I was at home, working, on a Saturday morning in January 2010, when a message arrived in my e-mail in-box with these words in the subject heading:
Help with 15 year old’s seizures no one can diagnosis it the past three weeks have been very scary. Please read this information.
I then read two pages of notes, single-spaced, from a desperate New Hampshire woman looking for help for her once healthy teenage daughter—and the situation was indeed scary. Maureen’s daughter, Holly, was about to turn sixteen. Two years earlier, Holly had been an avid athlete, a competitive cheerleader, a track star, a snowboarder, and a member of the boys’ football team. Her only issue was an anxiety disorder, but it barely seemed to slow her active extracurricular life. Then, in October 2007, Holly suffered two concussions in the space of just two weeks, both of them from football collisions. The first was in practice; the second was courtesy of an opponent who Maureen believed had targeted Holly because she was a girl. For the next few months her daughter seemed fine, but in March 2008 a series of events set off alarm bells. It began with a constant headache, which Holly had for two weeks. Then, sitting at the computer at home, she suddenly passed out, without warning, and smashed her face into the computer’s keyboard. Holly was so scared she ran to her parents, who immediately took her to the local hospital for an EEG of her brain. The diagnosis: “Teenage girls just pass out.” Three days later, however, there was an escalation of symptoms. Holly was at a friend’s house when she suffered a seizure: her eyes rolled back and fluttered; she drooled and again passed out. Again she was rushed to the ER and given an EEG, and again came the same diagnosis: “Teenage girls just pass out.”
The following day, her parents took her to their primary care physician, who evaluated her for either basilar migraine, a migraine with an aura that originates in the brainstem, or epilepsy. A few days later, Holly had a grand mal epileptic seizure at home that lasted more than four minutes. Her doctor immediately put her on anticonvulsant medication, and for months she was symptom free. She even started playing football again, but twice in practice she reported having chest pains and shortness of breath. Even though a cardiologist could find nothing wrong, she eventually had to quit the team. When Holly started the ninth grade, in 2009, she hadn’t had a seizure in three months. But in January 2010, working on a report in the school library, she had a seizure that lasted more than six minutes. Two weeks later she had another, in French class, which lasted for eleven minutes. And so it went. Though her first seizure didn’t happen until months after her injury, the seizures had gradually increased in number and intensity until Holly’s mother was at wit’s end. I recommended a neurologist in her area.
Head trauma can have lots of consequences, even when there is no obvious major brain injury. There are many new studies that have focused on early and late effects of concussion, and many are showing that adolescents’ brains may take a kind of “hit” that is different from adults’. In some cases, for an injury of given severity, an adolescent fares worse than an adult. This is an increasing issue because physical contact has been progressively escalating in high school and middle school sports for both sexes, partly because of Title IX. In addition, there has a been a lot of controversy around closed-head injuries in the military from IED blasts, and the fact that the young service people affected are often still in their teens or early twenties, with not yet fully mature brains, is cause for concern.
Holly’s case was clearly unusual, but it was also deeply troubling because more girls participate in athletics than ever before, and even in traditionally noncontact sports like soccer and field hockey they are suffering concussions, whether from heading a ball or being knocked to the ground, at a rate far greater than boys. Only 5 percent of closed-head injuries, which include concussion, result in the development of a seizure disorder like Holly’s. She suffered the unfortunate consequence of developing epilepsy, something that happens in about 20 to 30 percent of people with a severe head injury. When epilepsy is acquired, it is more commonly the result of a severe, and immediately life-threatening, injury, either a compound skull fracture or a penetrating brain wound. Post-traumatic epilepsy is rarely the result of an athletic injury. But Holly, unbeknownst to her family, had three strikes against her: she was an adolescent, she was female, and she’d had several concussions within a short period of time.
