Repeated Concussions Can Cause Lifelong Damage To The Brain

MAUREEN CAVANAUGH (Host): When you hear that the National Football League, home to head-bashing, bone crushing, rough and tumble sport, is now taking a serious look at the effect of concussion, you realize something must have changed. Some of that change comes in the form of increasing evidence that even mild blows to the head, from sports or accidents, can have serious consequences, especially if those blows are repeated. And it also notes a change in the definition of concussion and a new battery of tests to measure cognitive function before and after an injury. Now sports organizations, both professional and amateur, from hockey to basketball are re-examining their rules involving concussions. And doctors are working to learn more about how such injuries affect our brains. Joining me to discuss these increased concern (sic) about concussions are my guests. Dr. Lawrence Marshall is chairman of the Division of Neurological Surgery at the UCSD School of Medicine. And, Dr. Marshall, welcome to These Days.

DR. LAWRENCE MARSHALL (Chairman, Division of Neurological Surgery, UCSD School of Medicine): Thank you very much for having me.

CAVANAUGH: Dr. William Perry is a professor of psychiatry at the UCSD School of Medicine, past president of the National Academy of Neuropsychology. Dr. Perry is also a member of the Defense Health Board for Traumatic Brain Injury, and served as a consultant to the NFL on their dementia study. Dr. Perry, welcome.

DR WILLIAM PERRY (Professor of Psychiatry, UCSD School of Medicine): Good morning.

CAVANAUGH: We’d like to invite our audience to join the conversation. Have you ever suffered a concussion? What were the consequences of that? Do you have concerns about kids playing sports and getting head injuries? Give us a call with your questions and comments, 1-888-895-5727 begin_of_the_skype_highlighting              1-888-895-5727      end_of_the_skype_highlighting, or you can post your comments online at KPBS.org/thesedays. Dr. Marshall, let’s start off with a real basic kind of a question, and that is what is a concussion. What’s the difference between a concussion and just your average bump on the head?

DR. MARSHALL: Concussion used to be defined as a brief loss of consciousness followed by rapid recovery but over the last 10 or 15 years, we really have redefined concussion as following a blow to the head, an episode of confusion, potentially difficulty with vision, headache, and that, obviously, is a much more accurate description of what one might call transient brain dysfunction. And because of any increasing attention and actually the participation of millions of adolescents, young adults, in soccer, which is now the most frequently played game in the United States for adolescents, more attention has been paid to the consequences of these transient episodes, which sometimes, unfortunately, are not so transient. And to give you an example, I can talk about my own experience, which is somewhat ironic. I was chairing a meeting on measuring outcomes following head injury and I was at Vail, not skiing very fast, talking to my wife, and suddenly tripped over something, was unconscious for less than 10 seconds, and when I awakened, the earth was on the bottom – the sky was on the bottom and the earth was on the top and I was trying to figure out how am I going to get up because I’m going to fall…

CAVANAUGH: Oh, yeah.

DR. MARSHALL: …through the sky. And then I’m a multi-tasker and just to take a very trivial injury, had no headache, didn’t seem to have any trouble in the operating room, but I was very much a multi-tasker, couldn’t do it. And I used to be – I have almost a photographic memory, I used to be able to tell you where an article is in a journal, I couldn’t do that for two years.

CAVANAUGH: That’s fascinating.

DR. MARSHALL: It was a trivial injury.

CAVANAUGH: Do we know exactly how the brain is injured in a concussion?

DR. MARSHALL: I think that there are two really major issues. One is that the skull contains the brain, which you might think of as—it’s not the way it functions—as jello. And then the head suddenly stops and the jello keeps moving. And inside the skull there are numerous grooves, and certain areas will strike the skull and instead of being a smooth surface, so that’s one feature. The second factor, which is probably very important, is the fact that when the head is rotated, the likelihood of injury, concussion, is much greater. And so those factors clearly play a significant role in the production of concussion. The other point to make, which I think is critically important and why we have now focused to much on younger people, is that they are at the time of major information acquisition in school and these ‘minor injuries,’ in quotation marks, are often the cause of significant loss of good academic performance in the schools and, therefore, it becomes increasingly important to protect the heads of young people, not to mention the tragic event last March of Natasha Richardson…

CAVANAUGH: Exactly, yeah.

DR. MARSHALL: …who appeared to have a mild injury, fell while skiing, unhelmeted, which we’ll get back to, I’m sure…

CAVANAUGH: Right, yes, yes.

DR. MARSHALL: …in a few minutes, and then who died.

CAVANAUGH: Let –

DR. PERRY: Just to…

CAVANAUGH: Yes, go ahead, Dr. Perry. Yes.

