by a doctor and said he believed that hyperbaric oxygen, even if it just made patients feel better, should be used instead of dangerous psychotropic drugs that veterans are often given.

“No one has committed suicide from being treated with oxygen,” Mr. Jones said.

Medical experts say that after a decade of intense focus, there is a heightened awareness of the consequences of concussions. The military has adopted new battlefield procedures to examine soldiers, new research is underway and schools are far more vigilant in making sure students are checked out after a head injury.

Experts say that the most effective treatment is addressing each of a patient’s symptoms individually, and in some ways, the search for new approaches has returned to the starting line. A concussion expert with the Mayo Clinic, Dr. David W. Dodick, said he believed a cheap nutritional supplement, N-acetylcysteine, could help treat concussion symptoms, and he hoped to study it.

It would not be the first time that the supplement, which is an antioxidant, has been tested for that use. In 2008, the Defense Department began a study of the supplement in soldiers in Iraq who had sustained a concussion. That trial showed benefits, but the study quickly became engulfed in controversy.

Dr. Dodick said that the dispute about the trial overshadowed a possible breakthrough and that N-acetylcysteine might be a valuable tool. “Every coach and parent could be carrying this on the sidelines,” he said.

Some researchers have also started trials of hyperbaric oxygen, and Dr. Harch is working on a trial he believes will provide compelling data about the treatment. Funding for the $1.2 million trial was originally allocated in 2008 as part of legislation backed by Louisiana’s congressional delegation, but the study was delayed.

An advertisement recruiting patients for the trial states, “If You Continue to Have Symptoms From a Mild Concussion You Experienced While Playing Sports, In a Car Accident, or During Military Service, You May Qualify.”

Dr. Harch has recruited more than 20 of the 50 patients he hopes to enroll. He is certain that the study will show breakthrough results.

Ken Belson contributed reporting.

Permalink: The New York Times

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High School Coaches Know Concussion Signs but Don’t Act

Often make the wrong decisions when faced with actual cases

Excerpted from MedPage Today | By Megan Brooks, Reuters Health

NEW YORK (Reuters Health) — High school coaches have a good understanding of the signs and symptoms of concussion, but they often don’t make the right management decisions, a new survey shows.

That’s where athletic trainers come in, said Meredith Madden, athletic trainer at Boston College who did the survey and reported the results June 26 at the National Athletic Trainers’ Association (NATA) annual convention.

“Most of our coaches are there for a very specific job description — to coach. Athletic trainers are important members of the team and at the end of the day it’s our job to keep the kids safe. Not every hit to the head will result in a concussion, but that is up to a qualified athletic trainer to determine, not a coach,” Madden noted in an interview with Reuters Health.

Madden and colleagues got 104 Massachusetts’ public high school coaches to complete an online survey to test their knowledge of concussion signs and symptoms and management. They also interviewed 12 coaches by phone or in person.

Most of the coaches correctly identified symptoms of confusion (94%), headache (94%), dizziness (91%) and blurred vision (90%) as indicators of a concussion. Most also identified loss of consciousness (87%), nausea (82%) and amnesia (75%) as indicators of concussion, but fewer than half (42%) recognized sleep problems as a sign of concussion.

About one in 10 associated non-concussion symptoms as primary indicators of concussion, which suggests that they are unable to distinguish concussion symptoms from other injuries and lack in-depth knowledge or understanding about concussion, the researchers say.

Over 90% of coaches knew appropriate management strategies in typical concussion scenarios, but when faced with atypical scenarios, only 57% would appropriately remove an athlete from play.

“The coaches had really good knowledge about signs and symptoms of concussion,” Madden told Reuters Health. “But when we looked at their overall management, they often weren’t making the right decisions.

This suggests that they know what to look for, but they don’t necessarily know what to do, or they are uncertain, or there is some other conflict that is coming into play.”

Larry Cooper, head athletic trainer, Penn Trafford High School in Harrison City, Pennsylvania, and Chair of the National Athletic Trainers’ Association Secondary School Committee, told Reuters Health, “We have come a long way in educating coaches and they certainly have increased their knowledge of concussions and certain things to look for but we still have a ways to go.”

This survey “underlies what we have been trying to push all along and that is to have an athletic trainer in every secondary school,” said Cooper, who wasn’t involved in the survey.

