words by Eve Jacobs
oncussion has moved front and center in the line-up of parental health concerns. Two years ago, a 16-year-old high school football player from Montclair, NJ, died of a brain hemorrhage after returning to the game three weeks following a concussion, a wake-up call to many. In fact, the word concussion is currently losing its foothold in the medical world to the term traumatic brain injury, with symptoms ranging from mild to severe, indicating the difference between a brain injury caused by a football or car accident, and a blast injury experienced in war, is just a matter of degree. More than 85 percent of the approximately 300,000 sports-related concussions occurring yearly in the U.S. are mild and resolve within weeks; the other 10 to 15 percent result in post-concussive syndrome with symptoms that persist for months and even years.
The junior linebacker’s continuing headaches should have kept him from play. All symptoms — including dizziness, light and noise sensitivity, headaches, sleep issues, exhaustion, and memory and concentration problems — must be gone before an athlete can safely resume sports. However, this kind of brain damage does not show up on a brain scan; and the Montclair teenager did not complain about pain to the doctor who cleared him.
Therein lies at least part of the problem: TBI is most often invisible, and athletes are anxious to get back in the game. Peter Yonclas, MD, director of trauma rehabilitation at University Hospital, knows about traumatic brain injury (TBI) firsthand — he has had a number of concussions since his teen years. “Several were from bumping heads with another player in soccer and basketball and weren’t even diagnosed. Looking back, I recognize them as concussions,” he says. “I was just dazed for a few minutes or so.” He also experienced two recent concussions, one from a mountain biking accident, and one following a car accident in 2005 in which the airbag deployed. “I lost consciousness,” he remembers. “I took one day off and then had to head back to work.” Yonclas recalls the overwhelming fatigue that made it hard for him to function.
“Because of these experiences, I can relate to my patients in some ways,” says the physician, whose job is the acute care management of head injuries caused by car accidents, assaults, falls and athletics.
“There’s been a shift in the definition of concussion,” he states. “It used to be a blow to the head that caused a loss of consciousness. But now you don’t need to lose consciousness. It’s any change of neurological status due to a blow to any part of the body, like whiplash, and not just the head.”
Diagnosing TBI is now all about the history of the events and the symptoms. “When the symptoms resolve, the athlete can return to sports in a stepwise fashion, starting with conditioning. If the symptoms return, then the athlete is sidelined again,” he explains.
Two studies of former NFL players — one in 2000 and the other in 2007 — ignited public awareness. NFL players who had suffered concussions reported long-term problems with memory, concentration, headaches and other neurological issues; and those who had three or more concussions were found to be three times more likely to have depression than players who had not had any. Then a 2009 study pushed concern even higher, reporting that former NFL players had rates of dementia and other serious memory disorders that were way off the charts when compared with the general population, especially among athletes age 30 to 49.
“The effects of concussions are likely cumulative,” says Yonclas. “Some of these former athletes have encephalopathy, depression, early dementia and symptoms that mimic ALS [amyotrophic lateral sclerosis].”
While multiple concussions can be damaging for anyone, Yonclas says that young people are likely more susceptible to the cumulative effects of injury. “There’s an expression in brain injury rehabilitation that ‘kids will grow into their deficits,’” he comments. “Recent studies suggest that cumulative concussions may cause structural changes in an immature brain that may produce problems later on.”
On a cellular level, the physician explains, “There is a release of neurotransmitters that raises the demand for glucose [energy]. The brain can’t handle the increased demand, so it ramps up metabolism, creating a metabolic crisis.” While the brain cells generally repair themselves, it can be slow going.
If a second concussion occurs before the first has entirely healed, the consequences can be deadly. “It’s called second impact syndrome or SIS and kids are more susceptible,” says Yonclas. “The second concussion can be very mild but can still sometimes cause death. We don’t really know why this happens. There may be genetic factors involved.”
Yonclas advises pulling kids out of school, not just sports. “Cognitive rest and physical rest are prescribed for everyone. Then we have other therapies that address various symptoms patients may experience, including dizziness and headaches. If they persist for an extended period of time, we may try using stimulants for persistent attention difficulties, anti-depressants, sleep agents, Provigil for fatigue, dopamine drugs, and natural anti-inflammatory agents depending on the symptoms and how long they last,” he explains. “These approaches can be used for any TBI, whether it results from a fall, a sports injury, a car accident or an assault.”
Is the number of concussions growing? “Probably yes,” he says. “First the definition and our understanding have changed and secondly there are more people playing sports and more safety features in cars. For instance, I was knocked out by an airbag. Prior to airbags, I could have had a more serious injury.”
