Has Anybody Seen My Mind? Recognizing signs and symptoms of brain injury linked to repetitive sports related concussions

1. Has Anybody Seen My Mind?Recognizing signs and symptoms of brain injury linked to repetitive sports related concussions. Teresa R. (Hedges) Headley M.Ed., AbD., Professional Counselor Volunteer Ambassador Sports Legacy Institute

2. Michael Franti • Personal impact of lyrics. • Personal history and story has led to a passion to make the voices of those impacted heard. • Those impacted aren’t only the victims, they also include wives, children, parents and partners.

3. Are you ready for some football? • For clarification- I LOVE THE GAME! • Teamwork, leadership, lessons in winning and losing, physical development.

4. Credentials and Personal Experience • Licensed Professional Counselor • PhD. Research regarding the experiences of wives whose husbands have died due to chronic traumatic encephalopathy. • Personal Experience

5. Sports Legacy Institute • The mission of the Sports Legacy Institute is to advance the study, treatment and prevention of the effects of brain trauma in athletes and other at-risk groups. SLI was founded in 2007 to “Solve the Sports Concussion Crisis,” and in 2009, SLI launched programs to also serve our military veterans. SLI is primarily focused on the study of the degenerative brain disease Chronic Traumatic Encephalopathy, or CTE, a condition caused by repetitive concussive and sub-concussive brain injuries.

6. What is a Concussion? • Pat White • Tim Tebow • Kevin Kolb • What do you think a concussion is?

7. A Blow to the Brain • 60 Minutes Presentation

8. Concussion Defined • “A traumatically induced alteration in brain function manifested by an alteration of awareness or consciousness, including but not limited to a loss of consciousness, “ding”, sensation of being dazed or stunned, sensation of “wooziness” or “fogginess” seizure, or amnesic period, and by symptoms commonly associated with post-concussion syndrome, including persistent headaches, vertigo (dizziness), light-headedness, loss of balance, unsteadiness, syncope (LOC), near-syncope, cognitive dysfunction, memory disturbances, hearing loss, tinnitus (ringing in the ears), blurred vision, diplopia (double-vision), visual loss, personality change, drowsiness, lethargy, fatigue, and inability to perform usual daily activities.” • Pellman, Viano, & Tucker (2003).

9. Repetitive Concussions • How many is too many?

10. Prevention • Implementing standard concussion guidelines • Centers for Disease Control • Educating parents/coaches/athletes

11. Proper Assessment • Proper sideline medical assessment and diagnosis of concussion. • NOT • Self-assessment

12. Minimum Standards • Preseason Education for Coaches • Preseason Education for Athletes • Preseason Education for Parents • Coaches use CDS’s Head’s Up Clipboard Sticker • Adopt CDC’s Concussion Action Plan to Remove a Player from Play • Prevention through neck strengthening • Prevention through overall brain trauma reduction

13. Shocked? • Only 30 – 33 percent of all high schools have a certified athletic trainer on staff. In poor districts like those in Chicago’s public school system, just 2 percent of high schools have trainers at practice, and only 9 percent have them at games. (Tonino & Bollier, 2004). • “a two to three fold greater impact force is required to produce clinical symptoms in children compared to adults…This means that if a child exhibits clinical symptoms after a head injury, then it is reasonable to assume that they have sustained a far greater impact force compared to an adult with the same post concussive symptoms.”- (McCrory et al., 2004).

14. Utilization of Baseline Data • Most commonly used examination is the Standardized Assessment of Concussion (SAC). • Evaluates orientation, immediate memory, concentration, and delayed recall. • IT IS NOT SENSITIVE ENOUGH TO CATCH ANY BUT THE MOST SEVERE INJURIES. • Doctors are now advocating not grading the concussion until symptoms have disappeared due to the unpredictable nature of the injury.

15. Consequences of Repetitive Injury • At a certain point one doesn’t recover as quickly or fully from concussions. • “After suffering one concussion, athletes are three to six times more likely to have a second one. Plus, additional concussions tend to be more severe. People with a history of concussions are between four and seven times more likely to get knocked unconscious. The “brain reserve” is depleted.”- (Collins et al, 1999) (Moser & Schatz, 2002;2005) (McKee et al, 2009)

16. The Concussion Crisis Revealed In 2007, pathological evidence was accumulating that brain trauma in sports caused a unique brain disease called Chronic Traumatic Encephalopathy, or CTE, that eventually leads to dementia. CTE is preventable, but nothing was being done to prevent it. Justin Strzelczyk Andre Waters Died at 36 Suicide at age 44 Murder/Suicide age 40 16