DR. PERRY: Just to add to what Dr. Marshall was saying, we know that school age children take longer to recover than even high school and college athletes and certainly than other adults. And one of the other factors that we’re now researching is the release of neurochemicals, excitatory neurochemicals. And in the young, immature brain it’s suggested that they may be much more sensitive to these excitatory chemicals, and these excitatory chemicals can be toxic to nerve cells when they’re released in high levels. So that’s some of the thinking behind why it is that young children require considerably more attention and take longer to recover from minor head injuries.

CAVANAUGH: Now, Dr. Marshall, you said just a minute ago that the definition of a concussion used to be a loss of consciousness but now it’s changed. Why has that definition changed?

DR. MARSHALL: Because I think it’s been increasingly clear, and it started with the elderly, that you didn’t need to lose consciousness to have potentially longterm consequences of this what we thought were trivial or mild injuries. And over time, that, plus the fact that particularly in the National Football League we have seen the consequences. And also Muhammad Ali is a very classic example of someone who perhaps lost consciousness once but has gone on to develop major symptomatology, a Parkinson like syndrome, and that repetitive concussion has been shown, again, primarily, initially in college, high school and professional football players to produce longterm brain damage, and there are a couple of striking examples on the National Football League. John Mackey, who was an All Pro, Hall of Fame tight end who now very severely demented, and Al Toon, who was a wide receiver for the New York Jets who had approximately four or five concussions and is now completely disabled. So I think the attention focused first on the National Football League, it’s in the public arena, and then we also saw a significant number of injuries in college athletes, so the focus was much less on high school, younger kids playing soccer, and so on. And so I think that this was a natural evolution because one of the factors about neurosurgeons is we had a big problem with severe head injury and the high mortality rate. So that tended to be the focus in the seventies and the early eighties. And once we did a lot better, particularly San Diego County, with a very sophisticated pre-hospital system, the trauma system, we started to look much more at milder injuries and saw, since they make up about 80 to 85% of all ‘head injuries,’ in quotation marks, that we really needed to start to pay attention to this. And that’s, I think, the reason that the definition evolved over time because we recognized that these injuries, while they were thought to be trivial, often resulted in longterm problems for these younger people.

CAVANAUGH: Let’s take a call. My guests are Dr. Lawrence Marshall and Dr. William Perry, and we are talking about the effects of concussion and new research into how concussion can have longterm effects on our brains. Our number is 1-888-895-5727. And Ian is calling from Solana Beach. And good morning, Ian, and welcome to These Days.

IAN (Caller, Solana Beach): Good morning, Maureen. I’d like to bring up a sport that’s a lot more mundane to – or at least practiced a lot in our culture and that is surfing. And I’d like the doctors to address the effects of a collision on a board with another board or even their own board, especially in the high waves that we’ve got today. I had a friend who was killed in Jalama on a two-foot wave when his board reared up and smacked him on the head. The problem is that when you fall in the water, as he did, you’re in an adverse environment and he drowned due to the concussion. So if your doctors could talk about helmets and surfing.

CAVANAUGH: Thank you so much for that, Ian. I’m wondering, Dr. Marshall, do we see a lot of head injuries due to surfing?

DR. MARSHALL: Not in my experience. I think the much greater danger is neck injuries and potential quadriplegia or paraplegia. But it does lead into a subject, and I hope Bill Perry will comment on this as well, and that is that we really didn’t pay attention to a lot of sports. For example, skiing, and I remember when I first told my daughters that they had to wear helmets, they looked at me like I came from Jupiter. And I used to have a home in Big Bear and I liked to bike up there and my wife said, well, how are you going out there with a helmet. And from my childhood, I never wore a helmet. I drove – rode my bike to school. So I think it took a lot of time to see changes, particularly in adults. I mean, it’s – children always put on their seatbelts…

CAVANAUGH: Right.

DR. MARSHALL: …right? But adults often do not. And I think that this evolution in thinking went from bicycles requiring helmets in younger people and the resistance you saw in adults. And I think one of the most poignant examples is the National Hockey League. When I was a youngster, very interested in hockey, nobody wore a helmet. And it took a lot of courage, Jacque Plante was the first, a goalie, a Hall of Fame goalie, to wear a helmet and a face mask, and they all thought he was a fool.

CAVANAUGH: Now…

DR. MARSHALL: And now everybody’s helmeted, so I think this is an evolution in time, and the area where you see tragedy still is on the mountaintops in skiing. I think we’ve made much more progress except for soccer, which, I think, we’ll come back to.

CAVANAUGH: Right.

DR. MARSHALL: But I have never seen a case of death or significant concussion – I’m sure it happens, and I think that the comment of your caller is very – shows a lot of insight in that they’re in an environment where it’s hard to get to them and you don’t realize until it’s too late that they may have been unconscious.

