Some people, including officials for the sport, think that NASCAR needs energizing. That’s why the organization plans to loosen up some of its rules so that the races become more of “a contact sport” (we guess like football) this year, NASCAR chairman Brian France said recently.
“We’re going to open it up, because we want to see what you want to see,” France said during a Jan. 21 http://espn.go.com/espn/page2/index?id=4851656
press conference. “More contact. This is a contact sport. We want to see drivers mixing it up. We want to see the emotion of the world’s best drivers just as much as everybody else does. And that’s the goal in 2010 and beyond.”
Here is a YouTube video of France making the remarks: http://www.youtube.com/watch?v=J7dWRhRnj58
You don’t have to be a genius to figure out that these rule changes, meant to increase “contact,” will likely lead to more accidents and injuries, possibly brain trauma.
NASCAR fans and drivers alike have been griping that the sport has become too namby-pamby and watered down, losing much of its excitement, because of restrictive rules on practices such as “bump-drafting.”
Bump-drafting is a controversial practice that some NASCAR veterans have labeled “idotic.” http://auto.howstuffworks.com/auto-racing/nascar/nascar-basics/stock-car-racing-techniques4.htm
It’s fancy tailgating, where NASCAR drivers nudge the car ahead of them, moving it forward, and their forward along with it. The front car slows down, and that gives the car behind a chance to pass and move ahead, creating some excitement.
But bump-drafting can turn dangerous, because the front driver’s wheels can lose traction and the car can go into a spin. So the practice has led to fatal NASCAR accidents.
NASCAR banned bumping at the Talladega race in November, and drew the ire of diehard race fans.
Despite the past fatalities and accidents, the bump-drafting ban didn’t sit well with fans or some drivers. “There’s an age-old saying that NASCAR, “If you ain’t rubbing, you ain’t racing,” NASCARr president told the Associated Press. http://sports.espn.go.com/rpm/nascar/cup/news/story?id=4845878
At the January press conference, France basically said NASCAR was lifting its old restrictions and putting racing back in the drivers’ hands. The ban on bumping is being scrapped, in time for the NASCAR season opener, the Daytona 500, which is a restrictor-plate race. Those plates give a racecar more power and speed.
NASCAR officials are hoping the changes will bring back the excitement to racing, while seemingly not being too concerned about the increased chance of injuries of this new “contact sport.”
In his AP interview, Helton maintained that the sport is much safer than it was five or six years ago, with the improvements on the cars and tracks. It remains to be seen this year.
Is it energizing the sport needs, or greater ratings? One of our favorite sports, boxing, it is the goal to cause a concussion/brain damage to your opponent. In football, it is at least a by-product of the best plays. Now we have perhaps our most dangerous sport, car racing, wanting to increase its ratings by making it a contact sport. It may not be the goal to kill the opponent, but it certainly is a foreseeable outcome.
NFL Players Brain Injury Committee Holds First Meeting
The committee formed by the NFL Player’s Association to tackle, so to speak, the issue of brain injuries and professional football has its first meeting this week in Palm Beach, Fla. http://www.google.com/hostednews/canadianpress/article/ALeqM5hN5mqFoFXXSvkaDO9Nec2JaZ1GKQ
The Mackey-White Traumatic Brain Injury Committee was named after two Hall of Fame players: John Mackey, who has Alzheimer’s disease, and Reggie White, who passed away at the young age of 43 after retiring from the NFL. See http://news.bostonherald.com/sports/football/other_nfl/view/20100127nfl_establishes_brain_trust/srvc=home&position;=recent
The special committee is made up of past and current NFL players, researchers and physicians. They want to start a discussion on brain trauma and professional football, evaluate the latest research and begin work on recommendations for player safety.
The issue of the dangers of players, NFL and high school, going back on the field after sustaining concussions a hot topic in the past few months, receiving a lot of press. Congress recently conducted hearings on head injuries, taking testimony from players, doctors and NFL commissioner Roger Goodell.
The Mackey-White committee is being chaired by Arizona Cardinals wide receiver Sean Morey and Dr. Thom Mayer, medical director for the NFL union.
Chris Nowinski, an ex-college football player and pro wrestler, is a member of the committee. Nowinski, who has had at least a half dozen concussions, has taken on less dangerous work now. He is president of the Sports Legacy Institute and co-director of the Center for the Study of Traumatic Encephalopathy at Boston University.
The Mackey-White Traumatic Brain Injury Committee was named after two Hall of Fame players: John Mackey, who has Alzheimer’s disease, and Reggie White, who passed away at the young age of 43 after retiring from the NFL. See http://news.bostonherald.com/sports/football/other_nfl/view/20100127nfl_establishes_brain_trust/srvc=home&position;=recent
The special committee is made up of past and current NFL players, researchers and physicians. They want to start a discussion on brain trauma and professional football, evaluate the latest research and begin work on recommendations for player safety.
The issue of the dangers of players, NFL and high school, going back on the field after sustaining concussions a hot topic in the past few months, receiving a lot of press. Congress recently conducted hearings on head injuries, taking testimony from players, doctors and NFL commissioner Roger Goodell.
The Mackey-White committee is being chaired by Arizona Cardinals wide receiver Sean Morey and Dr. Thom Mayer, medical director for the NFL union.
Chris Nowinski, an ex-college football player and pro wrestler, is a member of the committee. Nowinski, who has had at least a half dozen concussions, has taken on less dangerous work now. He is president of the Sports Legacy Institute and co-director of the Center for the Study of Traumatic Encephalopathy at Boston University.
NFL and Concussion Hearings – Neurologist Joseph Maroon of Pittsburg Testimony
Among those testifying at Congressional hearings on the NFL and Concussion was Joseph Maroon, M.D., of the Department of Neurosurgery at the University of Pittsburgh Medical Center. The hearings were held in Detroit on January 4, 2010. Maroon is also the Team Neurosurgeon, The Pittsburgh Steelers and has been on the NFL _s Mild Traumatic Brain Injury (MTBI) Committee since it was created in 1994.
