Treating concussions: A baseline for success

By MIKE FORNABAIO

The University of Bridgeport student in the corner of the Human Performance Lab looks like she is auditioning for a marching band.

Up, down. Up, down.

But to Dr. Frank Zolli, a professor of clinical sciences, each step is another clue to how well her central nervous system is functioning.

The muscles, the cadence, the foot strikes, it’s all measured with sophisticated equipment to establish a tailored baseline.

Or, in the event of a concussion, to find the deviation from that baseline.

“We’re providing objective data and relating it to performance,” said Zolli, a former St. Peter’s College football player who has spent the last 25 years teaching and conducting research at UB.

“As a result of a concussion or some other injury, we can use the new data to measure it against a baseline, and then measure the progress during the recovery process.

“Once that deviation is corrected, then you can objectively say, ‘This athlete is ready to return to play.’ That’s a big difference from, ‘Well, the symptoms went away — the headaches, the dizziness, the nausea — so this athlete can return to play now.’ This is much more scientific.”

The marching test — once with your eyes open, once with your eyes closed — is among several tests that Zolli and his colleagues use at UB.

There is a treadmill that measures the smallest details of gait, the way a person walks. There is also a room with lights that flash in certain sequences to test reaction time and how that dovetails with cognition, how a person thinks.

“We’ve never had anything like this. We’ve never had access to this kind of objective data before,” Zolli said. “We know it’s absolutely critical to exercise the central nervous system. That’s got to be part of the recovery process, especially with concussions.

“You’ve had a traumatic brain injury. You don’t know what the results have been. We can now translate those results to how the body is functioning or not functioning based on your baseline. It helps us create a strategy for the recovery process.”

For the high school athlete, and even the middle school athlete, recent state legislation has established guidelines to help reduce exposure to concussions.

Concussion data must be tracked and submitted to the state Department of Education. Information about concussions — recognizing the signs and learning about treatment — must be shared with coaches, parents and students.

High schools and middle schools must also have a protocol in place for when a student may return to class, never mind athletic competion.

But what about youth sports? What about their baselines and using sophisticated tools to track their recoveries?

What about the little boy who suffers a head injury playing football? What about the little girl who bumps her head playing soccer?

In Norwalk, social worker and concussions-awareness advocate Katherine Snedaker says the new state law covers just 1-in-11 kids in her city.

A three-year pilot study will now collect data on concussions incurred by Norwalk’s children. The city also requires youth sports groups using its fields to follow guidelines similar to the state law.

Anyone using a field in Norwalk needs to follow the city’s guidelines: educate coaches, educate parents, make sure parents are notified about possible concussions, and make sure parents have the information about a particular injury to give to medical providers.

In addition, Snedaker wants to make sure that parents notify schools of any concussions involving their children.

“This fall, we’ll have trained almost 1,000 coaches,” said Mike Mocciae, Norwalk’s director of recreation and parks, during a recent concussion summit.

“That’s non-profit groups that use our field. That’s for-profit groups that use our fields. And that’s for all programs the recreation department runs, from our playgrounds, to our basketball program, to everything that we offer.”

Mocciae said he has worked in parks and recreation for 31 years, and this is among his most important accomplishments.

As part of the “C4 Project” — concussion care connected community — data was collected from school nurses.

For the 2014-15 school year, there were 111 reported concussions in Norwalk: 51 were sports concussions, 60 were non-sports concussions.

Only 27 of the sports concussions were incurred in high school sports, which are covered by the law. Another 24 sports concussions occurred outside of high school, which are not protected under the new state law.

State legislators moved this summer to try and educate families of even younger athletes.

A section was inserted into the legislation that will require youth organizations, as of Jan. 1 2016, to provide parents with either written or online information about concussions that is consistent with recommendations by the U.S. Centers for Disease Control and Prevention.

The provision, however, specifically says that youth sports organizations won’t be subject to civil liability if they don’t adhere to the new recommendations.