DR. PERRY: So…

CAVANAUGH: Dr. Per – Yes, go ahead, Dr. Perry.

DR. PERRY: Well, it’s kind of interesting. It’s certainly clear that concussion can happen in any circumstance, be it in the water, on land. Unusual events can take place. Someone standing up can hit their head on a shelf and sustain a concussion. In terms of children, I think one of the areas that needs considerable attention is, particularly for young children, is both cycling, as Dr. Marshall said, and skateboarding. And this is an area of increased concern as children are…

CAVANAUGH: Right.

DR. PERRY: …skateboarding without helmets and doing unusual and wild tricks on their skateboard, and leaving them vulnerable to smacking the back of their head, and that’s often the case. Now the issue about helmets is complicated. One of the concerns that’s been raised is that when people wear protective equipment, they often feel that they can adopt more dangerous playing techniques, that this equipment will protect them. So it’s important that we recognize that safety education is critical because it can result in yet a paradoxical increase in injury rates as people feel that they are adequately protected.

CAVANAUGH: I want to talk more about helmets but I also want to talk more about what we are learning about the effects of concussion also in the idea of how it affects our cognitive abilities in the longterm but we do have to take a short break. So when we return we’ll continue talking about concussions. And you’re listening to These Days on KPBS.

CAVANAUGH: Welcome back. I'm Maureen Cavanaugh. You're listening to These Days on KPBS. Our topic for this hour is concussions. And my guests are Dr. Lawrence Marshall, who is chairman of the Division of Neurological Surgery at UCSD School of Medicine, and Dr. William Perry, a professor of psychology at UCSD School of Medicine. He’s past president of the National Academy of Neuropsychology, also a member of the Defense Health Board for Traumatic Brain Injury and served as a consultant to the NFL on their dementia study. We’re taking your calls about concussions at 1-888-895-5727, and you can also post your comments and questions online at KPBS.org/thesedays. Dr. Perry, we heard – Dr. Marshall gave us a really very good description of what it was like for him when he was – suffered a mild concussion, unconscious for a few seconds and then couldn’t find the earth, and the sky seemed to be reversed. How does one know if you’ve suffered a concussion if the definition no longer has to be that you’ve been unconscious for even a few seconds?

DR. PERRY: Right. Well, as Dr. Marshall indicated, loss of consciousness is actually relatively rare particularly in mild traumatic brain injury and particularly in those associated with athletics. In fact, less than 10% of people who sustain a concussion have lost consciousness. So more often, they will have a series of symptoms that include headache, nausea or vomiting, dizziness, sensitivity to noise, and cognitive symptoms that include difficulty concentrating and, particularly, problems with memory and attention. It’s also often the case that there’ll be some amnesia or loss of memory of events that have surrounded the actual accident itself.

CAVANAUGH: Now we started this discussion talking about the change in the way the National Football League has been – looks and – at concussions suffered by athletes. You mentioned athletes sometimes don’t know that they’ve suffered a concussion. So tell us how the NFL has changed its rules regarding concussions.

DR. PERRY: Well, I can’t speak specifically to how they’ve changed their rules. They are quickly coming up to speed. I think the most innovative program has been the National Hockey League and so I can comment…

CAVANAUGH: Sure, yes.

DR. PERRY: …that the National Hockey League has a required neuropsychologist, trainer and physician on the sidelines monitoring individuals who come to the sideline having had a – having exhibited concussion-like symptoms. They’re then assessed on the sideline and if they’re found to have signs of a concussion, they are pulled from play and they cannot return to play until they have been cleared by their medical staff and found to have their symptoms resolved.

CAVANAUGH: And in the past, basically somebody said I feel okay, and they were just allowed back on the field?

DR. PERRY: Well, that’s the interesting problem with athletics in general. Sports serves as an interesting laboratory to understand concussion because sports is unlike the sorts of events that take place and that create concussions in everyday adult life. It’s perhaps the only setting in which the patient is eager to return to work, return to the very activity that caused their injury. So it’s very common for athletes to under-report that they’ve had a concussion or to deny it and to beg their doctor to let them back into the competition.

DR. MARSHALL: Well, we have – It’s interesting, Bill’s comments, because we have an analogy in a very perhaps tragic way and that is the same is true in Iraq and in Afghanistan.

DR. PERRY: That’s right.