Maroon called the Congress’s attention to what advances in the way in the NFL treatment of concussion since 1994. He said in his prepared remarks:
Clearly there was insufficient culture change between 1994 and 2009, to make a significant difference, which is why the hearings in October of 2009 caused such a stir. Maroon commented on the changes since October:
I am here today to report on additional steps relating to concussions that the NFL has taken since the October 28 hearing. The long _running arc of improvement continues.
If you read the above statement carefully, it really makes no sense. If a player suffered a concussion, by definition if a player “suffers a concussion” he would show a sign or symptom of concussion. What Maroon left out, is sign or symptom of a concussion at what point. As a football fan, I understand the enormity of keeping a star player out of a game, potentially a playoff game, because he was knocked woozy on one play. But if you are going to provide a guideline, then provide it. If there is any return to play after a concussion in the same game, then you must clearly state at what point in time, 15 minutes, 30 minutes, a quarter of the game, the symptoms must have cleared.
My biggest quarrel with what Maroon states here is the abandonment of the stated time period of not returning if the player is found to have the “signs or symptoms of a concussion.” Most sport and concussion guidelines specific 7 days or longer period for the concussion that is still symptomatic for more than a short period of time after the original injury. The best part of the guidelines is putting that finite “no play” period because it required the serial follow-ups, that are the most sensitive determination of the severity of a concussion. Leaving the finite “no play” time period out, guts the guidelines.
Maroon did get it right when he addressed the most serious problem in implementing the any guidelines, changing the culture of the sideline, the locker room so that players aren’t short sighted or intimidated into not fully reporting concussions. He stated:
According to Maroon, the NFL is trying to make a difference outside of its own games:
All positive steps. The biggest step is the publicity that these hearings have created on one simple theme: Concussion can be serious.
Maroon called the Congress’s attention to what advances in the way in the NFL treatment of concussion since 1994. He said in his prepared remarks:
Our committee was specifically charged in 1994 with initiating and supporting independent scientific research to further the understanding of the causes, diagnosis, treatment and prevention of concussion.
This work has involved research on helmet standards, injury data collection and analysis, and an ongoing study of the long _term effects of concussions on NFL players. As a result, the NFL in recent years has initiated educational and preventive measures, guidelines for the management of concussions, and rule changes to eliminate unnecessary hits that can lead to concussions. Since the formation of the committee in 1994, there has been a significant positive culture change in the NFL on the issue of concussions. I have personally witnessed this culture change among NFL teams and players and I am confident that it will continue in a positive direction.
Clearly there was insufficient culture change between 1994 and 2009, to make a significant difference, which is why the hearings in October of 2009 caused such a stir. Maroon commented on the changes since October:
I am here today to report on additional steps relating to concussions that the NFL has taken since the October 28 hearing. The long _running arc of improvement continues.
The NFL now has stricter return _to _play guidelines. It includes the addition of an independent neurological consultant for each team approved by the medical advisors of the NFL and the NFL Players Association. The 2009 statement on return to play says that a player who suffers a concussion should not return to play or practice on the same day if he shows any signs or symptoms of a concussion. It also states that once a player is removed for the duration of a practice or game, he should not be considered for return _to _play activities until he is fully asymptomatic, both at rest and after exertion, has a normal neurological examination, normal neuropsychological testing, and has been cleared to return by both his team physicians and the independent neurological consultant.
If you read the above statement carefully, it really makes no sense. If a player suffered a concussion, by definition if a player “suffers a concussion” he would show a sign or symptom of concussion. What Maroon left out, is sign or symptom of a concussion at what point. As a football fan, I understand the enormity of keeping a star player out of a game, potentially a playoff game, because he was knocked woozy on one play. But if you are going to provide a guideline, then provide it. If there is any return to play after a concussion in the same game, then you must clearly state at what point in time, 15 minutes, 30 minutes, a quarter of the game, the symptoms must have cleared.
My biggest quarrel with what Maroon states here is the abandonment of the stated time period of not returning if the player is found to have the “signs or symptoms of a concussion.” Most sport and concussion guidelines specific 7 days or longer period for the concussion that is still symptomatic for more than a short period of time after the original injury. The best part of the guidelines is putting that finite “no play” period because it required the serial follow-ups, that are the most sensitive determination of the severity of a concussion. Leaving the finite “no play” time period out, guts the guidelines.
Maroon did get it right when he addressed the most serious problem in implementing the any guidelines, changing the culture of the sideline, the locker room so that players aren’t short sighted or intimidated into not fully reporting concussions. He stated:
The 2009 statement also addresses the responsibility of the players. It states that players are encouraged to be candid with team medical staffs and fully disclose any signs or symptoms that either they themselves or their teammates are showing that may be associated with a concussion. The nature of concussions, which can be difficult to diagnose in the absence of loss of consciousness, places an important responsibility on players to put their health above competitive considerations. This is the policy of the league with respect to its teams _ medical decisions must override playing considerations _ and it is extremely important that the players commit to meeting that standard.
In December, the NFL, in conjunction with the Centers for Disease Control (CDC), produced a public service messaged directed primarily at young athletes and their parents and coaches on the importance of head injury awareness. The theme is _Take Head Injuries Out of Play _ and the message has been airing and will continue to air on NFL game telecasts throughout the playoffs. This PSA also was sent to a group of conference commissioners of college sports so that they could adapt for their use on
television and with their athletes.
According to Maroon, the NFL is trying to make a difference outside of its own games:
In addition, the NFL is working with the CDC and other organizations on educational material for young athletes and high school coaches, and to develop an overall certification program for coaches at those levels addressing player health and safety.
Further, John Madden, in his role as a special advisor to Commissioner Goodell, is chairing a committee of coaches that is exploring ways of providing players with a safer environment to reduce the risk of head trauma in practices.
