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The New Science of Concussions

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As doctors learn more about their consequences, people who have suffered traumatic brain injuries are finding renewed hope.

More than three years later, Amy Zellmer can still recall the sound of her head hitting the frozen concrete. She slipped on ice near her St. Paul, Minn., home in February 2014, and that noise signaled a change in her life that resonates even today.

“It happened just like that!” she says, snapping her fingers. “I imagine I looked like Charlie Brown.”

Zellmer landed on the back of her head and estimates she was knocked out for a minute or two. When she stood up, she realized something wasn’t right. She was dizzy, wobbly, sick to her stomach. “It was like little lightning bolts going off in the -corners of my eyes — the proverbial ‘seeing stars.’”

She realized she needed to go to the ER, but when she tried to locate the nearest hospital on her computer, she couldn’t read the screen: “That’s when I knew I had a problem.”

So she telephoned a neighbor, who soon arrived and soothed the bump on Zellmer’s head with a package of frozen peas. The neighbor then asked the time-tested question, “Who’s the president?” Zellmer answered “Bill Clinton” — two presidents off. A friend’s husband happened to be a chiropractic neurologist and he immediately made time to see her at his office. He told Zellmer she had suffered a concussion and major whiplash, including torn muscles and a dislocated sternum.

The stars disappeared in a couple of days, but effects of the fall lingered. Zellmer experienced aphasia and short-term memory lapses. She got lost while driving. She struggled to concentrate and tired easily. Dizziness made her head spin. Strange mood swings disrupted her days.

“It was like I had been on a boat for a long time, or had just taken off roller skates, and I still felt like I was moving. It was constant, like I was drunk all the time.” Other days, it seemed she had an evil head cold and was lost in a never-ending fog.

Zellmer, now 43, saw several doctors, ophthalmologists, and other specialists over the next two years. Nothing seemed to help. She was finally referred to a craniosacral therapist, who gently massaged her scalp. After a couple of treatments, she remembers hearing a distinct noise in her head and feeling a huge sense of relief. That sound signaled a release of pressure, which instantly cleared her fogginess. (For more on craniosacral therapy, see below.)

Still, Zellmer’s cognitive issues endured. She consulted a neurologist, who referred her for a four-hour exam: She scored worse than a dementia patient. A neuropsychologist prescribed Ritalin and antidepressants, but Zellmer refused to take them, viewing the pills as Band-Aids for the real problem. Whatever that real problem was.

The Invisible Disability

Seeing stars. Getting your bell rung. A knock on the noggin. In the not-so-distant past, we shrugged off head injuries with quaint euphemisms — a cute way of skirting the seriousness of a traumatic brain injury, or TBI.

These days, the medical world takes TBIs seriously, as we now know that seeing birdies is more dangerous than we ever imagined. The far-reaching and seemingly disparate health effects of TBIs can include cognitive problems, coordination dysfunction, hormonal disruption, digestive issues, and mood disorders. At the same time, we’re learning more about how to treat TBIs and their repercussions.

TBIs cover a spectrum of severity, from subconcussive to concussive (which account for 70 to 90 percent of all cases) to fractured skulls and worse, explains Vani Rao, MD, a Johns Hopkins University School of Medicine neuropsychiatrist, in The Traumatized Brain.

The brain is jarred in a concussion. It accelerates forward, crashing into the skull (known as a coup injury), then it often bounces back and hits the rear of the skull (contrecoup). Sometimes, it twists atop the brain stem as well.

Contrary to common perception, you don’t actually have to hit your head to get a concussion: It can result from whiplash, or even from the shock waves of an explosion, like those that troops experience in combat. This can lead to or exacerbate PTSD, according to a recent study.

A TBI can harm the brain in numerous ways. It may cause bleeding (an intracranial hemorrhage) or create a blood pool or clot (a hematoma); the brain tissue itself may be bruised or torn. These injuries can then put pressure on the brain, resulting in harmful inflammation.

It can also cause oxygen deprivation, leading to the death of brain cells, and twisting on the brain stem might result in vestibular or endocrine issues. In addition, a TBI can damage the axon fibers that carry messages between different parts of the brain.

The effects might be subtle or dramatic, singular or myriad:

Physical conditions, such as headaches, seizures, hearing loss, and vision issues, including seeing double, blurriness, eyestrain, light sensitivity, and depth-perception dysfunction.

Hormonal disruption resulting in blood-sugar dysregulation and emotional problems, such as depression, anxiety, mania, or apathy.