“The worry is, if you think of, say, T-ball, (the coaches) are all volunteers,” said state Rep. Diana Urban, a Democrat who represents North Stonington and Stonington. “The worry is that if we ask them to be trained, they’re not going to want to volunteer.”

But Norwalk hasn’t seen that, Urban said.

The bigger issue for youth sports programs is making sure parents get the necessary concussion information.

“It wasn’t so bad for the coaches because they’re used to having to jump through hoops,” said Jack Couch of Norwalk Youth Lacrosse. “Getting paper from parents is like herding cats in a nightmare.”

Snedaker likes to use a video with parents called “Brain 101: What’s a Concussion?” — https://bit.ly/1uLCmoM — from theOregon Center for Applied Science.

“It’s funny. It’s cute. It doesn’t scare kids,” Snedaker said. “It’s kind of fun. There’s vomit. There’s all kinds of things to appeal to kids.”

But the concussion video makes clear that it’s important to get treatment for an injury that, left untreated, can have long-term detrimental effects on many facets of a child’s life.

“The good news is that in a lot of ways, a lot of the coaches, parent organizations, youth programs are somewhat out ahead of where a lot of folks think they are,” said state Rep. John Shaban, a Republican from Weston, and the president of Aspetuck Youth Football.

But there’s still room for improvement.

“When you think about it, not every kid plays sports,” said Bob Fosina of Norwalk Junior Soccer. “Every kid walks up and down stairs. Every kid gets in a car. Every kid goes on a scooter. I would love to see this be implemented at the (primary) school level.”

Source: Fornabaio, Mike. “Treating Concussions: A Baseline for Success.” Connecticut Post. N.p., 31 Oct. 2015. Web. 31 Oct. 2015.

Every head injury is not a concussion

By MIKE FORNABAIO

Michael Lee figures he’s seen thousands of patients with concussions, many of them in his Fairfield office.

Sometimes, the children are athletes — youth soccer players or high school football players — but plenty of times they’re just kids who have fallen off their bikes or dropped out of their favorite trees.

But just because a child suffers a head injury, the diagnosis isn’t always a concussion, which doctors describe as a jolt to the head or body that disrupts the function of the brain and causes the brain to move rapidly within the skull.

Sometimes, it’s simply a bump on the head that will go away pretty quickly. Other times, it’s a clear concussion that requires prompt, vigilant attention. Still other times, it’s a much worse injury, perhaps even a fatal one.

“There are so many cases, times when there are glaring examples of (head injuries) — the actress (Natasha Richardson, who died after a 2009 accident), skiing … ‘Oh, a concussion,’ ” Lee said.

“No, that was a brain bleed. You’ve got to distinguish a concussion, a mild traumatic brain injury, from a (more severe) brain injury.”

Given the recent attention surrounding concussions, the temptation is to view every head injury through the same lens. That isn’t just a mistake, it can also be dangerous.

“Science is moving fast,” said Patricia McDonough Ryan, a pediatric neuropsychologist at Gaylord Specialty Hospital in Wallingford. “You’ve got to keep on top of it. … And the media is outpacing science. So what you read on the Internet, what you hear on TV, the majority is not true.”

And so, anxious parents can lead to anxious patients, Ryan said. This can sometimes delay a child’s recovery from a concussion injury.

“(The media) catastrophize concussions, making it sound like the effects of a single concussion can have lifelong detrimental brain damage,” Ryan said. “They apply what we know from adult literature to kids. They’re not mini-adults. Kids’ brains are still growing.

“There was a research study that was just completed that talked about changes in the hippocampus of football players. It was related to a certain group of athletes that had concussions, but the headlines read, ‘NFL players have changes in hippocampus.’ ”

A uniform state policy is trying to take some of the mystery and misinformation out of the equation.

With stronger concussion legislation passed last year, state lawmakers now require schools and youth groups to get concussion information into the hands of parents and young athletes, urging them to seek medical attention at the first sign of a symptom.

“Better recognition, earlier recognition and diagnosis leads to better outcomes,” Ryan said flatly.