“With concussion evaluation and management, or any other type of injury, the athletic trainers are the health care professional that can do it, regardless of the sport, the event, the score, and provide even-keel medical evaluation,” he said.

He added that coaches’ ability to evaluate an athlete “with a neutral mind is sometimes lacking.”

“Athletic trainers are the ones who should decide whether an athlete stays in the game or doesn’t. Any coach in their right mind would not want to take that on, just because that is not what they are trained to do. We’re the ones providing the health care, the coaches are the ones doing the coaching,” Cooper said.

Madden added, “We all want to make athletics safe, because they are a good vehicle for our students for character development and for scholarships. We have qualified athletic trainers to assess and provide care for our student athletes.”

Permalink: MedPage Today

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An Athlete Felled by Concussions, Despite Playing a ‘Safer’ Sport

Excerpted from The New York Times | By Dan Barry

CLARKSVILLE, Tenn. — Months later, the father mustered the strength to sort through what was left in his dead son’s bedroom. A Little League photo collage. Mardi Gras beads from that soccer tournament in New Orleans. And a typewritten personal essay tucked into a yellow folder, with a single word pen-carved into its plastic cover: “Concussions.”

His son Curtis had written the paper for a college composition class in 2009, five years before his death. In it, Curtis recalled having been knocked unconscious three times in 14 years while playing soccer, twice after leaping to head the ball, only to — “WHAM” — collide with another player. The continuing side effects, he wrote, included “horrendous migraine headaches.”

“If I feel this way now,” he wondered, “what will it be like when I’m older?” He was 19.

Reading those words, his father, Bill Baushke, felt the floor drop beneath him. This meant that Curtis knew. He knew well before most of us that repeated concussions could also lead soccer players — and not just those who box or play football — down the dark spiral of cognitive damage and decline.

Well before the death in 2012 of the semiprofessional soccer player Patrick Grange, 29, who was posthumously found to have chronic traumatic encephalopathy, the degenerative brain disease linked to concussions. Before the 2014 death of Hilderaldo Bellini, 83, the retired Brazilian soccer star, also found to have C.T.E. Before the specter of C.T.E. began to loom over every contact sport.

Curtis Baushke, racked by migraines and struggling with focus, was still focused enough to know. “Allowing kids to play too soon after a concussion could be very dangerous,” he wrote. “We need to find out the actual damage concussions cause people.”

When Curtis was not quite 5, a neighborhood boy bragged that his father was signing him up for soccer. Curtis then wanted to play soccer, too, but his parents were football and baseball people. “You go ahead and play soccer,” Bill Baushke recalled saying. “But next year you’re going to play baseball.”

Although Curtis excelled at both games, he eventually chose to concentrate on soccer, partly because he had been hit by pitches several times, once to the head. “He wanted to play a safe sport like soccer,” his father said.

With Curtis’s older brother, Ryan, playing as well, the Baushkes became a soccer family, their free time revolving around practices and games, field conditions and out-of-town tournaments. Life was lived on the mosquito-rich lawns down by the Cumberland River, under the lights at the sprawling Heritage Park and in the stands at the athletic field behind Clarksville High School.

Curtis played as a freshman on the varsity team, as well as for a premier club that served as a feeder system to colleges. “You’d start him maybe on defense,” Dave Donahue, one of his high school coaches, said. “But if you needed some punch, you’d put him in midfield, and then if you were a goal behind, you’d put him up front.”

“He was full speed, and just a terrific athlete,” said Donahue, who coached hundreds of players in his 26 years at Clarksville High. “He stands out, even to this day.”

Bill Baushke, 57, recalled how gifted his son had been at winning balls in the air with headers, at setting up teammates with pinpoint-perfect passes, at sending corner kicks curving toward the goal. But he also remembered the many times when Curtis “had his bell rung, sat out a couple of plays, and was told to go back in” — as well as that upsetting day when a disturbed classmate hit him in the head with a bowling ball, knocking him out.

Curtis began exhibiting behavior now recognized as suggestive of postconcussive trauma. Dramatic mood swings. Depression. Headaches so debilitating he would need to lie down in a dark room.

After high school, Curtis took a few classes at Hopkinsville Community College, where he wrote his personal essay about concussions. He moved to Chattanooga, Tenn., to live with his brother and took more college courses in hopes of becoming a sportswriter.