Digestive issues, including microbial changes, motility problems, and increased gut permeability.

Behavioral upsets like sleep disturbances, impulsivity, aggression, even psychosis.

Cognitive issues including problems with attention, memory, language, and executive functions, such as organizing, planning, sequencing, and monitoring or modifying behavior.

“Most people with mild TBI make a spontaneous recovery within the first few months of injury,” Rao explains. “But mild brain injuries are not always benign.

“Traumatic brain injuries are, in a sense, a silent epidemic, because often, after persons with TBI have been treated in the emergency department or released from the hospital, family members or friends may assume that they are now ‘fixed.’ There may be no physical evidence of injury, so it is easy for others to believe that everything is back to normal. Unfortunately, that is often not the case, especially with more severe injuries.”

Accurately determining how many head injuries Americans sustain each year is difficult because many of us don’t visit a doctor after hitting our heads. Still, the Centers for Disease Control and Prevention (CDC) estimates that Americans suffer between 1.6 million and 3.8 million sports- and recreation-related concussions annually. This discrepancy is huge because so many TBIs are never reported.

But those statistics don’t reveal the true scope of the issue for one crucial reason: While sports-related TBIs get the spotlight, they account for a minority of all head injuries. Forty-seven percent of all TBIs are the result of everyday falls, according to the CDC. These incidents are especially prevalent among the elderly; a new CDC study finds that one in 45 people age 75 and older suffers a fall and TBI.

Innocuous falls happen to all of us in daily life as we slip on stairs, trip over rugs, tumble from ladders, or stumble while carrying items when we can’t see where we’re going.

Because of these everyday head injuries, an estimated 5.3 million Americans are currently living with a lifelong disability — that’s roughly one in every 60 people. TBIs also account for 30 percent of all injury-related deaths.

The fact that there’s no clear count of head injuries suggests we’re still largely in the dark concerning their dangers. Public awareness is growing, however, thanks — ironically, as it turns out — to one source: The National Football League (NFL).

“Shaken Up On the Play”

Football players wear helmets — exhaustively engineered, thoroughly tested, incredibly expensive helmets — that are supposed to protect them from TBIs, even after the uncountable instances of head contact many sustain during every practice and game.

But in 2002 a young forensic pathologist named Bennet Omalu, MD, in the county coroner’s office in Pittsburgh, performed an autopsy of “Iron Mike” Webster, the legendary Pittsburgh Steelers lineman who died at age 50. A Hall of Famer, Webster was known for his durability, never missing a game during a 10-year stretch between 1976 and 1985. He spent the last decades of his life struggling with dementia, delusions, paranoia, and explosive moods. Though Webster was believed to have died of a heart attack, Omalu sensed something else.

CT and MRI scans of Webster’s brain found nothing abnormal. So Omalu did a specialized protein-stain test; the results were startling. Webster’s brain was clouded with massive accumulations of tau, one of the proteins that causes Alzheimer’s.

Omalu believed that Webster’s brain had been rattled by the cumulative effect of all the subconcussive head injuries he suffered over his 17 NFL seasons. His report on Webster’s autopsy was published in the peer-reviewed journal Neurosurgery, where Omalu coined a name for the syndrome — chronic traumatic encephalopathy, or CTE. Encephalopathy is a broad term for a disease that alters the brain’s structure or function.

Omalu’s report garnered wide attention for CTE, and for TBIs generally, prompting a slew of studies. Among the more notable is an ongoing study at Johns Hopkins School of Medicine that began in 2014, in which researchers are examining a group of retired pro football players; their findings to date suggest that repeated brain trauma causes molecular changes to brain tissue that can have consequences for decades after.

Notably, some brain injuries happen without a concussion: They can result from a single blow to the head or repetitive hits over time. “There’s no such thing as a safe blow to the head,” says Omalu.

Fearing for football’s very existence, the NFL went on the offensive. League lawyers and doctors took a page from Big Tobacco’s playbook to obscure the link between cigarettes and lung cancer and worked to discredit Omalu and downplay CTE. At the time, the NFL didn’t even have concussion guidelines for assessing players — as sports commentators like to say, they were merely “shaken up on the play.”

The NFL seemed to be winning the game in dismissing CTE. But after Omalu found CTE in autopsies of four more NFL players, the media, and soon the public, took notice. Head injuries became big news.