Concussions are like snowflakes, she added. No two are alike and no two patients respond the same way to treatment.

In a concussion, rapid movement stretches and damages the brain, Ryan said. It’s also a rotational injury. Force against the head doesn’t necessarily mean there will be a concussion.

Youngsters and teenagers are at greater risk, and can take longer to heal than adults, according to doctors. Certain studies also indicate that girls are at greater risk than boys.

Some people may also be at a higher risk for concussions, including those with migraines, learning or developmental disabilities, or those with previous concussions.

A first concussion isn’t the end of the line, doctors stress, but every concussion must be taken seriously. It’s no different with the treatment of concussions, Ryan said.

Each treatment must be tailored to fit a person’s symptoms, risk factors and the amount of time that has passed since the injury. Ryan will often reduce stimulation for a few days, and then increase it gradually.

“I think of ‘Goldilocks and the Three Bears.’ Too much stimulation is not good. Too little stimulation is not good, either,” Ryan said. “You’ve got to find that sweet spot: Where is it just right? And that takes a lot of training and education.”

Lee agreed.

His “Cocoon Therapy” treatment was never meant for extended use, but some have used it that way.

“I felt kids should sleep as much as they could in a dark room for a day or two to help them get better quicker,” Lee said. “That got misinterpreted by a lot of people to keep kids locked up in dark rooms for days on end, which was never what we wanted to do.”

Most children with concussions show signs of improvement relatively quickly, according to doctors. For athletes, the protocol is usually a step-by-step return to activity, then to practice, then to playing games.

However, few medical tests provide clarity about what’s going on with a concussion inside a person’s head. Cognitive tests can be revealing, Ryan said, but it’s key to make sure the tests are administrated correctly and consistently.

Recovery can be helped by setting expectations and reviewing biofeedback, she said, generally helping kids take control of their lives.

“We can do things to empower kids around their habits,” Ryan said.

But what about multiple concussions? When does that pattern lead to the possibility of giving up a contact sport?

“There used to be this notion of three (concussions) and you’re out. There’s no research behind it,” Ryan said. “It was just kind of let’s-just-put-a-number-out-there. You’ve got, really, the research pushing toward an understanding of the individual.”

The return-to-learn protocol must also be a part of this discussion, according to many experts.

“If a child has a concussion, looking at formal policies to help them return to school could be the next step to the concussion laws,” said Diana Coyne, a Westport parent who has pushed for stronger state laws and served on the state’s concussion task force. “Some states have them in place. That could be a possibility.”

Shelton High School athletic director John Niski appreciates the balance between school and sports.

Niski said a teacher who sees a student with a broken right arm understands the child won’t be writing essays anytime soon. But some teachers don’t quite get that a concussion may temporarily force a child to miss math class for a while.

“If students miss three or four days of AP European History class, three or four days of AP Calculus, they start to really panic,” Niski said. “That exacerbates the (concussion) recovery process.”

But it doesn’t have to be this way, Niski said. The best recovery protocol is a collaborative process involving the student, family, doctors, school officials and athletic officials.

“There are so many great things about sports,” Ryan said. “There are so many benefits. Exercise, mental health. Learning how to be team players, how to lose with dignity, win with grace.”

With more and more concussion questions being answered, there just may be safety in numbers.

Source: Fornabaio, Mike. “Every Head Injury Is Not a Concussion.” Connecticut Post. N.p., 24 Oct. 2015. Web. 24 Oct. 2015.

Confronting concussions: The real heads-up play

By MIKE FORNABAIO

GREENWICH — Like most everyone else who has ever put on a helmet, John Marinelli figures he had a few concussions during his career.

They were collateral damage, the risk associated with playing football in the best league in the state, and later, at Division III Trinity College in Hartford.

Now, as the first-year head coach of the Greenwich High School football team, Marinelli is among those all across the country who are keenly aware of these game-changing head injuries and are working to identify them swiftly and address them deeply.

“Concussions have always been a concern in football,” Marinelli said Friday night. “In the era when I played, your teammates would help you hide it so you could play. But as a kid, you don’t realize how important it is to get the proper treatment.