DR. MARSHALL: The unit – the loyalty, just as it is to the football team is to your unit, your platoon. And so we have been able, finally, to convince the Department of Defense that if soldiers concuss—and these are usually IEDs in Iraq—not to allow them to return to the unit until they have improved, where before there was a rush both by the soldier and by their commanding officers to get them back in the field and, as they said, their loyalty to the unit. And that brings me to a topic with regard – and I’ll be interested in Bill’s comments, which is that there’s a basic conflict in sports which involves the player, the coach, the parents, so what you’ve had is that – and the most recent but really bizarre example was at Texas Tech where a young man was concussed and it is said, although this is speculation, that the coach, Mike Leach, actually put him in a darkened room for reasons that nobody quite understands, and he was fired as the coach, somebody with a multi-million dollar salary. And I think it has to do with the fact that, inherently – and I can give you one example of my own experience of a young man who was concussed on a couple of occasions, from the inner city, whose only ticket to college was with a football scholarship. And, therefore, his parents as well as his coach and him – he put pressure on me to allow him to return to play. So as Bill said, we need to be sensitive to that and I think that the education of athletic trainers and the availability of pre-season testing has become increasingly important in convincing people that once you test these kids or adults using a number of tools, you have a baseline upon which you can look and say, wait a second, you’re not functioning at the same level as you did before. And then Bill, I’m sure, will comment on the fact that decisions about return to play and what they should be based on have really changed…

DR. PERRY: Yeah.

DR. MARSHALL: …over the last five or six years.

CAVANAUGH: Let me just ask before you comment, Dr. Perry, is there any efficacy in putting somebody in a dark room after they’ve had a concussion.

DR. MARSHALL: No, I think – And, again, one has to be a little bit careful since Coach Leach has sued Texas Tech. It seemed to me to be a punitive action rather than one of…

CAVANAUGH: Huh.

DR. MARSHALL: …consideration of the wellbeing of the player. And whether it was to be a lesson to other players who complained of cognitive symptoms or headache, I don’t think anybody really knows what really happened but to fire a coach who’s been extremely successful after a brief investigation would suggest that this was bizarre behavior by the coach and indicative of, again, the motivation to get players back on the field. It’s not just the guy making a million dollars a game…

DR. PERRY: Right.

DR. MARSHALL: …it’s at the high school level, and the pressure from parents can be really incredible to return a kid to play.

CAVANAUGH: Right. Dr. Perry, yes.

DR. PERRY: Right. Yeah, I’d like to underscore what Dr. Marshall was saying. It’s critically important and perhaps it’s the greatest challenge right now for us to educate players, coaches and physicians who are not familiar with concussion on the appropriate return to play protocols. And recently there was a international consensus panel on sports concussion. It met in Zurich. It’s the third such panel. And a good bit of their attention was paid to developing a graduated return to play protocol. And this protocol starts with no activity and they complete their physical and cognitive testing at rest, and then over time they increase their aerobic exercise, their sport specific exercise, and then if it’s a contact sport they start with non-contact training, full contact training, and they have to demonstrate at each of those steps that they do not exhibit symptoms of concussion or have the cognitive sequella associated with concussion before they’re allowed to return to play.

CAVANAUGH: Now you’ll have to translate that…

DR. PERRY: Sure.

CAVANAUGH: …for us. What is cognitive sequella?

DR. PERRY: Well, those are the cognitive symptoms such as problems with attention and concentration and memory in particular.

CAVANAUGH: How long does that take, that protocol?

DR. PERRY: In general, it’s recommended that the player not return for one week.

CAVANAUGH: I see.

DR. PERRY: Now, it’s recognized that with some elite athletes, they’re able to return much faster. But, certainly, for the high school and college athlete, it requires approximately one week before they’re able to return.

CAVANAUGH: We’re taking your calls at 1-888-895-5727. A lot of people want to join our conversation. I want to take a couple of calls. Josephine is calling us from Poway. Good morning, Josephine, and welcome to These Days.

JOSEPHINE (Caller, Poway): Hi. Thank you for taking my call. Very interesting topic. My question was directed towards the use of helmets because from what I understand the doctors saying, the brain, which is like jello, moves within the skull. So I’m confused now how will a helmet stop the movement of the brain within the skull? Although it will help the exterior of your head, I’m not sure how it’s going to stop the jello from moving.

DR. MARSHALL: Well, it won’t stop the jello from moving but it will re – it will diffuse the forces.

DR. PERRY: Right.

DR. MARSHALL: In other words, if you think about the skull, let’s make it into a ball. If you strike the ball in one place and the force is concentrated in one place and if you have a mechanism by which the forces are spread out over the entire circular structure that I am using as analogous to the skull, then the force is going to be dispersed over a much wider area. To give you a very poor analogy but since you’re a woman, a woman’s heel produces 4,000 foot pounds per square inch if you’re wearing stilettos and if you wear a flat shoe, it’s about 200 pounds per square inch. So that’s why women, on wood floors, can make holes, actually, in the wood.