Brain Games

Head injuries are not limited to football, of course: They happen in hockey, cycling, soccer — most any sport. Nor are they limited to the pros.

In a study published in Radiology in 2016, researchers examined the potential effects of subconcussive head blows on the 3 million U.S. kids playing organized youth football. They studied 25 players age 8 to 13 over a single football season, conducting advanced neuroimaging using MRI with diffusion tensor imaging (DTI) scans both pre- and postseason. The players’ helmets were fitted with Head Impact Telemetry System (HITS) sensors to assess frequency and magnitude of impact.

The kids were “hitting their heads hundreds of times over the approximately three-month season” without suffering actual concussions, says lead study author Christopher Whitlow, MD, PhD, chief of neuroradiology at Wake Forest School of Medicine in Winston-Salem, N.C. He was interested in understanding the cumulative effect of these subconcussive hits.

Whitlow’s team found “measurable brain changes” to the white matter in the youths’ brains: “When you look at these players, they don’t look any different; they’re not behaving any differently. Do these changes mean anything at all? Perhaps not. Maybe these changes all go away like their bruises after the season and this is just another manifestation of a physical sport.

“But the issue is that we don’t know,” he says. “What happens after two seasons? And ultimately, is your lifetime cumulative head-impact exposure the thing that makes a difference?”

In a 2016 study of amateur soccer players published in EBioMedicine, researchers found that heading a soccer ball — just once — causes instant changes to the brain. They did trans-cranial magnetic stimulation (TMS) and electromyographic (EMG) recordings followed by cognitive tests of 19 players age 19 to 25 before and after routinely heading balls. They discovered alterations in brain corticomotor inhibition and cognitive function — in particular, memory-test performance was reduced by up to 67 percent.

“The good news is that these changes in brain function were transient, with effects normalizing within 24 hours,” explains lead study author Magdalena Ietswaart, PhD, professor of psychology at Scotland’s University of Stirling.

“The bad news is that we do not know whether there is an accumulative effect when this biochemical disruption is repeated over and over again through weekly heading-practice drills, or what the long-term consequences of heading on brain health are.”

The Road Back

As doctors learn more about the consequence of TBIs, their knowledge is leading to new treatments. Given the range of seemingly disconnected symptoms, protocols are often individualized based on the results of sophisticated tests.

“Treating head injury requires a multifaceted approach,” explains functional neurologist Brandon Brock, DC, of Cerebrum Health Centers in Dallas–Fort Worth. “Sometimes it requires medication to control symptoms. Sometimes it requires diet and nutrition to allow appropriate healing. Sometimes it requires the appropriate neurological exercises to give the brain harmony and symmetric function.

“We need to make sure there are no underlying triggers that were there beforehand that would keep the person from healing, like diabetes, thyroid problems, or infectious disease that can make the inflammation so sustained that people can’t recover.”

Receiving treatment soon after an injury is preferable, because the brain remains plastic and responsive for days or weeks, Brock says. The longer you wait, the more likely the brain gets set in new, problematic patterns. But if an injury is months or even years old, a new battery of functional-neurology tests can still detect symptoms, and treatment remains possible.

For Amy Zellmer, it wasn’t until two and a half years after hitting her head that she found hope for recovery. She connected with functional neurologist Jeremy Schmoe, DC, of Minnesota Functional Neurology and Chiropractic in Minneapolis in August 2016. By this point, she was begging for help. She described her many symptoms — and, for the first time in all her consultations with specialists, Schmoe validated them. “I was like, Hallelujah, somebody understands!” Zellmer remembers.

Using a platform posturography test, Schmoe examined her balance. He conducted video analysis of her gait. He checked her autonomic nervous system, since concussions often skew heart rates and blood pressures; the combination of a higher resting heart rate and uncertain spatial awareness can result in an overactive startle response and hyperanxiety. He used videonystagmography (VNG) to check her eye tracking. Then he outlined a course of vestibular rehab to improve her balance and dizziness, and manual therapy to treat the effects of her whiplash.

Schmoe prescribed neuro-orthopedic rehabilitative exercises to help Zellmer restore her eye–brain coordination. And he recommends yoga — in particular, TBI survivor Kevin Pearce’s Love Your Brain program (www.loveyourbrain.com).

“We challenge the nervous system with different types of sensory inputs to activate the brain to make changes to the objective findings that we identify during examination,” Schmoe explains. “If we see that you’re off balance to the left, we might do an exercise to stimulate the left side of your body to give your brain better awareness of where you are in space.