All positive steps. The biggest step is the publicity that these hearings have created on one simple theme: Concussion can be serious.
NFL Football Concussions Versus Real World Brain Injuries
I am always pleased when the news cycle shifts to concussion and brain injury because that raises public awareness that concussion means brain injury and that brain injuries can cause permanent brain damage. Thus, the NFL being grilled by Congress as to the safety of its players is a very good thing. Likewise, the greatly increased awareness of brain injury coming out of all the publicity that the Iraq and Afghanistan wars brain injuries is also increasing public awareness. But I always worry that people will think that because athletes recover from concussions so quickly, that accidental concussion does not have the potential to permanently injure someone.
The bigger problem in the legal arena is that there is some very bad research being published now that would directly correlate a young athlete’s recovery from a concussion to real world brain injuries. (I apologize to those who see the obvious that sports is also part of the real world, but I find the phrase works to distinguish better than the use of other terms, such as civilian, because of course athletes are civilians, too.)
So, before we spend the next several blogs commenting on the NFL Congressional hearings, I think it is important to discuss what makes accidental (real world) concussions potentially more serious than sports injuries. Here is a partial list.
Sport Concussion a Young Person Injury. First, sport concussions typically happen to those with the greatest chance of a good recovery from concussion, young and athletic people. If we were going to list the three or four most common risk factors for a bad result from concussion, age would be at the top of that list. The reason for this is multiple but includes the fact that younger brains have a gene that stimulates neuronal regrowth that just does not exist when a person is over 40. The closer someone is to 40 at the time of the concussion, the more likely they will have persisting deficits from the brain injury.
Men Are at Less Risk. Most sport concussions happen to men and men are at less risk of poor outcomes from brain injury. This may be seem politically incorrect to say, but women are just simply more vulnerable, not just because they are not as strong, but also because concussive type forces are more likely to damage the white matter of the brain and women are more white matter dependant in there thinking. Complicated topic for another blog.
The Blow is Expected. Sport concussions happen to people who most times are prepared to get hit. The sport concussions that are the most serious are usually to someone who is surprised or motionless at the time of the blow. In contrast, almost all accidental concussions are a surprise. When the body knows it is going to get hit, it protects itself, considerably reducing the extent of and the arc of the acceleration/deceleration.
Athletes are Stronger. Sport concussions happen to people whose bodies have stronger muscles, which also significantly reduces the speed and the length of the acceleration/deceleration arc. When I speak about arc, I am speaking about how far forward, backwards or sideways the head will move on the neck, after being hit. It is this motion that accounts for most of the force on the brain’s axons.
There are about another half of dozen things I could add to this list, but the point of this blog is to remember when you hear about permanent brain damage to professional athletes, there is a far higher risk of that occurring to a 40 year old person who is in a motor vehicle wreck.
The bigger problem in the legal arena is that there is some very bad research being published now that would directly correlate a young athlete’s recovery from a concussion to real world brain injuries. (I apologize to those who see the obvious that sports is also part of the real world, but I find the phrase works to distinguish better than the use of other terms, such as civilian, because of course athletes are civilians, too.)
So, before we spend the next several blogs commenting on the NFL Congressional hearings, I think it is important to discuss what makes accidental (real world) concussions potentially more serious than sports injuries. Here is a partial list.
Sport Concussion a Young Person Injury. First, sport concussions typically happen to those with the greatest chance of a good recovery from concussion, young and athletic people. If we were going to list the three or four most common risk factors for a bad result from concussion, age would be at the top of that list. The reason for this is multiple but includes the fact that younger brains have a gene that stimulates neuronal regrowth that just does not exist when a person is over 40. The closer someone is to 40 at the time of the concussion, the more likely they will have persisting deficits from the brain injury.
Men Are at Less Risk. Most sport concussions happen to men and men are at less risk of poor outcomes from brain injury. This may be seem politically incorrect to say, but women are just simply more vulnerable, not just because they are not as strong, but also because concussive type forces are more likely to damage the white matter of the brain and women are more white matter dependant in there thinking. Complicated topic for another blog.
The Blow is Expected. Sport concussions happen to people who most times are prepared to get hit. The sport concussions that are the most serious are usually to someone who is surprised or motionless at the time of the blow. In contrast, almost all accidental concussions are a surprise. When the body knows it is going to get hit, it protects itself, considerably reducing the extent of and the arc of the acceleration/deceleration.
Athletes are Stronger. Sport concussions happen to people whose bodies have stronger muscles, which also significantly reduces the speed and the length of the acceleration/deceleration arc. When I speak about arc, I am speaking about how far forward, backwards or sideways the head will move on the neck, after being hit. It is this motion that accounts for most of the force on the brain’s axons.
There are about another half of dozen things I could add to this list, but the point of this blog is to remember when you hear about permanent brain damage to professional athletes, there is a far higher risk of that occurring to a 40 year old person who is in a motor vehicle wreck.
Congressional NFL Hearings – Dr. Ronald Benson Testifies about Neuroimaging Advances – Diffusion Tensor Imaging
In my search for the holy grail of objective proof of brain damage in those with Post Concussion Syndrome, I try to stay as current as possible on neuroimaging advances. Yesterday I focused on Dr. Ronald Benson’s testimony with respect to Susceptibility Weight Imaging. Today I will focus on Diffusion Tensor Imaging, DTI.
As a professional who works exclusively in the field of brain injury I believe that DTI may offer more short term benefit in diagnosing Mild Traumatic Brain Injury (“MTBI”). The reason is that MTBI appears to be more a syndrome with attentional and processing problems which are white matter dependant functions and DTI is primarily a white matter test.