“I played for two great programs at New Canaan and Trinity. The practice schedules, the techniques, the fundamentals, all of it was geared toward avoiding contact until game day.”

Striking a balance between competing at full speed and confronting concussions isn’t always easy.

In this Hearst series about concussions, we’ll look at how evaluation and treatment have evolved in recent years. We’ll also examine the push at every level — local, state and national — to improve concussion awareness and to ensure that young athletes who suffer concussions get the medical attention they need to recover.

A concussion, according to the U.S. Centers for Disease Control and Prevention, is a mild traumatic brain injury. The CDC describes it as an injury that changes the way the brain normally works.

Symptoms include headaches and dizziness, but unusual behavior such as altered sleep patterns and a sensitivity to light can also be signs.

Judicious treatment is essential — not only to rule out a more-serious head injury, but because delayed treatment can lead to a longer recovery time, experts say.

Tricia McDonough Ryan, a pediatric neuropsychologist at Gaylord Specialty Hospital in Wallingford, noted in a recent presentation in Norwalk that of the three million concussions reported each year in the United States, two million are suffered by children.

The recovery process is critical, an incremental regimen of mental stimulation and rest from activities, including classwork and athletic competition.

After three games this season — Greenwich High had a bye this weekend — Marinelli said four of his players have been diagnosed with mild concussions. At this point last year, another 10 to 15 players had experienced concussions, he said.

“A lot of coaches used to think the more you hit, the better you’re going to be on game day. I couldn’t disagree with that more,” Marinelli said. “It’s more important to teach good tackling fundamentals in practice so when game day comes, the kids are in a situation where they have the proper tools and technique to succeed.”

As research on the long-term effects of multiple concussions continues, the narrative focuses on the likes of former San Francisco 49ers linebacker Chris Borland, who retired this year after playing just one season in the NFL because of his concern for future head injuries.

There is a dramatic difference between one or a few concussions, and repeated ones that go ignored, experts say.

In Connecticut, state legislators have passed laws aimed at increasing awareness of concussions in youth sports, including high schools. The Connecticut Interscholastic Athletic Conference has also made big changes in football to limit exposure to concussions.

The state Board of Education now requires schools to compile head injury data. The new protocol calls for athletes to be removed from competition the moment a concussion is even suspected. Athletes with concussions are not allowed to resume play until they are cleared by a medical professional, typically a neurologist.

That awareness is a good thing, says Shelton High athletic director John Niski.

“We don’t want to go overboard and swing the pendulum too far, where it’s flag football and everyone’s running around in bubbles,” Niski said.

The careful inspection of equipment and the proper use of techniques on the field will also help limit exposure to concussions. But they won’t eliminate them.

“I started doing this 12, 13 years ago. At that time, nobody really saw that many kids with concussions because they all went into the emergency room,” said Michael Lee, a Fairfield pediatrician who specializes in concussions. “The doctors in the emergency room (back then) said, ‘Oh, take it easy, and when you feel better, go back.’

“I think there are kids who will fall through the cracks,” Lee said. “A kid goes to the emergency room with a fractured nose, very often they forget there’s a concussion associated with it because they’re so focused on the fractured nose. Sometimes, people don’t look for a concussion when it presents itself.”

Traumatic brain injuries can happen anywhere and anytime — a car accident on the Merritt Parkway, the detonation of an IED in Afghanistan, a toddler who stumbles and hits the corner of a coffee table.

Soccer headers are often seen as a primary source of concussions, but a recent study published in JAMA Pediatrics said player collisions are more often the cause.

For example, a hockey player could suffer a concussion on a borderline check, but being hit in the head by a puck could also yield the forces necessary for a concussion.

The scenarios continue in basketball, lacrosse, baseball, softball and other sports.

If concussions aren’t considered an epidemic, they seem to be on everyone’s mind.

Concussions can cost athletes chunks of their careers, pages of their memories, or worse, years of their lives.

