Tag: brain injury

Teens Heal Differently Than Adults After Concussion

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March 22, 2023 — Layla Blitzer, a 17-year-old high school junior in New York City, was playing field hockey for her school last October and was hit hard by the ball, right above her eye.

She sustained a serious concussion. She’s also had neck issues and headaches for the last 4 months. “They’re so severe I still need physical therapy for them,” she said.

At first, the staff at the opposing high school where she was playing didn’t realize she had a concussion. “Even the referee said, ‘You’re not throwing up, so you’re fine,’” Allison Blitzer, Layla’s mother, said. 

It was soon clear that Layla wasn’t “fine.” She consulted with a school-referred neurologist who diagnosed the concussion. 

Similar Symptoms, Different Severity

David Wang, MD, head team doctor at Quinnipiac University in Hamden, CT, said concussion symptoms — such as headaches, dizziness, visual disturbances, light and sound sensitivity, mood and cognitive problems, fatigue, and nausea — are similar between adolescents and adults. 

“But the symptom scores and severity are higher in adolescents, compared to younger kids and adults,” he said.

Moreover, the recovery time is longer. 

“The effects of an adult concussion, especially in men, may be around 7 days, but 3 to 4 weeks isn’t unusual in teenagers, and it can be even longer in female teens,” Wang, who is the director of Comprehensive Sports Medicine in Connecticut, said. 

The severity of symptoms, and how long they last, in teens “has to do with their stage of life because adolescents are going through puberty and in a rapid evolution phase, biologically, and are not neurologically mature,” he said. “The changes going on in their bodies may make them more vulnerable to the impact of a concussion, compared to younger children and adults.”

Similar to patterns found in adult women compared to men, girls tend to have more severe symptoms and a longer recovery, compared to boys — something Allison Blitzer was surprised to learn. Her older son has had sustained two concussions playing sports in high school, but after a couple of weeks, “he was fine and back at it.” Layla’s symptoms were more severe and long-lasting.

One of several possible reasons for the sex differences in concussion is that females generally have less neck strength, Wang said. Weaker neck muscles allow for more head acceleration following a blow, which results in greater forces to the brain. 

Working With a Teen’s Recovery Time

Layla attempted to go to school 3 days after the concussion, but “it didn’t go well,” she said. The bright classroom lights disturbed her eyes. And most of the instruction was digital, on a computer or a projector, and too much screen time causes eye strain and headaches following a concussion. 

“I couldn’t look up and I couldn’t do any of the work my class was doing,” Layla said. The noise stimulation in the lobbies, cafeteria, and elsewhere was overwhelming, too, so after 2 weeks, she stopped going to school.

Because Layla has several siblings, her home wasn’t consistently quiet either, so she isolated in her room.

“I fell behind in work,” Layla said, despite help from a concussion specialist who arranged with the school so Layla could have a reduction in workload, breaks, and extra time to complete assignments and exams.

Even after a few months, Layla was unable to keep up with her schoolwork. The school was “super supportive,” she said, but still didn’t understand how extensive her recovery time would be.

“It seemed like I was expected to be fully better much quicker. And although I’ve been improving, it’s almost 5 months since the injury and we’re in the middle of midterms, but I can’t take them because I’m still behind on my work,” Layla said.

In addition to headaches and memory issues, Layla experienced prolonged fatigue, which was worsened because of insomnia. The neurologist gave her medication for sleep, which helped the fatigue, but the headaches continued.

Finally, Layla consulted another specialist who was able to localize exactly where the headaches were coming from. He prescribed highly targeted physical therapy, which Layla attends twice a week.

“PT has been the most helpful for me and I’m finally beginning to catch up on my work, even though I’m still behind,” she says.

A recent analysis of eight studies (including almost 200 participants) looked at the effectiveness of physical therpay for post-concussion symptoms (such as headaches) in adolescents. 

The researchers found evidence that physical therapy is effective in treating adolescents and young adults following a concussion, and that it may lead to a quicker recovery compared to complete physical and cognitive rest, which are traditionally prescribed. 

Return to sports cannot be rushed, Wang said, not only because the person is still recovering and might not be “on top of their game” but because a second injury can be more harmful during recovery time.

“We call this “overlapping concussion syndrome,” he said. “The concussion is partially resolved, and the adolescent is functional enough to return to some playing, but then they get hit again. This complicates the situation and prolongs the recovery even more.”

‘Academic Quicksand’

Adolescence is a “challenging time,” Wang said. Teens are learning about themselves in the world, in school, and in their social group. An interruption in this process can disrupt the flow and make this process even more challenging.