Briefly, the grey matter of the brain is primarily on the cerebral cortex of the brain and is where our memories are stored and our higher thought processes likely are centered. The white matter is the axonal fibers that connect different parts of the grey matter of different sections of the brain to each other. White matter is what allows the different brain cells to work together. A white matter injury will most often manifest itself with the attentional and processing problems easiest to prove after a concussion. Post Concussion Syndrome is far more complex than attention and processing problems, but those are the functions where there is the most consistent change across the wide range of PCS patients. For more on Diffuse Axonal Injury see http://subtlebraininjury.com/diffuse.html
Axons are extremely small. It is unlikely that neuroimaging will ever get to the point where we can see actual axonal damage in a live person. However, most axons travel through axonal pathways, which because they include tens of thousands of axons, are visible. DTI is an imaging technique that can visualize the axonal tracts. When there has been a significant disruption of any one axonal tract in the brain, DTI may show that disruption. The reason that DTI doesn’t tell us everything we want to know is that like all other imaging techniques in a live brain injured person, it is limited by the resolution of the scanner, which generally can only see pathology of as small as one millimeter.
In the image below, you can see a DTI scan with respect to the corpus callosum fiber tracts in the brain:
Dr. Benson explained DTI in his testimony this way:
According to Dr. Benson, DTI is showing abnormalities in mild traumatic brain injury survivors.
In our next blog, we will focus on the value of using NFL players and other sport concussion survivors as the prototype for all concussion diagnosis and treatment.
As a professional who works exclusively in the field of brain injury I believe that DTI may offer more short term benefit in diagnosing Mild Traumatic Brain Injury (“MTBI”). The reason is that MTBI appears to be more a syndrome with attentional and processing problems which are white matter dependant functions and DTI is primarily a white matter test.
Briefly, the grey matter of the brain is primarily on the cerebral cortex of the brain and is where our memories are stored and our higher thought processes likely are centered. The white matter is the axonal fibers that connect different parts of the grey matter of different sections of the brain to each other. White matter is what allows the different brain cells to work together. A white matter injury will most often manifest itself with the attentional and processing problems easiest to prove after a concussion. Post Concussion Syndrome is far more complex than attention and processing problems, but those are the functions where there is the most consistent change across the wide range of PCS patients. For more on Diffuse Axonal Injury see http://subtlebraininjury.com/diffuse.html
Axons are extremely small. It is unlikely that neuroimaging will ever get to the point where we can see actual axonal damage in a live person. However, most axons travel through axonal pathways, which because they include tens of thousands of axons, are visible. DTI is an imaging technique that can visualize the axonal tracts. When there has been a significant disruption of any one axonal tract in the brain, DTI may show that disruption. The reason that DTI doesn’t tell us everything we want to know is that like all other imaging techniques in a live brain injured person, it is limited by the resolution of the scanner, which generally can only see pathology of as small as one millimeter.
In the image below, you can see a DTI scan with respect to the corpus callosum fiber tracts in the brain:
Dr. Benson explained DTI in his testimony this way:
Diffusion Tensor Imaging
Developed in the mid-1990’s, diffusion tensor imaging (DTI) is sensitive to the 3D flow of water inside and outside of white matter fibers (the long extensions from nerve cell bodies which connect nearby or distant cells). Closed head injuries (non-penetrating) including concussion are caused by sudden acceleration or deceleration of the head which causes local deformationsof the brain within the cranium. The anatomical and biomechanical properties of the brain are such that white matter fibers are stretched and damaged, resulting in diffuse axonal injury (DAI) which is the hallmark pathology and accounts for most of the neurological disability in TBI.
The typical cognitive deficits in TBI, i.e., slowed information processing, decreased attention and memory, and psychiatric symptoms are caused by damage to the “cables” which allow for efficient transmission of information between neurons. TBI reduces brain network efficiency resulting in decreased capacity and global functional impairment. Concussive injury such as occurs in football with high speed collisions also causes deformation of brain substance and is felt to account for many of the immediate and delayed symptoms including the post-concussive syndrome. ERP studies of sports related concussion suggest that symptomatic recovery may occur while neurologic and brain metabolic functioning continues to be impaired from weeks to months after injury.
Incurring a second concussion before neurologic recovery has been shown to worsen outcome and may begin a downward spiral culminating in chronic traumatic encephalopathy (CTE) but this is not known. Diffusion tensor imaging (DTI) is able to detect damaged white matter fibers (axons) which have altered flow of water molecules compared with healthy axons (see Figure 5). DTI, like SWI can be performed on a standard clinical scanner (1.5-3 Tesla) and is available on virtually all clinical scanners.
According to Dr. Benson, DTI is showing abnormalities in mild traumatic brain injury survivors.
Our initial investigation of DTI in 20 TBI cases found that (similar to SWI and hemorrhage) an index of DTI, fractional anisotropy (FA), is decreased uniformly in TBI compared with 14 controls (see Figure 6), and that the magnitude of the decrease in average FA for global white matter is highly correlated with TBI severity (Figure 7). Even the 6 mild TBI cases (GCS 13-15)had decreased FA compared with the controls. The separation of the milds from the controls is especially relevant to sports concussions where the great majority of injuries are mild.
In summary, DTI is able to “visualize” diffuse axonal injury from TBI. In some cases location of lesions appears to correlate with specific symptoms but generally the severity of DAI as indicated by DTI is strongly predictive of general neurocognitive disability. Since concussion produces axonal injury, particularly repetitive concussion, imaging with DTI would appear to be ideal to study NFL players. Certainly, a large scale cross-sectional study wherein head injury history, position, age, genetic risk (ApoE genotype), neuropsychological testing (focused) and possibly electrophysiological testing with EEG (ERP, qEEG) and PET are factors. In addition, a prospective study with serial scans over a player’s career, tracking concussions or hits and relating imaging to neurocognitive performance (IMPACT or similar) and other factors as in cross-sectional study. Imaging would also facilitate the evaluation of helmet and neck support designs in animal models and in the field.
In our next blog, we will focus on the value of using NFL players and other sport concussion survivors as the prototype for all concussion diagnosis and treatment.
