Moderated by Doris McMillon Concussion: Understanding Mild Traumatic Brain Injury

Featuring James Kelly, M.D. Professor of Neurosurgery and Physical Medicine and Rehabilitation at the University of Colorado Denver School of Medicine Aditya Bhagwat, M.D. Clinical Neuropsychologist from Walter Reed Army Medical Center Lesley LeMasurier a college senior at the University of Colorado; trained with the United States Ski Team until the toll of cumulative mild TBIs ended her ski career

Mild TBIs are concussions Each year, more than 1.5 million people experience some form of traumatic brain injury (TBI) 85% of people with mild TBI have no long-term symptoms 15% of people with mild TBI have lingering or long-term symptoms Many people don’t realize they have sustained a mild TBI

What is a concussion? It is at the mild end of the spectrum of traumatic brain injury May be confused or have a lapse in memory –Reflecting brain dysfunction You don’t have to lose consciousness in order to sustain a concussion

What happens to the brain? Impact shakes the brain inside the skull A wave through brain tissue causes discharge of damaging chemicals Nerve cells can shear Microscopic damage can affect the anatomy and function of brain cells

How can I tell if I’d had a concussion? You don’t have to lose consciousness The person may think they were unconscious because they can’t account for some span of time (memory gap)

Common signs of mild TBI Headaches Nausea Confusion Slow thinking Sleep changes Mood changes Dizziness

Common signs of mild TBI (cont.) State of confusion –Length of time can vary, depending on the severity of the injury –Could last a few seconds, minutes, or even hours

Common signs of mild TBI (cont.) Nausea –Due to the swelling of the brain and the release of neuro- chemicals Headaches –Most common sign of a concussion

Common signs of mild TBI (cont.) Mood changes –May result in depression due to the dysfunction of the brain –Depression may go away, but some need help in counseling or medications

Common causes of mild TBI Motor vehicle collisions Falls –Toddlers learning to walk –Elderly who are beginning to experience coordination problems Contact sports –More common amongst 15 – 25 year old males

TBI in the military 20% of soldiers in Iraq and Afghanistan have suffered some type of TBI Most are mild TBIs, but some are moderate to severe Increased awareness is leading to better tracking and screening

TBI in the military (cont.) Concussions –The majority of military injuries are mild concussions Moderate to severe TBI –More severe loss of consciousness –Contusions or bleeds, such as a brain hemorrhage –More symptomatic –Longer recovery

Causes of TBI in service members Falls –Being thrown against the ground or a wall during an explosion –Falling out of a motor vehicle Penetrating injuries (the more moderate to severe TBI) –gunshot wounds –shrapnel from improvised explosive devices (IEDs) Blast injuries Other combat-related injuries

Similar symptoms in civilian and military populations Headache Confusion Nausea Mood and behavior changes Sensitivity to light and noise

Identifying TBI in service members Screenings –Wounded are screened at the hospital –Returning soldiers are screened by a physician – usually a questionnaire that asks about symptoms Diagnosis –Cognitive –Neuro-testing –Interview –Medical records

Short video on mild TBI Featuring –Dr. James Kelly –Dr. Randall Chestnut, neurosurgeon –Pat LaFontaine, retired NHL ice hockey player –Garrick Utley, reporter

Alpine ski racer Lesley LaMasurier Started skiing at age six Attracted by challenge and speed

Crashing and TBI – part and parcel of skiing? For many years, Lesley rarely questioned her crashing –It was just something that came with the sport She became more fearful when she was a teenager and started crashing more and more frequently

Lesley’s history of concussions First mild concussion occurred playing soccer –did not lose consciousness –confused state of mind –headache Experienced two more concussion while skiing Doctors and coaches told her simply to be careful

Lesley’s major crash Was training with the United States Ski Team while dealing with TBI symptoms for two years –Migraines –Trouble sleeping –Difficulty staying focused Entered a race with a broken leg and torn ligaments –Crashed and found her helmet in two pieces at her side

Pressure to continue Pressure from coaches, teammates, and family members Pressure to tough it out; get back on the slopes Kept her symptoms from others so she wouldn’t come across as complaining