“The nervous system is amazing. It’s elastic: You can make changes to it with repetition, intensity, and frequency. You just have to give it the right stimulation to help build plasticity.”

He next ran blood labs to check Zellmer for anemia, infection, inflammation, thyroid and hormonal imbalances, autoimmune disorders, and vitamin D or magnesium deficiencies — all of which can affect recovery.

Hormonal disruption can cause issues ranging from emotional imbalance to mood disorders, as well as blood-sugar dysregulation, says Schmoe. “When you hit your head, the midline areas of your brain get torsion, which can injure the areas that affect your pituitary output. This can affect the adrenals and thyroid. We see people develop a whole metabolic cascade of symptoms after a brain injury.”

There’s an axis between the brain and gut, he explains, and “literally within a couple of days after a brain injury, your gut lining could start to be affected.” Schmoe explains that this can cause recurrences of past gut issues, including infections and insulin dysregulation.

“If you can address the brain and you can improve the circuits in the brain, you can make changes to the gut — it’s a bidirectional pathway,” he says. “By improving the brain, you can improve the gut. Then if you loop back around and improve the gut even more, your brain’s going to heal faster. You have to look at everything when it comes to brain injuries.”

For Zellmer, the improvements were swift.

“Within two weeks, my dizziness went from a nine out of 10, to a two. Once I got the dizziness under control, it freed up so much energy.”

Today, she continues her therapy and is improving. She runs her own business as a photographer, but has also started new work: raising TBI awareness. She lobbies state and national legislatures, serves on the advisory council of the Brain Injury Association of America, and has self-published two books on the subject.

Her recovery is still in progress, but Zellmer is optimistic. She says she is now on “the road back to normal.”

WEB EXTRA!

Full Interviews With Bennet Omalu, MD,  Jeremy Schmoe, DC, and Brandon Brock, DC

Head Injuries and Recovery: An Interview With Brandon Brock, DC — Download the PDF

Head Injuries and Sports: An Interview With Bennet Omalu, MD — Download the PDF

A Whole-Body Approach to TBI: An Interview With Jeremy Schmoe, DC — Download the PDF

WEB EXTRA!

Head Injuries and Craniosacral Therapy

By Michael Dregni

In the months after Amy Zellmer slipped on a patch of ice outside her home and hit her head in St. Paul, Minn., in February 2014, she remembers feeling like she was lost “in a constant fog.”

After seeing neurologists and other specialists, she was referred to a craniosacral therapist, who applied light pressure to her neck and scalp. After a couple of treatments, she remembers hearing a distinct noise in her head and feeling a huge sense of relief: That was the sound of a release of pressure, which cleared up the fogginess.

“It was the first or the second treatment, and I could hear the release in my head,” she says. “That fog went away, and my therapist told me that that fog was the pressure in my brain. . . . Getting rid of that fog, that was a huge breakthrough.”

Craniosacral therapy, or CST, uses light touch to manipulate the immovable synarthrodial joints of the skull. The gentle, hands-on approach can release tensions deep in the head and body to relieve pain and improve whole-body health.

Ana Bennett is a trained cranial osteopath and runs Biodynamic Craniosacral Therapy in Amherst, Mass. She explains how CST can help with traumatic brain injuries (TBI):

“Craniosacral therapy and cranial osteopathy has a role to play in recovery from concussion by gently removing any structural restrictions in the head and neck that are maintaining the injury and delaying healing of the concussion. The bones of the cranium and the membranes around the brain itself all exhibit, in a normal healthy situation, a very small, but vital amount of motion, a bit like a very fine form of breathing. Through this motion, or the absence of it due to trauma, it is possible to detect which areas of the cranium have received some sort of impact and where the force vectors of that impact are still retained in the tissues. . . .

“By using gentle pressure the CST practitioner is able to gradually release the restricted areas and restore the natural, gentle motion through the bones and the membranes of the head. This helps relieve pressure, restore good blood supply to and drainage from the brain, relieve symptoms of concussion, and enable a speedier recovery.”

She typically waits at least 10 days after a TBI before beginning CST therapy.

“The waiting for 10 days is a precautionary measure, in case there may be a bleed or other injury that would be a contraindication to treatment directly on the head. However, the CST or cranial osteopathy practitioner can still treat within that time but might want to avoid treating directly on the head for the first 10 days.”

is an Experience Life deputy editor.

Photo illustrations by Alex Williamson

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