Congressional NFL Hearings – Dr. Ronald Benson Testifies about Neuroimaging Advances – Susceptibility Weighted Imaging
As I have stated here and elsewhere, diagnosing accidental concussions involves reconstructed evidence and the reliance on history from someone who likely has memory problems as to what happened, because they were concussed. In contrast to football or boxing concussions, real world concussions are rarely witnessed in the critical 30 second time window when the evidence is the clearest. See today’s blog at http://www.subtlebraininjury.com/blog/2010/01/evolution-in-understanding-of_07.html
Thus, with such an imperfect diagnostic process I am always hoping that the newest neuroimaging technique can provide us with a bright light of “objective evidence” of injury. I have heard Dr. Ronald Benson speak and his state of the art imaging techniques are the most promising of any of those I have seen to date. Dr. Benson testified to Congress about the advances being made in those techniques, principally through new ways of using the familiar MRI scanner.
Dr. Benson testified principally to two state of the art methods of using MRI, Diffusion Tensor Imaging (“DTI”) and Susceptibility Weighted Imaging (“SWI”).
Dr. Benson said in his prepared remarks:
I have been using DTI for years now in our forensic cases, with significant success, but SWI is something new to me. Dr. Benson explained SWI as follows:
It was exciting when I learned about Gradient Echo Imaging. It has not had any actual value in my cases. The exciting news about SWI is that it is five times more sensitive than Gradient Echo Imaging. The challenge in neuroimaging is whether five times better is enough when you are talking about multiplying zero. The math analogy isn’t totally valid, but if no hemosidrin deposits show up on even disabling mild traumatic brain injury cases, it may very well be that the kind of bleeds that leave hemosiderin behind are not the principal culprit in the Post Concussion Syndrome. Time will tell.
Diffusion Tensor Imaging (DTI) is more focused at the likely pathology, injury to the axons. We will discuss Dr. Benson’s testimony about DTI in our next blog.
Thus, with such an imperfect diagnostic process I am always hoping that the newest neuroimaging technique can provide us with a bright light of “objective evidence” of injury. I have heard Dr. Ronald Benson speak and his state of the art imaging techniques are the most promising of any of those I have seen to date. Dr. Benson testified to Congress about the advances being made in those techniques, principally through new ways of using the familiar MRI scanner.
Dr. Benson testified principally to two state of the art methods of using MRI, Diffusion Tensor Imaging (“DTI”) and Susceptibility Weighted Imaging (“SWI”).
Dr. Benson said in his prepared remarks:
Most of our work has used victims of transportation related injuries and falls, however our principle research focus has always been closed head injury, under which concussion falls and is otherwise known as mild head injury. I will also include some examples of former players scans. The focus of my testimony will be susceptibility-weighted imaging (SWI) and diffusion tensor imaging (DTI).
I have been using DTI for years now in our forensic cases, with significant success, but SWI is something new to me. Dr. Benson explained SWI as follows:
Susceptibility-Weighted Imaging (SWI) Imaging research of TBI began at WSU in 2004 when an eleven year old boy (C.G.) survived after his family’s ATV skidded off a mountain road in Colorado plunging 200 ft. He was still in coma two months later when we scanned him at WSU. His CT and standard MRI revealed a skull fracture and atrophy but not much more. Figure 1 compares a standard, clinically available T1-weighted image with a susceptibility-weighted image (SWI) through the temporal lobes and brainstem for C.G. sixty days after injury. Note the many “black holes” present in theEvery few years, I get newly excited about a neuroimaging technique that will give us a bright line of diagnosis for those with long term problems after a concussion. In 2000 what gave me great hope was learning about the development of techniques to see hemosiderin staining, principally the technique Gradient Echo Imaging. The theory of Gradient Echo Imaging is that when bleeding in the brain occurs, it leaves behind iron deposits, even after the there is no liquid blood visible on a CT or MRI. Those iron deposits are the hemosiderin. The hemosiderin is highly magnetic because it is principally iron. So if the magnet in the MRI is tuned precisely, this imaging technique can show evidence of a non-acute bleed, in theory years after the original injury. Here is a comparison between a conventional MRI image and the SWI image. The SWI is on the right and of import is the small black circles which don’t appear on the image to the left.
SWI image which are small (“micro”) hemorrhages indicating severe diffuse axonal injury (DAI) from TBI.
Developed by Mark Haacke, SWI is extremely sensitive to iron and blood products and detects microhemorrhages where conventional MRI fails. SWI detects hemorrhage at all stages, since iron remains even after the fluid from blood is reabsorbed. Prior work by Dr. Haacke with Loma Linda University (Karen Tong, M.D.) had demonstrated the value of SWI for detecting DAI in children with “shaken baby syndrome” where it was five times more sensitive than gradient echo imaging. In a series of 20 TBI patients (transportation related and falls) varying in severity and elapsed time since injury, we found an excellent correlation (Ρ =0.54) between total hemorrhage volume and the number of days in post-traumatic amnesia which is known to be a good T1‐Weighted SWI predictor of one-year neurological outcome (JMRI, 2009). We have, since 2004, scanned over 100 TBI patients with SWI at WSU alone and a similar number at Loma Linda. In addition to TBI, it is being used in stroke, cerebral amyloid angiopathy (CAA) (Figure 2), Alzheimer’s disease and disorders of iron metabolism. SWI is now clinically available on GE and Siemens MRI scanners.
Figure 1. Comparison of T1 and SWI images for C.G. Note the many dark
“holes” in the SWI image that are not present on the T1 weighted image. These
“black holes” are caused by signal loss induced by paramagnetic hemoglobin or
other iron containing blood products.
It was exciting when I learned about Gradient Echo Imaging. It has not had any actual value in my cases. The exciting news about SWI is that it is five times more sensitive than Gradient Echo Imaging. The challenge in neuroimaging is whether five times better is enough when you are talking about multiplying zero. The math analogy isn’t totally valid, but if no hemosidrin deposits show up on even disabling mild traumatic brain injury cases, it may very well be that the kind of bleeds that leave hemosiderin behind are not the principal culprit in the Post Concussion Syndrome. Time will tell.