“What we’ve seen with 2 years of teens who have missed school due to COVID is that they’re often not well adapted and not yet ready for the college environment,” Wang said. “These are critical maturation years. Similarly, when a teenager misses school or social activities due to a concussion, it increases the stress.”

Wang likens this to “academic quicksand,” and said, “it feels like the more the teenager struggles, the deeper they sink because the struggle itself can be so stressful.”

Layla can attest to this. 

“The stress of being behind, especially in a highly competitive academic environment, has definitely caused me a lot of anxiety,” she said. “I see everyone in my grade moving up and I’m still catching up on old math units, doing one old unit that the class had finished a long time ago, as well as the one everyone is working on now.”

Her mother said it’s hard for Layla to watch her friends go out on weekends and knowing that wherever they hang out is likely to be too loud and too bright for her while she’s still recovering. 

“This is an invisible injury and it’s hard to quantify or show someone else how much a person is suffering, so it’s very isolating,” she said.

Advocacy Efforts 

Layla is an intern at PINK Concussions, a nonprofit organization focused on concussions in women, where she advocates for other teenagers who have sustained concussions.

When she was playing field hockey, “we weren’t wearing goggles or helmets because the hockey league felt there wasn’t enough evidence to support wearing protective gear for girls,” Layla said.

Now she’s working with her school’s athletic director and with the director of other private schools to change her league’s rules so that protective gear will be required in field hockey games. 

“I think my concussion could have been prevented if I’d been better protected,” she said.

She’s also advocating for a more realistic back-to-school protocol. 

“Some teachers might worry that students with concussions might delay returning to school,” Katherine Snedaker, a licensed clinical social worker and founder of PINK Concussions, said. “But our research found that students want to be back in school so badly, they were minimizing their symptoms to get back to school/sport before they were ready. Students were not using their concussion as an excuse to stay out longer.” 

Layla said teachers “should be educated to expect that kids who have had a concussion may not be up to speed in work for some time. Some teachers may not be aware that recovery in girls and boys can be different. And they should know how to help a student successfully handle schoolwork again.”

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Not Just for Men: Meeting the Needs of Women With Concussion

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March 14, 2023 – Jacqueline Theis, a Virginia-based optometrist, was an avid soccer player during her teens. In the course of her athletic career, she had several concussions that triggered severe headaches when she tried to read.

“I was told that I had migraines and I’d ‘get over them’ and that I was ‘complaining too much’ – comments that are unfortunately all too common for women to hear,” she says. 

“After 6 years, I saw an optometrist who noticed that my eyes weren’t coordinating and thought this was due to the concussions,” she recounts. “She prescribed glasses and vision therapy, and my headaches went away.”

Theis was angry that her headaches had been minimized and her visual issues overlooked. “I had 20/20 vision, so it didn’t occur to anyone that I could be having eye problems,” she says.

‘Invisible’ and Neglected

Katherine Snedaker, a licensed clinical social worker, agrees that women’s concussions are often minimized or overlooked. She created and leads PINK Concussions, a nonprofit group focused on concussions in women. 

She says almost all of the previous concussion research has used male lab animals and men as subjects, although concussions are common in women too. And while people think of concussions in women as being sports-related injuries, PINK Concussions’ mission includes shining a spotlight on accidents, military service injuries, and domestic violence.

Over the past 5 years, “we’ve been able to raise awareness of brain injuries in female athletes and women veterans, but the far greater number of repetitive brain injuries are still hidden and endured by the invisible women who suffer intimate partner violence in every social and economic group of society,” she says.

“Concussions affect women and men differently, so it’s important for clinicians, parents, and others to be aware of how concussions might present in females as well as males,” says Snedaker, who has had multiple concussions, two of which came from car accidents.

Hormonal Connection?

David Wang, MD, head team doctor at Quinnipiac University in Hamden, CT, says that when women and men compete in the same sports, women get concussions at higher rates than men. Their symptoms also tend to be more severe, and they often have more prolonged symptoms.

There are several theories as to why women are more vulnerable to concussions and often have more severe symptoms or poorer outcomes, says Wang, who is the director of Comprehensive Sports Medicine in Connecticut.

Some studies suggest that female hormones may play a role. For example, one study found that women at certain phases of their menstrual cycle had worse symptoms after their concussion. And women often notice changes in their menstrual patterns after a concussion.

But Wang believes the story is more complex. “Concussions shake the pituitary gland, which is located in the head,” he says. “The pituitary is responsible for regulating aspects of women’s hormones. Stress to the pituitary – whether due to the mechanical injury of the concussion or to emotional stress that can follow a concussion – may affect the menstrual cycle.”