CAVANAUGH: Right, right.

DR. MARSHALL: Whereas if you walk with a flat shoe, nothing happens. And it’s similar with a helmet. And, in fact, the National Football League and a number of manufacturers are now looking at even better head protection than we have at present for football. But it also raises the issue, and it was a very good question, as to where blows occur and it depends on the sport. The National Football League has taken increasing steps with regard to the rules of play that helmet-to-helmet contact is an automatic significant penalty and also results in a fine. Again, with these players making so much money, $10,000 or $15,000 may not matter but I think it has brought attention to this in a major way. And, again, there are specific factors in a sport that may influence the area of the head where you need to have protection. And, for example, in soccer, you don’t need a full helmet, you just need protection of the sides of the head where the bone is relatively thin, and if you can disperse those forces not only will you reduce the risk of concussion but you also dramatically decrease the risk of a blot clot, that is a hemorrhage occurring either on the surface of the brain or inside the brain.

CAVANAUGH: Let’s…

DR. MARSHALL: It’s an excellent question.

DR. PERRY: Just…

CAVANAUGH: Yes, Dr. Perry.

DR. PERRY: …to add to what Larry was saying, there’s – the NFL has now encouraged the adoption of helmet – increased innovative helmet technology. And there are two helmets that are on the market. They’re actually being used both at the college and high school level as well. One of them is fitted with this increased shock absorbers so that they can blunt the impact of the skull to the hard surface of the helmet but they also have telemetry sensors that transmit information to the sideline so that there could be a trainer on the sideline that can obtain information about the degree of acceleration and impact. And, over time, they hope to develop these algorithms to determine if the blow to the head was so significant that that person should be brought out and assessed for a concussion.

CAVANAUGH: That’s fascinating.

DR. PERRY: The…

CAVANAUGH: Let’s take another call, if I may, Dr. Perry. Brian is calling from San Diego. Good morning, Brian, and welcome to These Days.

BRIAN (Caller, San Diego): Thank you. Can you hear me?

CAVANAUGH: Yes, I can, Brian.

BRIAN: Yes. Did you want my statement? Basically, my brother had the same sort of problem. He played at Penn State for five years and then played for the NFL with the Rams, LA Rams at that time in the sixties.

CAVANAUGH: Umm-hmm.

BRIAN: He functioned very well for a number of years, very successfully as a businessman for IBM and other places, and it wasn’t until he was in his fifties that he started to disintegrate. And eventually he died in his fifties and the examination of him afterwards, the examination of his body afterwards, indicated that the whole frontal part of the body was completely destroyed and his – He went down, like almost became a child over a period of time except that he was 6’6” and weighed about 260.

DR. PERRY: Well…

CAVANAUGH: Thank you for that. Thank you for sharing that, Brian.

DR. PERRY: I’m so sorry to hear that, and it’s such a poignant story. And this is – it’s stories like this that have now intensified the NFL to – or have intensified the studies that have been commissioned by the NFL because of these dementia related diseases that they have, that have been reported in individuals who are younger than the age expected to have these diseases. And I think one of the things that’s important to remember is that the vast majority of people who have a concussion will have those symptoms resolve within one week and not have any longterm effects. So I would hate for people out there who’ve experienced a concussion to believe that they are vulnerable to having early dementia. But…

CAVANAUGH: Certainly.

DR. PERRY: …it’s…

DR. MARSHALL: I think it’s important, Bill, to emphasize a couple of factors, which are – one is really new, in the last decade or so, and the other one is the whole issue of repetitive concussions…

DR. PERRY: Right.

DR. MARSHALL: …which people said, well, it didn’t really matter, and that’s clearly not true.

DR. PERRY: That’s right.

DR. MARSHALL: And the other area is the whole issue of potential genetic susceptibility…

DR. PERRY: Umm-hmm.

DR. MARSHALL: …to the effects of brain injury and this was originally described about 15 years ago by my very close friends—in fact, I spent a year in Glasgow—in more severe head injuries where they showed that the genetic components that predict familial Alzheimer’s disease, which is about 15% of the total number of people, also predicted poorer recovery from brain injury. And in the NFL, what Bob can’t do and a number of other people, is now doing a project looking at the genetic makeup of the football players to see whether or not following repetitive concussion, this may make people uniquely susceptible to longterm brain damage and the tragic deterioration that your caller referred to. And I think that there’s increasing evidence – There’ve been a number of papers published in the neurosurgical literature and also the sports medicine literature suggesting that this may be a big factor. And they’re now collecting blood on – in the National Football League and also at a couple of universities to look at that over the long term and it’s a unique area and one of longterm interest because potentially you might be able to do something about that. I mean, we’re talking far…

DR. PERRY: Right.