Diffusion Tensor Imaging (DTI) is more focused at the likely pathology, injury to the axons. We will discuss Dr. Benson’s testimony about DTI in our next blog.
Congressional NFL Hearings – Dr. Ronald Benson Testifies about Neuroimaging Advances
I began my treatment of the Congressional hearings on the long term brain damage of concussion in the NFL yesterday at my Brain Injury Lawyer Blog – http://www.waiting.com/blog/2010/01/nfl-concussion-hearings-in-congress.html I will continue that discussion on this blog for the next several blogs, as I tackled an even more important topic at http://waiting.com/blog that of why an experienced brain injury attorney is even more important in a severe brain injury case than it is in a non-coma brain injury case.
Much of the controversy at the hearings was over the statements of Ira. R. Casson, M.D., formerly co-chair of the NFL concussion committee, that there was insufficient scientific evidence to prove this narrow question: Whether playing NFL football causes permanent brain damage. Fortunately, Dr. Casson’s academic skepticism was not the sole testimony heard by the committee. The committee also heard about evolving neuro-imaging techniques in the diagnosis of concussion, principally from Ronald Benson, M.D. of Department of Neurology, Wayne State University Medical School. Dr. Benson’s prepared remarks begin much differently than Casson’s:
1. Misdiagnosis. Frankly all six points could all be summarized with the statement that because the diagnosis of TBI is subjective, that misdiagnosis of the existence and severity of brain injury is the norm.
2. TBI is Often Labeled Psychiatric. I have said this before and will say it again: The challenge in diagnosing and treating brain injury is not in afixing a label of organic or psychiatric on the symptoms, but on treating the entire spectrum of brain related disability. Any TBI diagnostician who labels an emotional symptom after concussion as psychiatric or pre-existing, is missing the point. Brain injury impacts the emotions and those with pre-existing emotional problems are those most likely to be impacted.
3. Neuropsychologists Disagree. As is now common knowledge within the field of brain injury, neuropsychology is as polarized as our politics and almost on party lines. Neuropsychology is made up believers and non-believers that concussion can cause permanent brain damage. There is a lot of objective and subjective evidence for the believers to rely on. There is the academic skepticism of (similar to what Dr. Casson testified to) for the non-believers to rely on. There is no middle ground. For that reason, virtually every forensic case has two neuropsychologists who radically disagree.
4. TBI Symptoms Overlap. The neurons and the emotions are both in the brain. It is fundamental that one cannot injure neurons without effecting emotions. It is less evident but as true that one cannot impact emotions without changing neurons. Our brain’s hard wiring is the synergistic total of our genetic organic network and the sum of the changes to that network as a result of our experiences and pathologies that occur whether by disease, by trauma or via living.
5. Without Seeing the Pathology, No Objective Way to Prove TBI. I disagree with Dr. Benson to some degree on this issue. Differential diagnosis is not about looking at the results of some test, in any field of medical science. It is about a learned professional looking at the clinical history, listening to the patient’s story and reviewing more objective tests. Without the subjective application of an experienced mind to the entire spectrum of the problem, no diagnosis can be made, certainly not in a field as complex and subjective as brain injury. Neuroimaging may improve the accuracy of such diagnosis in the future but the goal is not to find an objective test we can rely on but to have better and less biased professionals engage in more thorough differential diagnosis. There is no 15 minute diagnosis of brain injury and no 15 minute solution.
6. Outcome unpredictable. Something I wrote over a decade ago was an essay entitled “Miracles and Tragedies.” http://tbilaw.com/essays.mildsevere.php I wrote that essay as I contemplated the “miracles in severe cases”and the “tragedies in so-called mild cases.” Such ironic criss-crossing of outcomes has been a universal theme of my career. I am continually amazed at how much better catastrophically brain injured survivors can get while aghast at how many mild brain injury survivors get worse and worse. I have gained greater insight into the problem since I wrote that essay but only because of the frequency that the criss-crossing of outcomes occurs. It is heartening to see a nationally recognized doctor educating Congress about that irony.
In our next blog more about advances in MRI and neuroimaging.
Much of the controversy at the hearings was over the statements of Ira. R. Casson, M.D., formerly co-chair of the NFL concussion committee, that there was insufficient scientific evidence to prove this narrow question: Whether playing NFL football causes permanent brain damage. Fortunately, Dr. Casson’s academic skepticism was not the sole testimony heard by the committee. The committee also heard about evolving neuro-imaging techniques in the diagnosis of concussion, principally from Ronald Benson, M.D. of Department of Neurology, Wayne State University Medical School. Dr. Benson’s prepared remarks begin much differently than Casson’s:
I would like to share with you some observations from eight years of evaluating traumatic brain injury cases, the vast majority of which I obtain neuropsychological testing and advanced MRimaging:That was a hell of an introductory statement from Dr. Benson. He seemed to capture the challenge in representing the survivors of brain injury in those seven bullet points. He goes on to detail the excitement of using state of the art MRI techniques to diagnosing mild traumatic brain injury, which I will discuss in future blogs. But today, I want to focus on the first six bullet points.
- 1) People with TBI are frequently misdiagnosed, often by multiple physicians;
- 2) The most frequent diagnostic category given is psychiatric—anxiety, depression, conversiondisorder;
- 3) Two neuropsychologists studying the same patient may differ considerably regarding existence of TBI;
- 4) TBI symptoms overlap considerably with those of “primary” psychiatric disorders;
- 5) Without the ability to “see” the brain injury with imaging, there is no completely objective way to determine what is TBI and what is something else, e.g., posttraumatic stress, conversion, malingering;
- 6) People with brain injury seem to vary considerably in severity of symptoms and recovery in the face of similar falls, crashes, etc. This may speak to population differences in resistance to injury or effectiveness of neural recovery mechanisms and is in agreement with Collins, et al. who found large differences in recovery from single concussion (North American Brain Injury Society Annual Meeting, 2009);
- 7) Advanced MR imaging techniques, including susceptibility-weighted (SWI), diffusion tensor (DTI) and MR spectroscopy (MRSI) are able to reveal brain injuries where CT scans and conventional MRI appear normal.