This is supported by a new study. The researchers screened for hypopituitarism (low hormonal production by the pituitary) in 133 female athletes with a history of traumatic brain injury. The researchers found that the majority of women (66.2%) had abnormal pituitary screening blood test results. Certain hormones were too high, while others that were too low. Younger athletes and those with more symptoms had more pituitary hormone abnormalities. 

Neck, Eyes, and Brain

Wang shared several other theories regarding women’s vulnerability to concussions.

“Women in general have weaker necks; and since the neck is weaker, the head accelerates more when it’s hit because the impact is more severe and violent,” he explains. Although this “isn’t the whole story, it is a contributing factor.”

Theis, who is affiliated with the Concussion Care Centre of Virginia, says there’s an “intimate relationship between eye movements, the brainstem, and the neck; and since women have weaker necks, compared to men, their eye movements are going to be more vulnerable to neck-related injuries.”

She says eye problems are also a little-known complication of whiplash as well. “The connection is in the brainstem and the neck.”

She says that the neck may not necessarily be painful, but eye pain or headaches can be “referred” pain from the neck.

Other theories include that women also may have different levels of inflammation, compared to men, Wang says. And concussions often target an area of the brain called the corpus callosum, which connects the right and left hemispheres. “This area receives the majority of the strain from a concussive blow, and that area is more robustly used by women than by men because females tend to use both hemispheres in process more than males do.”

Myths About Women

All the experts agree that there are common myths about the greater frequency of concussions in women and their more severe symptoms.

“Some people think women have more concussions because they complain more about symptoms, so they’re more likely to be diagnosed,” Wang says. “I don’t like to hear that, because it suggests that women are ‘complainers’ and also that female athletes are less competitive than male athletes, which simply isn’t true.” 

Wang and his colleagues studied athletes and found that females were at least as likely as males to hide symptoms so as not to be taken out of the game. “In fact, some of the most driven people I’ve ever met are female athletes,” he says.

Snedaker recommends that women take their symptoms seriously. “I’ve spoken to countless women who said their concussion symptoms were dismissed by doctors or were told that they’re simply anxious.” she says.

So if you’ve had a blow to the head and your health care provider doesn’t do a thorough concussion workup, “it’s time to look for a different provider,” Snedaker advises.

Different Symptoms, Different Treatments?

Most of the symptoms of concussion – other than menstrual dysfunction – don’t differ between the sexes, according to Wang. “It’s not like a heart attack, where often, women actually have different symptoms than men – like nausea rather than chest or jaw pain,” he says.

Typical symptoms of concussion in both men and women include headaches, dizziness, blurry vision or other visual disturbances, agitation or cognitive changes, light and sound sensitivity, disorientation, nausea or vomiting, or feeling dazed.

Because concussions can affect the menstrual cycle, Snedaker encourages health care professionals to ask women who have had a concussion about their periods. “If there’s an issue, follow up with endocrine testing,” she recommends. And if you’ve had a concussion and notice changes in your periods, be sure to bring this up to your provider.

Men and women have similar “landmarks” and “rules” for returning to play or to any other activity, such as employment or academics. “We expect them to be without symptoms, and we put them through a graded return to activity,” Wang states.

But since women’s symptoms tend to last longer than those of men, “women need to be supported throughout that time,” Snedaker emphasizes. All too often “women are called ‘malingering’ or ‘mentally ill’ when they don’t recover as fast as men.”

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Concussions from Football Tied to Long-Term Cognitive Problems

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March 10, 2023 — Eric Washington, former linebacker for the University of Kansas’ football team, got involved with sports as a child. “We crashed into each other when we played, and whoever was strongest or most reckless was thought to have the best sports career ahead of them,” he says.

He and his friends boxed and played football on each other’s lawns “with no equipment or protection, just a lot of guys engaging in high collision together.”

In high school, Washington became a successful football player. “You had to show people you weren’t scared, so you took on bigger … guys and ran into them,” he recalls. “I became one of those fearless people who was known as ‘that guy’ — a hard-hitter, relentless, reckless person.”

Washington’s first major brain injury took place in ninth grade. “It was the first head-on-head collision that knocked me out and I missed much of ninth grade because of it,” he says. “I went from being a quiet, reserved, mild-mannered person to being aggressive, having mood swings, and lashing out.”

He developed problems with memory and concentration, which worsened as he got into college football. “I remember two or three times when I got dazed after a head injury and they took me out, but then I got right back in the game,” he says. 

Like Washington, many athletes experience brain injuries during their careers, with between 1.6 and 3 million sports- and recreation-related concussions taking place annually, around 300,000 of which are from football. 

Cognitive changes following concussions are also common. A new study published in the Archives of Clinical Neuropsychology shines light on the problem.