No more faking it Lesley’s symptoms started to get worse: –Migraines –Increased heart rate –Vision difficulties –Didn’t feel like herself, wondered what was wrong “No blood, no break…keep going” Ended up in the hospital for MRI scans and other tests

What can parents and coaches do to help their young athletes? Take even seemingly minor injuries to the head seriously Seek closer monitoring to protect athletes from additional concussions Identify healthcare professionals to diagnose the nature of the injury Seek additional, more specialized care if necessary

Changing the “no pain, no gain” mindset There is often pressure from coaches, teammates, parents, and the athletes themselves to continue to play even when injured Education and awareness about the short- and long-term effects of TBI are crucial Athletes often tend to listen more to their teammates than to doctors when it comes to being careful and seeking treatment after a TBI

Military TBI assessment tool: MACE Military Acute Concussion Evaluation (MACE) –Developed by Defense and Veterans Brain Injury Center Anytime there is an incident – whether an explosion or car crash – this instrument can be brought out and the solider can be quickly assessed for signs of a TBI Includes history of incident and questions that assess neurological state of person

Do multiple concussions make a person like Lesley more vulnerable? The persistence of symptoms and some subtle findings on examinations suggest that it would be unwise for Lesley to return to her previous level of competitive skiing Lesley has retired –The risks are too high, but continued improvement is definitely part of the picture

How long do cumulative effects last? If there is another risk or exposure soon after a concussion, the likelihood of experiencing a repeated concussion is great With athletes who have had at least two or three concussions, a decade, two, or even a lifetime of increased risk of concussion is possible Statistically the risk is greater if people have a history of concussions

Lesley’s most serious symptoms Increased heart rate –So high for so long that it would lead to exhaustion –Elevated even when she was just standing Shortness of breath Trouble sleeping Ongoing migraines and exhaustion Sweating

What is postural orthostatic tachycardia syndrome? The heart rate goes up dramatically and abnormally when you stand –This is something physicians haven’t paid enough attention to It can be one of the residual effects of concussion or mild TBI

Invisible TBI-related symptoms in soldiers The military’s goal is to make sure no TBI is invisible –Every hospital service will know about the possibility of a TBI Every patient with a possible TBI or any injury above the neck is thoroughly evaluated

Treatment for concussion Common effective treatment –Eliminate or reduce their pain for better sleep Sleep is crucial –If physicians can help patients sleep better in a predictable, every-night pattern and get deep, restful, rejuvenating sleep, concussion symptoms often resolve

Treatment for concussion (cont.) Treatment has to be individualized The main treatments are for: –Pain relief –Sleep issues –Mood and behavioral issues

Quality of treatment The nation is improving in all areas little by little, but we’ve still got a long way to go –Still struggling with emergency departments dismissing a concussion rather than identifying and dealing with it

Treatment of TBI in the military population Treatment is symptom-driven –Soldiers often have other traumatic injuries as well as psychological trauma from post-traumatic stress disorder (PTSD) Physicians first work to control pain The military also works to educate service members about prevention and early intervention

Unique challenges dealing with mild TBI in the military Patients often have multiple traumas that may perpetuate the symptoms that might have started with a concussion –Multiple injuries that can lead to multiple surgeries and ongoing rehabilitation The overlay of pain and other injuries along with the psychological issues can complicate the medical picture

Rehabilitation protocols in the military A multidisciplinary team tracks every TBI patient This team includes: –Neurologists –Physical therapists –Occupational therapists –Speech therapists –Psychologists –Neuropsychologists

Rehabilitation protocols in the military (cont.) Rehabilitation and treatment starts at Walter Reed Army Medical Center (WRAMC) Then the team works with the Veterans Administration (VA) and community-based organizations to help each TBI patient get the help he or she needs

Determining the best treatment for a mild TBI Doctors actions for treatment –Will look at what happened to the person at the time of injury –Might speak with paramedics to get more information about the event –Might interview the person’s family, friends, or co-workers to look at the whole spectrum of change in that person post-TBI, to determine whether a concussion actually occurred, how bad it was, and what kind of treatment would be best

Researchers’ contributions to mild TBI Discovering what are ideal treatments for mild TBI Information dissemination –What are the effects? –What the recovery expectations? –What treatments work best with certain types of symptoms?

