Ask The Expert: Dr. Gerard Gioia Answers Listeners’ Questions On Head Trauma And Sports

Are concussions linked to bipolar disease? Who is more likely to suffer the football injury, the tackler or the player getting tackled? Dr. Gerard Gioia, director of the Pediatric Neuropsychology Program at Children’s National Medical Center, answered these listener questions and more. Some questions have been edited for space and clarity.

Q: When should a young adult stop playing soccer due to repeated concussions? My son started soccer at age 5, didn’t start doing headers of the ball until Middle Scool, had a lacrosse concussion as a freshman in high school with symptoms lasting less than a day and a second concussion one week later in soccer also with symptoms lasting less than a day. He didn’t restart soccer for a week and his Impact baseline testing was at baseline. He had no further injuries for 5 years when he had another soccer concussion and it took 2 weeks for his impact testing to return to baseline. His symptoms were less than a day. When should it be recommended that he stop soccer? — from Ann via email

A: We have general criteria for stopping participation in a contact sport with repeated concussions — multiple concussions, with subsequent concussions that are produced by less force to the head/body, that take longer to recover from, or that produce lasting cognitive, emotional, or physical symptoms. This patterns concerns us that the brain may becoming more vulnerable to forces, and would indicate the need to stop contact sports. This determination should be made by a concussion specialist after a careful clinical exam, neurological exam, neuropsychological testing and thorough symptom assessment.

Q: How come, when we know so much about sustaining hits regularly, players continue to congratulate each other by butting helmets, or hand-clipping a helmet of another player? — from susanhepler2602 via Web

A: Not every force to the head has dire consequences. Although the view that the number of subconcussive blows is seen theoretically as related to CTE, the brain does have tolerances for forces that do not produce any kind of known effects. A single head butt or slap to the head is not likely to have any adverse effects.

Q: Today’s show deals with brain trauma and CTE. Some symptoms were given for CTE, but they seemed to me to be quite vague. Can you please offer some detail about how CTE is diagnosed in order to avoid ambiguity with other conditions which may have similar appearance? — from Jeff via email

A: At this point, CTE cannot be diagnosed while the person is still alive. It is only confirmed after death when a careful and specialized exmination of the brain tissue is conducted. Dr. Bob Stern at Boston University is working on research now that is attempting to develop diagnostic criteria and tests that would allow diagnosis in the living person. The symptoms and presentation of CTE is similar to the presentation of other psychiatric and neurological disorders, though the BU researchers indicate that the cause / problem in the brain is unique to CTE.

Q: I had a traumatic injury to my head as a toddler (fell between the handrail and stairs and landed on my head on the basement floor below) and am now in my early 30s. Are there specific things I should be aware of as I get older? — from Jason via Facebook

A: It is important to note that virtually all people recover from an uncomplicated concussion fully without any long-term effects. Following your injury, if you did not have any time-related problems with your development or learning or social-emotional functioning (i.e., within a few days to a week post-injury), then there is no reason to be concerned that the injury as a toddler had any effect on you as an adult.

Q: My husband and I would like our boys to participate in team sports, but fear of head injuries like football. My oldest is 7 and youngest is 5, so we have some time to do some research. What would you recommend? I was thinking of swimming and golf, my husband was thinking of wrestling. Do we worry too much? — from Helen via Facebook

A: As a parent, with all the current media about concussions and youth sports, it is hard not to be worried. As I had said on the program, in whatever sport you choose, you need to do your homework with the league and ask questions like:

1. Does the league have a general policy in how they manage concussions?
2. Do you coaches take a concussion education and training course? Who is responsible for the sideline concussion recognition and response to suspected concussions?
3. Do the coaches have readily available during practice and games the Signs & Symptoms cards, clipboards, fact sheets, smartphone apps, etc. to guide them in their proper recognition and response of a suspected concussion?
4. Are the parents given any education, and what is the policy for informing parents of suspected concussions?
5. When do you allow a player to return to play the sports? (Correct answer – when an appropriate medical professional provides me with written clearance that the athlete is fully recovered and ready to return.)
6. Do you / does the league teach the sport’s technique in a way that is “headsafe” by not putting the head in a direct position to be struck? If the player does demonstrate unsafe technique during practice or a game, do you re-instruct them with the proper technique/ method?
7. If a contact sport, how often (# days a week, # minutes per practice) do you practice with live contact? Is that any different than past years?
8. Do you encourage parents to attend practice? How amenable is the league/ team / you (coach) in getting feedback from a parent if they are concerned about their child’s safety as it relates to their learning of the game?

As for which sports to choose, you have to be comfortable with contact sports if your son is going to play. There is a risk benefit equation – and you need to feel comfortable – based on the information you gather from the questions above – that safety is a priorty.

Q: A CT scan is not without risks but they are recommended routinely by insurance nurse lines following any bump to the head. What outcomes from the use of CT in diagnosing and treating a child make the risk worthwhile? — from Cyle via Facebook

A: CT sans because of the radiation exposure to the child’s brain should be used judiciously. They should not be done standardly or routinely. Generally speaking, most kids with a concussion do not need a CT scan. There are now decision rules for when to have a CT scan done, but this is typically done only when there is significant concern that the child may have sustained a significant brain injury or may be deteriorating in their function (see www.cdc.gov/concussion and search for Concussion Danger Signs). A very large study by the Pediatric Emergency Care Applied Research Network (PECARN) has published the decision rules that should be applied to reduce harmful exposure to undue radiation from CT scans.