Casey Cochran, the former UConn and Masuk High quarterback, abruptly chose to end his football career last season after suffering repeated concussions behind center.

Professional hockey players Mike Richter, Pat LaFontaine, Marc Savard, Jeff Beukeboom, Jeremy Colliton and Patrick Wey have all been impacted by concussions.

But for youngsters playing recreational or high school sports, the focus is on one concussion and how to handle it, making sure removal-from-play guidelines are followed and treatment begins promptly.

Attorney Paul Slager, a partner at Silver Golub & Teitell in Stamford, said at a recent conference in Norwalk that he appreciates concerns about liability. Slager also said that as new legislation is passed, these efforts will help decrease potential liability.

“When things are safer, when policies are put in place designed to keep people from having multiple concussions, for example, or in some cases from having concussions at all, liability decreases,” Slager said.

“When that happens, when people are acting in a safe way, and they don’t subject themselves to liability by acting in a safe way. … We have plenty of other kinds of cases we’d rather be doing than kids getting hurt with concussions.”

Parents can stay informed, too, said Jack Couch of Norwalk Youth Lacrosse: Know the rules of the sport and understand how to keep the game safe.

When injuries happen, following the protocols will get young players back to normal activities quickly.

“I’m not looking to try to pull in sports,” said state Rep. Diana Urban, a Democrat representing North Stonington and Stonington. “I want (sports) to be as safe as they can be.”

Urban said she’s an equestrian rider and her son played tennis at Williams College. As a rider, Urban said, she always wears a helmet.

“That’s a parameter I can control,” she said. “I can’t control if the horse crashes.”

Source: Fornabaio, Mike. “Confronting Concussions: The Real Heads-up Play.” GreenwichTime. N.p., 17 Oct. 2015. Web. 17 Oct. 2015.

Concussion prevention in soccer tied to strength, technique

By RANDY WHITEHOUSE

Researchers, doctors and athletic trainers are always searching for ways to prevent concussions. Part of that requires having a better idea of the risks athletes face.

But parents can put athletes at greater risk for other health problems by taking drastic actions to protect their children.

“My biggest worry with concussions right now is the fact that we are terrifying parents about playing sports, whether it be soccer, football, rugby, lacrosse, hockey, basketball, you name it. We’re terrifying our parents and they’re making decisions about activities, and that’s the worst thing we can do,” said Dr. Paul Berkner, director of the Maine Concussion Management Initiative at Colby College.

“We have a population of young adults who don’t do anything near as much. Our obesity rate in children in Maine is terrible. If we start having people not participating, I think the long-term risks from obesity are probably higher than the long-term risks from concussions,” Berkner said.

Athletes can take steps to reduce their risk of concussions, experts say. Some are quite basic.

“Being in good overall physical condition is very, very important,” said Dr. Chris Lutrzykowski, a specialist with Maine General Health.

Much like tackling in football, experts are still debating banning or placing age restrictions on heading in soccer. Some suggest simply enforcing the rules will reduce aggressive body contact and reduce concussions, while others believe that even repetitive head-to-ball contact in younger children can cause brain trauma.

More and more soccer players are now wearing headgear for protection. The equipment, which can cost anywhere between $20-$80, can prevent external head injuries such as cuts and bruises, but experts say they don’t have a clinical link to reducing concussions.

“There is no data that supports the use of headgear makes a difference whatsoever,” Berkner said. “In football, helmets are designed to reduce skull fractures, not to reduce concussions.”

Lutrzykowski said some studies have shown improved neck strength can reduce the risk of soccer concussions. Stronger necks can reduce the whiplash effect that can cause or exacerbate a concussion.

With that in mind, Colby College head athletic trainer Tim Weston said his athletes are incorporating more exercises to strengthen their necks and trapezius muscles into their conditioning programs.

Contact from heading the ball is the biggest risk factor, although head-to-head or head-to-body contact poses a far greater risk than head-to-ball contact.

“I think it’s critical to have that neck and upper-body strength, particularly in soccer,” he said.