How are psychological effects of TBI addressed? Early intervention with psychotherapy Cognitive behavioral therapies Empowering the individual with related knowledge and education

Finally finding out why TBI can alter a person’s moods and behavior – his or her whole sense of self For Lesley, it was an enormous relief to her as well as to her family and friends to understand that her behavioral changes were a result of her repeat concussions, not something else

Short video on preventing TBI Featuring –Dr. James Kelly –Dr. Randall Chestnut, neurosurgeon –Pat LaFontaine, retired NHL ice hockey player –Garrick Utley, reporter

Should kids be allowed to play certain sports? That is an individual family’s choice The most important thing that parents can do to keep their children safe is to make sure they wear helmets and other proper safety equipment

Ways to make sports safer Wear the proper helmet for each sport Reduce risk of injury by changing some of the rules in certain sports –banning intentional hitting from football and ice hockey Ban boxing entirely Stop players from taking unnecessary risks in sports when it comes to repeat concussions

Baseline testing for TBI To date, there is no baseline testing for the general population –Pro sports teams and big colleges mostly perform baseline testing on their players

Baseline testing for TBI (cont.) Baseline testing includes a battery of cognitive and other tests that can be done before the individual is at risk of some kind of concussion After an injury, the same test would be repeated to show any differences or deficits and then to track the recovery from there

The challenges of baseline testing for TBI Getting an individual at his or her optimal level both for the baseline test and the test(s) post-injury would be challenging –People get the flu, they might have a bad sleep, or a fight with their spouse causing their test to run lower than it might For the military: the sheer volume of testing necessary for the number of service members alone would make efficiency difficult

Getting people to take prevention seriously Getting the average person to wear a seatbelt, or a helmet when riding a motorcycle or bicycle is often challenging Some people simply don’t want to be told what to do –They don’t like restrictions Some people may minimize what the effects of a concussion can be –They may not think “getting their bell rung” is a big deal because they have not been properly educated about the effects of a concussion

How can you encourage adults to wear helmets? Injury can still occur while wearing a helmet Everyone should take that extra precaution to avoid more severe injuries Put your pride aside

Can heading a soccer ball lead to a concussion? The Institute of Medicine claims that if it’s done correctly in the usual manner of propelling the ball in the other direction, a concussion will not occur There is no current evidence that children’s brains are being injured by heading a ball

Can concussions lead to Alzheimer’s? Repeated concussions can increase your risk The issue is a combination of genetic predisposition and the exposure to concussion

What are some long-term effects of concussions? The statistical risk of a future concussion is increased, but long-term risks are unknown –No data at this time

Aging issues versus concussion symptoms? Has the senior citizen experienced a head injury from a fall or has been struck in the head –Look at the effects of a concussion Memory loss Headaches Nausea Dizziness Light sensitivity If no injury has occurred and the senior citizen is only experiencing memory loss, it is possible dementia

Any recommendations for those who are forced to give up sports? Having to give up a sport is often difficult to accept –Focus attention on other activities Academics Working out Mild activities, such as tennis or golf Probably never experience their thrill, but they can find other avenues

Can brain exercises help a concussion? Brain exercises are part of the rehabilitation process –Used by speech language pathologists and occupational therapists Beneficial for the general population –with or without an injury

Dr. Bhagwat’s final thoughts Educating the public and raising awareness about concussion and its short- and long-term effects is crucial

Lesley’s final thoughts If people are feeling the symptoms related to TBI – athletes, anybody – they need to seek the proper help These symptoms aren’t a result of a poor attitude –There may have something wrong with the brain

Dr. Kelly’s final thoughts One of the best treatments for brain injury is preventing it

Learn more To learn more about traumatic brain injury, signs and symptoms, treatment options, and ways to prevent it, please visit

BrainLine is funded by the Defense and Veterans Brain Injury Center, the primary operational TBI component of the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, through a subcontract award with the Henry M. Jackson Foundation for the Advancement of Military Medicine.

This material is based upon work supported by the USAMRAA under Contract Number W81XWH-07-C Any opinions, findings and conclusions or recommendations expressed in this material are those of the author(s) and do not necessarily reflect the views of the USAMRAA. Acknowledgment of Support and Disclaimer © Greater Washington Educational Telecommunications Association, Inc., 2008