But Curtis, who was also found to have bipolar disorder, continued to struggle. He lost his job writing a blog about college draft picks. He injured himself while competing in a new passion — disc golf — and became addicted to prescription medicine. He moved back to the family house in the country, with that large front lawn where he and his buddies used to kick around a soccer ball. He stole, and used drugs, and lied. Maybe not lied; maybe he forgot.

“He wouldn’t remember doing things,” his father said. “He would sit there and deny it, but in his mind, he was telling the truth.”

Because of those severe migraines, his parents took him to a series of specialists, to no avail. They even had his brain scanned for tumors. Nothing. But it had to be something, Curtis insisted. He began to maintain that he had C.T.E.

“He would delve into it headfirst, researching it on the computer,” his brother, Ryan, said. “Trying to find out what was going on.”

Looking back, the Baushkes might have dismissed his belief as a convenient self-diagnosis by Internet. All they knew was that their sweet younger boy — who loved his grandmother, loved practical jokes, loved duck hunting — was failing to find his footing. More than once he made arrangements to move out, only to pull back at the last moment.

“I just don’t think that he felt he could do it,” his mother, Patti Baushke, 55, said as she sat before family photographs splayed across the dining room table.

A year ago last week, Bill and Curtis Baushke made plans to watch the United States play Germany in the World Cup. The elder Baushke left his job in Nashville early, only to come upon his son snoring loudly on his bed. He went to his own bedroom, changed his clothes and turned on the television in the living room, where wooden duck decoys adorned the shelves.

The game began, and the father called for his son. Called again, then went to rouse him. But Curtis had stopped breathing, and neither his father nor emergency medical technicians could revive him. Accidental overdose of prescription drugs.

His parents did what they knew Curtis would have wanted.

A few months later, the Baushkes participated in a conference call with researchers who had examined

Curtis’s brain at Boston University’s CTE Center, which works with the Sports Legacy Institute, a nonprofit organization dedicated to brain trauma research and prevention.

Their determination: Curtis had Stage 2 C.T.E., meaning there was clear evidence of deterioration in the brain — surprising, given his young age.

“I cried and cried,” his mother recalled. “He was so right. Curtis wasn’t just making it up and talking crazy.

He thought he had it, and he did.”

With that, the silence of unspoken what-ifs filled a house in the country, where the photographs on the dining room table depicted a gifted and airborne young athlete, meeting yet another soccer ball head-on.

Permalink: The New York Times

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The Women Who Face More Traumatic Brain Injury Than NFL Players

Excerpted from The Huffington Post | By Melissa Jeltsen

Thirty years ago, Kerri Walker, now a coordinator for a domestic violence shelter in Phoenix, found herself inexplicably driving down the left side of the road into oncoming traffic. “It felt totally normal,” she said, recalling how she was oblivious to the danger. Walker escaped an accident that day, but looking back now, it was the first clue she had an undiagnosed brain injury.

At the time, Walker, 51, was in the throes of an abusive relationship, she said. She estimated that over a 2½-year period, she was hit in the head around 15 times — once with a gun — and violently shaken.

“I had major headaches, and every now and then I would have these moments when I would get dizzy and disoriented,” Walker said. But she didn’t connect her symptoms to the assaults until a year later, when a doctor at Geauga Medical Center in Ohio diagnosed her with traumatic brain injury, or TBI. “When you are in a relationship with that much trauma and violence, you don’t know what’s physical or what’s emotional or mental,” she said.

Soldiers returning from war and athletes are regularly diagnosed with TBI — a complex brain injury caused by a blow or a jolt to the head — and many subsequently receive support and services for the condition.

But domestic violence survivors have been largely left out of the picture.

On Tuesday, the Sojourner Center, one of the largest U.S. domestic violence shelters and where Walker works in Phoenix, is taking a big step to change that. The center, along with TBI experts at local hospitals and medical institutions, is launching an ambitious program dedicated to the study of TBI in women and children living with domestic violence.

The Sojourner BRAIN (Brain Recovery And Inter-Professional Neuroscience) Program will study how common domestic violence-related TBI is, investigate short-term and long-term effects, develop domestic violence-specific tools to screen for head trauma, and provide individualized treatment plans.