Concussions have gotten increased attention in recent years, but mostly as they relate to men and professional sports. According to the American Academy of Pediatrics, however, the second highest rate of sports-related concussions in high school after boys’ football is girls’ soccer. Concussions can happen in any sport. I had a patient who was a high school wrestler, a top student, when I saw him one September to evaluate him after his second concussion, which he received at wrestling camp over the summer. He came to me because he was having headaches and attention and memory problems. He had scored very high on his practice SATs the prior spring, and was gearing up to take the real SAT that fall. With the second concussion he lost consciousness momentarily and was rushed to the local ER, where a head CT scan showed no visible damage. He was sent home and told to rest for a couple of weeks, and during that time he had problems sleeping and frequent headaches with some nausea and irritability. When he started back at school, on the first day of classes, things did not feel right. His mom was distraught because her A student son could not focus on his schoolwork and could not even complete a simple assignment. He was moody and agitated, too. When I saw him, his neurological physical exam was really quite normal, but he did falter on some short-term memory and attention tests. I had to make sure he had not developed epilepsy, as Holly had. Often a few, or even more, months go by before recurrent seizures are noted. Reassuringly, his EEG was normal. As is typical for postconcussion patients, though, his headaches had a migraine quality, with light bothering his eyes when the headaches were especially severe. As they were occurring daily, we put him on an antimigraine preventive medication, and over a few weeks his headaches decreased in severity and frequency.
In the meantime, however, he became increasingly anxious about his grades and also about getting another headache, and the anxiety eclipsed the other problems and became disabling. He withdrew from family and friends and continued to be moody. Furthermore, when he took the SAT, he sorely underperformed; this further increased his anxiety. The SAT score did confirm that his concussions had caused a quantifiable drop in cognitive performance, so he was now on everyone’s radar screen. Neuropsych testing was done, and it documented a learning deficit and inattention. These were totally new problems for this teen and ones he might have to battle for a long time.
This is just one case, and hardly an isolated one, of what repeated concussions during adolescence can do to mental and scholastic performance. But there are also myths about concussions I want to dispel right off the bat. First of all, concussions do not affect everyone the same way, and some people may even have a genetic predisposition to them. Also, concussions are a problem not just in contact sports but elsewhere; they can occur in noncontact sports, in car accidents, falls, and even from a severe jostling. The medical community now realizes that concussions can happen without a clear episode of blackout.
More than a decade ago the American Medical Association linked sports-related concussions to lower scores on several tests of cognitive function, but only recently has research helped us realize the complex and frightening truth about the dangers of these concussions on still-maturing brains. Among high school sports with male/female participation—soccer, lacrosse, basketball, baseball, softball, and gymnastics—girls sustain concussions nearly 70 percent more often than boys, even though boys participate in these sports at a rate slightly higher than girls. Moreover, in soccer in particular, female concussion rates are three times the rate for male players. In a study based on a survey of more than four hundred high school athletic trainers, researchers also found it took girls substantially longer than boys to recover from their symptoms and return to action. After a concussion, adolescent girls score significantly worse on visual memory tasks than boys and show greater reductions in reaction times on mental tests.
In order to understand why adolescents, and in particular adolescent girls, are so susceptible to these injuries, we have to understand exactly what a concussion is. That hasn’t always been easy because a concussion is by definition a closed-head injury. In other words, it’s an injury to the brain where there is no, or very little, indication of a wound to the head or skull. Essentially, the brain is a soft organ that floats in a protective sea of cerebrospinal fluid inside the skull. The fluid acts as a kind of cushion, protecting the brain from normal jostling of the head. With a concussion, however, that cushion isn’t thick enough to absorb the blow as the head is violently snapped forward and backward, in whiplike fashion. The injury occurs when the force is so great that it causes the brain to hit the side of the skull, damaging neurons. A hit so violent that the brain bounces off one side of the skull, only to rebound and strike the opposite side, is called a coup-contrecoup concussion.
The kind of power generated in athletic collisions can be measured in g-forces. A g-force is a measurement of acceleration in a cause-and-effect situation, and it is proportional to the reaction force experienced by the object or person undergoing the acceleration. A sneeze, for instance, generates just under 3 gs on the body, mostly the head; a slap on the back generates a bit more than 4 gs; and plopping down in a chair, 10 gs. In a low-impact rear-end collision, if the trailing car is traveling about ten miles an hour, it will hit the car in front of it with an impact in the 10-to-20 g-force range. If the impact is between 20 and 30 gs, you’re in a pretty bad car accident. A hard hit in the NFL can reach into the 30-to-60 g-force range. And an impact that produces 90 to 100 gs—the force of smashing your head against a wall at twenty miles per hour—will usually cause a concussion.