For Washington, the concussions, and their effects, continued into college. While on a football scholarship at Kansas, “I thought everything was OK. Even after my concussions, I could still get back in the game and my body retained ‘muscle memory’ of how to play football and could follow directions, even if my mind wasn’t quite there anymore.”

During senior year, a neck and spinal cord injury ended his sports career. “Everything spiraled downward after that,” he says. “I ended up in terrible relationships, distant from my family, and even homeless for a while. I ended up in mental institutions and in dark places and with cognitive problems.”

Does Concussion Affect Long-Term Cognitive Functioning?

In the new study, investigators examined 353 former NFL players (average age, 54 years old) who had been retired from their playing careers for close to 3 decades. 

Using a laptop or tablet, the former players completed a battery of neuropsychological tests through an online platform called TestMyBrain. An array of cognitive functions were tested, including processing speed, visual-spatial and working memory, short- and long-term memory, and vocabulary.

The players completed a 76-item questionnaire that included 10 questions about signs and symptoms of concussion following a blow to the head while playing football: headaches, nausea, dizziness, loss of consciousness, memory problems, disorientation, confusion, seizure, visual problems, or feeling unsteady on their feet. They were also asked if they had ever been diagnosed with a concussion.

Senior study author Laura Germine, PhD, director of the Laboratory for Brain and Cognitive Health Technology at McLean Hospital in Boston, says we know the impact of concussions on short-term health, but “it’s not as clear how concussion history impacts cognitive functioning in the longer term among former professional football players.” 

She says there “have been lots of mixed findings in former players, so we wanted to address this question using sensitive, state-of-the-art and objective measures of cognitive function in a larger samples of former players than has previously been tested for this kind of study.” 

One reason for the “mixed findings” in earlier research is that some studies have focused on diagnosed concussions and cognitive problems. But many football players’ concussions don’t end up being diagnosed, so the researchers decided to look specifically at concussion symptoms.

Accelerated Cognitive Aging 

Former players who reported more concussion symptoms scored worse on cognitive tests. For example, the differences in visual memory between the players with the highest- and lowest- reported concussion symptoms were equal to differences in cognitive performance between a typical 35-year-old and a typical 60-year-old.

On the other hand, poorer cognitive performance wasn’t connected to the number of diagnosed concussions, the number of years they played professional football, or the age when the first played football. 

The researchers conducted a follow-up study comparing the 353 players to 5,086 men who didn’t play football. They found that cognitive performance was generally worse in the former players

 “While our findings aren’t conclusive in this respect, we did see the biggest differences in cognitive performance (compared with men of similar age) among older players,” Germine says.

Long-Term Cognitive Issues

Washington continues to struggle with cognitive problems.

“My long-term memory seems like it’s intact sometimes, but after a period of time, there are ‘holes.’ Or I look at people and I might recognize a face, but I don’t remember who the people are.”

He also has difficulties with reading and memory. “My eyes have issues with tracking and tracing. And if I read out loud, I’ll be stuttering and sputtering and won’t be able to retain what I’ve just read. Sometimes, I’ll put the remote in the freezer, or I’ll set my phone down outside and won’t know where it is.”

Washington did complete college, graduating with a bachelor’s degree in applied behavioral science that led him to work with adults with developmental disabilities. However, schoolwork was difficult and has become even more difficult of late.

“I’d like to become a social worker to help other people, but trying to get through my classes may not be in the cards,” he says.

He’s currently being treated for cancer and the chemotherapy also affects his cognition. “I was getting A’s in my classwork in one course, but I couldn’t remember anything on the final, so I got an F and failed the course,” he says.

He hopes that as the cancer resolves, he’ll be able to give his studies another try. Although the cognitive challenges resulting from his concussions remain formidable, “not having ‘chemo-brain’ will free up some cognitive abilities and hopefully I’ll do better in my classes and get my social work degree.”

Get Appropriate Support

Germine says the study findings “underscore the need for parents, school systems, and anyone who plays football to understand the importance of reporting any and all concussion symptoms, even if they don’t feel serious at the time.” 

She notes that “appropriate measures to address and reduce the impact of head injury — even in the absence of diagnosed concussions — may be key to maintaining cognitive health long-term.”

Additionally, “we need to be doing everything we can to prevent head injury and concussion from happening in the first place. Measures that reduce the likelihood of head impact are important to make football safer for developing brains,” she says.

Washington urges people to take head injuries seriously and not just “return to the game” and to be evaluated for a concussion; and if a concussion is diagnosed, to receive treatment for the symptoms (such as emotional trauma, attentional or memory problems, or visual problems).

In addition, both encourage people who have sustained a concussion to get emotional support. Washington attends support groups offered by the Brain Injury Association of America.

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