17. The CSTE Brain Bank Through 2009, CSTE has now studied the brains of over 20 athletes 12 of 12 NFL and college football players have tested positive for CTE SLI Legacy Donors NFL Andre Waters - March 10, 1962 to November 20, 2006 Justin Strzelczyk - August 18, 1968 to September 30, 2004 John Grimsley -  February 25, 1962 to February 6, 2008 Tom McHale - February 25,1963 - May 25, 2008 Wally Hilgenberg- Sept 19, 1942 - Sept 23, 2008 Lou Creekmur - January 22, 1927 – July 5, 2009 National Hockey League Reggie Fleming - April 21, 1936 - July 11, 2009 Professional Wrestling Chris Benoit - May 21, 1967 to June 24, 2007 Amateur Football Mike Borich- December 8, 1962 - February 9, 2009 John Doe, died at age 18 17

18. Survey of All Pathologically Confirmed CTE cased since 1928 The first paper from the CSTE found only 48 cases of CTE existed in the medical literature • CSTE quickly added three more, and expects to double the known cases within 3 years • First described in boxers by Martland in 1928 • Martland HS: Punch drunk. JAMA 91:1103–1107, 1928

19. John Grimsley 1st NFL case studied at BU – 5th overall. Died Feb 2008 of self-inflicted gunshot wound • Houston Oilers 1984-1990 • Miami Dolphins 1991-1993 • Linebacker; Named to Pro-Bowl, 1988 • No history of performance-enhancing drugs • No significant medical history • Concussion history: • 3 concussions during college football at Kentucky • At least 8 concussions during NFL career • Only one "cerebral concussion“ medically confirmed • Died of gunshot wound to chest, apparently while cleaning gun. Police report: no evidence of suicide, believed to be a “very tragic accident.” 19

20. John Grimsley Findings John Grimsley had remarkable brain damage for a 45 year-old man • For the 5 years prior to his death at age 45, he reportedly was experiencing worsening memory and cognitive functioning, as well as increasing “short fuse.” • Although increasing use of alcohol, no evidence of depression, sadness, hopelessness. No alcohol in blood at time of death. 73 yr old boxer with dementia and CTE 65 yr old healthy control Grimsley 45 yr old CTE

21. Tom McHale 6th NFL Case of CTE. Died of a drug overdose Defensive lineman at Cornell and Maryland Offensive lineman in college Tampa Bay Buc 1987-1992 Philadelphia Eagles 1993-1994 Miami Dolphins 1995 No recorded concussion history, although teammates have come forward with at least one story of Tom being unable to remember plays on the field 21

22. Tom McHale 6th NFL Case of CTE Tom opened and operated multiple successful restaurants after retiring Began experiencing problems with drugs, beginning with painkillers from a back problem. In and out of rehab in the last years of his life 22

23. Chris Benoit • Michael Benoit (Chris’s father) on Larry King Live

24. Video Footage of Impacted Player

25. Chris Henry • Chris Henry Had Chronic Brain Injury • The 26-year-old Cincinnati Bengals wide receiver suffered from chronic traumatic encephalopathy, which may have influenced his mental state and behavior before he died in December. • Chicago Tribune, July, 2010

26. Symptoms Mimic Other Disorders • Depression • Mood Disorder • Substance Abuse/Dependency • “the brain injury of violence”- mimic Intermittent Explosive Disorder • Suicidal Ideation/Tendencies • Impulse Control

27. Impacts on Families • Little research • Anectodal stories (Michael Benoit) • Lisa McHale

28. Psychological Consequences • “It is common for an athlete to report significant emotional and somatic responses to injury, including fear, anger, disbelief, rage, depression, tension, upset stomach, fatigue, insomnia, and decreased appetite which is combined with or directly lead to anxiety, self-esteem issues, lowered pain tolerance, and introversion”- (Putikan & Echemendia, 2003).

29. Education/Prevention SLI operates as a though leader and innovator in sports concussion education and sport reform and works with established organizations to execute programs SLI Concussion Clinics (est. 2008) SLI Community Educators (est. 2009) SLI’s 10 Point Plan for Safer Sports • Reevaluate how the game is practiced • Encourage mandatory brain trauma and concussion education for coaches, athletic trainers, parents, and athletes • Reevaluate protective equipment • Develop better methods of concussion detection and diagnosis • Develop better methods of concussion management • Consider minimum medical resources • Reevaluate techniques of play • Reevaluate the rules • Reevaluate rule enforcement and the role of referees • Reconsider the culture of the game