DR. MARSHALL: …in the future.

CAVANAUGH: That’s in…

DR. MARSHALL: I think it’s a very important potential looking at the prediction that one player may be much more susceptible than the other, not because of the degree of force applied to the head but also because what they bring…

CAVANAUGH: Because of their genetics.

DR. MARSHALL: …from their parents…

DR. PERRY: Right.

CAVANAUGH: That’s amazing.

DR. PERRY: You know, to also add additional support from the research literature to the caller’s comments, there’s a recent study that found that players at age 50 and above reported five times higher than the national average of being diagnosed with a dementia related illness. And this increased threefold when those individuals had repetitive concussions, and the magic number seems to be three. That number seems to affect a lot of outcome data so that individuals with repeated concussions are more vulnerable to having other concussions, require longer periods of time to regain their baseline functioning and then down the road may have poorer outcomes and higher vulnerability to cognitive disorders like Alzheimer’s disease.

CAVANAUGH: As part…

DR. MARSHALL: Well…

CAVANAUGH: …of the – Oh, excuse me. As part of this continuing research, I read that some athletes who have suffered brain injury are actually donating their brains to science so that this research can continue and people can learn more about how these injuries actually affect the brain.

DR. PERRY: That – that’s…

DR. MARSHALL: Yes. Go ahead, Bill.

DR. PERRY: I was just going to say that – that’s correct, that Bob Cantu, I think, a friend of Larry’s, a colleague of mine, and Bob Stern are co-directors of the Center for the Study of Traumatic Encephalopathy at Boston University and they’ve been now tapped by the NFL and the NFL Players Association to conduct studies. And so a lot of athletes have stepped up and have donated their brains so that we can get a better understanding about the genetics and some of the other factors that influence how people resolve from head injury.

DR. MARSHALL: And I think…

CAVANAUGH: Yeah.

DR. MARSHALL: …it would be interesting to ask your caller whether or not his brother was depressed because I think although…

DR. PERRY: Yes.

DR. MARSHALL: …Bill is a neuropsychiatrist and I’m just a neurosurgeon, I think one of the most striking observations that’s been recently made is that depression appears to be much more common in individuals who’ve suffered multiple concussions.

DR. PERRY: That’s true.

DR. MARSHALL: And I’ve seen a number of professional athletes where I’ve been struck by the fact that the consequences of depression, which are so severe not just for the individual but also for the family, has been very striking. And so I wonder what your caller could tell us about his brother.

CAVANAUGH: Well, Brian isn’t on the line anymore…

DR. MARSHALL: Oh, okay.

CAVANAUGH: …but that’s an excellent observation. We do have to take a short break and when we return, we’ll continue our discussion about concussions, what we’re learning about these injuries, and we’ll be taking your calls as well, 1-888-895-5727 or you can post your comments online, KPBS.org/thesedays. You’re listening to These Days on KPBS.

CAVANAUGH: And we are back. I'm Maureen Cavanaugh. You're listening to These Days on KPBS. My guests are Dr. Lawrence Marshall and Dr. William Perry, and we’re talking about concussions, what we know about them now and what steps various sports organizations are now taking to perhaps change the rules a little bit on how they handle players who have concussion. 1-888-895-5727 is the number to call. We have a number of people who want to join our conversation. First of all, I want to take a question from Chrissie who went on our website, KPBS.org/thesedays, and asked if repeatedly hitting your head can cause migraines. I’m going to put this to Dr. Marshall. Is there any linkage there?

DR. MARSHALL: I don’t know about if you deliberately hit your head but…

CAVANAUGH: No, no, no, I mean, if you, you know, if…

DR. MARSHALL: You mean in a concussion.

CAVANAUGH: Yes. Right. Yes.

DR. MARSHALL: Well, one of the comments I was going to make about return to play—and Bill has been very active in this area—is that one of the arguments initially was if a player clearly has not returned to baseline intellectually, that is with memory and attention, trainers now have learned to keep the player out. The question is what do you do with a player whose intellectual function, so to speak, has returned to normal but still has persistent headaches…

CAVANAUGH: Umm-hmm.

DR. MARSHALL: …which is very common. And my recommendation has been to not allow them to play until headaches go away, so it’s a very good question.

DR. PERRY: Umm-hmm.

DR. MARSHALL: And headaches can be a significant problem. Usually they clear over several weeks but occasionally they do not. And our bias or my bias has been to not allow them to return to play. But this is a major issue among the Association of Athletic Trainers. What do you do? I’d be very interested in Bill’s comments…

CAVANAUGH: Sure.

