BY DR. JOHN SHUMKO, M.D., PHD AND DIANA TOTO, M.S.
In the end, it all comes back to those that are concussed understanding how truly important it is to report symptoms accurately and honestly.
In November 2013, Ryan Barcelona, a 14-year old from Berkeley Heights, New Jersey was playing a fierce soccer game for his club team when he suffered a hard body-to-body collision and was whipped around. At that time he was taken out of the game. Showing no signs of headache, nausea, memory loss, fogginess, or fatigue, his coaches put him back in to finish the game. That night, his parents, Christie and Kevin, saw that there was something wrong. Ryan began acting erratic and extremely overtired. His mother Christie noticed he was covering his eyes and had sensitivity to light and sounds. They brought him to the Saint Barnabas Medical Center Emergency Department and it was confirmed he had sustained a concussion.
“I wasn’t able to do the things I loved… sports, spending time with friends. Some things I could always remember I would forget so easily,” stated Ryan. After months of close monitoring and
management through the Matthew J. Morahan III Health Assessment Center for Athletes at Barnabas Health, Ryan’s road to recovery was challenged through many obstacles. He worked with therapists to gradually return to play through several stages of progressive exercise and was closely monitored by his team of physicians, therapists, family, and friends. It was not until several months later that he became symptom-free and could finally set foot back out on the soccer field. He now speaks about his concussion to other children his age, in hopes of educating them on the understanding and importance of reporting signs and symptoms honestly and allowing the brain the time it needs to heal.
Over 4.5 million Americans live with traumatic brain injury (TBI) related disabilities. 500,000 TBI’s occur under the age of 14. The word concussion means to shake violently. A concussion or traumatic brain injury can be caused by a blow to the head, face, jaw, neck or body. A common misconception is that a blow to the head must occur for a person to be “concussed.” Like Ryan, who sustained a hard hit to the body, any hard impact which causes the brain to move in the skull can cause a concussion. The mechanisms causing a TBI do vary from the more common blows to the head (minor TBI’s) to the more serious traumatic head injuries where the skull is compromised and brain tissue is structurally damaged (IED – major TBI’s). In the minor TBI’s, there is a chemical reaction in the brain that can impact the way it normally functions. There is a specialized protein in the brain called the “Tau protein.” This protein is responsible for holding the nerve cells in the brain together and helping them communicate with each other. When a concussion occurs, the Tau proteins undergo a chemical change. They become “tangled up” and can no longer hold the nerve cells together. This causes a miscommunication to occur in the brain. This overall reaction can cause symptoms such as headache, nausea, vomiting, sensitivity to light, sensitivity to noise, fatigue, exhaustion, sleep changes, behavioral changes, blurred vision, concentration or memory problems, fogginess and slowed reaction time.
A safe and conservative approach to allowing brain rest and healing is crucial towards preventing a second impact. The days of “getting your bell rung” and counting fingers to see if someone is ready to go back in the game are a thing of the past. Today, seven to 10 days of being symptom-free is the minimum timeline many physicians use before considering clearance for a gradual return to activity. Unfortunately, there is no specific imaging test available that will show a “concussion”. That is because the changes occurring in the brain during a concussion are not structurally seen. The changes are chemical and will not appear on any present day imaging studies.
In the last five years, the way in which we manage concussion has evolved more than in the last 20 years combined. State legislature has had a large hand in creating a proactive approach to awareness. According to the CDC, in 2009 Washington was the first state in the country to create a concussion based law. Year-to-date, all 50 states now have concussion laws. New Jersey’s declares that “any student who participates in an interscholastic sports program and who sustains or is suspected of having a concussion during sports or practice shall be immediately removed from the sports competition or practice.” That student must receive written clearance from a physician trained in the evaluation and management of concussions before returning to play.
The support of professional organizations such as the NFL and top researchers across the country has also set the bar to raise awareness. Retired New York Giants NFL offensive lineman, Fox Color Analyst, and Morahan spokesman, David Diehl, comments, “I believe the NFL has taken the necessary steps to not only protect current players, but also ensure the safety of their post-gridiron lives. Since the NFL is considered to be the most physically demanding level of athletic engagement, becoming one of the strongest proponents of concussion safety shows exactly how important proper monitoring and screening has become to the game. With the NFL setting such an influential standard for concussion recovery, I firmly believe that this will result in youth leagues taking a more comprehensive approach to injury.”