1. Misdiagnosis. Frankly all six points could all be summarized with the statement that because the diagnosis of TBI is subjective, that misdiagnosis of the existence and severity of brain injury is the norm.
2. TBI is Often Labeled Psychiatric. I have said this before and will say it again: The challenge in diagnosing and treating brain injury is not in afixing a label of organic or psychiatric on the symptoms, but on treating the entire spectrum of brain related disability. Any TBI diagnostician who labels an emotional symptom after concussion as psychiatric or pre-existing, is missing the point. Brain injury impacts the emotions and those with pre-existing emotional problems are those most likely to be impacted.
3. Neuropsychologists Disagree. As is now common knowledge within the field of brain injury, neuropsychology is as polarized as our politics and almost on party lines. Neuropsychology is made up believers and non-believers that concussion can cause permanent brain damage. There is a lot of objective and subjective evidence for the believers to rely on. There is the academic skepticism of (similar to what Dr. Casson testified to) for the non-believers to rely on. There is no middle ground. For that reason, virtually every forensic case has two neuropsychologists who radically disagree.
4. TBI Symptoms Overlap. The neurons and the emotions are both in the brain. It is fundamental that one cannot injure neurons without effecting emotions. It is less evident but as true that one cannot impact emotions without changing neurons. Our brain’s hard wiring is the synergistic total of our genetic organic network and the sum of the changes to that network as a result of our experiences and pathologies that occur whether by disease, by trauma or via living.
5. Without Seeing the Pathology, No Objective Way to Prove TBI. I disagree with Dr. Benson to some degree on this issue. Differential diagnosis is not about looking at the results of some test, in any field of medical science. It is about a learned professional looking at the clinical history, listening to the patient’s story and reviewing more objective tests. Without the subjective application of an experienced mind to the entire spectrum of the problem, no diagnosis can be made, certainly not in a field as complex and subjective as brain injury. Neuroimaging may improve the accuracy of such diagnosis in the future but the goal is not to find an objective test we can rely on but to have better and less biased professionals engage in more thorough differential diagnosis. There is no 15 minute diagnosis of brain injury and no 15 minute solution.
6. Outcome unpredictable. Something I wrote over a decade ago was an essay entitled “Miracles and Tragedies.” http://tbilaw.com/essays.mildsevere.php I wrote that essay as I contemplated the “miracles in severe cases”and the “tragedies in so-called mild cases.” Such ironic criss-crossing of outcomes has been a universal theme of my career. I am continually amazed at how much better catastrophically brain injured survivors can get while aghast at how many mild brain injury survivors get worse and worse. I have gained greater insight into the problem since I wrote that essay but only because of the frequency that the criss-crossing of outcomes occurs. It is heartening to see a nationally recognized doctor educating Congress about that irony.
In our next blog more about advances in MRI and neuroimaging.
Good Year for Concussion Advocacy – Public Awareness is Growing Exponentially
As angry as I get at the still stupid treatment of concussions, such as by Mike Leach at Texas Tech, I am so encouraged at the huge growth in public awareness of concussion. Almost every day there is a new story on concussion and some of those are really well done.
Yesterday Matthew Stanmyre of the Newark, New Jersey’s The Star-Ledger began one of the best treatments of concussion I have ever read, a piece on concussion in high school sports, “Kids and Concussions: The effects of head injuries in young athletes.” The article can be found at http://blog.nj.com/hssportsextra/2010/01/kids_and_concussions_-.html What makes Stanmyre’s piece so extraordinary is that he not only got the issues right, he found the right sources to quote and he made that story human with the stories of young athletes who had been impacted by concussion.
One of his sources, Micky Collins, M.D. is one of the top people in the field and may in fact be changing the dynamic of how the medical community diagnoses and treats concussion. Collins had this to say in the Star-Ledger piece:
Consider:
I am not completely surprised that New Jersey would be ahead of the curve on this issue. New Jersey has for a long time had one of the best state Brain Injury Associations and one of my best friends in the brain injury legal community, Attorney Bruce Stern of Princeton, has been pushing concussion awareness issues as long as I have.
Today’s second part of the Star-Ledger series focuses on concussions in cheerleaders. See http://blog.nj.com/hssportsextra/2010/01/kids_and_concussions_one_of_th.html
This story also comes at a time when concussion is in the news because of Congressional hearings about the potential permanent brain damage that might result. I will be commenting on those Congressional hearings at my Brain Damage Blog, http://waiting.com/blog
Yesterday Matthew Stanmyre of the Newark, New Jersey’s The Star-Ledger began one of the best treatments of concussion I have ever read, a piece on concussion in high school sports, “Kids and Concussions: The effects of head injuries in young athletes.” The article can be found at http://blog.nj.com/hssportsextra/2010/01/kids_and_concussions_-.html What makes Stanmyre’s piece so extraordinary is that he not only got the issues right, he found the right sources to quote and he made that story human with the stories of young athletes who had been impacted by concussion.
One of his sources, Micky Collins, M.D. is one of the top people in the field and may in fact be changing the dynamic of how the medical community diagnoses and treats concussion. Collins had this to say in the Star-Ledger piece:
“The morbidity of this injury is far greater than anyone ever realized,” says Micky Collins, one of the nation’s leading concussion doctors. “I never appreciated how many kids have problems with this until I started seeing 15 to 20 patients a day.”The Star-Ledger piece brought the urgency of this issue out with this timeline:
Consider:
And this all from the perspective of just the state of New Jersey. One of the encouraging aspects of what the Star-Ledger reports is that New Jersey has a far higher percentage of athletic trainers than the national average and that the use ImPACT testing (developed by Dr. Collins) is happening at a greater rate than nearly any other state, with 141 schools using the tool.