DR. MARSHALL: …about that.

DR. PERRY: No, I think that’s very true. I think that any of the physical symptoms associated with concussion are warning signs. And if a player, and if anyone, is experiencing those symptoms following a head injury, they should know that the important things are to have rest. I think that’s something that gets lost, that when – It’s not only that you’re not active in your sport, but you actually need cognitive rest and for young people that includes no texting, no computer games, and it may even require some time off from school. And then it’s only when you’ve had all of your symptoms resolve that you can go back to your full activities.

CAVANAUGH: Let’s talk to Juliette. She’s calling from San Diego. Hi, Juliette, welcome to These Days.

JULIETTE (Caller, San Diego): Hi. Thanks for taking my call. I had a very silly accident inside my house about five years ago. I opened my freezer door and something came – fell down and I went to pick it up and I forgot the door was still open…

CAVANAUGH: Ow, that’s…

JULIETTE: …and I hit my back of my head in full force in the handle and immediately I fell down on the ground. And my eyes immediately turned really blurry and the kids had to help me out of the floor and then call the neighbor. And the neighbor look at me and they said, well, your eyes look really funny. You know, I said, well, my vision is – is totally weird. I had this huge lump in the back of my head. I went to the doctor. They did a CT scan. They said everything was fine. I continued having headaches and they did a second CT scan, they still said everything is okay. But to this day, I still have some pain in that particular area and sometimes when I get the headache that, you know, that spot really hurts.

CAVANAUGH: Doc…

JULIETTE: And the doctors pretty much just say that’s how it is once you have a head injury. Should I pursue to go to a neurosurgeon or somebody to look at that any further?

CAVANAUGH: Well, thank you for that, Juliette. Dr. Perry.

DR. PERRY: I would – I’d like to actually turn this to Larry. I think that…

CAVANAUGH: Sure, yes.

DR. PERRY: …one of the issues the caller raises, and it’s very important, is the role of neuro-imaging and I don’t know if, Larry, if you have some thoughts about that.

DR. MARSHALL: Yeah, thank you, Bill. I have a couple of comments. One is one of the hallmarks of concussion with the changed definition is visual disturbances and that’s what – when you go to the sidelines, you’ll see that the trainer also is asking the player to follow their finger with their eyes. And this kind of visual obscuration, this feeling of visual fogginess, so to speak, is very common. Now, persistent headache that your caller referred to is not so common and the problem with imaging is, particularly with CT, it really looks at literally a quarter of inch of brain. Its resolution to see smaller than that is not very good. And even with the most powerful magnetic resonance imaging, you’ll often not see anything significant on imaging but there is a new non-brain picture method which is called magnetic encephalography, which is like a very sophisticated EEG, and we’ve seen a number of patients, we’re doing a study now both with sports injuries, other minor head injuries, where we’ve seen on a very powerful magnet nothing but grossly abnormal electrical activity. And to just give you a quick vignette of a friend of mine, who fell off one step at a golf club leaving a party and had not had any alcohol. Never lost consciousness. He runs a multi-million dollar business. For the first several weeks—and actually Bill has seen him as a patient—he couldn’t add 8 and 9 together. So never lost consciousness, destroyed his nose, which probably saved his brain because…

CAVANAUGH: Wow.

DR. MARSHALL: …I was talking about diffusion of forces…

CAVANAUGH: Sure, yes.

DR. MARSHALL: …it diffused the force to his face. And yet persistently has been having cognitive difficulties, he’s depressed, he’s very anxious. This is a sort of a classic example and…

DR. PERRY: Umm-hmm.

DR. MARSHALL: …also had trouble with visual accommodation.

DR. PERRY: Right.

DR. MARSHALL: And because I was so concerned about him, I actually sent him to Bill for assessment evaluation and whatever further treatment. And he continues with psychiatric treatment because of this.

CAVANAUGH: Is there anything, Dr. Marshall, that you do surgically to correct the effects of concussion?

DR. MARSHALL: No, the only – and it’s very rare, is the patient who – and Natasha Richardson is a classic, tragic example where it appears to be a minor head injury. She then developed progressive headache and, unfortunately, the whole saga is filled with tragic errors. She developed a blood clot, which if it had been recognized earlier, could have been removed and almost certainly she would’ve returned to being a successful actress within a very short period of time. But that’s very, very rare. We’re really talking about something that’s not very important in this general discussion where we have almost two million people a year showing up at emergency rooms in the United States who’ve been concussed.

CAVANAUGH: And, Dr. Perry…

DR. PERRY: Right.

CAVANAUGH: …how do you treat someone like Juliette who would come to you with an effect from a concussion that happened five years ago.