Football players routinely hit one another with forces in excess of 100 gs, and 150-g hits are not unheard of. In fact, Purdue researchers recently evaluated a high school football player they estimated to have received a blow to the head that carried the force of 289 gs—that’s nearly a hundred times more than the sustained g-forces associated with a shuttle launch—and yet this high school player had no outward signs of a concussion, nor did he report any symptoms. And therein lies the problem. Over the past few years, scientists have slowly begun to realize that brain damage can result even from non-concussive blows to the head. All it takes are repetitive strikes of moderate intensity. In other words, thousands of kids playing contact sports who have never had to sit out a game because of a concussion could be at risk of brain damage—brain damage that is going undetected and undiagnosed and will be likely to cause cognitive impairment later in life. Those Purdue researchers who evaluated that “nonconcussed” football player who had absorbed nearly 300 gs discovered this frightening fact only by accident, after the young man volunteered for the study.
Several years ago Eric Nauman, a biomedical engineering professor, and a handful of colleagues were studying concussions among high school football players. In order to do a proper analysis of the brain changes of the concussed players in the study, they needed a control group with which to compare them—that is, high school football players who had never been diagnosed with a concussion. So early in the football season the researchers recruited a number of these players from local high school teams and scanned their brains one by one. When Nauman and his colleagues compared these normal control images with the ones taken of the players before the season started, they were astonished. Although none of the players in the control group had ever been diagnosed with a concussion, their scans showed long-lasting brain changes similar to the changes in those who had been previously diagnosed. Nauman at first thought the university’s scanner was broken. Then he realized what he had stumbled on: there are more than one million high school football players who hit the gridiron every year, and upwards of sixty thousand of them will be diagnosed with a concussion. In actuality, there are likely to be at least twice that number who suffer concussions, who have all the symptoms, but who shake them off and either disregard the seriousness of the injuries or simply fail to report them to the coaches and trainers for fear of being taken out of the game. Some experts, in fact, believe there are closer to a quarter million concussions sustained by high school football players every year. When you add in tens of thousands more who have never been symptomatic but who have nonetheless suffered an injury resulting in brain damage, then the magnitude of the problem and the risk to our teenage athletes are staggering.
The damage to the brain is also not easy to detect because it is usually not structural. Rather, it is cellular, and yet it is severe enough to interrupt normal functioning and cause physical and cognitive symptoms, some of them immediate, others delayed for days, weeks, even months. Essentially, after the brain is violently moved inside the skull, a biochemical onslaught of calcium and potassium floods the brain, causing two things to happen. First, these chemicals, in excess, damage and destroy brain cells. Second, to pump out these excess chemicals, the brain needs its chief energy source, glucose. Normal blood flow in the brain carries the glucose to where it’s needed, but after a concussion glucose distribution is restricted for several reasons. The calcium flood causes the brain’s blood vessels to constrict and interferes with the breakdown of glucose, which is necessary for the production of energy, and as the brain swells with the influx of calcium and potassium, the blood vessels are further constricted. Not only are neurons affected, but white matter takes a “hit,” too. The white matter tracts are stretched by the impact force, and can get “sheared.” Experimental research using traumatic brain injury (TBI) models in rats and mice shows that the immature adolescent brain is very vulnerable to injury, and even mild injury can be associated with loss of synapses. In addition, there is a decrease in the NMDA type of glutamate receptor, which is required for LTP and memory. This may contribute to learning problems seen after concussion.
The physical side effects of concussion include dizziness, headache, blurry vision, sensitivity to light or sound, problems with balance, fatigue and lethargy, and a change in sleep patterns—either too much or too little sleep. The cognitive effects of concussion include amnesia, slow or fuzzy thinking, an inability to concentrate, and an inability to remember new information. A concussion can also result in mood changes, with the person becoming sad or irritable, nervous or anxious. When there are lingering symptoms—for weeks, months, even years—then a postconcussive syndrome is usually diagnosed.
The risk of a postconcussive syndrome and serious brain damage increases dramatically when an athlete suffers a second concussion before the symptoms of the first have fully resolved. All those energy-starved cells that are still trying to bounce back from the initial flood of calcium and potassium ions can be at risk of further injury. This is called second-impact syndrome.