Q: Can you address any trends re: cheerleading and concussion? — from Jenny via Facebook

A: Cheerleading is a sport that has clear risks for concussion in both the flier and base positions, with increasing recognition by the governing body of the need to reduce the risk. We see many cheerleaders in our clinic – and there continues to be a need for improvements in concussion education amongst the coaches and participants. But positive strides are being made.

Q: Are there cross studies with brain injuries suffered by troops in combat? — from @ronehardin

A: The military has had a signficant focus on brain injuries in their troops with a serious investment of clinical and research dollars (more than 2.5 billion dollars) over the past 5-6 years toward better diagnosis and treatment.

Q: Who is more likely to suffer the injury, the tackler or the player getting tackled? — from @billradun

A: For more serious sports neurological injuries (permanent brain injury and spinal cord injuries), the National Center for Catastrophic Sport Injuries at UNC tells us that the tackler represents about 2/3 of the injuries. These injuries, by the way, were found mostly in high school athletes (82-90 percent) not youth players (2.5 percent).

Q: I wonder if they have extended their studies to victims of child abuse? I know many children that have been hit on the head many times and I wonder if they have studied children and adults that were victims of child abuse. — from jturne02 via Web

A: Not as of yet, although this is an interesting question that should be studied.

Q: Are concussions linked to bipolar disease? My wonderful nephew played football in high school and college and suffered several concussions. One sent him unconscious to the hospital. He has had several severe bipolar episodes, the first when he was in college and the last a year ago when he was in his mid-40s. — from dimaurie via Web

A: Though this has not been studied specifically, concussions alone do not likely directly produce bipolar disease in most people, although in the short-term concussion does produce difficulties managing or controlling one’s emotional responses. It is important to note that most concussions do not produce long-term problems as far as we can tell, but in some people a significant concussion history may be one factor amongst others that worsens emotional functioning.

Q: Why aren’t football helmets changed to some soft absorbant material like boxing gloves or nerf balls? — from Big Wave Dave via Web

A: There is a lot of work that is being done to improve helmets but their main purpose is to protect the skull from fracturing. The helmet, and its padding, cannot absorb enough of the force to keep the brain from moving back and forth inside the skull. It is the stretching, straining, and compression of the brain’s soft tissue that results in the concussion.

Q: I have followed this problem of head injuries from football for many years. It was the primary reason I got my son interested in soccer to avoid his being involved in football. As the athletes get bigger, faster and stronger, the movement in the field seems to be to provide helmets, shoulder pads, knee pads, elbow pads that are harder and harder. Thus, when a huge defensive player running as fast as he can delivers a helmet to helmet blow to a ball carrier, the transfer of energy travels right to the brains of the two players. Why don’t those in charge insist on equipment that has shock absorbent padding on the outside, especially on football helmets, so that the energy at contact is dissipated or redirected before it affects the brain? — from Cliff via email

A: To date, the efforts to develop helmets to dissipate or redirect forces that produce concussion has not been successful though a number of companies have attempted to do so. At this point, the helmet, and its padding, cannot absorb enough of the force to keep the brain from moving back and forth inside the skull. It is the stretching, straining, and compression of the brain’s soft tissue that results in the concussion.

Q: I had multiple concussions as a child, three of which resulted in me being knocked unconscious. All of these incidents occurred before I reached 16. I am now 36 years old and I’m notorious for forgetting things. Is there the potential that there is a link between the two? If so, would you recommend that I see a specialist or are there any effective treatment options? — from Sonny via email

A: While it is difficult to know what the contribution of the multiple concussions may have been on your current functioning, there is a certainly an increased risk of long-term problems with a history of multiple injuries. I would recommend an evaluation by a concussion specialist who might be able to unravel your history and determine the likely relationship and make recommendations for treatment.

Q: I see that recently a lot of focus is on football players. My question is what about the sport of boxing. Are you finding a lot of head injuries in boxers? – from Dae via email

A: Boxing has long been studied, and concussions are frequent, and in fact the objective of boxing.

Q: I am studying neurobiology at the University of Cincinnati and am greatly enjoying your discussion of CTE. I have a question about the study however. It was stated on your show that some of the symptoms include behavioral disturbances, but was it looked into if these patients had these behavioral characteristics prior to the injuries? Or if these characteristics are common among the athlete’s peers? I’m just thinking that some of the symptoms described (aggression, trouble handling frustration, etc) could be the reason these people found football as an outlet or could have been bred in all of their training to perform. — from Dylan via email

A: This is a great question and one your should direct to the study’s primary authors, Drs. McKee, Cantu and Stern.

Q: Could you comment on concussions in other sports such as during a collision at the plate with a catcher in baseball? — from Lee via email

A: All sports have some risk of concussion if there is any potential for head contact forces – catchers in baseball are the highest risk in baseball largely due to foul tips hitting them in the mask unexpectedly and possibly frequently in some cases. Soccer, lacrosse, ice hockey, wrestling, ruby, field hockey, basketball all have risks. The equestrian sports have the highest risk.