DR. PERRY: Well, a couple of things. I do want to make a comment, add to something that Larry had just said…

CAVANAUGH: Please, yes.

DR. PERRY: …that’s very important. It’s important that people recognize that while it is rare that these catastrophic events take place where people die or go into coma after a head injury, that that individual should not be left alone, should not drive a motor vehicle, and should be monitored for at least 24 hours, and that’s particularly important with young children so that if they become lethargic or increased confusion that they’re rushed over to an emergency room for emergency medical attention. But answering your question, I think what we have to do is a number of things. Fortunately, residual effects from concussion are rare. So for those individuals that have ongoing problems secondary to a head injury, we have to do very thorough assessment of their cognitive abilities, of their brain functioning. They should be seen by a neurologist. And then we can symptomatically treat them. I think Larry had raised, again, the issue about depression, and that’s really critical. I’m glad he did that because I think that depression often gets overlooked as a – as an outcome of head injury and we know that there’s not only a general increase in depressive symptoms but, again, back to the notion of people who’ve had repeated head injuries, they’re at threefold risk of having a major depressive episode as a result of that.

CAVANAUGH: One of our callers wanted to know if older people are affected different by a head injury, a concussion. Dr. Marshall, would you like to take that question?

DR. MARSHALL: Yes, it’s a great question and, in fact, it’s the one sort of sentinel event in my own life, my interest in concussion because a neurosurgeon, Philip Reisman in New Zealand, working with a neuropsychologist, Dorothy Grunwald, were the first to indicate, really, that not only is the brain more vulnerable but they were among the first to really recognize that you could have significant brain dysfunction, the brain didn’t work very well, particularly in older people. And the most dramatic example for me was a woman I saw about 25 years ago who was 63, working as a waitress, and she dropped a tray and somehow slipped and hit her head. Never lost consciousness. Came to see me with terrible disequilibrium, which Bill had referred to, this really significant problem with balance, and dramatic cognitive impairment and she was about 63. And the group in New Zealand described a number of elderly – elderly, I have to be careful. I’m 66 so I have to be careful what I’m – But in older people who had had modest traffic accidents, for example, or modest falls, who had profound interference with brain function. So I think, yes, the elderly brain or the older brain doesn’t have the plasticity that we recognize in younger people but, as Bill said, the young, young brain is particularly vulnerable so we really have two spectra. We have the two ends of the spectrum.

CAVANAUGH: Right.

DR. MARSHALL: In the older patient, it’s bad because they have lost what famous British neurologists call neuronal reserve. That is…

DR. PERRY: Umm-hmm.

DR. MARSHALL: …a lot more brain tissue’s there as you’re younger and that gives you the opportunity to potentially transfer functions within the brain which is then gradually lost over time. But I would make one other comment since you’re of the female gender.

CAVANAUGH: Umm-hmm.

DR. MARSHALL: It seems to be much worse in men than in women because women’s brains don’t atrophy nearly as quickly as ours. That’s why women are smarter as they get older and we’re not.

CAVANAUGH: I see. That explains it then. Dr. Perry, we’re running to the clock, to the top of the hour and I am wondering, though, with your work with the NFL, are you seeing that the actual play of the game may be changed because of concern about concussion?

DR. PERRY: I think that Larry indicated that earlier. I think that’s really true. I – With increased awareness and education, and that’s really key, we have rule changes that are taking place. And now with the ability and, again, looking back to the NHL where it’s often the case that the NHL and the NHL Players Association are on opposite sides of the table, they’ve come together in support of concussion management. And I think you’re going to see that in the NFL over the next several years, and there’s going to be increased efforts to educate, particularly young athletes about the problems of concussion and the risks associated with returning to play too soon. I’ll just add one thing for our – for your callers, that people interested in learning more about return to play can go to the National Academy of Neuropsychology website where they can download a video, a DVD rather, that was produced by the National Athletic Trainers Association, the NHL and the National Academy of Neuropsychology to educate young people about the appropriate time to return to play.

CAVANAUGH: Dr. William Perry, thank you so much for speaking with us today.

DR. PERRY: Thank you, Maureen. It’s my pleasure.

CAVANAUGH: And Dr. Lawrence Marshall, thanks for all your stories and your great information.

DR. MARSHALL: Thank you for having me also, Maureen.

CAVANAUGH: And I want to let everyone know, we had so many people who called and we couldn’t get a lot of those calls on the air. Please, we urge you to post your comments online at KPBS.org/thesedays. This segment was conceived and produced by Hank Crook as a project for the California Endowment Health Journalism Fellowships, a program of USC’s Annenberg School for Communication and Journalism. Stay with us for hour two of These Days coming up in just a few minutes right here on KPBS.