• Last year, Montclair High football player Ryne Dougherty died after sustaining his second brain injury in a month.
• Niki Popyer, a 16-year-old former basketball player from Marlboro, sustained 11 concussions over four years, becoming a national face of the dangers of concussion.
• Alexa McCormack, a former West Milford High cheerleader, still has migraine headaches and blurry vision after sustaining three concussions during competition in an 18-month span.
• Former La Salle University football player Preston Plevretes, a Marlboro native, needs 24-hour nursing care and can barely speak after sustaining two concussions in a month’s time four years ago.
I am not completely surprised that New Jersey would be ahead of the curve on this issue. New Jersey has for a long time had one of the best state Brain Injury Associations and one of my best friends in the brain injury legal community, Attorney Bruce Stern of Princeton, has been pushing concussion awareness issues as long as I have.
Today’s second part of the Star-Ledger series focuses on concussions in cheerleaders. See http://blog.nj.com/hssportsextra/2010/01/kids_and_concussions_one_of_th.html
This story also comes at a time when concussion is in the news because of Congressional hearings about the potential permanent brain damage that might result. I will be commenting on those Congressional hearings at my Brain Damage Blog, http://waiting.com/blog
Are Planes Getting Safer? Followup to American Airlines Flight 311
I have been talking on this blog the past week about the potential for brain injuries in the American Flight 311 crash in Jamaica. In continuing to follow the news of that crash, I found this story from CBS News about how planes are now safer than they once were. According to this story, the belly of planes have been reinforced, the seat secured better and the seats moved further from the bulkhead. See [youtube=http://www.youtube.com/watch?v=2Yjey_qZmJs]
The result of these improvements is more and more people survive plane crashes, especially those that take place or runways. Still, with the multi-million dollar investment in jets, it seems someone could add shoulder harnesses and air bags. But like in the Iraq and Afghanistan Wars, more people surviving means more surviving with brain injuries.
The result of these improvements is more and more people survive plane crashes, especially those that take place or runways. Still, with the multi-million dollar investment in jets, it seems someone could add shoulder harnesses and air bags. But like in the Iraq and Afghanistan Wars, more people surviving means more surviving with brain injuries.
American Airlines Flight 311 – Understanding the Vulnerability of the Brain in an Air Crash
On previous blogs, I have talked about how the survivor of an on the ground air crash is exposed to significant concussional forces. The reason is that the extreme speed of a jet as it lands can create siginificant acceleration/deceleration forces. Unlike a modern car, it does not have a shoulder harness/airbag combination to protect the brain from those forces. The below video shows how severe those forces can be on the head, neck and back.
http://www.blogger.com/img/videoplayer.swf?videoUrl=http%3A%2F%2Fv23.nonxt7.googlevideo.com%2Fvideoplayback%3Fid%3D738fa4231a89e5ca%26itag%3D5%26begin%3D0%26len%3D86400000%26app%3Dblogger%26et%3Dplay%26el%3DEMBEDDED%26ip%3D0.0.0.0%26ipbits%3D0%26expire%3D1269891760%26sparams%3Did%252Citag%252Cip%252Cipbits%252Cexpire%26signature%3D47F16D3AFC9A2EE22915B712CF38978D5237DF30.6BC93A452E002757F15D7C12B8BBEBB5E220CC42%26key%3Dck1&nogvlm=1&thumbnailUrl=http%3A%2F%2Fvideo.google.com%2FThumbnailServer2%3Fapp%3Dblogger%26contentid%3D738fa4231a89e5ca%26offsetms%3D5000%26itag%3Dw320%26sigh%3DNyTlnWDi5ZGKEC6gqh-h2AFIja0&messagesUrl=video.google.com%2FFlashUiStrings.xlb%3Fframe%3Dflashstrings%26hl%3Den
For more on how vulnerable a brain is to such forces, go to http://subtlebraininjury.com/biomechanics1.html
It has been more than a week now since this crash. If anyone on board is still confused, has headaches or dizziness, it is time they got some expert help. For dizziness or vertigo, it is essential that they see a neurootologist, a doctor who specializes in balance disorders. See http://vestibulardisorder.com For other post concussion symptoms, they must see someone who will take the head injury seriously.
http://www.blogger.com/img/videoplayer.swf?videoUrl=http%3A%2F%2Fv23.nonxt7.googlevideo.com%2Fvideoplayback%3Fid%3D738fa4231a89e5ca%26itag%3D5%26begin%3D0%26len%3D86400000%26app%3Dblogger%26et%3Dplay%26el%3DEMBEDDED%26ip%3D0.0.0.0%26ipbits%3D0%26expire%3D1269891760%26sparams%3Did%252Citag%252Cip%252Cipbits%252Cexpire%26signature%3D47F16D3AFC9A2EE22915B712CF38978D5237DF30.6BC93A452E002757F15D7C12B8BBEBB5E220CC42%26key%3Dck1&nogvlm=1&thumbnailUrl=http%3A%2F%2Fvideo.google.com%2FThumbnailServer2%3Fapp%3Dblogger%26contentid%3D738fa4231a89e5ca%26offsetms%3D5000%26itag%3Dw320%26sigh%3DNyTlnWDi5ZGKEC6gqh-h2AFIja0&messagesUrl=video.google.com%2FFlashUiStrings.xlb%3Fframe%3Dflashstrings%26hl%3Den
For more on how vulnerable a brain is to such forces, go to http://subtlebraininjury.com/biomechanics1.html
It has been more than a week now since this crash. If anyone on board is still confused, has headaches or dizziness, it is time they got some expert help. For dizziness or vertigo, it is essential that they see a neurootologist, a doctor who specializes in balance disorders. See http://vestibulardisorder.com For other post concussion symptoms, they must see someone who will take the head injury seriously.