A few years ago the New York Times told the story of Sarah Ingles, a high school basketball player in Ohio who sustained a concussion during a basketball game. Two hours later, while riding back to school on the bus with her teammates, she suddenly didn’t know where she was and had no memory of even playing in the game. This was her second concussion, and it caused her to miss six weeks of school. After graduation, Ingles attended Ohio Wesleyan University, where she continued to play field hockey—until suffering her seventh concussion. (Not all of the five concussions in between were the result of sports. One came from bumping her head on a bed frame.) In a video she made for the Midwest’s North Coast Athletic Conference while she was a student, she said that trainers and doctors told her she could no longer participate in contact sports, even at the intramural level. For months afterward she had repeated cognitive testing and was given a tutor to help her study. “Retaining information wasn’t possible,” she says in the video. “I had to go over it and over it and over it.”
According to the most recent research, high school athletes who suffer three or more concussions are at an 8-fold increased risk for loss of consciousness after a successive concussion and a 5.5-fold increased risk for anterograde post-traumatic amnesia, in which the adolescent has trouble forming new memories. Recently, many neurologists and researchers have said it is more accurate to call a concussion a mild traumatic brain injury. There are approximately 1.5 million incidents of traumatic brain injury reported in the United States every year. Seventy-five to 95 percent of these injuries are categorized as mild.
Second-impact syndrome can also be deadly. It was for Nathan Stiles, a seventeen-year-old star running back on his Spring Hill, Kansas, football team. In 2008, Nathan complained of a lingering headache after a game, and the team’s athletic trainer advised his parents to take him to the emergency room. A brain scan at the hospital showed no problems, but just to be safe, doctors advised him to sit out the next three weeks. Without their permission, Nathan was legally prevented from playing since Kansas is one of dozens of states that require a physician to clear a high school athlete for play after the athlete has suffered a head injury. Three weeks later, the doctor did. In Nathan’s first game back his mother watched him get hit and act a bit stunned. Afterward he said he was fine. Nothing seemed amiss the following week. It was the last football game of the year, the last of Nathan’s senior season, and, as it would turn out, the last of his life. Right before halftime, Nathan, playing defense, intercepted a pass and ran it back for a touchdown. On the sideline he collapsed, then began suffering seizures. He was airlifted to the University of Kansas Medical Center and underwent four hours of brain surgery to stop the bleeding in his brain. He never woke up and was taken off life support the next day.
After an autopsy, Nathan’s brain was sent to Boston University’s Center for the Study of Traumatic Encephalopathy, where diseases and disorders resulting from brain injuries are cataloged and analyzed. Boston University’s program works closely with the Veterans Affairs Center in nearby Bedford, Massachusetts, and when pathologists there opened Nathan Stiles’s teenage brain, they were horrified at what they saw—a young brain filled with tau protein, the twisted fibers that choke and kill brain cells in Alzheimer’s patients. There was only one explanation: At the time of his death, Nathan was suffering from chronic traumatic encephalopathy (CTE), a progressive degenerative disease normally found in athletes who have suffered repeated brain trauma. The disease was first identified in retired, elderly boxers in the 1920s. Nathan probably had suffered multiple undiagnosed concussions and may have had a genetic predisposition to concussions. To date, his is the youngest case of CTE ever recorded.
There is no concussion-proof helmet, and as doctors and researchers have recently realized, the damage in a young brain from a concussion can just as easily be caused by a subconcussive blow to the head. In 2011, the Canadian Paediatric Society declared that concussions were too common in youth sports, especially ice hockey, and that hits to the head, as well as fighting and checking from behind, should be banned in all youth sports. Currently bodychecking, where one player is allowed to slam another into the boards, is allowed even at the peewee level, ages eleven to twelve.
In 2012, Canadian researchers confirmed what many neuroscientists had been saying for some time, that a child’s or teenager’s brain is not as resilient as an adult’s. Their subjects were ninety-six teenage athletes (rugby, hockey, football) between the ages of thirteen and sixteen who had suffered a concussion sometime in the previous six months. Using standard neuropsych tests, the scientists evaluated the teens’ working memory abilities. Working memory is short-term memory, and it’s important to the smooth functioning of the prefrontal cortex, which helps us when we read, remember a phone number, or do a simple mental calculation. Compared with a control group of similar-aged subjects who had no history of concussion in the prior six months, the recently concussed athletes had markedly worse short-term memories.
Radiologists at New York University also have found mood swings, sleep disorders, obsessive-compulsive behavior, anxiety, and impulse control disorders in patients with postconcussive syndrome following a mild traumatic brain injury. And other studies have found 15 to 20 percent rates of depression in patients up to a full year after a concussion; these are greater than the rate of depression in the general population.