“These women are falling through the cracks,” said Maria E. Garay, the CEO of Sojourner Center who is spearheading the initiative. “This is a public health epidemic. The fact that no one is tracking this is, to me, a crime.”

Robert Knechtel, the interim director of the BRAIN program, said there is a lack of comprehensive research on TBI in domestic violence survivors. “Most of the work has been done with athletes or the military,” he said. “This is a group that, by extrapolating some numbers, would dwarf the military and the athletes combined.”

The first question they hope to answer is what percentage of domestic violence survivors are suffering from TBI caused by domestic violence. By screening women and children at Sojourner — about 9,000 people are seen at the shelter annually, Knechtel said — they hope to develop an accurate estimate.

According to a rough calculation by Hirsch Handmaker, a radiologist working with Sojourner and CEO of a nonprofit raising awareness of concussions, as many as 20 million women each year could have TBI caused by domestic violence. If that number bears out, it would mean 6 percent of the population experiences domestic violence-related TBI each year.

Compare that with the Centers for Disease Control and Prevention’s estimate that 1.7 million people experience TBI every year, and 2 percent of the population, or 5.3 million Americans, are living with a disability caused by it.

“It’s obvious — if someone is a victim of domestic violence, they are going to have a high propensity for head injuries,” Handmaker said.

Symptoms of TBI range in severity, depending where they occur in the brain and how much damage has occurred over time. They include headaches, double vision, imbalance and decreased motor ability, as well as problems with memory, planning and learning, aggression, irritability and depression. Doctors say it’s important to get a diagnosis early so that testing and treatment can begin.

Garay, the CEO of Sojourner, said that despite the increased likelihood that a domestic violence survivor has a history of head injury, it’s not standard practice for shelters to screen for TBI. “We are not asking questions and we are not providing treatment,” she said.

One goal of the Sojourner program is to develop a screening tool that can be used by non-medical staff, such as social workers and shelter employees.

Jonathan Lifshitz, a neuroscientist at Phoenix Children’s Hospital who is working with Sojourner, said the program will start by using tools already developed for the military and athletes. “We don’t know what tests will be the most effective in this particular population,” Lifshitz said. “The BRAIN program is going to provide the evidence necessary to change practice in this field.”

Kim Gandy, president of the National Network To End Domestic Violence, said undiagnosed TBI may play a role in some women being unable to leave an abusive relationship.

“Having a brain injury makes it a lot harder for her to get a job and support herself and her kids,” Gandy said. Some symptoms of TBI, such as problems with memory and irritability, may disadvantage a woman if she takes legal actions to protect herself. “She may have more difficulty making her case to the judge, to a police officer, getting a restraining order,” Gandy said, explaining that women with TBI may appear uncooperative or unreliable in court.

While Gandy acknowledged that brain injury is a significant and under-explored issue for domestic violence survivors, she cautioned that a push to diagnose may have unintended consequences. “It could be used against the women in custody battles, or in a variety of ways,” she said. “It’s a very realistic concern.”

Chris Nowinski, executive director of the Sports Legacy Institute, said a TBI diagnosis can have repercussions for athletes as well. “There are instances of athletes who are diagnosed with two concussions in one NFL season who get tagged as a ‘concussion case’ and are never signed again by another team,” he said.

But for the patient, Nowinski said, there are tremendous benefits to having a brain injury diagnosed.

“Rehabilitation, treatment and simply an understanding of why you’ve changed,” he said. “The vast majority of people can overcome a brain injury and return to a normal level of functioning.”

For Kerri Walker, a TBI diagnosis meant she finally had an explanation for all her cognitive issues. “The one thing that abusers tell us over and over is that we are stupid,” she said. “The relief factor for so many women is going to be unmeasurable.”

It’s taken her a long time — and a lot of work — to adjust to a life with brain injury.

Four months after Walker left her abusive partner, she said, a brain aneurysm ruptured, requiring surgery.

Since then, she’s spent years learning how to live with — and accept — the effects of cumulative brain injuries.

“It’s changed me for the rest of my life,” Walker said. “My short-term memory is shot. I’ll be writing and I’ll mix up letters. All of a sudden, I’ll write an E backwards. I had to find a new normal for myself.”

Need help? In the U.S., call 1-800-799-SAFE (7233) for the National Domestic Violence Hotline or click here.

Permalink: Huffington Post

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