The Matthew J. Morahan III Health Assessment Center for Athletes at Barnabas Health is facing concussion head on. As a statewide program, the Morahan Center is committed to the growth of their message. Including seven satellite centers across the state of New Jersey, the program has provided over 15,000 cardiac and concussion screenings since 2010 and works with over 20 local teams and schools to co-manage sports related injury. With over 9000 educated, the program continues to touch thousands of lives and send the important message of playing it safe. At the Morahan Center, new strides and advances in the way patients are clinically managed for concussion continues to evolve and change. In order to allow the brain to heal there are several approaches to recovery that have been successful in the management of concussion.
Although there is no “magic number” or timeline of how long the brain takes to heal after a concussion, we know that each brain injury needs to be looked at individually, and each person’s
timeline to heal is different. A previous concussion history can increase risk for additional concussions, especially if the brain did not heal properly from its’ initial blow. With a previous concussion history, any new brain injury increases risk of longterm memory problems, chronic symptoms, and life impacting changes. For this reason, concussion centers across the country are working to prevent secondimpact syndrome, defined as two concussions that occur within a short period of time. During second-impact syndrome, the brain’s blood vessels lose their ability to control their diameter and therefore lose control over regulating the brain’s blood flow. The result is severe brain swelling. This condition occurs rapidly and is often fatal.
The Matthew J. Morahan III Health Assessment Center for Athletes at Barnabas Health is focused on expanding the tools and resources it has to assist physicians in safely returning their athletes to work or play following a brain injury. Currently, the center provides neuro-cognitive or ImPACT testing and cutting edge assessments and therapies post-concussion. Newer evaluations now offered include King-Devick (K-D) testing at both baseline and post- concussion and Treadmill testing for patients that exhibit symptoms beyond 21 days.
Staying on the cutting edge of concussion is imperative for patients and athletes to return to a normal quality of life. Concussion programs such as the Morahan Center have to continuously evolve to provide more information to managing physicians on the way a brain injury is recovering. King-Devick testing is one example of this. K-D tests rapid eye movement at both baseline and as an acute measurement or sideline tool to monitor the visual pathways of the brain. Since 50 percent of the brain’s pathways are tied to vision, this assessment can become extremely valuable in the acute phase. In a baseline setting, the KD provides a series of cards and a total time of eye movement prior to an injury. If there is suspicion of concussion, this test can be re-administered and timed. The re-administration of the test should be done within a 24-hour window of when the injury first occurred. If the total time or total number of errors increases, a deficit may be evident and further medical evaluation would be recommended. K-D is also a valuable tool in catching what may be a silent concussion, otherwise known as a brain injury that may not display symptoms until several days later. Another valuable tool for concussion is treadmill evaluation and therapy. Using a balke protocol (established guidelines for increasing grade and speed), any child who exhibits symptoms beyond 21 days can be evaluated through a basic treadmill test. They are preevaluated for symptoms prior to the start of the test. Once the test begins they are monitored through increases in heart rate. The heart rate that corresponds with when they develop a new onset, or worsening of symptoms, marks their symptom threshold. Through therapy, working below this threshold or heart rate number, and improving it over time, has offered opportunity to develop safe parameters for exercise, for even the most severe concussion cases.
With no current neuroimaging or blood biomarker to diagnose concussion, these tools and follow-up therapies become more and more important to our medical experts. As the theory of prolonged rest being controversial continues to hit the presses, advancement in concussion protocols has become even more medically necessary to accurately track recovery timelines for physicians. Without a true diagnostic test or tool for concussion, new measures become that much more important in developing and implementing. In the end, it all comes back to those that are concussed understanding how truly important it is to report symptoms accurately and honestly. Therefore, it becomes a serious effort to change a culture: educate the athletes, athletic trainers, coaches and parents regarding all aspects of a “concussion.”
This is the goal of the Matthew J. Morahan III Health Assessment Center for Athletes. According to David Diehl, “I have seen the effects concussions have had on teammates throughout my 11 years in the NFL. While a football player must maintain a ‘warrior mentality,’ you have to be mindful of the brain’s safety. I have played through numerous injuries throughout my career, but I would never risk playing with a concussion. Concussions aren’t visible injuries. It requires a plethora of testing to determine whether you are ready to return. You may think you feel good and that you are ready to play, but one hit can completely change the rest of your career and, your life.”•
To find out more about the Matthew J. Morahan III Health Assessment Center for Athletes, Free Upcoming Screenings and Services please visit www.barnabashealth.org/morahan.
ABOUT THE AUTHORS:
Dr. John Shumko, M.D., PHD is Chairman of Physical Medicine and Rehabilitation, Medical Director, Sports and Physical Medicine Institute
Diana Toto, M.S. is Program Director, Matthew J. Morahan III Heath Assessment Center for Athletes at Barnabas Health.