Although it’s not understood why, adolescent athletes take longer to recover from mild traumatic brain injury than adults do. The younger the athlete, the longer it takes. On average, adults need three to five days to return to baseline on cognitive tests; college athletes need five to seven days, and high school athletes ten days to two weeks. In one survey, more than half of high school players, average age sixteen, took more than a week to recover, and 10 percent took longer than three weeks. In subtler brain-imaging tests, brain abnormalities have been discovered in young athletes who were no longer symptomatic. One of those studies, involving late-adolescent athletes with a history of concussion, found brain abnormalities more than three years after their most recent injury.
Today, the NCAA, which oversees college athletics, maintains guidelines for how concussions should be handled during a game. For instance, schools do not allow student-athletes to just “shake it off” and return to the game without being evaluated by a health professional. But many people, including many former college athletes, believe the NCAA has not gone far enough. In 2011 four of those former student-athletes filed a class action suit against the NCAA, claiming the organization failed to implement appropriate concussion screening, return-to-play guidelines, and other safety measures. (The suit is still working its way through the judicial system.)
Recently, a study by the Behavioral Health Services at Nationwide Children’s Hospital found that children and adolescents who suffer mild traumatic brain injury may be more likely to show an increase in symptoms, both cognitive and physiological, over time than children and adolescents who experience an orthopedic injury. Those cognitive and physiological symptoms were also associated with declines in physical and psychosocial quality of life.
Young people with severe brain injuries may be at risk for developing, during their recovery, what neurologists call a neurocognitive stall, which is a slowing of cognition as well as of social and motor development beyond a year after the injury. When they hit the wall or plateau, later developmental milestones are suddenly in jeopardy, especially in younger patients.
There is also a risk, although small, of developing epilepsy following a concussion just like Holly, the fifteen-year-old daughter of the woman who e-mailed me in 2010. Holly was a rare case in part because the sport she had been playing was boys’ football. Among young adults, however, post-traumatic epilepsy is the most common cause of new epilepsy in the United States. The exact neurological events are still unclear. For years researchers believed it was simply overly stimulated neurons that created epileptic seizures, but more recently scientists have discovered evidence suggesting that before neurons even become overexcited, the damage is caused by an influx of neurochemicals trying to repair a brain injury. These chemicals, the researchers say, are what cause the excitation that results in the neuronal damage.
Concussions can cause physiological damage as well as cognitive damage, especially to the pituitary, a teardrop-shaped gland at the base of the hypothalamus. Because it is located behind the bridge of the nose, the pituitary is injured from even low-level impacts to the head. Known as the “king” gland, the pituitary is responsible for metabolism, growth, and energy, and some studies suggest that close to 40 percent of teenage athletes who suffer concussion also incur sport-related post-traumatic hypopituitarism, which includes a host of symptoms:
• Reduced muscle mass
• Weakness
• Decreased exercise capacity
• Fatigue
• Irritability
• Depression
• Impaired memory
• Reduced sex drive
Researchers are still trying to figure out the specifics of why adolescents appear to suffer longer-lasting consequences after concussion, but the fact that adolescent brains are still maturing must certainly play a large role. When teenage brains take a hit, the injury isn’t static. Because the teenage brain is still developing, the injury is a trauma not just to a piece of gray matter but also to what would have been had the brain continued to develop without incident. Teenagers are damaging more than just their brains with concussions. They’re damaging their futures.
I’ve heard many startling stories from my colleagues about young people and concussion, but the most heartbreaking ones come from adolescents whose multiple concussions have left them afraid for their future. Sarah Ingles, the Ohio Wesleyan University student-athlete who suffered seven concussions from high school through college, said in her video interview for her school’s athletic conference, “Athletics was pretty much what I did.” Her first warning sign came with her first concussion, when her head violently hit the turf in a high school field hockey game and she couldn’t remember her name. Her second concussion, toward the end of the basketball season just a few months later, wasn’t even a hard impact, she said, but she still felt confused on the bus ride home. Even before her seventh concussion, Sarah was plagued with headaches and nausea, but worst of all were the problems she had just trying to think clearly. When doctors told her she should never again play contact sports, Sarah took the advice and started playing golf: “If I got hit, I’d be in the hospital. . . . It’s not only affected me in sports, but in life. . . . Head injuries are head injuries. It’s your brain.”