30. Role of Healthcare and Mental Health Care workers • HELPS Screening Tool (Hux et al, 2009).

31. How we can support the research • Chris Nowenski • HEAD GAMES- Football’s Concussion Crisis • (2007)

32. Analog - Smoking and Lung Cancer With smoking, it took 50 years from pathological evidence of the link between smoking and lung cancer to major policy change. SLI created the change in 3 years Smoking and Lung Cancer Timeline 1997: US tobacco firms agree a multi-billion-dollar settlement to cover healthcare costs incurred by treating people with smoking-related illnesses 1950 – first small study finds smokers twice as likely to die from lung cancer 1953 - Big Tobacco forms Tobacco Institute Research Committee ("TIRC"), 1965 – Surgeon General warning added to packaging 1984 - American Association for Cancer Research accepts the evidence gathered by cancer scientists 1994: Seven Dwarves testify before Congress 50 years 10 years 20 years 30 years 40 years 2007 – Andre Waters suicide linked to brain damage from concussions 2008 – SLI/BU Center for the Study of Traumatic Encephalopathy – Brain Bank and clinical research program established 2009 – NFL admits a link between brain trauma and CTE and begins to support CSTE research 2007 – SLI founded 2007 – Benoit tragedy Concussions and CTE Timeline 32

33. …and Inspired Real Change Study finds NHL players out 41% longer per concussion than 1 year ago NHL warns teams of stiffer penalties and fines for head shots WWE wrestler Chris Benoit 5th CTE case SLI incorporated Andre Waters suicide - 3rd NFL CTE Case Living Donor Registry reaches 100 brains NFL issues concussion management guidelines SLI and Boston University School of Medicine partner to found Center for the Study of Traumatic Encephalopathy NFL wives Mackey, Perfetto speak out Jan. 2007 July 2007 Jan 2008 July 2008 Jan 2009 July 2009 Ted Johnson speaks out on eve of Super Bowl NFL/NFLPA Acknowledge Link, Support BU Research WWE implements concussion program John Grimsley 5th NFL CTE case NFL holds “Concussion Summit” SLI members profiled on HBO Real Sports Tom McHale 6th NFL CTE case Justin Strzelczyk 4th NFL case NFL tells referees to eject players for helmet-to-helmet hits NHLPA seeks ban on hits to head NFL announces 4 new rule changes to protect heads 33

34. The CSTE Brain Donation Registry Living athletes are lining up to be part of this groundbreaking research. They have agreed to be studied throughout their lives as part of the IRB approved CONTACT study • National Football League (81) • Ted Johnson • Joe DeLamielleure • Isaiah Kacyvenski • Ben Lynch • Bernie Parrish • Kyle Turley • Frank Wycheck • Bruce Laird • Brent Boyd • Mel Owens • Dan Pastorini • Billy Ray Smith • Ken Gray • Harry Jacobs (more) • NBA • Paul Grant • Malcolm Huckaby • National Hockey League (6) • Keith Primeau • Noah Welch • Steve Heinze • Ryan Vandenbussche • Pro Wrestling (25) • Rob Van Dam • Lance Storm • Chris Nowinski • Spike Dudley • Molly Holly • April Hunter • Al Snow • Boxing • Micky Ward • Soccer • Cindy Parlow Swimming • Jenny Thompson • As of Sept 2009 34

35. Active NFL Players Sign Up – September 14, 2009 3 active NFL players promise their brains for concussion research: 'The culture has to change' Sean Morey Arizona Cardinals Lofa Tatupu Seattle Seahawks Matt Birk Minnesota Vikings

36. References • Collins, M., Grindel, S., & Lovell, M. (1999). Relationship between concussion and neuropsychological performance in college football players. JAMA, 282. • Hux, K., Schneider, T., & Bennett, K. (2009). Screening for traumatic brain injury. Brain Injury, 23(1). • McKee, A., Cantu, R., Nowinski, C., Hedley-Whyte, E., Gavett, B., Budson, A., Santni, v. Lee, H., Kubils, C., and Stern, R., (2009). Chronic Traumatic Encephalopathy in Athletes: Progressive Tauopathy After Repetitive Head Injury. Journal of Neuropathology and Experimental Neurology, 68,7. • McCrory, P., Collie, A., Anderson, V., & Davis, G. (2004). Can we manage sport related concussion in children the same as in adults? Br J Sports Med, 38. • Moser, R., & Schatz, P. (2002). Enduring effects of concussion in youth athletes. Neuropsychol, 17(1).

37. References Continued • Moser, R., Schatz, P., & Jordan, B. (2005). Prolonged effects of concussions in high school athletes. Neurosurgery, 57(2). • Nowenski, C. (2007). Head Games: Footballs’ Concussion Crisis. East Bridgewater, MA: Drummond Publishing. • Pellman, E., Viano, D, Tucker, A., et al. (2003). Concussion in professional football: Reconstruction of game impacts and injuries. Neurosurgery, 53(4). Putukian, M., & Echemendia, R. (2003). Psychological aspects of serious head injury in the competitive athlete. Clin Sports Med, 22. Tonino, M., & Bollier, M. (2004). Medical supervision of high school football in Chicago: Does inadequate staffing compromise healthcare? The Physician and Sportsmedicine, 32(2).