The TBI specialist recounts the story of a college wrestler who had had three concussions, wanted to go to medical school, but was having cognitive problems and extreme fatigue two to three years following his injuries. “He came to me for help. I told him initially to limit his classes and sent him for cognitive testing. I put him on a neurostimulant, Concerta, for his persistent attention difficulties and fatigue, and he improved,” he says. “And, by the way, he did make it into medical school.”
“There is a lot of art to this. Everyone’s brain is different,” he explains. “There’s so much that goes into managing TBI — you can’t use a cookie-cutter approach. It takes experience.”
Part of what Yonclas, who is also an assistant professor of surgery at NJMS, has learned on the job is that “reassuring patients early on that they will get better and educating them right away about the symptoms and the importance of cognitive rest are critical parts of the treatment. Otherwise, anxiety may set in and hold people back from healing,” he says.
“Even mild head injuries can be devastating to someone’s life,” he states.
Where would you be assured of getting the level of experience needed to address the complexities of treating concussion? At a concussion clinic, of course.
This one will be located at Kessler Institute for Rehabilitation in West Orange, NJ, one of U.S. News and World Report’s Top 10 rehabilitation hospitals in the nation, and part of the NJMS Physical Medicine and Rehabilitation residency program. The clinic will primarily care for athletes.
Neil Jasey, MD, the clinical chief of TBI at Kessler, will head up the clinic with Yonclas. “Many people say, ‘It’s just a concussion.’ They write it off. But it’s a brain injury and it needs to be taken seriously,” Jasey emphasizes.
While dizziness, loss of balance and confusion may come on right away after a concussion, and then resolve, these symptoms are often followed later by headaches, blurry vision, nausea and vomiting, and sleep and concentration problems, he explains. A CAT scan rarely shows effects of concussion. “You know — you can take a picture of a telephone, but it doesn’t tell you if it works,” he comments.
There are new, less complex guidelines, Jasey explains, that no longer rely on loss of consciousness or grading the concussion’s seriousness. “It’s simple. If you have a concussion, you’re out of the game. When you’re symptom-free, you return to cardiovascular training. If the symptoms don’t come back, you move on to drills. If the symptoms don’t return, you can play.”
Athletic trainers are often more well-versed in this than physicians, states Jasey, and they know when a specialist is needed. At the concussion clinic, an outpatient service, patients will be cared for by a TBI specialist, as well as a neuropsychologist, an occupational therapist and a physical therapist, as needed.
“The vast majority will fully recover with physical and cognitive rest. I tell them even to avoid video games, and school tests, and also to avoid social situations with a lot of people. The injured brain just can not multitask,” he explains.
He also points to the NFL data showing that a long history of multiple concussions can cause early onset dementia. “This is why it’s so important to take care of TBI right away,” he says.
Jasey observes that if high school athletes see professionals go back into the game after a concussion, they think they can do the same. “Everyone judges themselves against the NFL and the NFL kept debunking the concussion studies. There was a lot of controversy.” That controversy seems to be over.
Head trauma patients who are hospitalized at Kessler are those with moderate to severe TBI. They come from all over the country, and even from other countries, after they have been stabilized in their local hospitals, remaining at Kessler from a couple of weeks to a couple of months. Jasey and the team treat 15 to 18 such patients there at any given time. Their injuries range from gun shot wounds to serious trauma from a car accident to severe strokes. Some patients experienced brain injuries years ago and have lingering symptoms, such as sleep problems and an inability to concentrate. He also sees a lot of repeat injuries.
“Our goal is to make patients as functional as possible. When the TBI is really severe, we try what we can to wake up the brain,” he says. Although there is little in the conventional medical arsenal for severe TBI, Jasey says the team follows an aggressive approach, using off-label drugs along with stimulants and neutraceuticals such as co-enzyme Q-10, the B vitamins and fatty acids, and an acne antibiotic that reduces swelling in the brain. “We borrow from different sources — stroke, Alzheimer’s. We work with a multitude of stimulants and have had some successes.”
What he doesn’t see much of are concussion patients right after their injury “when we could treat it properly,” he states. He hopes the opening of their clinic, devoted to concussion treatment, will remedy that.
“What we want athletic trainers and other docs to know is that we need to see these athletes directly following the injury,” Jasey says, “the sooner, the better. That’s when we can really have an impact.”
Both Peter Yonclas and Neil Jasey are NJMS graduates and completed
residencies in the NJMS Department of Physical Medicine and Rehabilitation.